An evaluation of Birmingham Own Health telephone care management service among patients with poorly controlled diabetes. A retrospective comparison with the General Practice Research Database

An Investigation of Group-Based Mobile Learning on Stress, Anxiety, Depression, and Pain Among Beta-Thalassemia Major Patients: A Randomized Control Trial

Beta-thalassemia major (B-TM) is an inherited hematological disease that affects nearly 300 million people worldwide. This study aimed to evaluate the effects of group-based mobile learning on stress, anxiety, depression, and pain among beta-thalassemia major patients. This randomized clinical study was conducted on 48 patients with beta-thalassemia major in Jahrom, Iran. Participants were randomly assigned to the control and intervention groups. Their partners in the intervention group were trained in self-care through mobile learning. The 21-item Depression, Anxiety, and Stress Scale and a visual analog scale for pain assessment were used to collect the data. Data were analyzed using the Statistical package for the Social Sciences version 23.0. Although there was no significant difference between the control and intervention groups in the mean pre-test scores of depression (P = .21), anxiety (P = .05), stress (P = .48), and pain (P = .46), the mean post-test scores of depression, anxiety, and stress in the intervention group were significantly lower than the control group (P = .0001). The mean scores of depression (P = .33), anxiety (P = .74), stress (P = .83), and pain (P = .6) did not change significantly in the control group, while all these mean scores decreased significantly in the intervention group for DASS (P = .001) and pain (P = .002). Group-based mobile learning is effective in reducing depression, anxiety, stress, and pain in B-TM.

The effect of nurse-led diabetes self-management programmes on glycosylated haemoglobin levels in individuals with type 2 diabetes: A systematic review

AIMS

This review aimed to examine the content, frequency, duration, and outcomes of nurse-led diabetes self-management programmes on glycosylated haemoglobin levels in individuals with type 2 diabetes.

BACKGROUND

Diabetes self-management programmes improve glycemic control in individuals with type 2 diabetes to acquire specific behavioural changes and develop effective problem-solving skills.

DESIGN

A systematic review was used in this study.

DATA SOURCES

PubMed, Science Direct, Cochrane Library, Web of Science, Ovid, CINAHL, Proquest and Scopus databases were searched for studies published in English until February 2022. The risk of bias was assessed using the Cochrane Collaboration tool.

REVIEW METHODS

This study followed the recommendations of the Cochrane 2022 guidelines and was reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis.

RESULTS

Eight studies with 1747 participants met the inclusion criteria. Interventions included telephone coaching, consultation services and individual and group education. The duration of the intervention ranged from 3 to 15 months. The results showed that nurse-led diabetes self-management programmes had positive and clinically significant effects on glycosylated haemoglobin levels in individuals with type 2 diabetes.

CONCLUSION

These findings highlight the important role of nurses in improving self-management and achieving glycemic control in individuals with type 2 diabetes. The positive outcomes of this review offer suggestions for health care professionals to develop effective self-management programnmes in type 2 diabetes treatment and care.

Promoting nurse-led behaviour change interventions to prevent cardiovascular disease in disadvantaged communities: A scoping review

Cardiovascular diseases (CVD) are the leading cause of death worldwide and they disproportionally affect people living in disadvantaged communities. Nurse-led behaviour change interventions have shown great promise in preventing CVD. However, knowledge regarding the impact and nature of such interventions in disadvantaged communities is limited. This review aimed to address this knowledge gap. A six-stage scoping review framework developed by Arksey and O'Malley, with revisions by Levac et al., was used. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR). Three electronic databases were searched (PUBMED/MEDLINE, CINAHL Plus, and Cochrane CENTRAL), and included studies were analysed using Braun and Clarke's 'Thematic Analysis' approach. Initial searches yielded 952 papers and 30 studies were included in the review following duplicate, title/abstract, and full-text screening. The included studies indicate that nurse-led behaviour change primary prevention interventions in disadvantaged areas are largely effective; albeit the considerable variety of intervention approaches, study populations and outcome measures used to date make it difficult to ascertain this. Other identified key areas in the promotion of nurse-led behaviour change included tailoring interventions to specific populations, providing adequate training for nurses, overcoming patient access difficulties and encouraging patient engagement. Overall, the findings indicate that nurse-led behaviour change interventions for high-risk CVD patients in disadvantaged areas show much promise, although there is considerable variety in the interventions employed and studied to date. Further research is needed to examine the unique barriers and facilitators of interventions for specific disadvantaged groups.

