Increased number of structured diabetes education attendance was not associated with the improvement in patient-reported health-related quality of life: results from Patient Empowerment Programme (PEP)

Patient-centered care in diabetes care-concepts, relationships and practice

We still do not have comprehensive knowledge of which framework of patient-centered care (PCC) is appropriate for diabetes care, which elements of PCC are evidence-based, and the mechanism by which PCC elements are associated with outcomes through mediators. In this review, we elaborate on these issues. We found that for diabetes care, PCC elements such as autonomy support (patient individuality), cooperation and collaboration (system-level approach), com-munication and education (behavior change techniques), emotional support (biopsychosocial approach), and family/other involvement and support are critically important. All of these factors are directly associated with different patient outcomes and indirectly associated with outcomes through patient activation. We present the practical implications of these PCC elements.

Characteristics of self-management education and support programmes for people with chronic diseases delivered by primary care teams: a rapid review

BACKGROUND

Primary care actors can play a major role in developing and promoting access to Self-Management Education and Support (SMES) programmes for people with chronic disease. We reviewed studies on SMES programmes in primary care by focusing on the following dimensions: models of SMES programmes in primary care, SMES team's composition, and participants' characteristics.

METHODS

For this mixed-methods rapid review, we searched the PubMed and Cochrane Library databases to identify articles in English and French that assessed a SMES programme in primary care for four main chronic diseases (diabetes, cancer, cardiovascular disease and/or respiratory chronic disease) and published between 1 January 2013 and 31 December 2021. We excluded articles on non-original research and reviews. We evaluated the quality of the selected studies using the Mixed Methods Appraisal Tool. We reported the study results following the PRISMA guidelines.

RESULTS

We included 68 studies in the analysis. In 46/68 studies, a SMES model was described by focusing mainly on the organisational dimension (n = 24). The Chronic Care Model was the most used organisational model (n = 9). Only three studies described a multi-dimension model. In general, the SMES team was composed of two healthcare providers (mainly nurses), and partnerships with community actors were rarely reported. Participants were mainly patients with only one chronic disease. Only 20% of the described programmes took into account multimorbidity. Our rapid review focused on two databases and did not identify the SMES programme outcomes.

CONCLUSIONS

Our findings highlight the limited implication of community actors and the infrequent inclusion of multimorbidity in the SMES programmes, despite the recommendations to develop a more interdisciplinary approach in SMES programmes. This rapid review identified areas of improvement for SMES programme development in primary care, especially the privileged place of nurses in their promotion.

TRIAL REGISTRATION

PROSPERO 2021 CRD42021268290 .

Association of vascular endothelial function and quality of life in patients with ischemia and non-obstructive coronary artery disease

Improvements are required in the quality of life (QoL) of patients with ischemia and non-obstructive coronary artery disease (INOCA). Several patients with INOCA experience vascular endothelial dysfunction. However, the relationship between endothelial function and QoL remains unelucidated. This study aimed to initially investigate the relationship between endothelial function and QoL in patients with INOCA. This prospective observational study included 121 patients with INOCA (aged 31-85 years). Vascular endothelial function was assessed by flow-mediated dilatation (FMD) of the peripheral brachial artery. QoL was evaluated using the 36-Item Short-Form Health Survey (SF-36). Patients with INOCA were divided into two groups according to the median FMD change during the 1-year follow-up (group A, ≥ median FMD change cut-off; group B, < median FMD change cut-off). The median change in FMD was 0.92%. The mean baseline SF-36 scores were comparable between the two groups (53.95 ± 6.46 vs. 53.92 ± 4.29, p = 0.98). The QoL at follow-up was better in group A than in group B (56.61 ± 5.50 vs. 53.32 ± 5.58, p = 0.002). The change in FMD (r = 0.34, p < 0.01), rather than FMD at baseline (r = - 0.01, p = 0.89) or follow-up (r = 0.13, p = 0.15), was related to the follow-up SF-36 scores. FMD improvement was an independent predictor of increased QoL (odds ratio, 3.90; 95% confidence interval: 1.59-9.53, p = 0.003). Endothelial function change is associated with QoL, and patients with improved endothelial function have a better QoL than those without.

