Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis

Xiaoqin He, Jie Li, Bin Wang, Qiuming Yao, Ling Li, Ronghua Song, Xiaohong Shi, Jin-an Zhang

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.