Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis
- 705 Downloads
Diabetes self-management education is an essential part of diabetes care, but its impact on all-cause mortality risk of type 2 diabetes patients is unclear. A systematic review and meta-analysis aiming to elucidate the impact of diabetes self-management education on all-cause mortality risk of type 2 diabetes patients was performed.
Randomised controlled trials were identified though literature search in Medline, Embase, CENTRAL, conference abstracts, and reference lists. Only randomised controlled trials comparing diabetes self-management education with usual care in type 2 diabetes patients and reporting outcomes after a follow-up of at least 12 months were considered eligible. Risk ratios with 95 %CIs were pooled. This study was registered at PROSPERO with the number of CRD42016043911.
42 randomised controlled trials containing 13,017 participants were included. The mean time of follow-up was 1.5 years. There was no heterogeneity among those included studies (I 2 = 0 %). Mortality occurred in 159 participants (2.3 %) in the diabetes self-management education group and in 187 (3.1 %) in the usual care group, and diabetes self-management education significantly reduced risk of all-cause mortality in type 2 diabetes patients (pooled risk ratios : 0.74, 95 %CI 0.60–0.90, P = 0.003; absolute risk difference: −0.8 %, 95 %CI −1.4 to −0.3). Both multidisciplinary team education and nurse-led education could significantly reduce mortality risk in type 2 diabetes patients, and the pooled risk ratios were 0.66 (95 %CI 0.46–0.96, P = 0.02; I 2 = 0 %) and 0.64 (95 % CI 0.47– 0.88, P = 0.005; I 2 = 0 %), respectively. Subgroup analyses of studies with longer duration of follow-up (≥1.5 years) or larger sample size (≥300) also found a significant effect of diabetes self-management education in reducing mortality risk among type 2 diabetes. Significant effect of diabetes self-management education in reducing mortality risk was also found in those patients receiving diabetes self-management education with contact hours more than 10 h (pooled risk ratio: 0.60, 95 %CI 0.44–0.82, P = 0.001; I 2 = 0 %), those receiving repeated diabetes self-management education (pooled RR: 0.71, P = 0.001; I 2 = 0 %), those receiving diabetes self-management education using structured curriculum (pooled risk ratio: 0.72, P = 0.01; I 2 = 0 %) and those receiving diabetes self-management education using in-person communication (pooled risk ratio: 0.75, P = 0.02; I 2 = 0 %). The quality of evidence for the effect of diabetes self-management education in reducing all-cause mortality risk among type 2 diabetes patients was rated as moderate according to the Grading of Recommendations Assessment, Development, and Evaluation method, and the absolute risk reduction of all-cause mortality of type 2 diabetic patients by diabetes self-management education was estimated to be 4 fewer per 1000 person-years (from 1 fewer to 6 fewer).
The available evidence suggests that diabetes self-management education can reduce all-cause mortality risk in type 2 diabetes patients. Further clinical trials with longer time of follow-up are needed to validate the finding above.
KeywordsDiabetes self-management education Type 2 diabetes All-cause mortality Meta-analysis
We thank Prof. Zhang from Huadong Hospital of Fudan University for her helpful advice on our study.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no competing interests.
This article does not contain any studies with human participants performed by any of the authors.