Effects of patient education on the quality of life of patients with type 2 diabetes mellitus: A scoping review

INTRODUCTION

Patient education is an integral component of diabetes mellitus care. The emergence of different methods and characteristics of patient education has led to varying outcomes of quality of life (QoL). Herein, we systematically searched for published studies reporting patient education and its methods and characteristics for improving the QoL of patients with type 2 diabetes mellitus (T2DM).

METHOD

In this scoping review, eligible studies from six databases (PubMed, Scopus, Cochrane Library, Springer Link, Science Direct and Google Scholar) were identified. The keywords used in the search strategies were as follows: health education, health promotion, patient education, diabetes care, QoL, diabetes mellitus and type 2 diabetes mellitus. Two reviewers independently screened all references and full-text articles retrieved to identify articles eligible for inclusion.

RESULTS

A total of 203 articles were identified in the initial search. Of them, 166 were excluded after screening the titles and abstracts. Further full-text screening led to the subsequent removal of 22 articles, leaving 15 articles eligible for data extraction.

CONCLUSION

There is a broad array of methods of patient education for improving the QoL of patients with T2DM. Self-management education with supplementary supervision and monitoring effectively improves QoL. Future studies must emphasise the application of holistic education covering psychological distress, diet plan, and physical health.

The longitudinal association between patient empowerment and patient-reported outcomes: What is the direction of effect?

Background

Theoretical literature and cross-sectional studies suggest empowerment is associated with other patient-reported outcomes (PROs). However, it is not known if patient empowerment is leading to improvements in other PROs or vice versa.

Aims

The present study aimed to examine the direction of effects between patient empowerment and PROs in young persons with congenital heart disease (CHD).

Methods

As part of the STEPSTONES-CHD trial, adolescents with CHD from seven pediatric cardiology centers in Sweden were included in a longitudinal observational study (n = 132). Data were collected when patients were 16 (T0), 17 (T1) and 18 ½ years old (T2). The Gothenburg Young Persons Empowerment Scale (GYPES) was used to measure patient empowerment. Random intercepts cross-lagged panel models between patient empowerment and PROs (communication skills; patient-reported health; quality of life; and transition readiness) were undertaken.

Results

We found a significant cross-lagged effect of transition readiness over patient empowerment between T1 and T2, signifying that a higher level of transition readiness predicted a higher level of patient empowerment. No other significant cross-lagged relationships were found.

Conclusion

Feeling confident before the transition to adult care is necessary before young persons with CHD can feel in control to manage their health and their lives. Clinicians interested in improving patient empowerment during the transitional period should consider targeting transition readiness.

Impact of diabetes self-management, diabetes management self-efficacy and diabetes knowledge on glycemic control in people with Type 2 Diabetes (T2D): A multi-center study in Thailand

We investigate the relationship of diabetes knowledge, diabetes management self-efficacy and diabetes self-management with blood glucose control among people with Thai type 2 diabetes mellitus (T2D). Seven hundred outpatients from diabetes clinics from large university and small community hospitals in two provinces of Thailand (Khon Kaen and Bangkok) were interviewed to evaluate their diabetes knowledge (DK), diabetes management self-efficacy (DMSE) and diabetes self-management (DSM). In addition, patient medical records were accessed to obtain other patient characteristics including patients’ HbA1c levels. Bivariate and multivariable logistic regression modelling was conducted and unadjusted and adjusted odds ratios obtained, respectively. Over half (52.4%) of the patients in our sample failed to control their blood glucose (HbA1c > 7%). All three psychometric measures (DK, DMSE and DSM) were identified as associated with blood glucose control in the bivariate analysis (OR_DK(unadj) = 0.89, 95%CI: 0.82, 0.96; OR_DSM(unadj) = 1.64, 95%CI: 1.46, 1.82; OR_DMSE(unadj) = 2.84; 95%CI: 2.43, 3.32). However, after mutual adjustment and adjustment for other patient characteristics, of the three psychometric measures, only diabetes management self-efficacy remained associated with blood glucose control (OR_DMSE(adj) = 2.67; 95%CI: 2.20, 3.25). Diabetes management self-efficacy is shown to be strongly associated with blood glucose control in the Thai Type 2 diabetes population. Current early diabetes interventions in Thailand tend to focus on disease knowledge. A stronger emphasis on enhancing patients’ disease management self-efficacy in these interventions is likely to lead to substantial improvement in both diabetes self-management and blood glucose control, thereafter reducing the risk, or prolonging the development, of chronic diabetes complications.

