Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals. Enhancing the effectiveness of diabetes self-management education: the diabetes literacy project. The Lifestyle Intervention for the Treatment of Diabetes study (LIFT Diabetes): Design and baseline characteristics for a randomized translational trial to improve control of cardiovascular disease risk factors. A Community-Based Diabetes Prevention Program Design and Methods for a Comparative Effectiveness Pilot Study: Virtual World vs. Face-to-Face Diabetes Self-Management Integrated Tobacco Cessation Counseling in a Diabetes Self-management Training Program Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation - the CASCADE study. Enhancing Diabetes Self-care Among Rural African Americans With Diabetes Behavioural interventions for type 2 diabetes: an evidence-based analysis. Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes Peer support to decrease diabetes-related distress in patients with type 2 diabetes mellitus: design of a randomised controlled trial Tablet-Aided BehavioraL intervention EffecT on Self-management skills (TABLETS) for Diabetes Assessment of factors affecting quality of life in diabetic patients in Iran. The effect of a structured behavioral intervention on poorly controlled diabetes: a randomized controlled trial. Impact of Community Based Peer Support in Type 2 Diabetes: A Cluster Randomised Controlled Trial of Individual and/or Group Approaches The Impact of Patient-Centered versus Didactic Education Programs in Chronic Patients by Severity: The Case of Type 2 Diabetes Mellitus. A study protocol for a pilot randomised trial of a structured education programme for the self-management of Type 2 diabetes for adults with intellectual disabilities Utilization of 3-Month Yoga Program for Adults at High Risk for Type 2 Diabetes: A Pilot Study A Virtual World Versus Face-to-Face Intervention Format to Promote Diabetes Self-Management Among African American Women: A Pilot Randomized Clinical Trial Cardiovascular risk outcome and program evaluation of a cluster randomised controlled trial of a community-based, lay peer led program for people with diabetes The effects of education based on extended health belief model in type 2 diabetic patients: a randomized controlled trial The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs
BACKGROUND Diabetes education can improve the quality of care of people with diabetes , but many organizations are not equipped to manage its implementation . Involving people with diabetes in the education process can overcome the problem . Thus , we compared clinical , metabolic and psychological outcomes in people with type 2 diabetes 1 year after attending a structured diabetes education programme implemented by professional educators versus the same programme implemented by trained peers with diabetes  that also provided ongoing peer support . METHODS People with type 2 diabetes ( 25 - 75 years ) were r and omly assigned to attend a 4-week structured diabetes education course delivered by professional educators ( control ) or previously trained peers ( peer ) . Peers also received continuing psychological support , including examples on how to apply diabetes knowledge in daily life via weekly peer cellular phone calls and bimonthly face-to-face interviews in small groups ( ten patients ) , using a structured question naire related to the patient 's clinical , metabolic and psychological progress . Identical outcome data from both groups were used for follow-up . RESULTS Both groups had a comparable positive effect on clinical , metabolic and psychological indicators immediately following the programme . Over the following year , peer-educated subjects had lower A(1C ) and systolic blood pressure and showed higher adherence to physical activity and better control of hypoglycaemic episodes . CONCLUSION The non-inferiority of the peer outcomes and the mentioned improvements in this group suggest that volunteer trained peer educators and ongoing support can be successful . This approach provides an effective alternative method of education , especially in areas with limited availability of professionals and economic re sources Patient empowerment through self-management education is central to improving the quality of diabetes care and preventing Type 2 Diabetes .  Although national programs exist , there is no EU-wide strategy for diabetes self-management education , and patients with limited literacy face barriers to effective self-management . The Diabetes Literacy project , initiated with the support of the European Commission , aims to fill this gap . The project investigates the effectiveness of diabetes self-management education , targeting people with or at risk of Type 2 Diabetes in the 28 EU Member States , as part of a comprehensive EU-wide diabetes strategy . National diabetes strategies in the EU , US , Taiwan , and Israel are compared , and diabetes self-management programs inventorized . The costs of the diabetes care pathway are assessed on a per person basis at national level . A comparison is made of the (cost)-effectiveness of different methods for diabetes self-management support , and the moderating role of health literacy , organization of the health services , and implementation fidelity of education programs are considered . Web-based material s are developed and evaluated by r and omized trials to evaluate if interactive internet delivery can enhance self-management support for people with lower levels of health literacy . The 3-year project started in December 2012 . Several literature review s have been produced and protocol development and research design are in the final stages . Primary and secondary data collection and analysis take place in 2014 . The results will inform policy decisions on improving the prevention , treatment , and care for persons with diabetes across literacy levels The prevalence of type 2 diabetes continues to increase in minority and underserved patients , who are also more likely to have poorer control of diabetes and related risk factors for complications . Although the Look AHEAD trial has demonstrated improved risk factor control among overweight or obese diabetes patients who received an intensive lifestyle intervention  , translating such findings into accessible programs is a major public health challenge . The purpose of this paper is to report the design and baseline characteristics of the Lifestyle Interventions for the Treatment of Diabetes study ( LIFT Diabetes ) . The overall goal is to test the impact of a community-based lifestyle weight loss ( LWL ) intervention adapted from Look AHEAD on cardiovascular disease risk at 12-months and 24-months among minority and lower income diabetes patients . Secondary outcomes include body weight , physical activity , medication use , cost , re source utilization , and safety . The primary hypothesis being tested is that the  LWL  will result in 10 % relative reduction in CVD risk compared to the DSM . We have r and omized 260 overweight or obese adults with diabetes one of two 12-month interventions : a LWL condition delivered by community health workers or a diabetes self-management ( DSM ) education condition . The baseline demographic characteristics indicate that our sample