Does Self-Management Education Improve Glycemic Control in Diabetes?
A systematic review of evidence may help answer question of whether DSME benefits patients with diabetes.
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Joan K. Bardsley, MBA, RN, CDE, FAADE, discusses her presentation on a systematic review of studies outlining the benefits of diabetes self-management education.
NEW ORLEANS — The American Association of Diabetes Educators (AADE) conducted a systematic review of the literature to help answer the following question: In the setting of randomized controlled trials, does diabetes self-management education (DSME) improve glycemic control, as measured by HbA1c, in adults with type 2 diabetes as compared with those who received usual care without DSME?
At AADE 2015, Dawn Scherr, MS, RD, CDE, associate director of practice management for AADE, and I presented the background and results of this review.
During our presentation, Scherr described the reasons for conducting the review, including providing evidence for the most effective ways to engage those with type 2 diabetes in self-care behaviors such as lifestyle change.
The results showed that, overall, 62% of the unique interventions demonstrated statistically significant improvement in HbA1c among those who received the DSME intervention than those who received usual care.
The areas reviewed included mode of delivery (group, individual, remote or combined), who delivered the intervention (team-based or an individual), baseline HbA1c, the period over which the DSME was delivered and the number of hours the individual received.
Results showed that DSME delivered through a combination of individualized and group sessions not only significantly improved outcomes but was also ranked the highest among the four modes of delivery. While both group-only and individual-only delivery had more interventions with a positive outcome, the difference was not as great as when the two modalities were combined.
The randomized, controlled trial that looked at remote delivery did not find statistically improved outcomes. Yet, we might say that it is possible that remote engagement has not yet reached maturity as a mode of effective delivery.
When looking at all of these modes together, adding DSME resulted in a little more than a 0.56% reduction in HbA1c. I noted that because the FDA will look favorably on a medication with a safe side effect profile that improves HbA1c by 0.4%, this is an impressive demonstration that the behavioral intervention of DSME results in not only a statistically significant improvement in glycemic control but in a clinically significant improvement as well.
DSME is typically delivered by a single provider or a team of providers. The review showed that the team approach resulted in a greater proportion of positive studies than when one provider attempted to cover the full gamut of DSME content. However, in looking at the actual magnitude of improvement in HbA1c, there does not appear to be any difference between engaging one or more than one person in the provision of DSME.
While the proportion of studies in which HbA1c was improved in the DSME intervention group, the most striking difference was in those individuals starting with the highest HbA1c at baseline. Even so, we cautioned that we should not jump to the conclusion that we would naturally see the greatest change in HbA1c among patients who started with an HbA1c of greater than 9%, for example, as both the control and intervention groups received pharmacologic treatment.
Instead, we may conclude that adding DSME to the treatment of these individuals with poor glycemic control makes a difference in addition to the improvement seen with medication.
The time period during which DSME delivery occurred — whether people were engaged in DSME over a period of less than 2.5 months or greater than 12 months — did not appear to generate differences, with all resulting in a higher proportion of interventions demonstrating statistical improvement of HbA1c compared with those in the control group.
The maximum number of hours of DSME in which people participated, however, does seem to matter. The proportion of studies demonstrating a statistically significant improvement in HbA1c was great for those who have more than 10 hours of DSME.
Despite data that show the value of DMSE, there are robust data demonstrating that the vast majority of people with either private insurance or Medicare coverage fail to engage in DSME in the first year they are diagnosed. Further, the data show that those participating during that first year in which they are diagnosed engaged in 1.5 hours. Thirty percent only took part in half an hour. These are hard data to refute the claim that DSME doesn't have an impact. No one would expect an hour and half to result in meaningful change.
On a positive note, the fact that 45% of people with diabetes do not achieve glycemic targets represents an opportunity to encourage their participation in DSME to help them get closer to goal.
Joan K. Bardsley, MBA RN CDE FAADE, is Assistant Vice President of Special Projects at MedStar Health Research Institute, and 2014 President of the American Association of Diabetes Educators.
- Scherr D, Bardsley J. W08 – A Systematic Review of the Literature of the Effect of DSME on HbA1c for People with Type 2 Diabetes. Presented at: AADE 2015; Aug. 5-8, 2015; New Orleans.