Impact of patient-centred diabetes self-management education targeting people with type 2 diabetes: an integrative review

AIMS

To synthesize primary research into the impact of person-centred diabetes self-management education, and support that targets people with type 2 diabetes, on behavioural, psychosocial and cardiometabolic outcomes and to identify effective mechanisms underlying positive outcomes of person-centred diabetes self-management education and support.

METHODS

Using Whittemore and Knafl's integrative review method, we conducted a systematic search of peer-reviewed literature published between January 2008 and June 2019 using PubMed, Scopus and CINAHL. After article selection according to established criteria, study quality was assessed using Critical Appraisal Skills Programme checklists for cohort studies, randomized controlled trials and qualitative research.

RESULTS

From 1901 identified records, 22 (19 quantitative, two qualitative, and one mixed methods) were considered eligible for inclusion. Interventions were categorized by content, medium of delivery, and outcomes. Qualitative studies, quantitative cohort studies and randomized controlled trials demonstrated positive outcomes, with no differences in success rates across study design. Interventions were largely successful in improving HbA_1c and patient-reported outcomes such as quality of life but had limited success in lowering cholesterol and weight, or initiating long-term improvements in lifestyle behaviours. Primary objectives were achieved more often than secondary objectives, and studies with fewer outcomes appeared more successful in achieving specific outcomes.

CONCLUSIONS

Person-centred diabetes self-management education and support has demonstrated a considerable impact on desired diabetes-related outcomes in people with type 2 diabetes. To advance the field further, new studies should take advantage of systematic and transparent approaches to person-centred diabetes self-management education.

Can a modified theory of planned behavior explain the effects of empowerment education for people with type 2 diabetes?

BACKGROUND

The effectiveness of the Patient Empowerment Program (PEP) has been demonstrated in people with diabetes mellitus (DM); however, the underlying reasons for its effectiveness remain unclear. To improve effectiveness, we need to study the psychological mechanism(s) of PEP to understand why it is effective. This study hypothesized that the Theory of Planned Behavior (TPB), modified specifically for people with DM, could describe the mechanism explaining PEP effects.

METHODS

A longitudinal design was used. Patients with type 2 DM (n = 365; 151 males; mean age = 62.9 ± 9.6 years) received two education sessions (i.e. seminars delivered by registered nurses to provide disease-specific knowledge), and some (n = 210) further enrolled afterwards in five empowerment sessions (i.e. small-group interactive workshops conducted by social workers to practice action planning, problem solving, and experience sharing). Validated questionnaires were used to measure risk perception, health literacy, attitude, subjective norm, perceived behavioral control and behavioral intention on diabetes self-care behaviors, and four diabetes self-care behaviors (diet control, exercise, blood glucose monitoring, and foot care) at baseline. Three months later (i.e. at the end of PEP), all participants completed the behavioral intention and diabetes self-care behaviors measures again. Attitude, subjective norm, perceived behavioral control, behavioral intention, and diabetes self-care behaviors were assessed to represent the TPB constructs. Risk perception and health literacy elements relevant to people with DM were assessed and added to modify the TPB.

RESULTS

The behavioral intention was associated with three diabetes self-care behaviors: exercise, blood glucose monitoring, and foot care. The behavioral intention was found to be a significant mediator in the following relationships: empowerment session participation and exercise (β = 0.045, p = 0.04), and empowerment session participation and foot care (β = 0.099, p < 0.001).

CONCLUSIONS

The effects of enrollment of empowerment sessions in PEP on exercise and foot care were likely to be mediated through behavioral intention.

Long-term cost-effectiveness of a Patient Empowerment Programme for type 2 diabetes mellitus in primary care

AIM

To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care.

MATERIALS AND METHODS

PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve.

RESULTS

With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017).

CONCLUSIONS

Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.

Temporal trends in quality of primary care for patients with type 2 diabetes mellitus: A population-based retrospective cohort study after implementation of a quality improvement initiative

BACKGROUND

This study examined whether temporal trends exist in treatment of patients with type 2 diabetes (T2D) and quality of diabetes care after implementation of quality improvement initiative in primary care setting.

