The relationship between the strength of evidence of effectiveness and the strength of the recommendation is defined at the end of the "Major Recommendations" field.
Healthcare System Interventions
The Task Force reviewed two interventions to improve the performance of healthcare systems and providers delivering care to persons with diabetes: disease management and case management. In the last decade, new systems of heath care delivery such as these have emerged for many reasons: traditional systems have failed to meet the needs of persons with diabetes, population demographics have changed, new healthcare technology is continually emerging, more attention is being paid to quality of life and other patient-oriented outcomes, society demands the minimization of medical errors, and there is a desire to make the most of limited healthcare resources.
Disease management (strongly recommended)
Disease management of diabetes in the clinical setting is an organized, proactive, multi-component approach to health care delivery for all members of a population with diabetes or for a subpopulation with specific health risk factors. It embraces all aspects of the delivery system. Care is focused on, and integrated across, the entire spectrum of the disease and its complications as well as the prevention of comorbid conditions. The goal is to improve short- and long-term health or economic outcomes, or both, in the entire population with diabetes.
The essential components of disease management are:
- identification of individuals or populations with
diabetes (or a subset with certain risk factors)
- use of guidelines or performance standards to manage
those identified
- information systems to track and monitor
interventions and patient-, practice-, or population-based outcomes
- measurement and management of patient and population outcomes
Other interventions may be incorporated into disease management interventions, and these can be focused on:
- the healthcare system (e.g., practice redesign,
electronic information systems, changes in models of care)
- the provider (e.g., reminders, education, feedback,
decision support)
- the patient or population (e.g., patient-centered care strategies, diabetes self-management education (DMSE), reminders, feedback, telephone call outreach)
Disease management is strongly recommended by the Task Force based on strong evidence of its effectiveness in improving glycemic control, provider monitoring of glycosylated hemoglobin (GHb), and screening for diabetic retinopathy. Sufficient evidence is also available of its effectiveness in improving provider screening of the lower extremities for neuropathy and vascular changes, urine screening for protein, and monitoring of lipid concentrations. This recommendation is applicable to adults with diabetes, in the settings of managed care organizations and community clinics in the United States and Europe. Although a number of other important health outcomes were examined, including blood pressure and lipid concentrations, data were insufficient to make recommendations based on these outcomes.
Case management (strongly recommended)
Case management is "a set of activities whereby the needs of populations of patients at risk for excessive resource utilization, poor outcomes, or poor coordination of services are identified and addressed through improved planning, coordination, and provision of care". It usually involves the assignment of authority to a single professional (the case manager, most commonly a nurse) who is not a provider of direct health care.
The essential features of case management are:
- the identification of eligible patients
- the assessment of individual patients’ needs
- development of an individual care plan
- implementation of that care plan
- monitoring of outcomes
Case management is often combined with disease management but may also stand alone as an intervention or be combined with other clinical care interventions (e.g., practice guidelines or patient reminders).
Case management is strongly recommended by the Task Force based on strong evidence of its effectiveness in improving glycemic control. Evidence is also available of its effectiveness in improving provider monitoring of GHb, when case management is combined with disease management. These findings are applicable primarily in the U.S. managed care setting for adults with type 2 diabetes.
Diabetes Self-Management Education Interventions
The Task Force reviewed several interventions delivered in community settings to improve the self-management of persons with diabetes or to increase the understanding of diabetes among coworkers or school personnel. DMSE, the process of teaching people to manage their own diabetes, is considered by many to be "the cornerstone of care for all individuals with diabetes who want to achieve successful health-related outcomes". The goals of diabetes education are to optimize metabolic control, prevent acute and chronic complications, and achieve an optimal quality of life, while keeping costs acceptable. One of the Healthy People 2010 goals is to increase to 60% (from the 1998 baseline of 40%) the proportion of people with diabetes who receive formal diabetes education. Significant knowledge and skill deficits are found in 50%-80% of persons with diabetes and levels of glycemia (as measured by GHb, which includes hemoglobin A1 [HbA1] and hemoglobin A1c [HbA1c], both formed nonenzymatically from hemoglobin and glucose) are unacceptably high in both persons with type 1 and type 2 diabetes. DMSE is provided in a variety of settings, including recreational camps, schools, the worksite, the home, and community gathering places. Although these interventions have some common characteristics, target populations, providers, and content can differ, and thus we have defined them as separate interventions in this review.