- 5.A. Dinesh Shah, C. Langenberg, E. Rapsomaniki, S. Denaxas, M. Pujades-Rodriguez, C.P. Gale, J. Deanfield, L. Smeeth, A. Timmis, H. Hemingway, Type 2 diabetes and incidence of a wide range of cardiovascular diseases: a cohort study in 1.9 million people. Lancet. 385(Suppl 1), S86 (2015). doi: 10.1016/S0140-6736(15)60401-9 CrossRefPubMedGoogle Scholar
- 8.J.R. Brownrigg, C.O. Hughes, D. Burleigh, A. Karthikesalingam, B.O. Patterson, P.J. Holt, M.M. Thompson, S. de Lusignan, K.K. Ray, R.J. Hinchliffe, Microvascular disease and risk of cardiovascular events among individuals with type 2 diabetes: a population-level cohort study. Lancet Diabetes Endocrinol. 4(7), 588–597 (2016). doi: 10.1016/S2213-8587(16)30057-2 CrossRefPubMedGoogle Scholar
- 12.L. Haas, M. Maryniuk, J. Beck, C.E. Cox, P. Duker, L. Edwards, E.B. Fisher, L. Hanson, D. Kent, L. Kolb, S. McLaughlin, E. Orzeck, J.D. Piette, A.S. Rhinehart, R. Rothman, S. Sklaroff, D. Tomky, G. Youssef, National standards for diabetes self-management education and support. Diabetes. Care. 37(Suppl 1), S144–S153 (2014). doi: 10.2337/dc14-S144 CrossRefPubMedGoogle Scholar
- 13.M.A. Powers, J. Bardsley, M. Cypress, P. Duker, M.M. Funnell, A. Hess Fischl, M.D. Maryniuk, L. Siminerio, E. Vivian, Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American diabetes association, the American association of diabetes educators, and the academy of nutrition and dietetics. Diabetes Care 38(7), 1372–1382 (2015). doi: 10.2337/dc15-0730 CrossRefPubMedGoogle Scholar
- 16.J. Pillay, M.J. Armstrong, S. Butalia, L.E. Donovan, R.J. Sigal, B. Vandermeer, P. Chordiya, S. Dhakal, L. Hartling, M. Nuspl, R. Featherstone, D.M. Dryden, Behavioral programs for type 2 diabetes mellitus: a systematic review and network meta-analysis. Ann Intern Med 163(11), 848–860 (2015). doi: 10.7326/M15-1400 CrossRefPubMedGoogle Scholar
- 25.W. Palmas, D. March, S. Darakjy, S.E. Findley, J. Teresi, O. Carrasquillo, J.A. Luchsinger, Community health worker interventions to improve glycemic control in people with diabetes: a systematic review and meta-analysis. J. Gen. Intern. Med. 30(7), 1004–1012 (2015). doi: 10.1007/s11606-015-3247-0 CrossRefPubMedPubMedCentralGoogle Scholar
- 28.J.K. Tshiananga, S. Kocher, C. Weber, K. Erny-Albrecht, K. Berndt, K. Neeser, The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: a meta-analysis. Diabetes Educ. 38(1), 108–123 (2012). doi: 10.1177/0145721711423978 CrossRefPubMedGoogle Scholar
- 29.A. Steinsbekk, L.O. Rygg, M. Lisulo, M.B. Rise, A. Fretheim, Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv. Res. 12, 213 (2012). doi: 10.1186/1472-6963-12-213 CrossRefPubMedPubMedCentralGoogle Scholar
- 37.J.P. Higgins, S. Green (ed.), Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration (2011). Available from www.handbook.cochrane.org
- 41.W. Crasto, J. Jarvis, K. Khunti, T.C. Skinner, L.J. Gray, J. Brela, J. Troughton, H. Daly, I.G. Lawrence, P.G. McNally, M.E. Carey, M.J. Davies, Multifactorial intervention in individuals with type 2 diabetes and microalbuminuria: the microalbuminuria education and medication optimisation (MEMO) study. Diabetes Res. Clin. Pract. 93(3), 328–336 (2011). doi: 10.1016/j.diabres.2011.05.008 CrossRefPubMedGoogle Scholar
