Long-term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office

Effect of self-help interventions on psychological, glycemic, and behavioral outcomes in patients with diabetes: A meta-analysis of randomized controlled trials

BACKGROUND

Self-help interventions are beneficial for patients with diabetes; however, related studies have reported conflicting results. To date, no review has examined the effect of self-help interventions on diabetes outcomes.

OBJECTIVES

To systematically evaluate the effects of self-help interventions on psychological, glycemic, and behavioral outcomes in patients with diabetes.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Five databases-PubMed, CINAHL, Embase, PsycINFO, and ClinicalTrials.gov-were searched from 1996, 1937, 1947, 1887, and 2000, respectively, to 2 June 2023. Studies that employed a randomized controlled trial design, enrolled adults with diabetes, implemented a self-help intervention as the main or an additional intervention, and reported the outcomes of interest were included. Studies providing self-help interventions to patients with gestational diabetes or pregnant women were excluded. The primary outcomes were diabetes distress, depression, and anxiety, and the secondary outcomes were glycemic and behavioral outcomes (self-management behavior, self-efficacy, and quality of life). Hedges' g and the associated 95 % confidence interval (CI) were calculated using a random-effects model to obtain the pooled estimates of short-, mid-, and long-term effects of self-help interventions. Heterogeneity was explored using I2 and Q statistics, and moderator analysis was performed to identify the sources of heterogeneity.

RESULTS

Of 17 eligible studies, 16 provided data for meta-analysis. We included 3083 patients with diabetes; the majority were women (61.95 %), and their average age was 55.13 years. Self-help interventions exerted significant short-term effects on diabetes distress (g = -0.363; 95 % CI = -0.554, -0.173), depression (g = -0.465; 95 % CI = -0.773, -0.156), anxiety (g = -0.295; 95 % CI = -0.523, -0.068), glycosylated hemoglobin level (g = -0.497; 95 % CI = -0.791, -0.167), self-efficacy (g = 0.629; 95 % CI = 0.060, 1.197), and quality of life (g = 0.413; 95 % CI = 0.104, 0.721; g = 0.182; 95 % CI = 0.031, 0.333; and g = 0.469; 95 % CI = 0.156, 0.783 for overall, physical, and mental domains, respectively). We also noted significant mid-term effects of self-help interventions on diabetes distress (g = -0.195; 95 % CI = -0.374, -0.016), self-management behavior (g = 0.305; 95 % CI = 0.155, 0.454), and overall quality of life (g = 0.562; 95 % CI = 0.315, 0.810). The certainty of evidence ranged from high to very low certainty for the measured outcomes.

CONCLUSIONS

Self-help interventions may have some positive effects on diabetes distress, anxiety, self-management behavior, and quality of life.

REGISTRATION

This review was registered in PROSPERO (CRD42022329905).

TWEETABLE ABSTRACT

This meta-analysis demonstrated that self-help interventions might improve psychological and behavioral outcomes in patients with diabetes.

Effectiveness of Therapeutic Patient Education Interventions in Obesity and Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Diabetes mellitus (DM) and obesity account for the highest burden of non-communicable diseases. There is increasing evidence showing therapeutic patient education (TPE) as a clinically and cost-effective solution to improve biomedical and psychosocial outcomes among people with DM and obesity. The present systematic review and meta-analysis present a critical synthesis of the development of TPE interventions for DM and obesity and the efficacy of these interventions across a range of biomedical, psychosocial and psychological outcomes. A total of 54 of these RCTs were identified among patients with obesity and diabetes and were thus qualitatively synthesized. Out of these, 47 were included in the quantitative synthesis. There was substantial heterogeneity in the reporting of these outcomes (I2 = 88.35%, Q = 317.64), with a significant improvement noted in serum HbA1c levels (standardized mean difference (SMD) = 0.272, 95% CI: 0.118 to 0.525, n = 7360) and body weight (SMD = 0.526, 95% CI: 0.205 to 0.846, n = 1082) in the intervention group. The effect sizes were comparable across interventions delivered by different modes and delivery agents. These interventions can be delivered by allied health staff, doctors or electronically as self-help programs, with similar effectiveness (p < 0.001). These interventions should be implemented in healthcare and community settings to improve the health outcomes in patients suffering from obesity and DM.

A Systematic Review of Cost-Effectiveness Studies of Interventions With a Personalized Nutrition Component in Adults

OBJECTIVES

Important links between dietary patterns and diseases have been widely applied to establish nutrition interventions. However, knowledge about between-person heterogeneity regarding the benefits of nutrition intervention can be used to personalize the intervention and thereby improve health outcomes and efficiency. We performed a systematic review of cost-effectiveness analyses (CEAs) of interventions with a personalized nutrition (PN) component to assess their methodology and findings.

METHODS

A systematic search (March 2019) was performed in 5 databases: EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. CEAs involving interventions in adults with a PN component were included; CEAs focusing on clinical nutrition or undernutrition were excluded. The CHEERS checklist was used to assess the quality of CEAs.

RESULTS

We identified 49 eligible studies among 1792 unique records. Substantial variation in methodology was found. Most studies (91%) focused only on psychological concepts of PN such as behavior and preferences. Thirty-four CEAs were trial-based, 13 were modeling studies, and 4 studies were both trial- and model-based. Thirty-two studies used quality-adjusted life year as an outcome measure. Different time horizons, comparators, and modeling assumptions were applied, leading to differences in costs/quality-adjusted life years. Twenty-eight CEAs (49%) concluded that the intervention was cost-effective, and 75% of the incremental cost-utility ratios were cost-effective given a willingness-to-pay threshold of $50 000 per quality-adjusted life year.

CONCLUSIONS

Interventions with PN components are often evaluated using various types of models. However, most PN interventions have been considered cost-effective. More studies should examine the cost-effectiveness of PN interventions that combine psychological and biological concepts of personalization.

Panoramic and Personalised Intelligent Healthcare Mode

Although the development of national conditions and the increase in health risk factors undoubtedly pose a huge challenge to China’s medical health and labour security system, these simultaneously promote the elevation and transformation of national healthcare consciousness. Given that the current disease diagnosis and treatment models hardly satisfy the growing demand for medical and health care in China, based on the theory of healthcare and basic laws of human physiological activities, and combined with the characteristics of the information society, this paper presents a panoramic and personalised intelligent healthcare mode that is aimed at improving and promoting individual health. The basic definition and conceptual model are provided, and its basic characteristics and specific connotations are elaborated in detail. Subsequently, an intelligent coordination model of daily time allocation and a dynamic optimisation model for healthcare programmes are proposed. The implementation of this mode is explicitly illustrated with a practical application case. It is expected that this study will provide new ideas for further healthcare research and development.