Analysis of Palliative Care Utilization and Medical Expenses among Patients with Chronic Diseases in Taiwan: A Population-Based Cohort Study

Palliative care (PC) is an important alternative treatment for patients with chronic diseases, particularly for those in the later stages of disease progression. This is because these diseases are often irreversible, with progressive worsening of symptoms. By encouraging the use of tranquility resources for good death and spiritual relief, PC can reduce the physical and psychological burden on patients at the end of their lives. Currently, most discussions on PC have focused on patients with cancers, and few have further discussed the differences in medical expenses between PC and emergency treatment in patients with chronic diseases at the end of their lives. This study analyzed the top three chronic diseases in patients who used PC resources in the past decade and identified the impact of emergency treatment on mean survival time and medical expenses based on the medical records from the National Health Insurance Research Database. In total, 4061 patients with chronic diseases who were admitted to hospice wards were included in this study; of them, 85 patients still received emergency treatment, including urinary catheterization, nasogastric intubation, and respirator use, at the end of their lives. The mean survival time of patients aged 50-64 years who received emergency treatment was longer than that of the same age group who did not receive emergency treatment. Different comparisons of the mean survival time and medical expenses using real-world data provides important insights regarding PC management that may assist in establishing health policies in the future.

A telemedicine-based approach with real-time transmission of blood glucose data improves metabolic control in insulin-treated diabetes: the DIAMONDS randomized clinical trial

PURPOSE

To evaluate if a web-based telemedicine system (the Glucoonline® system) is effective to improve glucose control in insulin-treated patients with type 1 and type 2 diabetes, as compared to standard of care.

METHODS

This was a prospective, randomized, controlled trial, carried out at three tertiary referral centers for diabetes in Italy. Adults with insulin-treated type 1 and type 2 diabetes, inadequate glycemic control, and no severe diabetes-related complications and/or comorbidities were eligible for this study. Patients were randomized to either perform telemedicine-assisted (Group A) or standard (Group B) self-monitoring blood glucose (SMBG) for 6 months. In Group A, patients received prompt feedback about their blood glucose levels and therapy suggestions from the study staff via phone/SMS, when appropriate. In Group B, patients had no remote assistance from the study staff between planned visits.

RESULTS

123 patients were included in the final analysis. After 6 months, patients achieved a significant reduction in HbA1c in Group A (-0.38%, p < 0.05) but not in Group B (+ 0.08%, p = 0.53). A significant difference in the percentage of patients with HbA1c < 7% between Group A and Group B was found after 3 months (28.6% vs 11.1%, p = 0.02). Also, fewer patients (p < 0.05) with HbA1c > 8.5% were found in Group A vs Group B, respectively, after both 3 months (14.3% vs 35.2%) and 6 months (21.8% vs 42.9%).

CONCLUSIONS

The use of the Glucoonline™ system resulted in improved metabolic control. Telemedicine services have potential to support diabetes self-management and provide the patients with remote, prompt assistance using affordable technological equipment. Trial registration This study was registered at clinicaltrials.gov (NCT01804803) on March 5, 2013.

Effects of telephone-based health coaching on patient-reported outcomes and health behavior change: A randomized controlled trial

OBJECTIVE

Telephone based health coaching (TBHC) seems to be a promising approach to foster self-management in patients with chronic conditions. The aim of this study was to evaluate the effectiveness of a TBHC on patient-reported outcomes and health behavior for people living with chronic conditions in Germany.