METHODS

We conducted a population-based retrospective cohort study of 202,284 patients with T2D who were routinely managed in primary care clinics. We examined the change over time and the variability between clinics in quality of care from Hospital Authority administrative data over a 5-year period (2009-2013) and used multilevel logistic regression to adjust for patient and clinic characteristics. Observational period was partitioned in 5 calendar years. Ten quality-of-care criteria were selected: adherence to 7 process of care criteria (HbA_1c test, renal function test, full lipid profile, urine protein analysis, retinal screening, lipid-lowering agent prescriptions among patients with hypercholesterolaemia, and angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions among patients with microalbuminuria) and 3 outcome of care criteria (HbA_1c  ≤ 7%, BP ≤ 130/80 mmHg, and LDL-C ≤ 2.6 mmol/L). Variability of standards between clinics was assessed by using intracluster correlation coefficients.

RESULTS

Characteristics of patients with T2D managed in primary care changed substantially during the observational period, with increasing age and usage of insulin and longer duration of diabetes but improved metabolic profiles (all P trend < .001). Performance rates of the 7 process and 3 clinical outcomes of care criteria increased remarkably over time (all P trend < .001). Variations in retinal screening delivery between clinics were considerable, albeit decreasing over time.

CONCLUSIONS

Coinciding with implementation of quality improvement initiative, quality of diabetes care improved significantly in the past 5 years, in part attributable to benefits of integrated multidisciplinary diabetes management.

New model for diabetes primary health care based on patient empowerment and the right to preventive health: the MIDE program

Objective.

To evaluate Mexico’s national Integrated Management of Diabetes in Stages (Manejo Integral de la Diabetes por Etapas, MIDE) program using three types of indicators: process, structure, and impact.

Methods.

A cross-sectional study was conducted using data for 97 452 people with diabetes (PWD) who participated in the MIDE patient empowerment program (PEP) at “MIDE modules” (standardized diabetes health care units) at Mexico’s Institute for Social Security and Services for State Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE) hospital clinics and family medical clinics nationwide between 2007 and 2014. The program promotes diabetes patient empowerment and self-care through outpatient consultations with a multidisciplinary health care team supported by continuous training. Baseline data were compared with results post-program for the following indicators: process (metabolic control (MetC), based on glycated hemoglobin (HbA1c), triglyceride (TG), and total cholesterol (TC) levels); structure (number of MIDE modules installed at ISSSTE clinics and number of patients/health personnel accredited as diabetes experts/awarded diplomas); and impact (average number of patient illness days (IDs) and hospitalization episodes (HEs) per PWD over a 12-month period).

Results.

Over the seven-year study period, the proportion of patients with MetC (HbA1c < 7.0%, TG < 150 mg/dL, and TC < 200 mg/dL) increased significantly (from 35.4% to 60% (with a peak level of 62% in 2013); P < 0.001); average HbA1c, triglycerides, and total cholesterol per PWD dropped by 25%, 31%, and 11% respectively; average number of IDs and HEs per PWD over a 12-month period dropped by 38% and 41% respectively; a total of 140 MIDE modules were installed at ISSSTE clinics; and a total of 1 117 diplomas were awarded to 826 health professionals, and 2 613 PWD were accredited as “patient experts in diabetes.”

Conclusions.

The MIDE PEP is feasible, usable, and acceptable to PWD. The program improves MetC; reduces the frequency of IDs and HEs; and facilitates patient participation, the involvement of health personnel, and shared decision-making.

A latent profile analysis on patient empowerment programme in a Hong Kong primary care setting

OBJECTIVE

This study identified the profiles of subgroups of type 2 diabetic (T2DM) patients of the Patient Empowerment Programme (PEP) by different levels of benefits gained in diabetic self-management behaviors, self-efficacy, and health literacy.

METHODS

This study adopted a non-experimental repeated-measures design on T2DM patients who joined PEP, using structured questionnaires. Latent profile analysis (LPA) was used to identify patterns of participants' change on the outcome measures.

RESULTS

Findings of LPA revealed that participants who were older, unemployed, weaker in diabetic self-management, and having a higher self-perception in personal disease risk were more likely to join the empowerment sessions and gained more benefits from the program. Participants with lower impairment in energy function and lower autonomy in personal health care showed more improvement in the outcomes.

CONCLUSION

The study identified significant factors associated with patients' participation on and benefits gained from a service delivery model integrating health education and patient empowerment in a primary care setting.

PRACTICE IMPLICATION

Findings from this study shed light on strategies to improve the PEP design in order to meet the needs of individuals with different health-related profiles.