Cost and cost-effectiveness of mHealth interventions for the prevention and control of type 2 diabetes mellitus: A systematic review

The prevalence of type 2 diabetes mellitus continues to rise and simultaneously technology has contributed to the growth of MHealth interventions for its prevention, monitoring and management. This systematic review aimed to summarize and evaluate the quality of the published evidence on cost and cost-effectiveness of mHealth interventions for T2DM. A systematic literature search of PubMed, EMBASE, and Web of Science was conducted for papers up to end of April 2019. We included all partial or full economic evaluations providing cost or cost-effectiveness results for mHealth interventions targeting individuals diagnosed with, or at risk of, type 2 diabetes mellitus. Twenty-three studies met the inclusion criteria. Intervention cost varied substantially based on the type and numbers or combination of technologies used, ranging from 1.8 INT $ to 10101.1 INT $ per patient per year. The studies which presented cost effectiveness results demonstrated highly cost-effective interventions, with cost per QALY gained ranging from 0.4 to 62.5 percent of GDP per capita of the country. The quality of partial economic evaluations was on average lower than that of full economic evaluations. Cost of mHealth interventions varied substantially based on type and combination of technology used, however, where cost-effectiveness results were reported, the intervention was cost-effective. PROSPERO registration number: CRD42019123476; Registered: 27/01/2019.

Health for Hearts United Longitudinal Trial: Improving Dietary Behaviors in Older African Americans

INTRODUCTION

Church-based interventions have been shown to improve the dietary health of underserved populations, yet few studies have examined sustainability of health behavior change over time. This paper examines dietary outcomes over a 24-month period (baseline and 6, 18, and 24 months) for fruit and vegetable and fat consumption behaviors of African-American participants in the Health for Hearts United church-based intervention in North Florida.

STUDY DESIGN

This quasi-experimental, longitudinal trial was conducted from 2009 to 2012. Data were analyzed in 2018.

SETTING/PARTICIPANTS

Six churches in a 2-county area (3 treatment, 3 comparison) were selected for the study using community-based participatory research approaches. Participants were African-American adults (aged ≥45 years; n=211 at baseline) randomly selected from the churches, stratified by age and sex.

INTERVENTION

Health for Hearts United intervention was developed by the 3 treatment churches. The 18-month intervention was implemented in 3 6-month phases, framed around 3 conceptual components, which included 4 types of programs and 4 key messages.

MAIN OUTCOME MEASURES

Fruit and vegetable consumption was assessed using a single item (fruit and vegetable intake) and the National Cancer Institute Fruit and Vegetable Screener. Fat consumption was determined using a single item (fat intake) and the National Cancer Institute Fat Screener. Background characteristics included age, sex, educational level, and marital status.

RESULTS

Significant time effects only were found for daily fruit and vegetable intake (p<0.001), fat intake (p<0.001), and the Fat Screener (p<0.001) with dietary improvements in both treatment and comparison groups across the intervention phases. Fruit and Vegetable Screener results showed that time (p<0.001) and the interaction between time and treatment (p<0.01) were significant, with increases in fruit and vegetable consumption over time for both the treatment and comparison groups and with the increase differing between groups. Post hoc analysis revealed that the treatment group had greater increases in fruit and vegetable consumption than the comparison group between Phases 1 and 3 (p=0.03).

CONCLUSIONS

Dietary behaviors of mid-life and older African Americans can be improved and sustained over 24 months using a church-based heart health intervention, with similar improvements noted for both comparison and treatment participants.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.govNCT03339050.

Type 1 diabetes mellitus: can coaching improve health outcomes?

OBJECTIVE

To evaluate the introduction of coaching in the interdisciplinary care of individuals with type 1 diabetes mellitus in the public health care system.

SUBJECTS AND METHODS

Ten patients routinely attending a public health care service and with a glycated hemoglobin (HbA1c) level above 75% participated in eight coaching sessions. This study evaluated the patients' self-management of the disease and personal behavior. The participants were assessed at the beginning of the program and on two occasions after the intervention, with evaluation of biochemical and anthropometric data, and frequency of self-monitoring of blood glucose (SMBG). Questionnaires were applied during these evaluations to analyze emotional burden (B-PAID), medication adherence (Morisky Adherence Scale), and self-efficacy (IMDSES).

RESULTS

HbA1c had a median level of 8.0% (range 76-10.3%) at the beginning of the study and reduced significantly 3 months after initiation of the intervention (7.78% [6.5-10%], p = 0.028), with no significant increase at 6 months (8.3% [713-9.27%], p = 0.386). SMBG improved significantly from the beginning to the end of the study, with the median number of glucose tests per week varying from 16.5 (range 0-42) at baseline to 29.0 (7-42) at 3 months and 27.5 (10-48) at 6 months (p = 0.047). No significant differences were observed in anthropometric parameters or in the scores of the instruments between the three measurements.

CONCLUSION

A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs and could be an auxiliary method to help individuals with type 1 diabetes achieve their treatment goals.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Effects of consumer-oriented health information technologies in diabetes management over time: a systematic review and meta-analysis of randomized controlled trials

Objective

To reveal the effects of consumer-oriented health information technologies (CHITs) on patient outcomes in diabetes management over time through systematic review and meta-analysis.

Methods

We searched 5 electronic databases (from database inception to July 2016) for studies that reported on randomized controlled trials examining the effects of CHITs on glycemic control and other patient outcomes in diabetes management. Data were analyzed using either meta-analysis or a narrative synthesis approach.

Results

Eighty randomized controlled trial studies, representing 87 individual trials, were identified and included for analysis. Overall, the meta-analysis showed that the use of CHITs resulted in significant improvement in glycemic control compared to usual care (standardized mean difference = -0.31%, 95% confidence interval -0.38 to -0.23, P  < .001) in patients with diabetes. Specifically, improvement in glycemic control was significant at intervention durations of 3, 6, 8, 9, 12, 15, 30, and 60 months, while no significant differences were found at other time points reported. The narrative synthesis provided mixed effects of CHITs on other clinical, psychosocial, behavioral, and knowledge outcomes.

Conclusions

The use of CHITs appears to be more effective than usual care in improving glycemic control for patients with diabetes. However, their effectiveness did not remain consistent over time and in other patient outcomes. Further efforts are required to examine long-term effects of CHITs and to explore factors that can moderate the effects over time.

Web-based self-management support for people with type 2 diabetes (HeLP-Diabetes): randomised controlled trial in English primary care

OBJECTIVE

To determine the effectiveness of a web-based self-management programme for people with type 2 diabetes in improving glycaemic control and reducing diabetes-related distress.

METHODS AND DESIGN

Individually randomised two-arm controlled trial.

SETTING

21 general practices in England.

PARTICIPANTS

Adults aged 18 or over with a diagnosis of type 2 diabetes registered with participating general practices.

INTERVENTION AND COMPARATOR

Usual care plus either Healthy Living for People with Diabetes (HeLP-Diabetes), an interactive, theoretically informed, web-based self-management programme or a simple, text-based website containing basic information only.

OUTCOMES AND DATA COLLECTION

Joint primary outcomes were glycated haemoglobin (HbA1c) and diabetes-related distress, measured by the Problem Areas in Diabetes (PAID) scale, collected at 3 and 12 months after randomisation, with 12 months the primary outcome point. Research nurses, blind to allocation collected clinical data; participants completed self-report questionnaires online.