Diabetes self-management education in community gathering places (recommended for adults with type 2 diabetes)
In this intervention, DMSE is provided to persons over the age of 18 years in settings other than the home, clinic, school, or worksite (e.g., community centers, faith-based institutions, libraries, or private facilities such as residential cardiovascular risk-reduction centers). Community gathering places have been pursued because traditional clinical settings may not be ideal for DMSE of adults, the home setting is conducive only to individual or family teaching, and education at the worksite does not reach those not working outside the home.
Based on Community Guide rules of evidence, the Task Force concluded that there is sufficient evidence of effectiveness in improving glycemic control to recommend DMSE interventions in community gathering places for adults with type 2 diabetes. It should be noted, however, that these interventions were rarely coordinated with the patient’s clinical care provider and the nature and extent of care in the clinical setting was unclear. DMSE for adults with type 2 diabetes delivered in the setting of community gathering places should be coordinated with the person’s primary care provider, and these interventions are not meant to replace education delivered in the clinical setting.
Diabetes self-management education in the home (recommended for adolescents with type 1 diabetes; insufficient evidence for persons with type 2 diabetes)
The home may be a good setting for DMSE interventions because the educator can address issues that may be more difficult to deal with in the clinical setting, such as cultural, family, and environmental factors affecting lifestyle, self-monitoring of blood glucose, and barriers to optimal self-care.
Based on Community Guide rules of evidence, there is sufficient evidence that DMSE in the home is effective for improving glycemic control among adolescents with type 1 diabetes, whether using home visits or computer-assisted instruction. Too few studies were available to assess the effectiveness of DMSE in the home for persons with type 2 diabetes.
Diabetes self-management education in the camp setting (insufficient evidence)
DMSE in summer camps exposes children and adolescents with type 1 diabetes to intensive self-management education in a short-term recreational camp setting (usually 1-2 weeks). Summer camps, where education can be readily integrated into daily routines, have several advantages: medical treatment and compliance with educational programs can be optimized, food intake is controlled, physical activity can be pursued, and medical expertise is usually readily available.
The Task Force identified 10 qualifying studies, all of adolescents with type 1 diabetes. There was an insufficient number of quality studies demonstrating positive effects on health outcomes, such as glycemic control. Based on Community Guide rules of evidence, the Task Force concluded there was insufficient evidence to recommend for or against this intervention because:
- only a few studies evaluated relevant health
outcomes
- there were limitations in study design and execution
- results were inconsistent
Diabetes self-management education in the worksite (insufficient evidence)
Worksite interventions may involve DMSE, as well as education of coworkers or supervisors. Because workers spend a significant portion of their time at work, DMSE in the worksite may improve access to health promotion efforts. Education of supervisors, managers, and coworkers about diabetes can create a supportive environment for self-management, while minimizing discrimination and preparing fellow employees to respond appropriately to diabetes-related emergencies.
Based on Community Guide rules of evidence, the Task Force concluded that evidence was insufficient to assess the effectiveness of this intervention as there was only one qualifying study with design limitations.
Education of school personnel about diabetes (insufficient evidence)
Educating teachers and other school professionals about diabetes can create a supportive environment for self-management, minimize disruption in educational routines attributable to diabetes, and allow school personnel to respond appropriately to diabetes-related emergencies. Based on Community Guide rules of evidence, the Task Force concluded that there was insufficient evidence to assess the effectiveness of this intervention.
Additional Reviews
The Task Force is currently reviewing the evidence of effectiveness of several additional healthcare system interventions related to the treatment of persons with diabetes: provider and patient reminder and recall systems, models of care delivery, provider monitoring and feedback, and telephone call outreach to patients. In addition, reviews are planned to assess the effectiveness of family, public policy, and public service interventions in diabetes care. Completion and release of the Task Force evaluations and conclusions regarding these additional reviews are anticipated later this year.
Definitions:
Strongly recommended: Strong evidence of effectiveness was found.
Recommended: Sufficient evidence of effectiveness was found.
Insufficient evidence: The available studies provided insufficient evidence to assess the effectiveness of the intervention.
Not recommended: The available studies provided sufficient evidence that the intervention is ineffective or that harms exceed benefits.