METHODS

Patients insured at a statutory health insurance were randomized to an intervention group (IG; TBHC) and a control group (CG; usual care), using a stratified random allocation before giving informed consent (Zelen's single-consent design). The TBHC was based on motivational interviewing, goal setting, and shared decision-making and carried out by trained nurses. All outcomes were assessed yearly for three years. We used mixed effects models utilizing all available data in a modified intention-to-treat sample for the main analysis. Participants and study centers were included as random effects. All models were adjusted for age, education and campaign affiliation.

RESULTS

Of the 10,815 invited patients, 4,283 returned their questionnaires at baseline. The mean age was 67.23 years (SD = 9.3); 55.5% were female. According to the model, TBHC was statistically significant superior to CG regarding 6 of 19 outcomes: physical activity in hours per week (p = .030) and in metabolic rate per week (p = .048), BMI (p = .009) (although mainly at baseline), measuring blood pressure (p< .001), patient activation (p< .001), and health literacy (p< .001). Regarding stages of change (p = .005), the IG group also showed statistically different results than the CG group, however the conclusion remains inconclusive. Within-group contrasts indicating changes from baseline to follow-ups and significant between-group comparisons regarding these changes supported the findings. Standardized effect sizes were small. TBHC did not show any effect on mental QoL, health status, alcohol, smoking, adherence, measuring blood sugar, foot monitoring, anxiety, depression and distress. Campaign-specific subgroup effects were detected for 'foot monitoring by a physician' and 'blood sugar measurement'.

CONCLUSION

TBHC interventions might have small effects on some patient reported and behavioral outcomes.

PRACTICE IMPLICATIONS

Future research should focus on analyzing which intervention components are effective and who profits most from TBHC interventions.

REGISTRATION

German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS): DRKS00000584.

Differences in medical costs for end-of-life patients receiving traditional care and those receiving hospice care: A retrospective study

Background

Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer.

Methods

Data from Taiwan’s National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups.

Results

From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs.

Conclusion

Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier.

Effect of A Mobile-Phone Mediated Based Education on Self-Care Behaviors of Patients With Thalassemia Major

Introduction: One way to improve the quality of life of the patients with thalassemia major is to enable them through education. The present research aimed to explore the effects of an educational intervention through mobile phones on self-care behaviors of the patients with thalassemia major

Methods: In this quasi experimental study, which was done from May to January in 2017, 91 patients were enrolled who were suffering from thalassemia major.The census sampling method was performed with random allocation of interventional and control groups. Educational intervention was only applied to the intervention group. The study instrument was a questionnaire which was filled out by the patients before and two months after the educational intervention. For data analysis, statistical tests including independent samples t-test, paired-samples t-test, Mann-Whitney test and Wilcoxon test, were used through SPSS ver.13 software.

Results: Prior to the intervention, the mean scores of knowledge, attitude and self-care behaviors were not significantly different between the intervention and control groups. After the intervention, , however, there was a statistically significant increase in the aforementioned scores in the intervention group, but there was no statistically significant increase in scores of the control group.

Conclusion: The present findings showed the positive effect of the mobile-phone mediated education on knowledge, attitude and self-care behaviors of the patients with thalassemia major. Therefore, the use of mobile phone is recommended as an effective way of transferring instructional material as related to self-care to patients with thalassemia major particularly when access to them is limited.

Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document

OBJECTIVES

Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies.

METHODS

An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts.

RESULTS

The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice.

CONCLUSIONS

Previously published reporting statements have been instrumental in improving reporting standards; adoption by journals and authors may achieve a similar improvement in the reporting of implementation strategies that will facilitate translation of effective interventions into routine practice.

Does Telephone Follow-Up and Education Affect Self-Care and Metabolic Control in Diabetic Patients?