ANALYSIS

The analysis compared groups as randomised (intention to treat) using a linear mixed effects model, adjusted for baseline data with multiple imputation of missing values.

RESULTS

Of the 374 participants randomised between September 2013 and December 2014, 185 were allocated to the intervention and 189 to the control. Final (12 month) follow-up data for HbA1c were available for 318 (85%) and for PAID 337 (90%) of participants. Of these, 291 (78%) and 321 (86%) responses were recorded within the predefined window of 10-14 months. Participants in the intervention group had lower HbA1c than those in the control (mean difference -0.24%; 95% CI -0.44 to -0.049; p=0.014). There was no significant overall difference between groups in the mean PAID score (p=0.21), but prespecified subgroup analysis of participants who had been more recently diagnosed with diabetes showed a beneficial impact of the intervention in this group (p = 0.004). There were no reported harms.

CONCLUSIONS

Access to HeLP-Diabetes improved glycaemic control over 12 months.

TRIAL REGISTRATION NUMBER

ISRCTN02123133.

Systematic review on the cost-effectiveness of self-management education programme for type 2 diabetes mellitus

OBJECTIVES

A review of cost-effectiveness studies on self-management education programmes for Type 2 diabetes mellitus.

METHODS

Cochrane, PubMed and PsycINFO databases were searched for papers published from January 2003 through September 2015. Further hand searching using the reference lists of included papers was carried out.

RESULTS

In total, 777 papers were identified and 12 papers were finally included. We found eight programmes whose effectiveness analyses were based on randomised controlled trials and whose costs were comprehensively estimated from the stated perspective. Among these eight, four studies showed a cost per unit reduction in clinical risk factors (HbA1c or BMI) of US$491 to US$7723 or cost per glycaemic symptom day avoided of US$39. In three studies the cost per QALY gained, as estimated from a life-time model, was less than US$50,000. However, one study found the programme was not cost-effective despite a gain in QALYs at the one-year follow up.

CONCLUSION

A small number of cost-effectiveness studies were identified with only eight of sufficiently good quality. The cost of a self-management education programme achieving reduction in clinical risk factors seems to be modest and is likely to be cost-effective in the long-term.

Adherence to and factors associated with self-care behaviours in type 2 diabetes patients in Ghana

BACKGROUND

Previous research has failed to examine more than one self-care behaviour in type 2 diabetes patients in Ghana. The purpose of this study is to investigate adult Ghanaian type 2 diabetes patients' adherence to four self-care activities: diet (general and specific), exercise, self-monitoring of blood glucose (SMBG) and foot care.

METHODS

Consenting type 2 diabetes patients attending diabetes outpatient clinic appointments at three hospitals in the Tamale Metropolis of Ghana completed a cross-sectional survey comprising the Summary of Diabetes Self-Care Activities Measure, and questions about demographic characteristics and diabetes history. Height and weight were also measured. Multiple linear regression analyses were conducted to identify the factors associated with adherence to each of the four self-care behaviours.

RESULTS

In the last 7 days, participants exercised for a mean (SD) of 4.78 (2.09) days and followed diet, foot care and SMBG for a mean (SD) of 4.40 (1.52), 2.86 (2.16) and 2.15 (0.65) days, respectively. More education was associated with a higher frequency of reported participation in exercise (r = 0.168, p = 0.022), following a healthy diet (r = 0.223, p = 0.002) and foot care (r = 0.153, p = 0.037) in the last 7 days. Males reported performing SMBG (r = 0.198, p = 0.007) more frequently than their female counterparts.

CONCLUSION

Adherence to diet, SMBG and checking of feet were relatively low. People with low education and women may need additional support to improve adherence to self-care behaviours in this type 2 diabetes population.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials

BACKGROUND

Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care.

METHODS

We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA1C) reported at 3 time points (≤ 3 mo, 4-12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I2 statistic.

RESULTS

From 3688 citations, we identified 111 eligible RCTs (n = 23 648). Telemedicine achieved significant but modest reductions in HbA1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40% [39 trials]; at 4-12 mo: -0.28%, 95% CI -0.37% to -0.20% [87 trials]; and at > 12 mo: -0.26%, 95% CI -0.46% to -0.06% [5 trials]). Quantified heterogeneity (I2 statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA1C appeared greatest in trials with higher HbA1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia.

INTERPRETATION

Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA1C but not other clinically relevant outcomes among patients with diabetes.

A randomized controlled trial of a community health worker intervention in a population of patients with multiple chronic diseases: Study design and protocol

Upstream interventions - e.g. housing programs and community health worker interventions- address socioeconomic and behavioral factors that influence health outcomes across diseases. Studying these types of interventions in clinical trials raises a methodological challenge: how should researchers measure the effect of an upstream intervention in a sample of patients with different diseases? This paper addresses this question using an illustrative protocol of a randomized controlled trial of collaborative-goal setting versus goal-setting plus community health worker support among patients multiple chronic diseases: diabetes, obesity, hypertension and tobacco dependence. At study enrollment, patients met with their primary care providers to select one of their chronic diseases to focus on during the study, and to collaboratively set a goal for that disease. Patients randomly assigned to a community health worker also received six months of support to address socioeconomic and behavioral barriers to chronic disease control. The primary hypothesis was that there would be differences in patients' selected chronic disease control as measured by HbA1c, body mass index, systolic blood pressure and cigarettes per day, between the goal-setting alone and community health worker support arms. To test this hypothesis, we will conduct a stratum specific multivariate analysis of variance which allows all patients (regardless of their selected chronic disease) to be included in a single model for the primary outcome. Population health researchers can use this approach to measure clinical outcomes across diseases.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov Identifier: NCT01900470.

Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review

AIMS

To identify the reasons why those offered a place on diabetes education programmes declined the opportunity.

BACKGROUND

It is well established that diabetes education is critical to optimum diabetes care; it improves metabolic control, prevents complications, improves quality of life and empowers people to make informed choices to manage their condition. Despite the significant clinical and personal rewards offered by diabetes education, programmes are underused, with a significant proportion of patients choosing not to attend.

METHODS

A systematic search of the following databases was conducted for the period from 2005-2015: Medline; EMBASE; Scopus; CINAHL; and PsycINFO. Studies that met the inclusion criteria focusing on patient-reported reasons for non-attendance at structured diabetes education were selected.

RESULTS

A total of 12 studies spanning quantitative and qualitative methodologies were included. The selected studies were published in Europe, USA, Pakistan, Canada and India, with a total sample size of 2260 people. Two broad categories of non-attender were identified: 1) those who could not attend for logistical, medical or financial reasons (e.g. timing, costs or existing comorbidities) and 2) those who would not attend because they perceived no benefit from doing so, felt they had sufficient knowledge already or had emotional and cultural reasons (e.g. no perceived problem, denial or negative feelings towards education). Diabetes education was declined for many reasons, and the range of expressed reasons was more diverse and complex than anticipated.

CONCLUSION

New and innovative methods of delivering diabetes education are required which address the needs of people with diabetes whilst maintaining quality and efficiency.