is predominantly female , obese , low income , and ethnic minority . Translating evidence -based , lifestyle strategies , and targeting minority and underserved patients , will yield , if successful , a model for addressing the burden of diabetes and may favorably impact health disparities Purpose With growing numbers of people at risk for diabetes and cardiovascular disease , diabetes educators report increasing referrals for intervention in prevention of these conditions . Diabetes educators have expertise in diabetes self-management education ; however , they are generally not prepared for delivery of chronic disease primary prevention . The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease . Methods Diabetes educators in 3 outpatient-hospital programs ( urban , suburban , and rural ) received training and support for implementation of the Group Lifestyle Balance program , an adaptation of the Diabetes Prevention Program lifestyle intervention , from the Diabetes Prevention Support Center of the University of Pittsburgh . Adults with prediabetes and /or the metabolic syndrome were eligible to enroll in the program with physician referral . With use of existing diabetes educator networks , recruitment was completed via on-site physician in-services , informative letters , and e-mail contact as well as participant-directed newspaper advertisement . Results Eighty-one participants enrolled in the study ( 71 women , 10 men ) .  Mean overall weight loss was 11.3 lb ( 5.1 % , P < .001 ) ; in addition , significant decreases were noted in fasting plasma glucose , low-density lipoprotein cholesterol , triglycerides , and blood pressure . Conclusions These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals . Furthermore , diabetes educators , already integrated within the existing health care system , provide yet another re source for delivery of primary prevention programs in the community Background Type 2 diabetes ( diabetes ) is a serious threat to public health in the United States and disproportionally affects many racial/ethnic minority groups , including African Americans . Limited access to treatment and high attrition rates further contribute to health disparities in diabetes-related morbidity and mortality among minorities . Greater opportunities for increasing access and decreasing barriers to treatment are needed . Technology-based interventions have potential for accomplishing this goal but evidence of feasibility and potential effectiveness is lacking , especially for population s that traditionally have limited educational attainment and low computer literacy . Objective This paper describes the design and methods of a pilot r and omized clinical trial that will compare the feasibility and potential efficacy of delivering a diabetes self-management intervention via a virtual world vs. a face-to-face format . Methods Study participants ( n=100 ) will be African American women with uncontrolled type 2 diabetes recruited from primary care practice s and affiliated health centers at a large safety net hospital in Massachusetts . Participants will be r and omized into a virtual world-based ( VW ) intervention condition or a face-to-face control condition . Both conditions provide the same theory-based curriculum and equivalent exposure to the self-management program ( eight group sessions ) , and both will be delivered by a single intervention team ( a dietitian and a diabetes educator ) . Assessment s will be conducted at baseline and 4 months . Feasibility will be determined by evaluating the degree to which participants engage in the VW-based intervention compared to face to face ( number of sessions completed ) . Potential efficacy will be determined by comparing change in physiological ( glycemic control ) and behavioral ( self-reported dietary intake , physical activity , blood glucose self-monitoring , and medication adherence ) outcomes between the experimental and control groups . Results The primary outcomes of interest are feasibility of the VW intervention and its potential efficacy on glucose control and diabetes self-management behaviors , compared to the face-to-face condition . Analysis will use a two- sample Kolmogorov-Smirnov test for changes in variable distribution . P values will be calculated using binomial tests for proportions and t tests for continuous variables . Conclusions If the intervention is found to be feasible and promising , it will be tested in a larger RCT Purpose The purpose of this study was to evaluate the impact of a tobacco cessation intervention using motivational interviewing on smoking cessation rates during diabetes self-management training ( DSMT ) . Methods A r and omized controlled trial was conducted with subjects recruited from an ongoing type 2 diabetes adult education program at a large diabetes center . A total of 114 subjects were r and omized to intervention ( n = 57 ; face-to-face motivational interviewing plus telephone counseling and offering of medication ) or st and ard care ( n = 57 ) . Outcome measures included tobacco cessation rates , mean number of cigarettes smoked , A1C , weight , blood pressure , and lipids . Results Intensive intervention using motivational interviewing integrated into a st and ard DSMT program result ed in a trend toward greater abstinence at 3 months of follow-up in those receiving the intervention . However , this same trend was not observed at 6 months . The addition of this structured smoking cessation intervention did not negatively affect either diabetes education or other measures of diabetes management , including A1C values Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : BACKGROUND Type 1 diabetes ( T1D ) in children and young people is increasing worldwide with a particular increase in children under the age of 5 years . Fewer than one in six children and young people achieve glycosylated fraction of haemoglobin ( HbA1c ) values in the range identified as providing best future outcomes . There is an urgent need for clinic-based pragmatic , feasible and effective interventions that improve both glycaemic control and quality of life ( QoL ) . The intervention offers both structured education , to ensure young people know what they need to know , and a delivery model design ed to motivate self-management . OBJECTIVE To assess the feasibility of providing a clinic-based structured educational group programme incorporating psychological approaches to improve long-term glycaemic control , QoL and psychosocial functioning in a diverse range of young people . DESIGN The study was a pragmatic , cluster r and omised control trial with integral process and economic evaluation . SETTING Twenty-eight paediatric diabetes services across London , south-east Engl and and the Midl and s. R AND OMISATION Minimised by clinic size , age ( paediatric or adolescent ) and specialisation ( district general hospital clinic or teaching hospital/tertiary clinic ) . ALLOCATION Half of the sites were r and omised to the intervention arm and half to the control arm . Allocation was concealed until after clinics had consented and the first participant was recruited . Where possible , families were blind to allocation until recruitment finished . PARTICIPANTS Forty-three health-care practitioners ( 