The major goal of diabetes control is to assist patients to perform self-care and metabolic control. One possible way to achieve this goal is education and regular monitoring of patients by telephone. Thus, the present study was conducted with the aim of investigating the impact of education and telephone follow-up on self-care and metabolic control in diabetic patients. This experimental study was conducted at a hospital in the Central Anatolia region of Turkey, with 88 diabetic patients including 44 intervention subjects and 44 control subjects. After an initial discussion, patients in the intervention group received education and telephone follow-up for 3 months. Required approvals were obtained before initiation of the study. Data were collected using a questionnaire form and the Diabetes Self-Care Scale. The Diabetes Self-Care Scale scores ranged between 140 and 210, where higher scores indicated increased self-care activities of patients. At the end of the study, the self-care score was found to increase from 61.3 ± 10.9 to 89.9 ± 12.3 in the intervention group (P < .005), but it showed a reduction from 56.5 ± 7.6 to 54.7 ± 9.3 after 3-month period in the control group. Education and telephone follow-up was also found to reduce the values of several variables of metabolic control including hemoglobin A1c, total cholesterol, triglycerides, low-density lipoprotein cholesterol, and systolic blood pressure. In conclusion, education and telephone follow-up of diabetic patients led to increased self-care scores and had a positive impact on metabolic control variables. In light of these findings, we suggest that education and tele-health home monitoring may be provided on a continuous basis to help patients sustain self-care behaviors that they have adopted during the study period.

Conceptual Framework for Developing a Diabetes Information Network

Objective:

To provide a conceptual framework for managing diabetic patient care, and creating an information network for clinical research.

Background:

A wide range of information technology (IT) based interventions such as distance learning, diabetes registries, personal or electronic health record systems, clinical information systems, and clinical decision support systems have so far been used in supporting diabetic care. Previous studies demonstrated that IT could improve diabetes care at its different aspects. There is however no comprehensive conceptual framework that defines how different IT applications can support diverse aspects of this care. Therefore, a conceptual framework that combines different IT solutions into a wide information network for improving care processes and for research purposes is widely lacking. In this study we describe the theoretical underpin of a big project aiming at building a wide diabetic information network namely DIANET.

Research design and methods:

A literature review and a survey of national programs and existing regulations for diabetes management was conducted in order to define different aspects of diabetic care that should be supported by IT solutions. Both qualitative and quantitative research methods were used in this study. In addition to the results of a previous systematic literature review, two brainstorming and three expert panel sessions were conducted to identify requirements of a comprehensive information technology solution. Based on these inputs, the requirements for creating a diabetes information network were identified and used to create a questionnaire based on 9-point Likert scale. The questionnaire was finalized after removing some items based on calculated content validity ratio and content validity index coefficients. Cronbach’s alpha reliability coefficient was also calculated (αTotal= 0.98, P<0.05, CI=0.95). The final questionnaire was containing 45 items. It was sent to 13 clinicians at two diabetes clinics of endocrine and metabolism research institute in order to assess the necessity level of the requirements for diabetes information network conceptual framework. The questionnaires were returned by 10 clinicians. Each requirement item was labeled as essential, semi-essential, or non-essential based on the mean of its scores.

Results:

All requirement items were identified as essential or semi-essential. Thus, all of them were used to build the conceptual framework. The requirements were allocated into 11 groups each one representing a module in the conceptual framework. Each module was described separately.

Conclusion:

We proposed a conceptual framework for supporting diabetes care and research. Integrating different and heterogeneous clinical information systems of healthcare facilities and creating a comprehensive diabetics data warehouse for research purposes, would be possible by using the DIANET framework.

Does nutritional counseling in telemedicine improve treatment outcomes for diabetes? A systematic review and meta-analysis of results from 92 studies

BACKGROUND

A growing number of studies and reviews have documented the impact of telemedicine on diabetes management. However, no meta-analysis has assessed whether including nutritional counseling as part of a telemedicine program has a significant impact on diabetes outcomes or what kind of nutritional counseling is most effective.