Economic Analysis of the Mediterranean Lifestyle Program for Postmenopausal Women With Diabetes

PURPOSE

The purpose of this study was to evaluate costs associated with the primary intervention of the Mediterranean Lifestyle Program (MLP), which targeted postmenopausal women with type 2 diabetes at risk for coronary heart disease.

METHODS

Using retrospective data collected during MLP development and implementation, the authors estimated costs for the first 6 months relative to the usual care condition and incremental costs per behavioral, biologic, and quality-of-life change. Sensitivity analyses were conducted using variations in inflation rates, implementation settings, labor and nonlabor inputs, and market wage rates.

RESULTS

Of the sample of 279 study participants, 163 were randomized into the MLP condition. Total intervention costs were estimated at $211 061 ($148 022 direct costs) or $1295 per MLP participant relative to usual care ($908 direct costs). This translates to $3808 per average change in coronary heart disease risk as measured by an average 1-point reduction in hemoglobin A1C. Relative to other measured improvements, this corresponds to $2345 per unit reduction in body mass index and $644 per unit improvement in Problem Areas in Diabetes Quality-of-Life Self-care Summary score, and a $196 per-gram reduction in intake of saturated fatty acids as noted by the Food Frequency Questionnaire. A significant portion of the direct costs were related to the resources used during the recruitment phase.

CONCLUSIONS

Providing a relatively intensive lifestyle self-management program for this high-risk group is associated with modest incremental costs compared with usual care, making the program potentially appealing to policy makers.

Changes in life goals of people with neurological disabilities

Objective: To investigate the relationship between changes in life goals and progression of disabilities among subjects with neurological disorders over a period of four years.

Design: Retrospective study.

Setting: A centre for continuing disability management in the UK.

Subjects: Patients with static or progressive neurological disabilities.

Interventions: Review of rehabilitation team notes.

Main outcome measures: Barthel ADL Index and Rivermead Life Goals Questionnaire from four consecutive annual assessments from 1997 to 2000.

Results: Thirty-two subjects had progressive disabilities and 24 had static disabilities. In subjects with static disabilities there was no significant change in grades of any of the life goals over a period of four years. Among subjects with progressive disabilities, significant reductions were noted in importance given to partner ( p = 0.034), work ( p = 0.008) and leisure ( p = 0.028) over four years. While there was no significant change in number of life goals considered as extremely important in subjects with static disabilities, there was a significant reduction in number of goals considered as extremely important in subjects with progressive disabilities ( p = 0.022)

Conclusion: People with progressive disabilities tend to downgrade the significance attached to goals related to partner, work and leisure. They also reduce number of goals graded as extremely important. This change is not seen in people with static disability.

Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control

OBJECTIVE

Assess effect of diabetes self-management education and support methods, providers, duration, and contact time on glycemic control in adults with type 2 diabetes.

METHOD

We searched MEDLINE, CINAHL, EMBASE, ERIC, and PsycINFO to December 2013 for interventions which included elements to improve participants' knowledge, skills, and ability to perform self-management activities as well as informed decision-making around goal setting.

RESULTS

This review included 118 unique interventions, with 61.9% reporting significant changes in A1C. Overall mean reduction in A1C was 0.74 and 0.17 for intervention and control groups; an average absolute reduction in A1C of 0.57. A combination of group and individual engagement results in the largest decreases in A1C (0.88). Contact hours ≥10 were associated with a greater proportion of interventions with significant reduction in A1C (70.3%). In patients with persistently elevated glycemic values (A1C>9), a greater proportion of studies reported statistically significant reduction in A1C (83.9%).

CONCLUSIONS

This systematic review found robust data demonstrating that engagement in diabetes self-management education results in a statistically significant decrease in A1C levels.

PRACTICE IMPLICATIONS

The data suggest mode of delivery, hours of engagement, and baseline A1C can affect the likelihood of achieving statistically significant and clinically meaningful improvement in A1C.

The development of a mobile u-Health program and evaluation for self-diet management for diabetic patients

BACKGROUND/OBJECTIVES

This study aims to develop a mobile nutritional management program for integration into the already developed web-based program, Diabetes Mellitus Dietary Management Guide (DMDMG) for diabetic patients. Further, we aim to evaluate the amended DMDMG program.

SUBJECTS/METHODS

The mobile application based on an Android operating system includes three parts: 1) record of diet intake, which allows users to take pictures of the meal and save to later add diet records into DMDMG; 2) an alarm system that rings at each meal time, which reminds users to input the data; 3) displays the diet record and the results of nutrient intake, which can be also viewed through the web program. All three parts are linked to the web-based program. A survey was conducted to evaluate the program in terms of nutrition knowledge, dietary attitude, eating behavior and diet intake by non-equivalent control group design among diabetic patients with 14 DMDMG users and 12 non-user controls after a one-month trial of DMDMG.

RESULTS

Non-users did not use the program, but participated in the weekly off-line nutrition classes for one month. The program users showed increased healthful dietary behavior (P < 0.01) and dietary attitude scores (P < 0.05). More DMDMG users had higher nutrition knowledge scores after one-month trial than non-users. However, dietary intake significantly increased in non-user group for calcium and sodium (P < 0.05) while the user group did not show significant changes.

CONCLUSIONS

The program has created positive changes in patients' dietary life. All the users were satisfied with the program, although some expressed minor difficulties with an unfamiliar mobile app.

Automated Remote Monitoring of Depression: Acceptance Among Low-Income Patients in Diabetes Disease Management

BACKGROUND

Remote patient monitoring is increasingly integrated into health care delivery to expand access and increase effectiveness. Automation can add efficiency to remote monitoring, but patient acceptance of automated tools is critical for success. From 2010 to 2013, the Diabetes-Depression Care-management Adoption Trial (DCAT)-a quasi-experimental comparative effectiveness research trial aimed at accelerating the adoption of collaborative depression care in a safety-net health care system-tested a fully automated telephonic assessment (ATA) depression monitoring system serving low-income patients with diabetes.

OBJECTIVE

The aim of this study was to determine patient acceptance of ATA calls over time, and to identify factors predicting long-term patient acceptance of ATA calls.

METHODS

We conducted two analyses using data from the DCAT technology-facilitated care arm, in which for 12 months the ATA system periodically assessed depression symptoms, monitored treatment adherence, prompted self-care behaviors, and inquired about patients' needs for provider contact. Patients received assessments at 6, 12, and 18 months using Likert-scale measures of willingness to use ATA calls, preferred mode of reach, perceived ease of use, usefulness, nonintrusiveness, privacy/security, and long-term usefulness. For the first analysis (patient acceptance over time), we computed descriptive statistics of these measures. In the second analysis (predictive factors), we collapsed patients into two groups: those reporting "high" versus "low" willingness to use ATA calls. To compare them, we used independent t tests for continuous variables and Pearson chi-square tests for categorical variables. Next, we jointly entered independent factors found to be significantly associated with 18-month willingness to use ATA calls at the univariate level into a logistic regression model with backward selection to identify predictive factors. We performed a final logistic regression model with the identified significant predictive factors and reported the odds ratio estimates and 95% confidence intervals.