- 44.T. Johansson, S. Keller, H. Winkler, T. Ostermann, R. Weitgasser, A.C. Sonnichsen, Effectiveness of a peer support programme versus usual care in disease management of diabetes mellitus type 2 regarding improvement of metabolic control: A cluster-randomised controlled trial. J. Diabetes Res. 2016, 3248547 (2016). doi: 10.1155/2016/3248547 CrossRefPubMedGoogle Scholar
- 45.M.K. Ali, K. Singh, D. Kondal, R. Devarajan, S.A. Patel, R. Shivashankar, V.S. Ajay, A.G. Unnikrishnan, V.U. Menon, P.K. Varthakavi, V. Viswanathan, M. Dharmalingam, G. Bantwal, R.K. Sahay, M.Q. Masood, R. Khadgawat, A. Desai, B. Sethi, D. Prabhakaran, K.M. Narayan, N. Tandon, Effectiveness of a multicomponent quality improvement strategy to improve achievement of diabetes care goals: a randomized, controlled trial. Ann. Intern. Med. (2016). doi: 10.7326/M15-2807
- 46.R. Perez-Escamilla, G. Damio, J. Chhabra, M.L. Fernandez, S. Segura-Perez, S. Vega-Lopez, G. Kollannor-Samuel, M. Calle, F.M. Shebl, D. D’Agostino, Impact of a community health workers-led structured program on blood glucose control among latinos with type 2 diabetes: the DIALBEST trial. Diabetes Care. 38(2), 197–205 (2015). doi: 10.2337/dc14-0327 CrossRefPubMedGoogle Scholar
- 48.D. Edelman, R.J. Dolor, C.J. Coffman, K.C. Pereira, B.B. Granger, J.H. Lindquist, A.M. Neary, A.J. Harris, H.B. Bosworth, Nurse-led behavioral management of diabetes and hypertension in community practices: a randomized trial. J. Gen. Intern. Med. 30(5), 626–633 (2015). doi: 10.1007/s11606-014-3154-9 CrossRefPubMedPubMedCentralGoogle Scholar
- 50.E.G. Eakin, E.A. Winkler, D.W. Dunstan, G.N. Healy, N. Owen, A.M. Marshall, N. Graves, M.M. Reeves, Living well with diabetes: 24-month outcomes from a randomized trial of telephone-delivered weight loss and physical activity intervention to improve glycemic control. Diabetes Care 37(8), 2177–2185 (2014). doi: 10.2337/dc13-2427 CrossRefPubMedGoogle Scholar
- 51.L.M. Welschen, P. van Oppen, S.D. Bot, P.J. Kostense, J.M. Dekker, G. Nijpels, Effects of a cognitive behavioural treatment in patients with type 2 diabetes when added to managed care; a randomised controlled trial. J. Behav. Med. 36(6), 556–566 (2013). doi: 10.1007/s10865-012-9451-z CrossRefPubMedGoogle Scholar
- 53.U. Mons, E. Raum, H.U. Kramer, G. Ruter, D. Rothenbacher, T. Rosemann, J. Szecsenyi, H. Brenner, Effectiveness of a supportive telephone counseling intervention in type 2 diabetes patients: randomized controlled study. PLoS ONE. 8(10), e77954 (2013). doi: 10.1371/journal.pone.0077954 CrossRefPubMedPubMedCentralGoogle Scholar
- 54.J.J. Gagliardino, S. Lapertosa, G. Pfirter, M. Villagra, J.E. Caporale, C.D. Gonzalez, J. Elgart, L. Gonzalez, C. Cernadas, E. Rucci, C. Clark Jr., Clinical, metabolic and psychological outcomes and treatment costs of a prospective randomized trial based on different educational strategies to improve diabetes care (PRODIACOR). Diabetes Med. 30(9), 1102–1111 (2013). doi: 10.1111/dme.12230 CrossRefGoogle Scholar
- 55.M.J. Crowley, B.J. Powers, M.K. Olsen, J.M. Grubber, C. Koropchak, C.M. Rose, P. Gentry, L. Bowlby, G. Trujillo, M.L. Maciejewski, H.B. Bosworth, The cholesterol, hypertension, and glucose education (CHANGE) study: results from a randomized controlled trial in African Americans with diabetes. Am. Heart J. 166(1), 179–186 (2013). doi: 10.1016/j.ahj.2013.04.004 CrossRefPubMedGoogle Scholar