METHODS

Original research articles examining the effect of telemedicine interventions on HbA1c levels in patients with Type 1 or Type 2 diabetes were included in this study. A literature search was performed and 92 studies were retained for analysis. We examined stratified results by differentiating interventions using no nutritional counseling from those that used nutritional counseling. We further compared between nutritional counseling administered via short message systems (SMS) such as email and text messages, and nutritional counseling administered via telephone or videoconference.

RESULTS

Telemedicine programs that include a nutritional component show similar effect in diabetes management as those programs that do not. Furthermore, subgroup analysis reveals that nutritional intervention via SMS such as email and text messages is at least as equally effective in reducing HbA1c when compared to personal nutritional counseling with a practitioner over videoconference or telephone.

CONCLUSION

The inclusion of nutritional counseling as part of a telemedicine program does not make a significant difference to diabetes outcomes. Incorporating nutritional counseling into telemedicine programs via SMS is at least as effective as counseling via telephone or videoconference.

Making sense of the shadows: priorities for creating a learning healthcare system based on routinely collected data

Socrates described a group of people chained up inside a cave, who mistook shadows of objects on a wall for reality. This allegory comes to mind when considering 'routinely collected data'-the massive data sets, generated as part of the routine operation of the modern healthcare service. There is keen interest in routine data and the seemingly comprehensive view of healthcare they offer, and we outline a number of examples in which they were used successfully, including the Birmingham OwnHealth study, in which routine data were used with matched control groups to assess the effect of telephone health coaching on hospital utilisation.Routine data differ from data collected primarily for the purposes of research, and this means that analysts cannot assume that they provide the full or accurate clinical picture, let alone a full description of the health of the population. We show that major methodological challenges in using routine data arise from the difficulty of understanding the gap between patient and their 'data shadow'. Strategies to overcome this challenge include more extensive data linkage, developing analytical methods and collecting more data on a routine basis, including from the patient while away from the clinic. In addition, creating a learning health system will require greater alignment between the analysis and the decisions that will be taken; between analysts and people interested in quality improvement; and between the analysis undertaken and public attitudes regarding appropriate use of data.

Managing diabetes mellitus using information technology: a systematic review

Objective

To review published evidences about using information technology interventions in diabetes care and determine their effects on managing diabetes.

Design

Systematic review of information technology based interventions.

Research design and methods

MEDLINE®/PubMed were electronically searched for articles published between 2004/07/01 and 2014/07/01. A comprehensive, electronic search strategy was used to identify eligible articles.

Inclusion criteria were defined based on type of study and effect of information technology based intervention in relation to glucose control and other clinical outcomes in diabetic patients. Studies must have used a controlled design to evaluate an information technology based intervention.

A total of 3613 articles were identified based on the searches conducted in MEDLINE from PubMed. After excluding duplicates (n = 6), we screened titles and abstracts of 3607 articles based on inclusion criteria. The remaining articles matched with inclusion criteria (n = 277) were reviewed in full text, and 210 articles were excluded based on exclusion criteria. Finally, 67 articles complied with our eligibility criteria and were included in this study.

Results

In this study, the effect of various information technology based interventions on clinical outcomes in diabetic patients extracted and measured from selected articles is described and compared to each other.

Conclusion

Information technology based interventions combined with the usual care are associated with improved glycemic control with different efficacy on various clinical outcomes in diabetic patients.

The empirical evidence for the telemedicine intervention in diabetes management

OBJECTIVE

The research presented here assesses the scientific evidence for the telemedicine intervention in the management of diabetes (telediabetes), gestational diabetes, and diabetic retinopathy. The impetus derives from the confluence of high prevalence of these diseases, increasing incidence, and rising costs, while telemedicine promises to ameliorate, if not prevent, type 2 diabetes and its complications.

MATERIALS AND METHODS

A purposeful review of the literature identified relevant publications from January 2005 to December 2013. These were culled to retain only credible research articles for detailed review and analysis. The search yielded approximately 17,000 articles with no date constraints. Of these, 770 appeared to be research articles within our time frame. A review of the abstracts yielded 73 articles that met the criteria for inclusion in the final analysis. Evidence is organized by research findings regarding feasibility/acceptance, intermediate outcomes (e.g., use of service, and screening compliance), and health outcomes (control of glycemic level, lipids, body weight, and physical activity.)