14 teams ) were trained in the intervention . The study recruited 362 children aged 8 - 16 years , diagnosed with T1D for > 12 months , with a mean 12-month HbA1c level of ≥ 8.5 % . INTERVENTION Two 1-day workshops taught intervention delivery . A detailed manual and re sources were provided . The intervention consists of four group education sessions led by a paediatric diabetes specialist nurse with another team member . OUTCOMES The primary outcome was glycaemic control , assessed at the individual level using venous HbA1c values , measured at baseline , 12 and 24 months . Secondary outcomes were directly and indirectly related to diabetes management , including hypoglycaemic episodes , hospital admissions , diabetes regimen , knowledge , skills and responsibility for diabetes management , intervention compliance , clinic utilisation , emotional and behavioural adjustment , and general and diabetes-specific QoL. PROCESS EVALUATION Question naires , semistructured interviews , informal discussion following observation sessions , fieldwork notes and case note review were used to collect qualitative and quantitative data from key stakeholder groups at specific time points in the trial . STATISTICAL ANALYSES Primary and secondary analyses were intention-to-treat comparisons of outcomes at 12 and 24 months , using analysis of covariance with a r and om effect for clinic . Prespecified subgroup analyses based on age , gender , initial HbA1c value and socioeconomic status were estimated from models that included an interaction term . The economic analysis compared long-term costs and predicted quality -adjusted life-years ( QALYs ) . RESULTS The intervention did not improve HbA1c at 12 months [ intervention effect 0.11 ; 95 % confidence interval ( CI ) -0.28 to 0.50 ; p = 0.584 ] or 24 months ( intervention effect 0.03 ; 95 % CI -0.36 to 0.41 ; p = 0.891 ) . A total of 298/362 patients ( 82.3 % ) provided blood sample s at 12-month follow-up , and 284/362 ( 78.5 % ) provided blood sample s at 24-month follow-up . Follow-up question naires were completed by 307 patients ( 85.3 % ) at 12 months and by 295 patients ( 81.5 % ) at 24 months . Intervention group parents at 12 months ( 95 % CI 0.74 ; 0.03 to 1.52 ) and young people at 24 months ( 0.85 ; 95 % CI 0.03 to 1.61 ) had higher scores on the diabetes family responsibility question naire . Young people reported reduced happiness with body weight at 12 months ( -0.56 ; 95 % CI -1.03 to -0.06 ) . Only 68 % of groups were run . Of the 180 families recruited , 96 ( 53 % ) attended at least one module . Reasons for low uptake included difficulties organising groups , and work and school commitments . Young people with higher HbA1c levels were less likely to attend . Parents and young people who attended groups described improved family relationships , improved knowledge and underst and ing , greater confidence and increased motivation to manage diabetes . Twenty-four months after the intervention , nearly half of the young people reported that the groups had made them want to try harder and that they had carried on trying . A high- quality , complex , pragmatic trial of structured education can be delivered alongside st and ard care in NHS diabetes clinics . Health-care providers benefited from behaviour change skill training and can deliver pragmatic aspects of a National Institute for Health and Care Excellence (NICE)-compliant structured education programme after relatively brief training . The process evaluation provides insight into aspects of the model , and highlights strengths and aspects that may have contributed to the failure to influence primary and secondary outcomes . Current NHS practice dominates CASCADE ( Child and Adolescent Structured Competencies Approach to Diabetes Education ) in that it achieves the same number of QALYs at a lower cost . The mean cost of providing the intervention was £ 5098 per site or £ 683 per child . Members of paediatric diabetes services trained to deliver the CASCADE structured education package using behaviour change techniques did not improve glycaemic control in patients compared with control subjects 1 and 2 years after the intervention . The training workshops for practitioners were well evaluated ; however , more intensive training was needed . The intervention cost £ 683 per patient but was not cost-effective because it did not improve metabolic control . CONCLUSIONS A high- quality , complex , pragmatic trial of structured education can be successfully conducted alongside st and ard care in NHS diabetes clinics . Pragmatic components of a NICE-compliant structured education programme can be successfully delivered following a relatively brief 2-day training while paediatric health-care professionals benefit from training in behaviour change skills . The study provides invaluable information on barriers and opportunities regarding future , similar interventions . A low dropout rate and good attendance for the subgroup that attended the intervention suggests there might be improved uptake if offered to young people with lower HbA1c . Testing whether this approach can be more successful with a robust ongoing supervisory element should be a target of further research . TRIAL REGISTRATION Current Controlled Trials IS RCT N52537669 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 18 , No. 20 . See the NIHR Journals Library website for further project information Purpose The purpose of this study is to test the feasibility of conducting a community-based r and omized controlled trial evaluating a culturally tailored community-based group diabetes self-management education ( DSME ) program among rural African Americans . Methods Thirty-two African American rural adults with type 2 diabetes were recruited and 25 adults were retained and participated in an interventional study design ed to test the effectiveness of the “ Taking Care of Sugar ” DSME program for the 2-year follow-up . Participants were selected from rural central Virginia . Primary outcomes variables included average blood sugar levels , cardiovascular risk factors , and general physical and mental health . These outcomes were assessed at baseline , 3 months , 6 months , and 12 months post baseline . Results From baseline to 3-month follow-up assessment , participants exhibited significant improvement on several physiological and behavioral measures . Given the small sample size , hypothesis testing was limited . Results show change from baseline over time , illustrating that the primary outcome of A1C decreased , although not significant . Additionally , participants reported more knowledge about diabetes self-management and personal care skills ( ie , exercise and foot care ) that persisted over time . The feasibility of the culturally tailored DSME was established , and participation with the program was high . Conclusions A community-based group DSME program using storytelling is feasible . This research will help to inform clinicians and health policymakers as to the types of interventions that are feasible in a larger rural population . If such a program is carried out , we can improve knowledge , reduce complications , and improve quality of life among rural African Americans UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT Diabetes case management ( DCM ) may improve medical outcomes ( 1,2 ) . Case managers coordinate care and often provide a mix of interventions , e.g. , telephone outreach , education , reminders . However , the efficacy of DCM is unclear . Three systematic review s lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid , weight , or blood pressure benefits ( 3–5 ) . DCM studies typically target biomedical outcomes and ignore potential psychosocial effects . Yet , psychosocial variables ( e.g. , depression , anxiety , social support ) relate to hyperglycemia , complications , adherence , and quality of life ( 6–11 ) . Thus , a positive impact of DCM on these factors is important . Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction ( cluster visit ) ( 12 ) and quality of life ( dietitian-led DCM group ) ( 13 ) . Because barriers ( e.g. , distance , weather ) limit DCM access , telemedicine can be used . A review of telemedicine versus face-to-face trials concluded that , while feasible and acceptable , there is little evidence that telemedicine has clinical benefits ( 14 ) . Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients ( 15 ) . The intervention result ed in significant improvements in glycemic control , blood pressure , and total and LDL cholesterol ( 16 ) . The purpose of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project , funded by the Centers for Medicare and Medicaid Services , is to evaluate the feasibility and effectiveness of telemedicine with a diverse , medically underserved , elderly diabetic sample . The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes . A detailed description of the IDEATel study design has been previously reported ( 15,16 ) . Medicare recipients were recruited if they were aged ≥55 years , diagnosed with diabetes , and without moderate/severe impairments or comorbidities . Research nurses blinded to the groups Background Many type 2 diabetes mellitus patients face difficulties self-managing their illness , which can lead to high levels of diabetes-related distress . Diabetes distress may be decreased by peer support , as peers underst and and have dealt with similar problems , and can help motivate each other . A recent systematic review concluded that evidence of benefits of peer support in patients with type 2 diabetes mellitus is too inconsistent due to weak theoretical foundation of the interventions . This study describes the design of a trial evaluating the effectiveness of a group-based , peer support programme with a strong theoretical foundation on diabetes-related distress in type 2 diabetes patients . Methods This is a parallel group r and omised controlled trial of a six session group-based peer support intervention , delivered by peer leaders and group psychotherapists , compared with one educational meeting on diabetes .  At least 152 patients with a type 2 diabetes duration of three years or more and between 50 and 70 years of age , recruited via their general practitioner , will be r and omised to receive the peer support intervention or one educational meeting . The intervention is developed in line with three key stages of research development of the Medical Research Council framework . The primary outcome measure for this study is diabetes-related distress . Secondary outcomes include self-management behaviour , well-being and health-related quality of life . Perceived social support is a process measure . Outcomes will be measured one month before , and 6 , and 12 months after the intervention by means of self-reported question naires . Analysis will be on an intention-to-treat basis . Discussion This article contains a description of the design of a study that will investigate the effect of a group-based , peer support intervention on diabetes-related distress in type 2 diabetes patients . The intervention was developed in recognition of the limited evidence , and the importance of a theoretical foundation and its implementation . Findings will contribute to knowledge in the field of peer support and patient-important outcomes in type 2 diabetes patients .Trial registration Dutch Trial Registry : Background Multiple r and omized controlled trials ( RCTs ) show that behavioral lifestyle interventions are effective in improving diabetes management and that comprehensive risk factor management improves cardiovascular disease ( CVD ) outcomes . The role of technology has been gaining strong support as evidence builds of its potential to improve diabetes management ; however , evaluation of its impact in minority population s is limited . This study intends to provide early evidence of a theory-driven intervention , Tablet-Aided BehavioraL intervention EffecT on Self-management skills ( TABLETS ) , using real-time videoconferencing for education and skills training . We examine the potential for TABLETS to improve health risk behaviors and reduce CVD risk outcomes among a low-income African American ( AA ) population with poorly controlled type 2 diabetes . Methods The study is a two-arm , pilot controlled trial that r and omizes 30 participants to the TABLETS intervention and 30 participants to a usual care group . Blinded outcome assessment s will be completed at baseline , 2.5 months ( immediate post-intervention ) , and 6.5 months ( follow-up ) . The TABLETS intervention consists of culturally tailored telephone-delivered diabetes education and skills training delivered via videoconferencing on tablet devices , with two booster sessions delivered via tablet-based videoconferencing at 3 months and 5 months to stimulate ongoing use of the tablet device with access to intervention material s via videoconferencing slides and a manual of supplementary material s. The primary outcomes are physical activity , diet , medication adherence , and self-monitoring behavior , whereas the secondary outcomes are HbA1c , low-density lipoprotein cholesterol ( LDL-C ) , BP , CVD risk , and quality of life . Discussion This study provides a unique opportunity to assess the feasibility and efficacy of a theory-driven , tablet-aided behavioral intervention that utilizes real-time videoconferencing technology for education and skills training on self-management behaviors and quality of life among a high-risk , low-income AA population with an uncontrolled dyad or triad of CVD risk factors ( diabetes with or without hypertension or hyperlipidemia ) . The intervention leverages the use of novel technology for education and skill-building to foster improved diabetes self-management . The findings of this study will inform the process of disseminating the intervention to a broader and larger sample of people and can potentially be refined to align with clinical workflows that target a sub sample of patients with poor diabetes self-management . Trial registration The trial was registered in April 2014 with the United States National Institutes of Health Clinical Trials Registry ( Clinical Trials.gov identifier NCT02128854 ) , available online at : http:// clinical trials.gov/ct2/show/NCT02128854 OBJECTIVE Assess the pattern of relationships between personal- background characteristics and dimensions of quality of life ( QOL ) in diabetic patients . DESIGN Cross-sectional descriptive study . SAMPLE 117 adults with type 2 diabetes ( 100 female , 17 male ) r and omly selected from out patients referred to Sina hospital ( Tabriz , Iran ) . METHODS Participants answered a three-part question naire including ( 1 ) sociodemographic and medical ( diabetes-related ) personal- background characteristics ; ( 2 ) general health-related QOL instrument based on Swedish Health-Related QOL ; ( 3 ) disease-specific instrument for diabetic patients . Nine QOL dimensions were covered : physical function , pain , daily activities , feelings , sleep , relationships with relatives , overall health , problems with diabetes , satisfaction with diabetes treatment methods . Data were analyzed with inferential statistics , correlation , and multi-stage stepwise regression . RESULTS Personal background characteristics ( age , presence of medically educated people in family , whether patient was family breadwinner , unemployment , complications of diabetes ) accounted for 27 % of variance in the physical function dimension of QOL dimension . Other QOL dimensions ( daily activities , overall health , sleep , satisfaction with diabetes treatment . ) were also related to personal background characteristics . CONCLUSIONS Diabetic patients face great challenges in many dimensions of QOL . Nursing instructors and nursing educators in educational centers for diabetics can use the findings of this research to assess their patients more effectively BACKGROUND Although maintaining nearly normal glycemia delays onset and slows progression of diabetes complications , many patients with diabetes and their physicians struggle to achieve glycemic targets . The best methods to support patients as they follow diabetes prescriptions and recommendations are unclear . METHODS To test the efficacy of a behavioral diabetes intervention in improving glycemia in long- duration , poorly controlled diabetes , we r and omized 222 adults with diabetes ( 49 % type 1 ) ( mean [ SD ] age , 53 [ 12 ] years ; mean [ SD ] disease duration 18 [ 12 ] years ; mean [ SD ] hemoglobin A(1c ) [ HbA(1c ) ] concentration , 9.0 % [ 1.1 % ] ) to attend ( 1 ) a 5-session manual-based , educator-led structured group intervention with cognitive behavioral strategies ( structured behavioral arm ) ; ( 2 ) an educator-led attention control group education program ( group attention control ) ; or ( 3 ) unlimited individual nurse and dietitian education sessions for 6 months ( individual control ) . Outcomes were baseline and 3- , 6- , and 12-month postintervention HbA(1c ) levels ( primary ) and frequency of diabetes self-care , 3-day pedometer readings , 24-hour diet recalls , average number of glucose checks , physical fitness , depression , coping style , self-efficacy , and quality of life ( secondary ) . RESULTS Linear mixed modeling found that all groups showed improved HbA(1c ) levels ( P < .001 ) . However , the structured behavioral arm showed greater improvements than the group and individual control arms ( 3-month HbA(1c ) concentration changes : -0.8 % vs -0.4 % and -0.4 % , respectively ( P = .04 for group × time interaction ) . Furthermore , participants with type 2 disease showed greater improvement than those with type 1 ( P = .04 for type of diabetes × time interaction ) . Quality of life , glucose monitoring , and frequency of diabetes self-care did not differ by intervention over time . CONCLUSIONS A structured , cognitive behavioral program is more effective than 2 control interventions in improving glycemia in adults with long- duration diabetes . Educators can successfully use modified psychological and behavioral strategies . TRIAL REGISTRATION clinical trials.gov Identifier : NCT000142922 BACKGROUND Diabetes peer support , where one person with diabetes helps guide and support others , has been proposed as a way to improve diabetes management . We have tested whether different diabetes peer support strategies can improve metabolic and /or psychological outcomes . METHODS People with type 2 diabetes ( n = 1,299 ) were invited to participate as either '  peer ' or ' peer support facilitator '  ( PSF ) in a 2x2 factorial r and omised cluster controlled trial across rural communities ( 130 clusters ) in Engl and .  Peer support was delivered over 8 - 12 months by trained PSFs , supported by monthly meetings with a diabetes educator . Primary end point was HbA1c . Secondary outcomes included quality of life , diabetes distress , blood pressure , waist , total cholesterol and weight . Outcome assessors and investigators were masked to arm allocation . Main factors were 1:1 or group intervention . Analysis was by intention-to-treat adjusting for baseline . RESULTS The 4 arms were well matched ( Group n = 330 , 1:1(individual ) n = 325 , combined n = 322 , control n = 322 ) ; 1035 ( 79·7 % ) completed the mid-point postal question naire and 1064 ( 81·9 % ) had a final HbA1c . A limitation was that although 92.6 % PSFs and peers were in telephone contact , only 61.4 % of intervention participants attended a face to face session . Mean baseline HbA1c was 57 mmol/mol ( 7·4 % ) , with no significant change across arms . Follow up systolic blood pressure was 2·3 mm Hg ( 0.6 to 4.0 ) lower among those allocated group peer-support and 3·0 mm Hg ( 1.1 to 5.0 ) lower if the group support was attended at least once . There was no impact on other outcomes by intention to treat or significant differences between arms in self-reported adherence or medication . CONCLUSIONS Group diabetes peer support over 8 - 12 months was associated with a small improvement in blood pressure but no other significant outcomes . Long term benefits should be investigated . TRIAL REGISTRATION IS RCT N.com IS RCT N6696362166963621 BACKGROUND Education leads to better health-related decisions and protective behaviors , being especially important for patients with chronic conditions .  Self-management education programs have been shown to be beneficial for patients with different chronic conditions and to have a higher impact on health outcomes than does didactic education . OBJECTIVE To investigate improvements in glycemic control ( measured by glycated hemoglobin A1c ) in patients with type 2 diabetes mellitus . METHODS Our comparative trial involved one group of patients receiving patient-centered education and another receiving didactic education .  