RESULTS

At 6 and 12 months, respectively, 89.6% (69/77) and 63.7% (49/77) of patients "agreed" or "strongly agreed" that they would be willing to use ATA calls in the future. At 18 months, 51.0% (64/125) of patients perceived ATA calls as useful and 59.7% (46/77) were willing to use the technology. Moreover, in the first 6 months, most patients reported that ATA calls felt private/secure (75.9%, 82/108) and were easy to use (86.2%, 94/109), useful (65.1%, 71/109), and nonintrusive (87.2%, 95/109). Perceived usefulness, however, decreased to 54.1% (59/109) in the second 6 months of the trial. Factors predicting willingness to use ATA calls at the 18-month follow-up were perceived privacy/security and long-term perceived usefulness of ATA calls. No patient characteristics were significant predictors of long-term acceptance.

CONCLUSIONS

In the short term, patients are generally accepting of ATA calls for depression monitoring, with ATA call design and the care management intervention being primary factors influencing patient acceptance. Acceptance over the long term requires that the system be perceived as private/secure, and that it be constantly useful for patients' needs of awareness of feelings, self-care reminders, and connectivity with health care providers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013 (Archived by WebCite at http://www.webcitation.org/6e7NGku56).

The Effect of Blood Glucose Self-Monitoring Among Inmates With Diabetes

The increasing prevalence and risk of complications from diabetes necessitate patient participation and attentiveness to select appropriate foods, perform regular physical activity, and be active in diabetes management and self-maintenance. Diabetes is often largely asymptomatic; consequently, early diagnosis and treatment are necessary. Inmates are a unique population challenged by the increased prevalence of chronic conditions including diabetes. Diabetes standards for inmates contain diagnostic and treatment management guidelines that incorporate personal glucose monitoring for insulin users. In December 2009, the Federal Bureau of Prisons initiated a program to distribute glucose meters to insulin-dependent inmates to facilitate self-monitoring blood glucose. The purpose of this study was to evaluate the effect of these glucose meters on hemoglobin A1c levels.

Effects of diabetic case management on knowledge, self-management abilities, health behaviors, and health service utilization for diabetes in Korea

PURPOSE

This study aimed to evaluate the effects of a case management program for diabetics, using a pre-post comparison design.

MATERIALS AND METHODS

The study population comprised 6007 diabetics who received case management intervention in 2006 and were sampled nationwide in Korea. Before and after the intervention, the study population answered questions regarding their knowledge of diabetes, self-management ability, and health behaviors. Body mass index (BMI) was also calculated. Healthcare service utilization for diabetes was extracted from health insurance claim data from 2005 to 2007.

RESULTS

The case management program significantly improved the study population's knowledge of diabetes and ability to self-manage nutrition, blood glucose monitoring, foot and oral care, and medications. This program also significantly changed the study population's health behaviors regarding smoking, alcohol drinking, and exercise, and BMI was positively affected. In the over-serviced subgroup, there was a significant decrease in the number of consultations (mean=7.0; SD=19.5) after intervention. Conversely, in the under-serviced subgroup, there was a significant increase in the number of consultations (mean=3.2; SD=7.9) and the days of prescribed medication (mean=66.4; SD=120.3) after intervention.

CONCLUSION

This study showed that the case management program led the study population to improve their knowledge, self-management ability, health behaviors, and utilization of health care. It is necessary in future studies to evaluate the appropriateness of healthcare usage and clinical outcome by using a control group to determine the direct effectiveness of this case management program.

Psychosocial interventions for the diabetic patient

Diabetes usually requires substantial life-long self-management by the patient. Psychological factors and the patient's health beliefs are important determinants of self-care behavior. Education has a modest influence on generating better self-care, but psychologically based interventions are clearly more effective. This review gives an overview of these interventions with some discussion of their basis in psychological theory. Some labels such as cognitive behavioral therapy and family therapy include a wide range of approaches. Randomized trials have generally produced improvement in measures of psychological well-being, but improved glycemic control has been more elusive. The influence on behavior can be very dependent on the individual therapist. Only a few trials have managed to sustain improvement in glycosylated hemoglobin beyond a year. Not all patients are prepared to engage and accept these forms of therapeutic intervention. We are still some way from moving psychological management from the trial situation into the diabetic clinic.

Computer-based interventions to improve self-management in adults with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

Structured patient education programs can reduce the risk of diabetes-related complications. However, people appear to have difficulties attending face-to-face education and alternatives are needed. This review looked at the impact of computer-based diabetes self-management interventions on health status, cardiovascular risk factors, and quality of life of adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We searched The Cochrane Library, Medline, Embase, PsycINFO, Web of Science, and CINAHL for relevant trials from inception to November 2011. Reference lists from relevant published studies were screened and authors contacted for further information when required. Two authors independently extracted relevant data using standard data extraction templates.

RESULTS

Sixteen randomized controlled trials with 3,578 participants met the inclusion criteria. Interventions were delivered via clinics, the Internet, and mobile phones. Computer-based diabetes self-management interventions appear to have small benefits on glycemic control: the pooled effect on HbA1c was -0.2% (-2.3 mmol/mol [95% CI -0.4 to -0.1%]). A subgroup analysis on mobile phone-based interventions showed a larger effect: the pooled effect on HbA1c from three studies was -0.50% (-5.46 mmol/mol [95% CI -0.7 to -0.3%]). There was no evidence of improvement in depression, quality of life, blood pressure, serum lipids, or weight. There was no evidence of significant adverse effects.

CONCLUSIONS

Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control, and this effect was larger in the mobile phone subgroup. There was no evidence of benefit for other biological, cognitive, behavioral, or emotional outcomes.

Does the use of consumer health information technology improve outcomes in the patient self-management of diabetes? A meta-analysis and narrative review of randomized controlled trials

PURPOSE

To assess whether the use of consumer health information technologies (CHITs) improves outcomes in the patient self-management of diabetes.

METHOD

The evidence from randomized controlled trials (RCTs) on the effects of CHITs on patient outcomes was analyzed using either meta-analysis or a narrative synthesis approach. A systematic search of seven electronic databases was conducted to identify relevant reports of RCTs for the analysis. In the meta-analyses, standardized mean differences in patient outcomes were calculated and random-effects models were applied in cases where the heterogeneity of the results was moderate or high, otherwise fixed-effects models were used.

RESULTS

Sixty-two studies, representing 67 RCTs, met the inclusion criteria. The results of the meta-analyses showed that the use of CHITs was associated with significant reductions in HbA1c, blood pressure, total cholesterol, and triglycerides levels when compared with the usual care. The findings from the narrative synthesis indicated that only a small proportion of the trials reported positive effects of CHITs on patient outcomes.

CONCLUSIONS

The use of CHITs in supporting diabetes self-management appears to have potential benefits for patients' self-management of diabetes. However, the effectiveness of the technologies in improving patient outcomes still awaits confirmation in future studies.

Using the health action process approach to predict and improve health outcomes in individuals with type 2 diabetes mellitus

BACKGROUND

The purpose of this study was to explore the predictive utility of the Health Action Process Approach (HAPA) and test a HAPA-based healthy eating intervention, in adults with type 2 diabetes mellitus.