RESULTS

Definitions of telediabetes varied from study to study vis-à-vis diabetes subtype, setting, technology, staffing, duration, frequency, and target population. Outcome measures also varied. Despite these vagaries, sufficient evidence was obtained from a wide variety of research studies, consistently pointing to positive effects of telemonitoring and telescreening in terms of glycemic control, reduced body weight, and increased physical exercise. The major contributions point to telemedicine's potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated.

CONCLUSIONS

Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.

Patient self-management in primary care patients with mild COPD - protocol of a randomised controlled trial of telephone health coaching

Background

The prevalence of diagnosed chronic obstructive pulmonary disease (COPD) in the UK is 1.8%, although it is estimated that this represents less than half of the total disease in the population as much remains undiagnosed. Case finding initiatives in primary care will identify people with mild disease and symptoms. The majority of self-management trials have identified patients from secondary care clinics or following a hospital admission for exacerbation of their condition. This trial will recruit a primary care population with mild symptoms of COPD and use telephone health coaching to encourage self-management.

Methods/Design

In this study, using a multi-centred randomised controlled trial (RCT) across at least 70 general practices in England, we plan to establish the effectiveness of nurse-led telephone health coaching to support self-management in primary care for people who report only mild symptoms of their COPD (MRC grade 1 and 2) compared to usual care. The intervention focuses on taking up smoking cessation services, increasing physical activity, medication management and action planning and is underpinned by behavioural change theory. In total, we aim to recruit 556 patients with COPD confirmed by spirometry with follow up at six and 12 months. The primary outcome is health related quality of life using the St Georges Respiratory Questionnaire (SGRQ). Spirometry and BMI are measured at baseline. Secondary outcomes include self-reported health behaviours (smoking and physical activity), physical activity measured by accelerometery (at 12 months), psychological morbidity, self-efficacy and cost-effectiveness of the intervention. Longitudinal qualitative interviews will explore how engaged participants were with the intervention and how embedded behaviour change was in every day practices.

Discussion

This trial will provide robust evidence about the effectiveness of a novel telephone health coaching intervention to promote behaviour change and prevent disease progression in patients with mild symptoms of dyspnoea in primary care.

Trial registration

Current controlled trials ISRCTN06710391.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Diabetes self-management arrangements in Europe: a realist review to facilitate a project implemented in six countries

Background

Self-management of long term conditions can promote quality of life whilst delivering benefits to the financing of health care systems. However, rarely are the meso-level influences, likely to be of direct relevance to these desired outcomes, systematically explored. No specific international guidelines exist suggesting the features of the most appropriate structure and organisation of health care systems within which to situate self-management approaches and practices. This review aimed to identify the quantitative literature with regard to diabetes self-management arrangements currently in place within the health care systems of six countries (The United Kingdom, The Netherlands, Norway, Spain, Bulgaria, and Greece) and explore how these are integrated into the broader health care and welfare systems in each country.

Methods

The methodology for a realist review was followed. Publications of interest dating from 2000 to 2013 were identified through appropriate MeSH terms by a systematic search in six bibliographic databases. A search diary was maintained and the studies were assessed for their quality and risk of bias.

Results

Following the multi-step search strategy, 56 studies were included in the final review (the majority from the UK) reporting design methods and findings on 21 interventions and programmes for diabetes and chronic disease self-management. Most (11/21, 52%) of the interventions were designed to fit within the context of primary care. The majority (11/21, 52%) highlighted behavioural change as an important goal. Finally, some (5/21, 24%) referred explicitly to Internet-based tools.