- 56.I.D. Blackberry, J.S. Furler, J.D. Best, P. Chondros, M. Vale, C. Walker, T. Dunning, L. Segal, J. Dunbar, R. Audehm, D. Liew, D. Young, Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the patient engagement and coaching for health (PEACH) pragmatic cluster randomised controlled trial. BMJ. 347, f5272 (2013). doi: 10.1136/bmj.f5272 CrossRefPubMedPubMedCentralGoogle Scholar
- 58.K. Khunti, L.J. Gray, T. Skinner, M.E. Carey, K. Realf, H. Dallosso, H. Fisher, M. Campbell, S. Heller, M.J. Davies, Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ. 344, e2333 (2012). doi: 10.1136/bmj.e2333 CrossRefPubMedPubMedCentralGoogle Scholar
- 60.R.C. Andrews, A.R. Cooper, A.A. Montgomery, A.J. Norcross, T.J. Peters, D.J. Sharp, N. Jackson, K. Fitzsimons, J. Bright, K. Coulman, C.Y. England, J. Gorton, A. McLenaghan, E. Paxton, A. Polet, C. Thompson, C.M. Dayan, Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial. Lancet. 378(9786), 129–139 (2011). doi: 10.1016/S0140-6736(11)60442-X CrossRefPubMedGoogle Scholar
- 61.G.A. Piatt, R.M. Anderson, M.M. Brooks, T. Songer, L.M. Siminerio, M.M. Korytkowski, J.C. Zgibor, 3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial. Diabetes Educ. 36(2), 301–309 (2010). doi: 10.1177/0145721710361388 CrossRefPubMedGoogle Scholar
- 62.D. Edelman, S.K. Fredrickson, S.D. Melnyk, C.J. Coffman, A.S. Jeffreys, S. Datta, G.L. Jackson, A.C. Harris, N.S. Hamilton, H. Stewart, J. Stein, M. Weinberger, Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Ann. Intern. Med. 152(11), 689–696 (2010). doi: 10.7326/0003-4819-152-11-201006010-00001 CrossRefPubMedGoogle Scholar
- 66.T. Shibayama, K. Kobayashi, A. Takano, T. Kadowaki, K. Kazuma, Effectiveness of lifestyle counseling by certified expert nurse of Japan for non-insulin-treated diabetic outpatients: a 1-year randomized controlled trial. Diabetes Res. Clin. Pract. 76(2), 265–268 (2007). doi: 10.1016/j.diabres.2006.09.017 CrossRefPubMedGoogle Scholar
- 69.R.L. Rothman, R. Malone, B. Bryant, A.K. Shintani, B. Crigler, D.A. Dewalt, R.S. Dittus, M. Weinberger, M.P. Pignone, A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am. J. Med. 118(3), 276–284 (2005). doi: 10.1016/j.amjmed.2004.09.017 CrossRefPubMedGoogle Scholar
- 72.A.N. Goudswaard, R.P. Stolk, N.P. Zuithoff, H.W. de Valk, G.E. Rutten, Long-term effects of self-management education for patients with Type 2 diabetes taking maximal oral hypoglycaemic therapy: a randomized trial in primary care. Diabetes Med. 21(5), 491–496 (2004). doi: 10.1111/j.1464-5491.2004.01153.x CrossRefGoogle Scholar
- 75.J.P. New, J.M. Mason, N. Freemantle, S. Teasdale, L.M. Wong, N.J. Bruce, J.A. Burns, J.M. Gibson, Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial. Diabetes Care 26(8), 2250–2255 (2003)CrossRefPubMedGoogle Scholar
- 76.T.L. Gary, L.R. Bone, M.N. Hill, D.M. Levine, M. McGuire, C. Saudek, F.L. Brancati, Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Prev. Med. 37(1), 23–32 (2003)CrossRefPubMedGoogle Scholar
- 80.M. Weinberger, M.S. Kirkman, G.P. Samsa, E.A. Shortliffe, P.B. Landsman, P.A. Cowper, D.L. Simel, J.R. Feussner, A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J. Gen. Intern. Med. 10(2), 59–66 (1995)CrossRefPubMedGoogle Scholar