MATERIALS AND METHODS

The study employed a prospective, randomized, controlled trial design. The 4-month intervention consisted of self-guided HAPA-based workbooks in addition to two telephone calls to assist participants with the program implementation, and was compared to "treatment as usual". Participants (n=87) completed health measures (diet, body mass index [BMI], waist circumference, blood pressure, blood glucose levels, lipid levels, and diabetes distress) and HAPA measures prior to the intervention and again upon completion 4 months later.

RESULTS

The overall HAPA model predicted BMI, although only risk awareness and recovery self-efficacy were significant independent contributors. Risk awareness, intentions, and self-efficacy were also independent predictors of health outcomes; however, the HAPA did not predict healthy eating. No significant time × condition interaction effects were found for diet or any HAPA outcome measures.

CONCLUSION

Despite the success of HAPA in predicting health outcomes for those with type 2 diabetes mellitus, the intervention was unsuccessful in changing healthy eating or any of the other measured variables, and alternative low-cost health interventions for those with type 2 diabetes mellitus should be explored.

Addressing unmet need for HIV testing in emergency care settings: a role for computer-facilitated rapid HIV testing?

HIV testing in emergency departments (EDs) remains underutilized. The authors evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned nonacute adult ED patients were randomly assigned to a computer tool (CARE) and rapid HIV testing before a standard visit (n = 258) or to a standard visit (n = 259) with chart access. The authors assessed intervention acceptability and compared noted HIV risks. Participants were 56% nonWhite and 58% male; median age was 37 years. In the CARE arm, nearly all (251/258) of the patients completed the session and received HIV results; four declined to consent to the test. HIV risks were reported by 54% of users; one participant was confirmed HIV-positive, and two were confirmed false-positive (seroprevalence 0.4%, 95% CI [0.01, 2.2]). Half (55%) of the patients preferred computerized rather than face-to-face counseling for future HIV testing. In the standard arm, one HIV test and two referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches.

Maximizing the healthcare environment: a systematic review exploring the potential of computer technology to promote self-management of chronic illness in healthcare settings

OBJECTIVE

The aim of this systematic review is to investigate the effectiveness of using computers to deliver patient self-management programs (PSMPs) to patients with chronic illness in health supported settings.

METHODS

We included randomized controlled trials (RCTs), where the experimental intervention was compared either with an equivalent 'standard' PSMP delivered by staff, usual care or no intervention and reported data either on clinical or behavioral outcomes. We conducted a narrative synthesis, incorporating a small quantitative analysis to enable comparisons across studies.

RESULTS

A total of 11 studies met the inclusion criteria. There was insufficient evidence to determine whether computer-based PSMPs were superior to standard programs. However, it appeared that these interventions were effective when compared to no intervention. Interventions incorporating behavior change techniques beyond the provision of information appeared more effective than those that did not.

CONCLUSION

Evidence from the current review, whilst limited, suggests that computer-based PSMPs, delivered in health-supported settings, show potential for changing health behaviors and improving clinical outcomes in patients with chronic illness.

PRACTICE IMPLICATIONS

Although the approach shows promise, it is premature to recommend the integration of these interventions into clinical practice. However, more well designed trials are warranted to test their efficacy and cost-benefit.

Intensive weight loss intervention in older individuals: results from the Action for Health in Diabetes Type 2 diabetes mellitus trial

OBJECTIVES

To compare the effects of 4 years of intensive lifestyle intervention on weight, fitness, and cardiovascular disease risk factors in older and younger individuals.

DESIGN

Randomized controlled clinical trial.

SETTING

Sixteen U.S. clinical sites.

PARTICIPANTS

Individuals with type 2 diabetes mellitus: 1,053 aged 65 to 76 and 4,092 aged 45 to 64.

INTERVENTIONS

An intensive behavioral intervention designed to promote and maintain weight loss through caloric restriction and increased physical activity was compared with diabetes mellitus support and education.

MEASUREMENTS

Standardized assessments of weight, fitness (based on graded exercise testing), and cardiovascular disease risk factors.

RESULTS

Over 4 years, older individuals had greater intervention-related mean weight losses (6.2%) than younger participants (5.1%; interaction P = .006) and comparable relative mean increases in fitness (0.56 vs 0.53 metabolic equivalents; interaction P = .72). These benefits were seen consistently across subgroups of older adults formed according to many demographic and health factors. Of a panel of age-related health conditions, only self-reported worsening vision was associated with poorer intervention-related weight loss in older individuals. The intensive lifestyle intervention produced mean increases in high-density lipoprotein cholesterol (2.03 mg/dL; P < .001) and decreases in glycated hemoglobin (0.21%; P < .001) and waist circumference (3.52 cm; P < .001) over 4 years that were at least as large in older as in younger individuals.

CONCLUSION

Intensive lifestyle intervention targeting weight loss and increased physical activity is effective in overweight and obese older individuals to produce sustained weight loss and improvements in fitness and cardiovascular risk factors.

Effects of self-management health information technology on glycaemic control for patients with diabetes: a meta-analysis of randomized controlled trials

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) which had evaluated self-management health information technology (SMHIT) for glycaemic control in patients with diabetes. A total of 43 RCTs was identified, which reported on 52 control-intervention comparisons. The glycosylated haemoglobin (HbA_1c) data were pooled using a random effects meta-analysis method, followed by a meta-regression and subgroup analyses to examine the effects of a set of moderators. The meta-analysis showed that use of SMHITs was associated with a significant reduction in HbA_1c compared to usual care, with a pooled standardized mean difference of -0.30% (95% CI -0.39 to -0.21, P < 0.001). Sample size, age, study setting, type of application and method of data entry significantly moderated the effects of SMHIT use. The review supports the use of SMHITs as a self-management approach to improve glycaemic control. The effect of SMHIT use is significantly greater when the technology is a web-based application, when a mechanism for patients' health data entry is provided (manual or automatic) and when the technology is operated in the home or without location restrictions. Integrating these variables into the design of SMHITs may augment the effectiveness of the interventions.

Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus

BACKGROUND

Diabetes is one of the commonest chronic medical conditions, affecting around 347 million adults worldwide. Structured patient education programmes reduce the risk of diabetes-related complications four-fold. Internet-based self-management programmes have been shown to be effective for a number of long-term conditions, but it is unclear what are the essential or effective components of such programmes. If computer-based self-management interventions improve outcomes in type 2 diabetes, they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition.

OBJECTIVES

To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus.

SEARCH METHODS

We searched six electronic bibliographic databases for published articles and conference proceedings and three online databases for theses (all up to November 2011). Reference lists of relevant reports and reviews were also screened.

SELECTION CRITERIA

Randomised controlled trials of computer-based self-management interventions for adults with type 2 diabetes, i.e. computer-based software applications that respond to user input and aim to generate tailored content to improve one or more self-management domains through feedback, tailored advice, reinforcement and rewards, patient decision support, goal setting or reminders.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the abstracts and extracted data. A taxonomy for behaviour change techniques was used to describe the active ingredients of the intervention.

