Long-term Effects Of Group-based Diabetes Self-management For People With Type 2 Diabetes In Community

BackgroundGroup-based diabetes self-management education is low cost and high efficiency.The study on its’ long-term effect is rare,and the effect remains to be unclear.Literature retrieval found that most studies reported clinical outcomes,but a few presented adverse prognostic events,so this study was carried out by two steps.First,a systematic review was used to evaluate the long-term effect of self-management on clinical outcomes.Second,a follow-up study was conducted to evaluate its’ effect on adverse prognostic events,which gave a supplement to the systematic review.Objectives1.To evaluate the long-term effects of group-based diabetes self-management education on blood glucose,blood lipids,blood pressure,weight control,quality of life,cardiovascular events,self-management compliance,number of visits to health care institution,and death events.To analyze influencing factors of glycosylated hemoglobin(HbA1c)control.2.To evaluate the long-term effects of group-based diabetes self-management education on diabetes complications,comorbidities,and death events.To analyze influencing factors of diabetic complications,comorbidities,and death among self-management patients.3.To explore the improvement method and priority of group-based diabetes self-management education.Methods1.The method of systematic review was used to retrieve the randomized controlled trials and cluster randomized controlled trials published until July 28,2020.Literature screening and quality evaluation was carried out by two researchers independently.The Cochrane Q test and inconsistency index test were employed to estimate the heterogeneity.If the heterogeneity was small,or large with an identifiable source,mean difference(MD)was used for Meta analysis to estimate effect size and its confidence interval;otherwise,descriptive analysis was performed.Then the Meta regression,subgroup analysis,sensitivity analysis,publication bias test,and evidence quality assessment were conducted.Figures were drawn by RevMan 5.3 and Microsoft Excel 2019.Stata16.0 and GRADE Profiler 3.6 were used for data analysis.2.The method of field investigation and system data matching was used to investigate 500 participants who participated in the trial of group-based diabetes self-management education in Fangshan District,Beijing from July 2014 to November.The information of demography,diabetes complications and comorbidities were collected by field investigation.Survival condition was checked by the basic public health service system.Death condition was collected by the death cause surveillance system of Beijing.Logistic regression model was used to determine the relationship between the intervention and the incidence of diabetes complications,complications,and death events.This model was also used to analyze the influencing factors and interactions for the occurrence of diabetes complications,complications,and death events among self-management patients.SAS 9.4 software was used for data analysis.Results1.A total of 5 071 follow-up patients from 25 studies were included in the systematic review.Two studies were low risk of bias,11 were uncertain,and 12 were high.Group-based diabetes self-management education had statistically significant impacts on HbA1c[MD=-0.39%(95%CI:-0.56,-0.21)],diastolic blood pressure[MD=-1.32 mmHg(95%CI:-2.44,-0.21)]and systolic blood pressure[MD=-1.92 mmHg(95%CI:-3.47,-0.37)]with the most significant effect at 12 months after the study was carried out.The result of HbA1c may be affected by publication bias,and the findings of blood pressure were not robust.There was no statistically significant impact on triglyceride,high-density lipoprotein cholesterol,total cholesterol,body mass index and body weight(all P>0.05).The finding of body mass index was not robust and may be affected by publication bias.Meta analysis was not available for low-density lipoprotein cholesterol,quality of life,self-management compliance,number of visits to health care institution,cardiovascular events,and death events.The evidence quality of total cholesterol,blood pressure and body weight were moderate,and the rest was low or very low.Taking doctors/nurses/experts as facilitators[MD=-0.53%(95%CI:-0.79,-0.27)]and conducting long-term education[MD=-0.87%(95%CI:-0.79,-0.27)]were favorable factors for HbA1c control.Participation of families/friends,the number of patients in the group ≤10,and the patients’age<60 may be favorable factors for the reduction of HbA1c.2.In the follow-up study,362 patients with type 2 diabetes were followed up by field investigation with a follow-up rate of 72.40%,and 483 patients were matched by two systems with the rate of 96.60%.The result showed that the group-based diabetes self-management education had no significant effect on the incidence of diabetes complications,comorbidities,and death after adjustment for covariates(all P>0.05).For self-management patients,self-efficacy score ≥80 was a protective factor to prevent diabetic nephropathy[OR=0.06(95%CI:0.01,0.59)]and diabetic lower extremity vascular disease[OR=0.06(95%CI:0.01,0.55)].Urban residence[OR=0.24(95%CI:0.07,0.89)]was a protective factor against diabetes complications.Compared with family per capita monthly income<1000 yuan,income of 1000-3000 yuan[OR=0.28(95%CI:0.08,0.98)]was a protective factor against hyperlipidemia.The income of 1000-3000 yuan[OR=0.36(95%CI:0.14,0.88)],≥3000 yuan[OR=0.15(95%CI:0.03,0.70)]and self-reported comorbidities before enrollment[OR=0.20(95%CI:0.07,0.52)]were protective factors for the incidence of other comorbidities after receiving the education.Urban residence[OR= 0.16(95%CI:0.04,0.55)]was a protective factor against death events.There was an additive interaction between family per capita monthly income and self-efficacy score,family per capita monthly income and self-report of comorbidities before enrollment,place of residence and course of diabetes.Conclusions1.Group-based diabetes self-management education contributes to the reduction of HbA1c and blood pressure in the long term,but may have no effect on blood lipid,weight control,diabetes complications,comorbidities,and death.The long-term impact on the quality of life,self-management compliance,number of visits to health care institution was still inconclusive.2.Taking doctors/nurses/experts as facilitators and conducting long-term education are favorable factors for HbA1c control;high self-efficacy is a protective factor for the prevention of diabetes complications;low income and rural residents are risk factors for the incidence of diabetes complications,comorbidities,and death.3.It is recommended that diabetes self-management education is carried out by doctors/nurses/experts with the improvement of patients’self-efficacy as the core goal,and the system of conducting long-term education should be established.4.Low-income patients and rural residents should be the key population for diabetes control in the future.