- 82.Z.T. Bloomgarden, W. Karmally, M.J. Metzger, M. Brothers, C. Nechemias, J. Bookman, D. Faierman, F. Ginsberg-Fellner, E. Rayfield, W.V. Brown, Randomized, controlled trial of diabetic patient education: improved knowledge without improved metabolic status. Diabetes Care. 10(3), 263–272 (1987)CrossRefPubMedGoogle Scholar
- 84.M. Peyrot, K.K. Burns, M. Davies, A. Forbes, N. Hermanns, R. Holt, S. Kalra, A. Nicolucci, F. Pouwer, J. Wens, I. Willaing, S.E. Skovlund, Diabetes attitudes wishes and needs 2 (DAWN2): a multinational, multi-stakeholder study of psychosocial issues in diabetes and person-centred diabetes care. Diabetes Res. Clin. Pract. 99(2), 174–184 (2013). doi: 10.1016/j.diabres.2012.11.016 CrossRefPubMedGoogle Scholar
- 85.M.E. Chomko, P.S. Odegard, A.B. Evert, Enhancing access to diabetes self-management education in primary care. Diabetes Educ. (2016). doi: 10.1177/0145721716659147
- 86.A.C. Tricco, N.M. Ivers, J.M. Grimshaw, D. Moher, L. Turner, J. Galipeau, I. Halperin, B. Vachon, T. Ramsay, B. Manns, M. Tonelli, K. Shojania, Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet. 379(9833), 2252–2261 (2012). doi: 10.1016/S0140-6736(12)60480-2 CrossRefPubMedGoogle Scholar
- 87.C.K. Wong, W.C. Wong, Y.F. Wan, A.K. Chan, K.L. Chung, F.W. Chan, C.L. Lam, Patient empowerment programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study. Diabetes Obes. Metab. 17(2), 128–135 (2015). doi: 10.1111/dom.12397 CrossRefPubMedGoogle Scholar
- 89.B.R. Shah, J. Hwee, K. Cauch-Dudek, R. Ng, J.C. Victor, Diabetes self-management education is not associated with a reduction in long-term diabetes complications: an effectiveness study in an elderly population. J. Eval. Clin. Pract. 21(4), 656–661 (2015). doi: 10.1111/jep.12360 CrossRefPubMedGoogle Scholar
- 90.G. Perman, A. Beratarrechea, V. Aliperti, L. Litwak, S. Figar, A. Alvarez, E. Langlois, Mortality in an elderly type 2 diabetic patients’ cohort who attended a self-management educational workshop. Prim. Care Diabetes. 5(3), 175–184 (2011). doi: 10.1016/j.pcd.2011.03.002 CrossRefPubMedGoogle Scholar
- 92.C.K. Wong, W.C. Wong, E.Y. Wan, A.K. Chan, F.W. Chan, C.L. Lam, 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). Endocrine 53(2), 412–422 (2016). doi: 10.1007/s12020-015-0843-z CrossRefPubMedGoogle Scholar
- 93.H.M. Hsieh, T.H. Lin, I.C. Lee, C.J. Huang, S.J. Shin, H.C. Chiu, The association between participation in a pay-for-performance program and macrovascular complications in patients with type 2 diabetes in Taiwan: a nationwide population-based cohort study. Prev. Med. 85, 53–59 (2016). doi: 10.1016/j.ypmed.2015.12.013 CrossRefPubMedGoogle Scholar
- 99.N.H. Jonkman, H. Westland, R.H. Groenwold, S. Agren, F. Atienza, L. Blue, P.W. Bruggink-Andre de la Porte, D.A. DeWalt, P.L. Hebert, M. Heisler, T. Jaarsma, G.I. Kempen, M.E. Leventhal, D.J. Lok, J. Martensson, J. Muniz, H. Otsu, F. Peters-Klimm, M.W. Rich, B. Riegel, A. Stromberg, R.T. Tsuyuki, D.J. van Veldhuisen, J.C. Trappenburg, M.J. Schuurmans, A.W. Hoes, Do self-management interventions work in patients with heart failure? An individual patient data meta-analysis. Circulation. 133(12), 1189–1198 (2016). doi: 10.1161/CIRCULATIONAHA.115.018006 CrossRefPubMedGoogle Scholar
- 100.K. Ismail, K. Winkley, S. Rabe-Hesketh, Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 363(9421), 1589–1597 (2004). doi: 10.1016/S0140-6736(04)16202-8 CrossRefPubMedGoogle Scholar