MAIN RESULTS

We identified 16 randomised controlled trials with 3578 participants that fitted our inclusion criteria. These studies included a wide spectrum of interventions covering clinic-based brief interventions, Internet-based interventions that could be used from home and mobile phone-based interventions. The mean age of participants was between 46 to 67 years old and mean time since diagnosis was 6 to 13 years. The duration of the interventions varied between 1 to 12 months. There were three reported deaths out of 3578 participants.Computer-based diabetes self-management interventions currently have limited effectiveness. They appear to have small benefits on glycaemic control (pooled effect on glycosylated haemoglobin A1c (HbA1c): -2.3 mmol/mol or -0.2% (95% confidence interval (CI) -0.4 to -0.1; P = 0.009; 2637 participants; 11 trials). The effect size on HbA1c was larger in the mobile phone subgroup (subgroup analysis: mean difference in HbA1c -5.5 mmol/mol or -0.5% (95% CI -0.7 to -0.3); P < 0.00001; 280 participants; three trials). Current interventions do not show adequate evidence for improving depression, health-related quality of life or weight. Four (out of 10) interventions showed beneficial effects on lipid profile.One participant withdrew because of anxiety but there were no other documented adverse effects. Two studies provided limited cost-effectiveness data - with one study suggesting costs per patient of less than $140 (in 1997) or 105 EURO and another study showed no change in health behaviour and resource utilisation.

AUTHORS' CONCLUSIONS

Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup. There is no evidence to show benefits in other biological outcomes or any cognitive, behavioural or emotional outcomes.

Effectiveness of weight loss interventions for obese older adults

OBJECTIVE

The consequences of obesity among older adults are significant, yet few obesity interventions target this group. Unfamiliarity with weight loss intervention effectiveness and concerns that weight loss negatively affects older adults may be inhibiting targeting this group. This paper reviews the evidence on intentional weight loss and effective weight loss interventions for obese older adults to help dispel concerns and guide health promotion practice.

DATA SOURCE

PubMed articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized controlled trials examining behavioral and pharmaceutical weight loss strategies with 1-year follow-up targeting obese (body mass index ≥ 30) older adults (mean age ≥ 60 years), and studies with quasi-experimental designs examining surgical weight loss strategies targeting older adults were examined.

DATA EXTRACTION

Abstracts were reviewed for study objective relevancy, with relevant articles extracted and reviewed.

DATA SYNTHESIS

Data were inserted into an analysis matrix.

RESULTS

Evidence indicates behavioral strategies are effective in producing significant (all p < .05) weight loss without significant risk to obese older adults, but effectiveness evidence for surgical and pharmaceutical strategies for obese older adults is lacking, primarily because this group has not been targeted in trials or analyses did not isolate this group.

CONCLUSION

These findings support the promotion of intentional weight loss among obese older adults and provide guidance to health promotion practitioners on effective weight loss interventions to use with this group.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Adoption of self-management interventions for prevention and care

Seventy-five percent of health care costs can be attributed to chronic diseases, making prevention and management imperative. Collaborative patient self-management in primary care is efficacious in reducing symptoms and increasing quality of life. In this article, the authors argue that self-management interventions span the continuum of prevention and disease management. Self-management interventions rest on a foundation of 5 core actions: (1) activate motivation to change, (2) apply domain-specific information from education and self-monitoring, (3) develop skills, (4) acquire environmental resources, and (5) build social support. Several delivery vehicles are described and evaluated in terms of diffusion and cost-containment goals.

Identifying preferences for mobile health applications for self-monitoring and self-management: focus group findings from HIV-positive persons and young mothers

OBJECTIVE

Self-management of risk behaviors is a cornerstone of future population health interventions. Using mobile phones for routine self-monitoring and feedback is a cost-efficient strategy for self-management and ecological momentary interventions (EMI). However, mobile health applications need to be designed to be highly attractive and acceptable to a broad range of user groups. To inform the design of an adaptable mobile health application we aimed to identify the dimensions and range of user preferences for application features by different user groups.

METHODS

Five focus group interviews were conducted: two (n=9; n=20) with people living with HIV (PLH) and three with young mothers (n=6; n=8; n=10). Thematic analyses were conducted on the focus group sessions' notes and transcripts.

RESULTS

Both groups considered customization of reminders and prompts as necessary, and goal setting, motivational messaging, problem solving, and feedback as attractive. For PLH, automated and location-based reminders for medication adherence and sharing data with healthcare providers were both acceptable and attractive features. Privacy protection and invasiveness were the primary concerns, particularly around location tracking, illegal drug use, and sexual partner information. Concerns were ameliorated by use scenario or purpose, monetary incentives, and password protection. Privacy was not a major concern to mothers who considered passwords burdensome. Mothers' preferences focused on customization that supports mood, exercise and eating patterns, and especially using the mobile phone camera to photograph food to increase self-accountability.

CONCLUSIONS

Individualization emerged as the key feature and design principle to reduce user burden and increase attractiveness and acceptability. Mobile phone EMI uniquely enables individualization, context-aware and real-time feedback, and tailored intervention delivery.

Self-efficacy and self-care behavior of Malaysian patients with type 2 diabetes: a cross sectional survey

This study investigated the association between self-efficacy and self-care behavior to determine the degree of self-efficacy and to examine differences in self-efficacy according to patient variables, including state of health, of Malaysian patients with type 2 diabetes. The sample comprised 388 patients (respondents). We collected the data from December 2010 to February 2011. We found a significant positive relationship between self-efficacy and self-care behavior (r(s) = 0.481, P < 0.001). The degree of self-efficacy was moderately high (mean = 7.570). We found significant differences between self-efficacy and education level (Wilk's Lambda = 0.918, F[12, 1008] = 2.779, P < 0.05), duration of diabetes (Wilk's Lambda = 0.954, F[8, 736] = 2.264, P < 0.05), other chronic conditions (Wilk's Lambda = 0.967, F[4, 383] = 3.304, P < 0.05) and diabetic complications (Wilk's Lambda = 0.963, F[4, 383] = 3.653, P < 0.05). Self-efficacy can be used as a model to understand self-care behavior. Individualized nursing interventions based on self-efficacy theory should be utilized in high risk diabetic patients so as to assist and improve self-care behavior.

Interactive media for diabetes self-management: issues in maximizing public health impact

BACKGROUND

Diabetes self-management presents a series of challenging tasks, and primary care, where the majority of cases of adult diabetes are treated, is hard-pressed to address these issues given competing demands. This article discusses how interactive media (IM) can be used to support diabetes self-management.

METHODS

Following a brief review of the literature, the 5 As framework for enhancing the effectiveness of health behavior counseling and the RE-AIM model for estimating and enhancing public health impact are used to frame discussion of the strengths and limitations of IM for diabetes shared decision making and self-management support.

