Contextual factors for the successful implementation of self-management interventions for chronic diseases: A qualitative review of reviews

Managing cardiovascular risk factors with telemedicine in primary care: A systematic review and meta-analysis of patients with arterial hypertension and type 2 diabetes

OBJECTIVES

To review the effect of telemedicine interventions on cardiovascular risk factors control in people with arterial hypertension (AH), type 2 diabetes (T2D), or both in primary care.

METHODS

We conducted a systematic review in February 2024 using PubMed/MEDLINE, Cochrane Library, and EMBASE databases. We included randomised controlled trials from 2010 onwards, lasting ≥3 months, comparing telemedicine to standard care for managing cardiovascular risk factors in adults with AH, T2D, or both.

RESULTS

Among 1803 records, 54 were included. Telemonitoring with teleconsultations showed the best outcomes. For AH, systolic blood pressure decreased by -5.63 mmHg (95% CI -9.13 to -2.13) at 6 months and -5.59 mmHg (95% CI -10.03 to -1.14) at 12 months compared to standard care. For T2D, HbA1c decreased by -0.45% (95% CI -0.90 to 0.00) at 6 months and -0.18% (95% CI -0.41 to 0.05) at 12 months compared to standard care. Blood glucose self-monitoring was as effective as telemonitoring for T2D at 6 months. The effect on diastolic blood pressure, low-density lipoprotein, triglycerides, and body mass index was non-significant.

DISCUSSION

Telemedicine offers short-term benefits but lacks long-term effectiveness. Optimal outcomes require a combined telemedicine approach, health education co-intervention, ≥12-month follow-up, and careful patient selection.

Recommendations on self-management interventions for adults living with obesity: COMPAR-EU project

Self-management interventions (SMIs) may improve disease management in adults living with obesity. We formulated evidence-based recommendations for SMIs within the context of the COMPAR-EU project. The multidisciplinary panel selected critical outcomes based on the COMPAR-EU core outcome set and established decision thresholds for each outcome. Recommendations were informed by systematic reviews of effects, cost-effectiveness, and a contextual assessment. To assess the certainty of the evidence and formulate the recommendations, we used the GRADE approach guidance. Overall, SMIs were deemed to have a small impact, but the absence of harmful effects and potential cumulative benefits indicated a favourable balance of effects, despite low certainty. SMIs showed variations in structure, intensity, and resource utilisation, but overall are likely to be cost-effective. Adapting SMIs to local contexts would enhance equity, acceptability, and feasibility, considering patients' values, and availability of resources and teamwork. Consequently, the panel made conditional recommendations favouring SMIs over usual care. The rigorous and explicit recommendations demonstrated the effectiveness of SMIs for adults living with obesity. However, the gaps in the literature influenced the panel to make only conditional recommendations in favour of SMIs. Further research is needed to strengthen the evidence base and improve recommendations' certainty and applicability.

COMPAR-EU Recommendations on Self-Management Interventions in Type 2 Diabetes Mellitus

Self-management interventions (SMIs) offer a promising approach to actively engage patients in the management of their chronic diseases. Within the scope of the COMPAR-EU project, our goal is to provide evidence-based recommendations for the utilisation and implementation of SMIs in the care of adult individuals with type 2 diabetes mellitus (T2DM). A multidisciplinary panel of experts, utilising a core outcome set (COS), identified critical outcomes and established effect thresholds for each outcome. The panel formulated recommendations using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, a transparent and rigorous framework for developing and presenting the best available evidence for the formulation of recommendations. All recommendations are based on systematic reviews (SR) of the effects and of values and preferences, a contextual analysis, and a cost-effectiveness analysis. The COMPAR-EU panel is in favour of using SMIs rather than usual care (UC) alone (conditional, very low certainty of the evidence). Furthermore, the panel specifically is in favour of using ten selected SMIs, rather than UC alone (conditional, low certainty of the evidence), mostly encompassing education, self-monitoring, and behavioural techniques. The panel acknowledges that, for most SMIs, moderate resource requirements exist, and cost-effectiveness analyses do not distinctly favour either the SMI or UC. Additionally, it recognises that SMIs are likely to enhance equity, deeming them acceptable and feasible for implementation.

Identifying most important contextual factors for the implementation of self-management interventions: A Delphi study

OBJECTIVE

To reach consensus amongst stakeholders about the most important contextual factors (CFs) that may influence the successful implementation of (components of) self-management interventions (SMIs) for type 2 diabetes, obesity, COPD and heart failure.

METHODS

Building on our literature review that identified 31 CFs on different levels we conducted a Delphi with 44 stakeholders to identify which of these CFs, or additional ones, contribute most to successful implementation of SMIs. The Delphi consisted of three rounds in which the CFs were scored, prioritized and discussed.

RESULTS

The most important CFs overlapped to a great extent across components of SMIs and diseases. Overall, stakeholders identified 'HCP's ability to adapt the advice, communication or intervention to patients' situation and level of knowledge' as most important CF.

CONCLUSION

CFs need to be taken into account when implementing promising SMIs. According to stakeholders, the most important CFs are patient-, HCP- or interaction related. 'Tailoring' was selected as the most crucial aspect for HCPs.

PRACTICE IMPLICATIONS

Stakeholders can make informed decisions on the adoption of the most suitable SMIs in a given context. These CFs are available through a self-management platform. Suggestions to implement self-management behaviour and to close the research-to-practice gap are made.