Conclusions

This review is based on results which are derived from a total of at least 5,500 individuals residing in the six participating countries. It indicates a policy shift towards patient-centred self-management of diabetes in a primary care context. The professional role of diabetes specialist nurses, the need for multidisciplinary approaches and a focus on patient education emerge as fundamental principles in the design of relevant programmes. Socio-economic circumstances are relevant to the capacity to self-manage and suggest that any gains and progress will be hard to maintain during economic austerity. This realist review should be interpreted within the wider context of a whole systems approach regarding self-care support and chronic illness management.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-453) contains supplementary material, which is available to authorized users.

Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia.

DESIGN

Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation.

SETTING

General practices in Victoria, Australia.

PARTICIPANTS

59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate.

INTERVENTION

Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient.

MAIN OUTCOME MEASURES

The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group.

RESULTS

The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months' follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval -0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups.

CONCLUSIONS

A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50662837.

Effect of telephone health coaching (Birmingham OwnHealth) on hospital use and associated costs: cohort study with matched controls

OBJECTIVES

To test the effect of a telephone health coaching service (Birmingham OwnHealth) on hospital use and associated costs.

DESIGN

Analysis of person level administrative data. Difference-in-difference analysis was done relative to matched controls.

SETTING

Community based intervention operating in a large English city with industry.

PARTICIPANTS

2698 patients recruited from local general practices before 2009 with heart failure, coronary heart disease, diabetes, or chronic obstructive pulmonary disease; and a history of inpatient or outpatient hospital use. These individuals were matched on a 1:1 basis to control patients from similar areas of England with respect to demographics, diagnoses of health conditions, previous hospital use, and a predictive risk score.

INTERVENTION

Telephone health coaching involved a personalised care plan and a series of outbound calls usually scheduled monthly. Median length of time enrolled on the service was 25.5 months. Control participants received usual healthcare in their areas, which did not include telephone health coaching.

MAIN OUTCOME MEASURES

Number of emergency hospital admissions per head over 12 months after enrolment. Secondary metrics calculated over 12 months were: hospital bed days, elective hospital admissions, outpatient attendances, and secondary care costs.

RESULTS

In relation to diagnoses of health conditions and other baseline variables, matched controls and intervention patients were similar before the date of enrolment. After this point, emergency admissions increased more quickly among intervention participants than matched controls (difference 0.05 admissions per head, 95% confidence interval 0.00 to 0.09, P=0.046). Outpatient attendances also increased more quickly in the intervention group (difference 0.37 attendances per head, 0.16 to 0.58, P<0.001), as did secondary care costs (difference £175 per head, £22 to £328, P=0.025). Checks showed that we were unlikely to have missed reductions in emergency admissions because of unobserved differences between intervention and matched control groups.

CONCLUSIONS

The Birmingham OwnHealth telephone health coaching intervention did not lead to the expected reductions in hospital admissions or secondary care costs over 12 months, and could have led to increases.

Patient empowerment, an additional characteristic of the European definitions of general practice/family medicine

Growing evidence supports the inclusion of patient empowerment as a key ingredient of care for patients with chronic conditions. In recent years, several studies based on patient empowerment, have been carried out in different European countries in the context of general practice and primary care to improve management of chronic diseases. These studies have shown good results of the care model, increasing patient and health professionals' satisfaction, adherence to guidelines and to treatment, and improving clinical outcomes. In 2011, the Wonca European Council included as the twelfth characteristic of the European definitions of general practice/family medicine: 'promote patient empowerment'. The aim of this paper is to clarify the meaning of 'patient empowerment' and to explain why family medicine should be considered the most suitable setting to promote it. The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being.

Identification of the factors associated with outcomes in a Condition Management Programme

BACKGROUND

A requirement of the Government's Pathways to Work (PtW) agenda was to introduce a Condition Management Programme (CMP). The aim of the present study was to identify the differences between those who engaged and made progress in this telephone-based biopsychosocial intervention, in terms of their health, and those who did not and to determine the client and practitioner characteristics and programme elements associated with success in a programme aimed at improving health.