We dealt with selection bias issues , estimated the different impact of both programs , and vali date d our analysis using quantile regression techniques . RESULTS We found evidence of better mean glycemic control in patients receiving the patient-centered program , which engaged better patients . Nevertheless , that differential impact is nonmonotonic . Patients initially at the healthy range at the patient-centered program maintained their condition better . Patients close to , but not within , the healthy range benefited equally from attending either program . Patients with very high  glycemic level benefited significantly more from attending the patient-centered program . Finally , patients with the worst initial glycemic control ( far from the healthy range ) improved equally their diabetic condition , regardless of which program they attended . CONCLUSIONS Different patients are sensitive to different categories of education programs . The optimal , cost-effective design of preventative programs for patients with chronic conditions needs to account for the different impact in different " patient categories . " This implies stratifying patients and providing the appropriate preventative education program , or looking for alternative policy implementations for unresponsive patients who have the most severe condition and are the most costly Background The need for structured education programmes for type 2 diabetes is a high priority for many governments around the world . One such national education programme in the United Kingdom is the DESMOND Programme , which has been shown to be robust and effective for patients in general . However , these programmes are not generally targeted to people with intellectual disabilities ( ID ) , and robust evidence on their effects for this population is lacking . We have adapted the DESMOND Programme for people with ID and type 2 diabetes to produce an amended programme known as DESMOND-ID.This protocol is for a pilot trial to determine whether a large-scale r and omised trial is feasible , to test if DESMOND-ID is more effective than usual care in adults with ID for self-management of their type 2 diabetes , in particular as a means to reduce glycated haemoglobin ( Hb1Ac ) , improve psychological wellbeing and quality of life and promote a healthier lifestyle . This protocol describes the rationale , methods , proposed analysis plan and organisational and administrative details . Methods / Design This trial is a two arm , individually r and omised , pilot trial for adults with ID and type 2 diabetes , and their family and /or paid carers . It compares the DESMOND-ID programme with usual care .  Approximately 36 adults with mild to moderate ID will be recruited from three countries in the United Kingdom . Family and /or paid carers may also participate in the study . Participants will be r and omly assigned to one of two conditions using a secure computerised system with robust allocation concealment . A range of data will be collected from the adults with ID ( biomedical , psychosocial and self-management strategies ) and from their carers . Focus groups with all the participants will assess the acceptability of the intervention and the trial . Discussion The lack of appropriate structured education programmes and educational material s for this population leads to secondary health conditions and may lead to premature deaths . There are significant benefits to be gained globally , if structured education programmes are adapted and shown to be successful for people with ID and other cognitive impairments . Trial registration Registered with International St and ard R and omised Controlled Trial ( identifier : IS RCT N93185560 ) on 10 November 2014 Various modes of physical activity , combined with dieting , have been widely recommended to prevent or delay type 2 diabetes . Among these , yoga holds promise for reducing risk factors for type 2 diabetes by promoting weight loss , improving glucose levels and reducing blood pressure and lipid levels . This pilot study aim ed to assess the feasibility of implementing a 12-week yoga program among adults at high risk for type 2 diabetes . Twenty-three adults ( 19 Whites and 4 non-Whites ) were r and omly assigned to the  yoga intervention group or the educational group . The yoga group participated in a 3-month yoga intervention with sessions twice per week and the educational group received general health educational material s every 2 weeks . All participants completed question naires and had blood tests at baseline and at the end of 3 months . Effect sizes were reported to summarize the efficacy of the intervention . All participants assigned to the yoga intervention completed the yoga program without complication and expressed high satisfaction with the program ( 99.2 % ) . Their yoga session attendance ranged from 58.3 to 100 % . Compared with the education group , the yoga group experienced improvements in weight , blood pressure , insulin , triglycerides and exercise self-efficacy indicated by small to large effect sizes . This preliminary study indicates that a yoga program would be a possible risk reduction option for adults at high risk for type 2 diabetes . In addition , yoga holds promise as an approach to reducing cardiometabolic risk factors and increasing exercise self-efficacy for this group Background Virtual world environments have the potential to increase access to diabetes self-management interventions and may lower cost . Objective We tested the feasibility and comparative effectiveness of a virtual world versus a face-to-face diabetes self-management group intervention . Methods We recruited African American women with type 2 diabetes to participate in an 8-week diabetes self-management program adapted from Power to Prevent , a behavior-change in-person group program for African Americans with diabetes or pre-diabetes . The program is social cognitive theory – guided , evidence -based , and culturally tailored . Participants were r and omized to participate in the program via virtual world ( Second Life ) or face-to-face , both delivered by a single intervention team . Blinded assessors conducted in-person clinical ( HbA1c ) , behavioral , and psychosocial measurements at baseline and 4-month follow-up . Pre-post differences within and between intervention groups were assessed using t tests and chi-square tests ( two-sided and intention-to-treat analyses for all comparisons ) . Results Participants ( N=89 ) were an average of 52 years old ( SD 10 ) , 60 % had ≤high school , 82 % had household incomes < US $ 30,000 , and computer experience was variable . Overall session attendance was similar across the groups ( 6.8/8 sessions , P=.90 ) . Compared to face-to-face , virtual world was slightly superior for total activity , light activity , and inactivity ( P=.05 , P=.07 , and P=.025 , respectively ) . HbA1c reduction was significant within face-to-face ( −0.46 , P=02 ) but not within virtual world ( −0.31 , P=.19 ) , although there were no significant between group differences in HbA1c ( P=.52 ) . In both groups , 14 % fewer patients had post-intervention HbA1c ≥9 % ( virtual world P=.014 ; face-to-face P=.002 ) , with no significant between group difference ( P=.493 ) . Compared to virtual world , face-to-face was marginally superior for reducing depression symptoms ( P=.051 ) . The virtual world intervention costs were US $ 1117 versus US $ 931 for face-to-face . Conclusions It is feasible to deliver diabetes self-management interventions to inner city African American women via virtual worlds , and outcomes may be comparable to those of face-to-face interventions . Further effectiveness research is warranted . Trial Registration Clinical Trials.gov NCT01340079 ; http:// clinical trials.gov/show/NCT01340079 ( Archived by WebCite at http://www.webcitation.org/6T2aSvmka ) Background The 2013 Global Burden of Disease Study demonstrated the increasing burden of diabetes and the challenge it poses to the health systems of all countries . The chronic and complex nature of diabetes requires active self-management by patients in addition to clinical management in order to achieve optimal glycaemic control and appropriate use of available clinical services . This study is an evaluation of a “ real world ” peer support program aim ed at improving the control and management of type 2 diabetes ( T2DM ) in Australia . Methods The trial used a r and omised cluster design with a peer support intervention and routine care control arms and 12-month follow up . Participants in both arms received a st and ardised session of self-management education at baseline . The intervention program comprised monthly community-based group meetings over 12 months led by trained peer supporters and active encouragement to use primary health care and other community re sources and supports related to diabetes .  