Five-year cost-effectiveness of the Patient Empowerment Programme (PEP) for type 2 diabetes mellitus in primary care

This study evaluated the short-term cost-effectiveness of the Patient Empowerment Programme (PEP) for diabetes mellitus (DM) in Hong Kong. Propensity score matching was used to select a matched group of PEP and non-PEP subjects. A societal perspective was adopted to estimate the cost of PEP. Outcome measures were the cumulative incidence of all-cause mortality and diabetic complication over a 5-year follow-up period and the number needed to treat (NNT) to avoid 1 event. The incremental cost-effectiveness ratio (ICER) of cost per event avoided was calculated using the PEP cost per subject multiplied by the NNT. The PEP cost per subject from the societal perspective was US$247. There was a significantly lower cumulative incidence of all-cause mortality (2.9% vs 4.6%, P < .001), any DM complication (9.5% vs 10.8%, P = .001) and CVD events (6.8% vs 7.6%, P = .018), in the PEP group. The costs per death from any cause, DM complication or case of CVD avoided were US$14 465, US$19 617 and US$30 796, respectively. The extra amount allocated to managing PEP was small and it appears cost-effective in the short-term as an addition to RAMP.

Health-related quality of life and health preference of Chinese patients with diabetes mellitus managed in primary care and secondary care setting: decrements associated with individual complication and number of complications

Background

Health-related quality of life (HRQoL) and health preference of patients with diabetes mellitus (DM) are essential in health economic evaluations but data on Chinese population is rare. This study aims to evaluate HRQoL and health preference of diabetic patients with different diabetic complications in Chinese population.

Methods

A cross-sectional study was conducted in 1275 patients with DM, including 518 subjects with various DM-related complications. HRQoL and health preference were estimated using SF-12 and SF-6D questionnaires, respectively. Disease status of DM and complications were identified from documented clinical diagnosis. Multivariable regression was used to investigate the effects of specific complications on HRQoL and health preference, adjusting for socio-demographic and clinical parameters.

Results

The presence of any diabetic complication was associated with lower physical component summary (−3.81 points, P < 0.01), and end-stage renal disease (ESRD) showed greatest reduction (−7.05 points, P < 0.01). Mental component summary and mental health (MH) scores were not decreased in any of the diabetic complications. The health preference score for diabetic subjects without complications was 0.882 (95% CI, 0.778 to 0.989). The reductions of health preference score were significant for stroke (−0.042, 95% CI -0.072 to −0.012), ESRD (−0.055, 95% CI -0.093 to −0.017), and sight-threatening diabetic retinopathy (STDR) (−0.043, 95% CI -0.075 to −0.010), while heart disease had an insignificant reduction (−0.017, 95% CI -0.042 to 0.008).

Conclusions

The presence of any of the four major diabetic complications (heart disease, stroke, ESRD and STDR) was associated with lower HRQoL and health preference scores. Findings of this study facilitated the cost-effectiveness studies of alternative management strategies for prevention of diabetic complications in Chinese population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-017-0699-4) contains supplementary material, which is available to authorized users.

Type 2 diabetes and quality of life

It is true that a primary goal of diabetes early diagnosis and treatment is quality of life (QoL). The term QoL is still confusing but it is agreed that it composes of four components: The physical component, mental, cogitative component, psychological and social component. Many articles have been written addressing those four components. During the last five years 15500 articles and reviews have been written addressing diabetes and coronary arterial disease, 16100 addressing diabetes and renal function, 28900 addressing diabetes and retinopathy, 16800 addressing diabetic foot ulcers and other 26300 addressing diabetic neuropathy. Moreover 17200 articles are dealing with diabetic sexual dysfunction, 24500 with the correlation of diabetes and depression 17500 about diabetes and dementia, only 1 about diabetes and family functioning and 1950000 about diabetes and QoL, indicating the worldwide interest. In order to confront this metabolic anomaly and its consequences, researchers developed numerous generic and disease specific psychometric tools. With the aid of those psychometric tools the scientific community has started to realize the gruesome effect of diabetes on patients’ lives. Diabetic’s QoL becomes worse when complications start to develop or comorbidities coexist. Dominant amongst complications, in health-related quality of life (HRQoL) lowering, but not related to risk factors (genetic, the weight of birth, or others) is coronary arterial disease followed by renal failure, blindness, and the combination of micro- and macro-vascular complications and in some studies by sexual dysfunction. Moreover many are the comorbidities which deteriorate further the effect of diabetes in a patient life. Among them obesity, hypertension, dyslipidemia, depression, arthritis are the most common. Most intriguing field for research is the interaction of diabetes and depression and in some cases the progression to dementia. Many aspects and combinations of actions are under researchers’ microscope regarding the improvement of HRQoL scores. Until now, the studies performed, have demonstrated little to moderate benefit. More of them are needed to draw safe conclusions on the topic of the best combination of actions to optimize the HRQoL scores.