METHODS

Data were obtained from the CMP electronic spreadsheets and clients paper-based case records. CMP standard practice was that questionnaires were administered during the pre- and post-assessment phases over the telephone. Each client's record contains their socio-demographic data, their primary health condition, as well as the pre- and post-intervention scores of the health assessment tool administered. Univariate and multivariate statistical analysis was used to investigate the relationships between the database variables. Clients were included in the study if their records were available for analysis from July 2006 to December 2007.

RESULTS

On average there were 112 referrals per month, totalling 2016 referrals during the evaluation period. The majority (62.8%) of clients had a mental-health condition. Successful completion of the programme was 28.5% (575 "completers"; 144 "discharges"). Several factors, such as age, health condition, mode of contact, and practitioner characteristics, were significant determinants of participation and completion of the programme. The results showed that completion of the CMP was associated with a better mental-health status, by reducing the number of clients that were either anxious, depressed or both, before undertaking the programme, from 74% to 32.5%.

CONCLUSIONS

Our findings showed that an individual's characteristics are associated with success in the programme, defined as completing the intervention and demonstrating an improved health status. This study provides some evidence that the systematic evaluation of such programmes and interventions could identify ways in which they could be improved.

Telemedicine and ocular health in diabetes mellitus

Teleretinal/teleophthalmological programs that use existing health information technology infrastructure solutions for people with diabetes increase access to and adherence to appropriate eye care. Teleophthalmological studies indicate that the single act of patients viewing their own retinal images improves self-management behaviour and clinical outcomes. In some settings this can be done at lower cost and with improved visual outcomes compared with standard eye care. Cost-effective and sustainable teleretinal surveillance for detection of diabetic retinopathy requires a combination of an inexpensive portable device for taking low light-level retinal images without the use of pharmacological dilation of the pupil and a computer-assisted methodology for rapidly detecting and diagnosing diabetic retinopathy. A more holistic telehealth-care paradigm augmented with the use of health information technology, medical devices, mobile phone and mobile health applications and software applications to improve health-care co-ordination, self-care management and education can significantly impact a broad range of health outcomes, including prevention of diabetes-associated visual loss. This approach will require a collaborative, transformational, patient-centred health-care program that integrates data from medical record systems with remote monitoring of data and a longitudinal health record. This includes data associated with social media applications and personal mobile health technology and should support continuous interactions between the patient, health-care team and the patient's social environment. Taken together, this system will deliver contextually and temporally relevant decision support to patients to facilitate their well-being and to reduce the risk of diabetic complications.

Telemedicine and telecare for older patients--a systematic review

Telemedicine is increasingly becoming a reality in medical care for the elderly. We performed a systematic literature review on telemedicine healthcare concepts for older patients. We included controlled studies in an ambulant setting that analyzed telemedicine interventions involving patients aged ≥60 years. 1585 articles matched the specified search criteria, thereof, 68 could be included in the review. Applications address an array of mostly frequent diseases, e.g. cardiovascular disease (N=37) or diabetes (N=18). The majority of patients is still living at home and is able to handle the telemedicine devices by themselves. In 59 of 68 articles (87%), the intervention can be categorized as monitoring. The largest proportion of telemedicine interventions consisted of measurements of vital signs combined with personal interaction between healthcare provider and patient (N=24), and concepts with only personal interaction (telephone or videoconferencing, N=14). The studies show predominantly positive results with a clear trend towards better results for "behavioral" endpoints, e.g. adherence to medication or diet, and self-efficacy compared to results for medical outcomes (e.g. blood pressure, or mortality), quality of life, and economic outcomes (e.g. costs or hospitalization). However, in 26 of 68 included studies, patients with characteristic limitations for older patients (e.g. cognitive and visual impairment, communication barriers, hearing problems) were excluded. A considerable number of projects use rather sophisticated technology (e.g. videoconferencing), limiting ready translation into routine care. Future research should focus on how to adapt systems to the individual needs and resources of elderly patients within the specific frameworks of the respective national healthcare systems.