Group based diabetes self‐management education compared to routine treatment, waiting list control or no intervention for people with type 2 diabetes mellitus

Aslak Steinsbekk, Lisbeth Ø. Rygg, Monde Lisulo, Marit By Rise, Atle Fretheim

Self-management skills are necessary for patients with type 2 diabetes. Group based diabetes self management education (DSME) is central among methods for teaching self-management. To assess effects of group-based DSME on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients. Computerised bibliographic database searches up to last week of December 2011, reference lists, other reviews and contact with experts. Randomised controlled trials (RCT's) evaluating group-based DSME for adult type-2 diabetics versus routine treatment, waiting list or no intervention. ; intervention having minimum 3 participants and one session of at least one hour, and at least 6 months follow-up. Reviewers independently extracted data, assessed study quality and graded outcomes according to standard guidacnce developed by The Cochrane Collaboration. In total 42 publications (36 studies, 7573 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 62.9 years, BMI 31.1, HbA1c 7.9%, diabetes duration 10.3 years and 57.3% used medication. Most of the studies we included were at an unclear (25 studies) or high risk of bias (2 studies). Nine were at a low risk of bias. Gropu based self-management education lowered HbA1c at 6 months (-0.32%; 95% CI -0.49 to -0.15, 23 studies, 3910 participants; moderate quality evidence). Lower HbA1c with self-management intervention persisted to 5 years of follow-up: (-1.53%; 95% CI -1.88 to -1.19, two studies, 216 participants; moderate quality evidence) . Fasting blood glucose levels was lower in intervention groups at 12 months (-0.96mmol/l; 95% CI -1.59 to -0.33, 6 studies, 794 participants) and at 4 years (-0.96 mmol/l; P = 0.04, 2 studies, 693 participants; moderate quality evidence), but not at 6 months (0.60 mmol/l; P = 0.13, 7 studies, 758 participants; low quality evidence). Self-management led to higher knowledge scores compared with usual care at 6 months (SMD 0.65; 95% CI 0.47 to 0.83, 9 studies, 1128 participants) and 12 months (SMD 0.85; P < 0.00001, 5 studies, 955 participants). Self management skills also improved significantly at 6 months (SMD 0.49; P = 0.007, 5 studies, 590 participants). Self-management interventions improved empowerment/self-efficacy at 6 months compared with usual care (SMD 0.32, P< 0.00001, 5 studies, 1006 participants). . Quality of life scores across individual studies suggested very substantial variation in the size of effect across the studies. Participant satisfaction was higher with intervention at 6 and 12 months. There was a low mortality rate across the studies which was balanced between intervention and control (OR 1.03; 95% CI 0.38 to 2.80). Body weight did not differ statistically at 6 months, but was lower at 12 months Body mass index, blood pressure and lipid profile at 6 and 12 months did not differ statistcally between treatment groups. Overall there is moderate quality evidence that group-based DSME interventions result in improved disease control and knowledge for people with type 2 diabetes. The main limitations of our findings are substantial variation between the results of the studies, which we could only partially explain by removing outlying results. There remains uncertainty as to the impact of self-management on quality of life.