Effectiveness of a multidisciplinary risk assessment and management programme-diabetes mellitus (RAMP-DM) on patient-reported outcomes

Little is known about how the patient-reported outcomes is influenced by multidisciplinary-risk-assessment-and-management-programme for patients with diabetes mellitus (RAMP-DM). This paper aims to evaluate the effectiveness of RAMP-DM on patient-reported outcomes. This was a prospective longitudinal study on 1039 diabetes mellitus patients (714/325 RAMP-DM/non-RAMP-DM) managed in primary care setting. 536 and 402 RAMP-DM participants, and 237 and 187 non-RAMP-DM participants were followed up at 12 and 24 months with completed survey, respectively. Patient-reported outcomes included health-related quality of life, change in global health condition and patient enablement measured by Short Form-12 Health Survey version-2 (SF-12v2), Global Rating Scale, Patient Enablement Instrument respectively. The effects of RAMP-DM on patient-reported outcomes were evaluated by mixed effect models. Subgroup analysis was performed by stratifying haemoglobin A1c (HbA1c) (optimal HbA1c < 7 % and suboptimal HbA1c ≥ 7 %). RAMP-DM with suboptimal HbA1c was associated with greater improvement in SF-12v2 physical component summary score at 12-month (coefficient:3.80; P-value < 0.05) and 24-month (coefficient:3.82;P-value < 0.05), more likely to feel more enabled at 12-month (odds ratio: 2.57; P-value < 0.05), and have improved in GRS at 24-month (odds ratio:4.05; P-value < 0.05) compared to non-RAMP-DM participants. However, there was no significant difference in patient-reported outcomes between RAMP-DM and non-RAMP-DM participants with optimal HbA1c. Participation in RAMP-DM is effective in improving physical component of HRQOL, Global Rating Scale and patient enablement among diabetes mellitus patients with suboptimal HbA1c, but not in those with optimal HbA1c. Patients with sub-optimal diabetes mellitus control should be the priority target population for RAMP-DM. This observational study design may have potential bias in the characteristics between groups, and randomized clinical trial is needed to confirm the results.

Evaluation of patient-reported outcomes data in structured diabetes education intervention: 2-year follow-up data of patient empowerment programme

To examine the effects of a structured group-based education programme, patient empowerment programme (PEP), compared with usual care on 2-year changes in patient-reported outcomes (PRO) in patients with diabetes mellitus (DM). A prospective observational study of 715 patients (PEP/non-PEP: 390/325) was conducted to complete the baseline PRO survey and followed up for 2 years. Health-related quality of life (HRQOL) was measured using the short-form 12 at baseline and annually at two follow-up assessments, which yielded physical and mental component summary and SF-6D preference-based scores. Perceived control over diabetes and general health status were measured using the patient enablement instrument (PEI) and global rating scale (GRS) at follow-ups. When compared with non-PEP, PEP participants significantly reported improvement in health condition (GRS score > 0; 24.55 % vs 10.16 %; odds ratio = 2.502; P = 0.018) in 2 years and enabled the self-perceived control over diabetes (PEI score > 0; 72.20 % vs 38.40 %; odds ratio = 3.25; P < 0.001) in 1-year follow-up but no sustained effects in year 2 (52.65 % vs 39.04 %; odds ratio = 1.366; P = 0.265). There were no significant differences between PEP and non-PEP groups in the changes in quality of life scores (all P > 0.05) at 1 year. Although HRQOL scores deteriorated over 2-year period in both groups, PEP participants reported similar changes in HRQOL scores to that of non-PEP. PEP for DM patients preserved self-perceived disease control and health condition, whereas PEP participants perceived their HRQOL similar to that of non-PEP participants. Findings of PRO should be considered alongside clinical outcomes when evaluating the overall benefits of PEP.

Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with Type 2 diabetes mellitus: results from the Patient Empowerment Programme

AIM

To assess whether a structured diabetes education programme, the Patient Empowerment Programme, was associated with a lower rate of all-cause hospitalization and emergency department visits in a population-based cohort of patients with Type 2 diabetes mellitus in primary care.

METHODS

A cohort of 24 250 patients was evaluated using a linked administrative database during 2009-2013. We selected 12 125 patients with Type 2 diabetes who had at least one Patient Empowerment Programme session attendance. Patients who did not participate in the Patient Empowerment Programme were matched one-to-one with patients who did, using the propensity score method. Hospitalization events and emergency department visits were the events of interest. Cox proportional hazard and negative binomial regressions were performed to estimate the hazard ratios for the initial event, and incidence rate ratios for the number of events.

RESULTS

During a median 30.5 months of follow-up, participants in the Patient Empowerment Programme had a lower incidence of an initial hospitalization event (22.1 vs 25.2%; hazard ratio 0.879; P < 0.001) and emergency department visit (40.5 vs 44%; hazard ratio 0.901; P < 0.001) than those who did not participate in the Patient Empowerment Programme. Participation in the Patient Empowerment Programme was associated with a significantly lower number of emergency department visits (incidence rate ratio 0.903; P < 0.001): 40.4 visits per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 36.2 per 100 patients annually in those who did. There were significantly fewer hospitalization episodes (incidence rate ratio 0.854; P < 0.001): 20.0 hospitalizations per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 16.9 hospitalizations per 100 patients annually in those who did.

CONCLUSIONS

Among patients with Type 2 diabetes, the Patient Empowerment Programme was shown to be effective in delaying the initial hospitalization event and in reducing their frequency.

Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP)

Patient Empowerment Programme (PEP) in primary care was effective in preventing diabetes-related complications in patients with diabetes. Nevertheless, the effect of PEP on glycaemic control, weight control, and complications was unclear in obese type 2 diabetic patients. We aimed to assess whether PEP reduced all-cause mortality, first macrovascular and microvascular disease events. A cohort of 6372 obese type 2 diabetic patients without prior occurrence of macrovascular or microvascular disease events on or before baseline study recruitment date was linked to the administrative database from 2008 to 2013. Non-PEP participants were matched one-to-one with the PEP participants using propensity score method with respect to their baseline covariates. Cox proportional hazard regressions were performed to estimate the associations of the PEP intervention with the occurrence of first macrovascular or microvascular disease events and death from any cause, controlling for demographic and clinical characteristics. During a median 31.5 months of follow-up, 350 (PEP/non-PEP: 151/199) patients suffered from a first macrovascular or microvascular disease event while 95 patients (PEP/non-PEP: 34/61) died from any cause. After adjusting for confounding variables, PEP participants had lower incidence rates of all-cause mortality [hazard ratio (HR): 0.589, 95 % confidence interval (CI) 0.380-0.915, P = 0.018] and first macrovascular or microvascular disease events (HR: 0.782, 95 % CI 0.632-0.968, P = 0.024) than those with PEP. Enrolment to PEP was an effective approach in reducing all-cause mortality and first macrovascular or microvascular disease events in obese patients with type 2 diabetes.

Empowerment in the Treatment of Diabetes and Obesity

As the available therapies for diabetes and obesity are not effective enough, diabetologists and educators search for new methods to collaborate with patients in order to support their health behaviors. The aim of this review is to discuss perspectives for the development of new empowerment-type therapies in the treatment of diabetes/obesity. Empowerment is a process whereby patients gain the necessary knowledge to influence their own behavior to improve the quality of their lives. It is carried out in five stages: (1) identify the problem, (2) explain the feelings and meanings, (3) build a plan, (4) act, and (5) experience and assess the execution. Although many years have passed since the advent and popularization of the concept of empowerment, the area remains controversial, mainly with regard to the methodology of therapy. Some previous studies have confirmed the positive effect of empowerment on body weight, metabolic control, and quality of life of patients with type 2 diabetes; however, few studies have been conducted in patients with type 1 diabetes. There is still a need to confirm the effectiveness of empowerment in accordance with Evidence Based Medicine by performing long-term observational studies in a large group of patients. In future, empowerment may become part of the standard of care for patients with diabetes and/or obesity.