Clinical , behavioural and other measures were collected at baseline , 6 and 12 months . The primary outcome was the predicted 5 year cardiovascular disease risk using the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) Risk Equation at 12 months . Secondary outcomes included clinical measures , quality of life , measures of support , psychosocial functioning and lifestyle measures . Results Eleven of 12 planned groups were successfully implemented in the intervention arm . Both the usual care and the intervention arms demonstrated a small reduction in 5 year UKPDS risk and the mean values for biochemical and anthropometric outcomes were close to target at 12 months . There were some small positive changes in self-management behaviours . Conclusions The positive changes in self-management behaviours among intervention participants were not sufficient to reduce cardiovascular risk , possibly because approximately half of the study participants already had quite well controlled T2DM at baseline . Future research needs to address how to enhance community based programs so that they reach and benefit those most in need of re sources and supports to improve metabolic control and associated clinical outcomes .Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) ACTRN12609000469213 . Registered 16 June 2009 Background Type II diabetes and its complications impose a large economic burden on health care systems . This study aims to assess the effectiveness of educational intervention based on extended health belief model on type 2 diabetic patients . Methods 120 patients with type II diabetes referring to r and omly selected hospitals of Tehran University of Medical Sciences were enrolled in this educational intervention study . Patients were r and omly divided into two groups ( intervention and control ) . Data were collected using a question naire including demographic information and extended health belief model constructs . Two face to face educational sessions were conducted for each patient . Data were collected in two groups at three stages of the study ; before the educational sessions and at 3 months and 6 months intervals . Analysis was performed by SPSS ( 17.0 ) and STATA ( 11.0 ) using independent T-test , Chi-square , Fisher ’s exact test , analysis of covariance and Generalized Estimating Equation . A p value of less than 0.05 was regarded as statistically significant . Results The educational program had a positive and significant impact ( p < 0.0001 ) on extended health model belief constructs ( including perceived susceptibility , perceived intensity , perceived benefits , perceived barriers and self-efficacy ) in experimental group , 3 and 6 months after the intervention . Conclusions The results of this study showed the importance of extended health belief model based education in improving the model constructs and increasing self-efficacy in patients with type-2 diabetes Context Little is known about the effects of quality -of-care improvement programs on the process of care and outcomes of diabetes . Contribution The study involved 8661 patients with diabetes , 63 provider groups , and 3 disease management strategies ( provider feedback , reminders , and structured care )  . The quality measures included 8 processes of care , 3 intermediate diabetes outcomes , and medication management of these outcomes . More intense disease management strategies predicted higher measures of many processes of care but only 1 intermediate outcome and 1 medication management outcome . Implication s The disease management strategies improved processes of care but not outcomes . Experts in quality improvement may need to refocus their efforts . The Editors Persons with diabetes continue to receive suboptimal care ( 16 ) . To improve quality , many health systems have implemented disease management programs for diabetes and other chronic conditions ( 79 ) . These programs typically incorporate population -based strategies , such as disease registries , clinical guidelines , performance feedback , physician reminders , self-management support for patients , and targeted case management for high-risk patients ( 10 ) . Evidence for the effectiveness of disease management comes primarily from small efficacy trials ( 1020 ) . Such studies consistently found improved processes of diabetes care ; however , improvements in outcomes ( such as control of cardiovascular disease risk factors ) were less consistent ( 12 , 17 , 18 , 2022 ) . Furthermore , most studies evaluated only 1 or 2 strategies ( instead of multicomponent programs ) in selected clinical setting s. It is unclear how well findings from these smaller studies apply to entire patient population s. Many components of disease management focus on improving processes of care . Early performance measurement projects , such as the Health Plan Employer Data Information System ( 23 ) and the Diabetes Quality Improvement Program ( 5 ) , emphasized the importance of such processes as annual retinal screening or hemoglobin A1c determination . Particularly for health plans , process measures are more readily available than are outcomes data . However , if disease management is to improve patient outcomes , it must also improve intermediate outcomes , such as hemoglobin A1c levels , systolic blood pressure , and serum low-density lipoprotein ( LDL ) cholesterol levels . Translating Research into Action for Diabetes ( TRIAD ) ( 24 ) is a multicenter study of diabetes care in managed care . The TRIAD study 's central hypothesis is that health care systems features can affect quality of care . Here , we examine how 3 disease management strategies vary in intensity across physician groups and whether physician groups with more intensive disease management have higher quality of diabetes care . We assess quality by processes of care , by levels of intermediate outcomes , and by current clinical management of these outcomes . Methods Overview of the TRIAD Study and Sample The TRIAD study 's sampling frame , methods , key hypotheses , and power calculations are detailed elsewhere ( 24 ) . The study comprised 6 collaborating translational research centers that were partnered with 10 managed care health plans in 7 states . Of the 10 plans , 7 contracted with 1 to 26 physician groups ( total , 68 groups ) , whereas 4 plans directly contracted with individual physicians . A st and ard algorithm was applied to automated pharmacy , laboratory utilization , and inpatient and outpatient diagnostic data ( 25 ) to identify all community-dwelling patients with diabetes who were 18 years of age and older and who had been continuously