RESULTS

Data and lessons learned from a series of randomized trials of IM for diabetes self-management education are summarized around 2 key issues. The first is enhancing patient engagement in decision making and includes enhancing user experience and engagement, improving quality of care, and promoting collaborative action planning and follow-up. The second is getting such resources into place and sustaining them in real-world primary care settings and involves enhancing participation at patient, clinician, and health care system levels and enhancing the generalizability of results.

CONCLUSIONS

. Key opportunities for IM to support diabetes self-management include assessment of information for shared decision making, assistance with problem-solving self-management challenges, and provision of follow-up support. A key current challenge is the linkage of IM supports to the rest of the patient's care, and collection of cost-effectiveness data is a key need for future research.

Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: the smart sex quest project

There is an increasing interest in developing interventions for HIV and STD prevention that can be delivered on the Internet. However, we know little about what it takes to identify, recruit and retain participants in interventions so that we can test their efficacy and effectiveness. Objectives for this investigation were to evaluate rates of recruitment and retention in an Internet-based randomized controlled trial (RCT) to increase sexually transmitted disease (STD) prevention among men who have sex with men (MSM). The Smart Sex Quest study was a RCT conducted online. Eligible participants were MSM, at least 18 years old and US residents. After completing a baseline risk assessment, participants were exposed to tailored or control messages and asked to return to the site at three months for a follow-up interview. From January 2002 through June 2003, 3,625 persons logged on as potential study participants; of these, 563 were not eligible, while 1,286 left the site without filling out a baseline survey. Complete baseline data were available for 1,776 participants, all of whom were eligible to complete a follow-up. Complete follow-up data were available for 270 (15.2%) participants. While the Internet is a valuable tool for conducting research, conducting this longitudinal research online was severely affected by a loss to follow-up, and analyzing outcome data was hampered by significant differences between those who did and did not complete the study. Alternate ways to recruit for and evaluate online trials must be considered.

Self-management interventions to improve outcomes in patients suffering from COPD

New research and evidence-based self-management programs are now emerging in chronic obstructive pulmonary disease. Patients with moderate-to-severe chronic obstructive pulmonary disease who receive a self-management education with supervision and support of a case manager, have better outcomes than patients receiving standard care. The benefits are on patients' health status and healthcare utilization with markedly decreased hospitalizations, emergency department and unscheduled physician visits. These benefits are worth considering since self-management could also be cost saving. There is no reason to question the value of self-management in chronic obstructive pulmonary disease, especially for those patients who have a decreased health-related quality of life and high exacerbation rate. Self-management should be an integral part of the long-term care of chronic obstructive pulmonary disease patients. Rather than telling the patient to learn to live with their disease, they should be taught to self-manage.

Technologically-assisted behaviour change: a systematic review of studies of novel technologies for the management of chronic illness

A systematic review was conducted to investigate the use of technology in achieving behaviour change in chronic illness. The areas reviewed were: (1) methods employed to adapt traditional therapy from a face-to-face medium to a computer-assisted platform; (2) targets of behaviour change; and (3) level of human (e.g. therapist) involvement. The initial literature search produced 2032 articles. A total of 45 articles reporting 33 separate interventions met the inclusion/exclusion criteria and were reviewed in detail. The majority of interventions reported a theoretical basis, with many arising from a cognitive-behavioural framework. There was a wide range of therapy content. Therapist involvement was reported in 73% of the interventions. A common problem was high participant attrition, which may have been related to reduced levels of human interaction. Instigating successful behaviour change through technological interventions poses many difficulties. However, there are potential benefits of delivering therapy in this way. For people with long-term health conditions, technological self-management systems could provide a practical method of understanding and monitoring their condition, as well as therapeutic guidance to alter maladaptive behaviour.

Efficacy of brief interventions in clinical care settings for persons living with HIV

Prevention of HIV transmission from patients living with HIV (PLH) is a high national priority and strategies that are easy to implement and sustain to eliminate sexual transmission acts among PLH are needed. We evaluated a brief intervention that focused primarily on the enhancing motivations and encouraging PLH to act in accordance with their values without providing the intensity of the existing evidence-based programs for PLH. Using a quasiexperimental design, six medical clinics in Los Angeles County, CA, were evaluated across three intervention conditions: 1) computerized delivery; 2) provider delivery; or 3) standard care. We examined longitudinal changes in patients' reports of the number of HIV-negative (HIV-) or serostatus-unknown sexual partners and the number of unprotected vaginal and anal sex acts. Among 566 PLH, PLH in the computerized delivery condition reported a significant decrease in the number of HIV-/unknown sexual partners compared with the provider delivery and standard care conditions and a significant decrease in the number of unprotected sex acts in comparison to the standard care condition. Computerized motivational interventions delivered in waiting rooms at medical clinics may be an efficient strategy to reduce unprotected sex acts among PLH.

Interventions to achieve long-term weight loss in obese older people: a systematic review and meta-analysis

PURPOSE

the prevalence of obesity is rapidly increasing in older adults. Information is required about what interventions are effective in reducing obesity and influencing health outcomes in this age group.

DESIGN

systematic review and meta-analysis.

DATA SOURCES

thirteen databases were searched, earliest date 1966 to December 2008, including Medline, CINAHL, PsycINFO, the Cochrane database and EMBASE.

STUDY SELECTION

we included studies with participants' mean age > or = 60 years and mean body mass index > or = 30 kg/m(2), with outcomes at a minimum of 1 year. Data were independently extracted by two reviewers and differences resolved by consensus.

DATA EXTRACTION

nine eligible trials were included. Study interventions targeted diet, physical activity and mixed approaches. Populations included patients with coronary artery disease, diabetes mellitus and osteoarthritis.

RESULTS

meta-analysis (seven studies) demonstrated a modest but significant weight loss of 3.0 kg [95% confidence interval (CI) 5.1-0.9] at 1 year. Total cholesterol (four studies) did not show a significant change: -0.36 mmol/l (95% CI -0.75 to 0.04). There was no significant change in high-density lipoprotein, low-density lipoprotein or triglycerides. In one study, recurrence of hypertension or cardiovascular events was significantly reduced (hazard ratio 0.65, 95% CI 0.50-0.85). Six-minute walk test did not significantly change in one study. Health-related quality of life significantly improved in one study but did not improve in a second study.

CONCLUSIONS

although modest weight reductions were observed, there is a lack of high-quality evidence to support the efficacy of weight loss programmes in older people.

Computer-mediated patient education: opportunities and challenges for supporting women with ovarian cancer

A majority of women with ovarian cancer will face recurrent disease despite receiving aggressive chemotherapy at the time of diagnosis. Given the complex medical and psychosocial needs of women with ovarian cancer and the time constraints within busy clinical settings, providing women with the necessary education related to their disease and treatments can be challenging. The advent of computers and web-based technologies has created new opportunities for educating cancer patients and supporting them to better cope with their disease. This article reviews prior studies of computer-based patient education interventions to identify key intervention components and other factors associated with improved patient outcomes. Opportunities for using computer-based technologies to support women with ovarian cancer are discussed and WRITE Symptoms (a Written Representational Intervention To Ease Symptoms), a web-based, symptom management intervention for women with recurrent ovarian cancer, is introduced.