Diabetes patient education: a meta-analysis and meta-regression

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Abstract

Diabetes education has largely been accepted in diabetes care. The effect of diabetes education on glycemic control and the components of education responsible for such an effect are uncertain. We performed a meta-analysis of randomized controlled trials of diabetes patient education published between 1990 and December 2000 to quantitatively assess and characterize the effect of patient education on glycated hemoglobin (HbA1c). Additionally, we used meta-regression to analyze which variables within an education intervention that best explained variance in glycemic control. Twenty-eight educational interventions (n=2439) were included in the analysis. The net glycemic change was 0.320% lower in the intervention group than in the control group. Meta-regression revealed that interventions which included a face-to-face delivery, cognitive reframing teaching method, and exercise content were more likely to improve glycemic control. Those three areas collectively explained 44% of the variance in glycemic control. Current patient education interventions modestly improve glycemic control in adults with diabetes. We highlight three potential components of educational interventions that may predict an increased likelihood of success in ameliorating glycemic control.

Introduction

Patient education is a cornerstone of diabetes care. National Standards for Diabetes Self-Management Education define patient education as “an exchange of knowledge, tools, and practices that will address the client’s … needs” [1]. Purposefully this definition is nonspecific and inclusive, encouraging educational processes that are adaptable and individualized. While this leaves much room for personal decision and variety in the educational process, it also leaves a process that is difficult to define and describe.

Others have attempted to better characterize educational interventions in diabetes. Earlier reviews have reported positive effects on patient knowledge, self-care behaviors, metabolic control, and psychological outcomes. Yet the most consistent finding of these previous meta-analyses was incomplete and inadequate descriptions of the interventions [2], [3], [4]. The authors use these conclusions to confirm the continued need for high quality studies and to encourage more complete and accurate descriptions of these interventions. More recent literature reviews echo these conclusions, again calling for more thorough descriptions of educational interventions [5], [6]. In follow-up of these admonitions, a framework to promote more consistent and accurate reporting of diabetes patient education interventions has been proposed [7]. This taxonomy permits systematic characterization of educational interventions in diabetes.

The main intent of this study was to characterize and assess the effect of more recent patient education interventions on glycemic control as represented by glycated hemoglobin (HbA1c). Additionally, using the taxonomy mentioned above, we systematically categorized each educational intervention and assessed the relationship between the specific variables within the interventions and metabolic control. We used the techniques of meta-regression to quantitatively analyze which components of educational interventions best explained variance in metabolic control.

Section snippets

Identification and selection of studies

We searched the MEDLINE, CINAHL, healthSTAR, ERIC, Science Citation Index, PsychINFO, and CRISP databases using the key words diabetes mellitus, education and patient education. A medical librarian performed a parallel search. We also searched the web-based database at the American Association of Diabetes Educators web site (http://www.aadenet.org). We limited our search to English language studies published between 1990 and December 2000. In an attempt to assure higher quality studies, we

Participants and patient education interventions

We identified 26 randomized controlled trials of educational interventions performed in adults with diabetes. Of these 26, five were excluded because they either were an incomplete report of a later publication [16], or did not report a measure of either standard deviation or standard error [17], [18], [19], [20]. Twenty-one articles met all of our inclusion criteria and constituted the final sample (Table 2) [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34],

Discussion

The results of this meta-analysis support that patient education improves glycemic control in patients with diabetes. The HbA1c net change was 0.32. This result is just slightly less than that of previous meta-analyses using earlier studies with a variety of study designs [2], [3], [4]. The meta-regression suggests several attributes of patient education that seem to predict improved glycemic control: face-to-face interaction; a cognitive reframing teaching method; and exercise content.

There is

Practice implications

This analysis supports the benefit of educational interventions in diabetes and suggests specific domains that may predict increased likelihood of success. Moreover, this study highlights opportunities to investigate specific attributes of educational interventions that may better impact glycemic control in adult patients with diabetes. Coordinated efforts of interventions, using specific delivery techniques, teaching methods, and content, given at a specific “dose” will better quantify the

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