enrolled in the TRIAD health plan for at least 18 months . The study cohort was r and omly sample d from this population . Sample d patients were recruited between July 2000 and October 2001 by using computer-assisted telephone interviews or written surveys that were conducted in English or Spanish . Eligibility was confirmed if patients verified that they had had diabetes for at least 12 months and had received most of their diabetes care through the TRIAD health plan . Permission was sought from all respondents to request copies of their outpatient medical records for the previous 18 months . All health plan and physician group directors received mailed surveys ( Appendix Figure ) during the same interval . Face-to-face or telephone interviews were used to complete and clarify responses . Each director was offered $ 100 for completing the survey . Appendix Figure . Translating Research into Action for Diabetes ( TRIAD ) Physician Group Survey . The TRIAD study was review ed and approved by the institutional review boards of each research center and by the Centers for Disease Control and Prevention ( CDC ) . Informed consent was obtained from all survey respondents . Data Sources Patient surveys included questions on health status , diabetes duration , current diabetes treatment , and demographic characteristics .  Of 13086 contacted and eligible persons , 11927 ( 91 % ) completed the survey ( 56.6 % by computer-assisted telephone interview and 43.4 % by written survey ) ( Figure ) . We were unable to contact many individuals . Using a practice that is endorsed by the Council of American Survey Research Organizations ( 26 ) , we assumed that persons whom we could not contact or for whom we could not confirm eligibility had the same eligibility rate as those contacted . Under that assumption , the response rate was 69 % . Figure . Description of sampling and response rate . xx Of 11927 patients who completed a survey , 8661 ( 73 % ) consented to medical record review and subsequently had charts available for review . Central ly trained review ers used st and ardized data collection software to abstract process measures , most recent levels of hemoglobin A1c , upper limits of normal for hemoglobin A1c measurements that were recorded , serum LDL cholesterol levels , systolic blood pressure , current medications , and comorbid conditions . Interrater reliability ( ) for the main quality measures ranged from 0.86 to 0.94 . All 10 health plan directors and 52 of 68 physician group directors completed surveys . Surveys assessed organizational age , size , structure , profit status , insurance products , contracting arrangements , history of involvement with managed care , and detailed information on the organization 's use of diabetes disease management strategies . Of the physician groups that did not respond ( 443 participants ) , 11 existed solely for the purpose of contracting with plans and had no diabetes disease management . These physician groups were assumed to have no care management strategies and were included in the analyses , as were patient groups ( 1150 participants ) from the 4 health plans that contracted directly with physicians . The remaining 5 groups ( 159 participants ) did not respond and were excluded from analyses ( Figure ) . Consequently , the result ing sample included a total of 8661 survey respondents with charts available for review and data from 63 physician groups and 4 additional health plans ( Figure ) . Mean duration of diabetes , body mass index , and health status did not meaningfully differ between persons whose medical records and physician group variables were available to the study team and those whose records were unavailable . Predictors , End Points , and Covariates The primary predictors were 3 measures of the intensity of disease management strategies : physician reminders , performance feedback , and structured care .  These were calculated for physician groups and health plans from multiple survey items . A detailed description of the methods used to calculate composite intensity scores is provided in Appendix 2 . Selected item-level responses for physician groups in the most intense versus least intense tercile of each strategy are displayed in Table 1 . Table 1 . Selected Item-Level Responses for Provider Groups for Each Disease Management Strategy * The physician reminders intensity score was derived from 2 questions , which detailed the types and content of the reminders physicians received . Groups whose use of reminders represented the upper tercile of intensity were found to have reminded physicians about 4 care processes on average . Most groups in the upper tercile delivered reminders electronically at the point of care . Performance feedback intensity was obtained by tallying responses to a checklist of possible diabetes process and outcome feedback items . A total of 86 % and 82 % of groups in the upper tercile included levels of hemoglobin A1c and serum LDL cholesterol , respectively , in feedback to physicians ( Table 1 ) . Physician feedback focused on many of the same elements of care as reminders . The use of formal case management , diabetes guidelines , patient reminders , and diabetes education correlated highly in physician groups ( Pearson correlation coefficients ranged from 0.63 to 0.88 ) ; therefore , we could not look at these approaches independently . Consequently , we combined the 4 approaches into a single composite score for structured diabetes care management . Use of formal case management was assessed by the  proportion of patients with diabetes who were enrolled  , the  number of case managers per 10000 patients  , the extent to which the program targeted high-risk patients , and a checklist of case management activities . The clinical guidelines were scored to reflect the extent of implementation . The highest score was assigned to physician groups that incorporated guidelines into automated physician or patient reminders . Patient reminder intensity incorporated the number , type , and frequency of reminders sent . On average , physician groups in the upper tercile had diabetes education as a covered benefit , whereas those in the lowest tercile generally did not have these programs . Because of the differing numbers of questions and wide range of possible values within each intensity score , each question was z-transformed to a mean of 0.0 and st and ard deviation near or equal to 1.0 to facilitate comparison .
There was no evidence of improvement in depression , quality of life , blood pressure , serum lipids , or weight .
There was no evidence of significant adverse effects .
CONCLUSIONS Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control , and this effect was larger in the mobile phone subgroup .
There was no evidence of benefit for other biological , cognitive , behavioral , or emotional outcomes
OBJECTIVE Structured patient education programs can reduce the risk of diabetes-related complications .
However , people appear to have difficulties attending face-to-face education and alternatives are needed .
This review looked at the impact of computer-based diabetes self-management interventions on health status , cardiovascular risk factors , and quality of life of adults with type 2 diabetes .