Diabetes Education for Children With Type 1 Diabetes ...

[Pages:282]Evidence Report/Technology Assessment

Number 166

Diabetes Education for Children With Type 1 Diabetes Mellitus and Their Families

Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850

Contract No. 290-02-0023

Prepared by: University of Alberta/Capital Health Evidence-based Practice Center, Edmonton, AB, Canada

Investigators Robert Couch, M.S., M.D., F.R.C.P.C. Mary Jetha, M.D., F.R.C.P.C. Donna M. Dryden, Ph.D. Nicola Hooton, B.Sc., M.P.H. Yuanyuan Liang, Ph.D. Tamara Durec, B.Sc. (Pharm.), M.L.I.S. Elizabeth Sumamo, B.Sc., M.P.H. Carol Spooner, B.Sc.N., M.S. Andrea Milne, B.Sc.N. Kate O'Gorman, B.Sc. Terry P. Klassen, M.D., M.S., F.R.C.P.C.

AHRQ Publication No. 08-E011 April 2008

This report is based on research conducted by the University of Alberta/Capital Health Evidence-based Practice Center (EPC), Edmonton, AB, Canada, under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-020023). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. Suggested Citation: Couch R, Jetha M, Dryden DM, Hooton N, Liang Y, Durec T, Sumamo E, Spooner C, Milne A, O'Gorman K, Klassen TP. Diabetes Education for Children With Type 1 Diabetes Mellitus and Their Families. Evidence Report/Technology Assessment No. 166. (Prepared by the University of Alberta/Capital Health Evidence-based Practice Center under Contract No. 290-02-0023.) AHRQ Publication No. 08-E011. Rockville, MD: Agency for Healthcare Research and Quality. April 2008.

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.

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Preface

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.

To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release.

AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality.

We welcome comments on this evidence report. They may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, or by e-mail to epc@.

Carolyn M. Clancy, M.D. Director Agency for Healthcare Research and Quality

Jean Slutsky, P.A., M.S.P.H. Director, Center for Outcomes and Evidence Agency for Healthcare Research and Quality

Beth A. Collins Sharp, R.N., Ph.D. Director, EPC Program Agency for Healthcare Research and Quality

Stephanie Chang, M.D., M.P.H. EPC Program Task Order Officer Agency for Healthcare Research and Quality

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Acknowledgments

We are grateful to members of the technical expert panel, Dr. Denis Daneman (University of Toronto), Alison Evert (University of Washington Medical Center), Dr. Jeff Johnson (University of Alberta), Dr. Richard Justman (United HealthCare), Dr. Lori Laffel (Joslin Diabetes Center), Dr. Gabriela Ramirez (Nemours Children's Clinic), Dr. Janet Silverstein (University of Florida), Linda Walsh (American Academy of Pediatrics), Caryn Davidson (American Academy of Pediatrics) and Stephanie Chang (Agency for Healthcare Research and Quality), who provided direction for the scope and content of the review.

We are grateful to Karalee Ratzlaff for collecting potentially relevant studies, Dr. Nina Buscemi for providing feedback on the draft of this report, and Ken Bond for editing the report.

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Structured Abstract

Objectives: To determine the effectiveness of diabetes education on metabolic control, diabetes-related hospitalizations, complications, and knowledge, quality of life and other psychosocial outcomes for children with type 1 diabetes and their families.

Data Sources: A systematic and comprehensive literature review was conducted in 21 electronic databases of medical and health education literature to identify randomized controlled trials (RCTs) and observational studies evaluating the effectiveness of diabetes education.

Review Methods: Study selection, quality assessment, and data extraction were conducted independently by several investigators in duplicate. A descriptive analysis is presented.

Results: From 12,756 citations, 80 studies were identified and included in the review (53 RCTs or CCTs, 27 observational studies). The methodological quality of studies was generally low.

Most studies (35/52) that examined the effect of educational interventions on HbA1c found no evidence of increased effectiveness of the interventions over the education provided as part of standard care. Successful interventions were heterogeneous and included cognitive behavioral therapy, family therapy, skills training and general diabetes education. Most studies reported a positive effect on health service utilization (i.e., reduced use), although less than half were statistically significant. There was no clear evidence that educational interventions had an effect on short-term complications.

The effect of educational interventions on diabetes knowledge was unclear with 12/30 studies reporting a significant improvement. Interventions which had varying effects on knowledge scores included diabetes camp, general diabetes education, and cognitive behavioral therapy. In the area of self management/regimen adherence, 10/21 studies reported improving this outcome significantly. Successful interventions included general diabetes education and cognitive behavioral therapy. Educational interventions were successful in improving various psychosocial outcomes.

The results of two studies examining refinements to intensive therapy education suggest that educational interventions may enhance the effects of intensive diabetes management in reducing HbA1c.

Conclusions: Due to the heterogeneity of reported diabetes education interventions, outcome measures, and duration of followup, there is insufficient evidence to identify a particular intervention that is more effective than standard care to improve diabetes control or quality of life or to reduce short-term complications.

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Contents

Executive Summary ............................................................................................................ 1

Evidence Report .............................................................................................................. 15

Chapter 1. Introduction .................................................................................................... 17 Type 1 Diabetes Mellitus .............................................................................................. 17 Current Standards.......................................................................................................... 19 Objective of this Evidence Report ................................................................................ 21 The Key Questions........................................................................................................ 21

Chapter 2. Methods.......................................................................................................... 23 Literature Search and Retrieval .................................................................................... 24 Study Selection ............................................................................................................. 25 Assessment of Methodological Quality ........................................................................ 25 Grading the Body of Evidence...................................................................................... 26 Data Extraction ............................................................................................................. 26 Data Analysis ................................................................................................................ 27 Peer Review .................................................................................................................. 28

Chapter 3. Results ............................................................................................................ 29 Literature Search........................................................................................................... 29 Description of Included Studies.................................................................................... 30 Methodological Quality of Included Studies ................................................................ 32 Results of Included Studies........................................................................................... 39 HbA1c ........................................................................................................................... 39 Health Services Utilization ........................................................................................... 57 Complications ............................................................................................................... 62 Knowledge .................................................................................................................... 69 Skills ............................................................................................................................. 80 Self-Management/Adherence ....................................................................................... 84 Psychosocial Outcomes ................................................................................................ 94 Quality of Life............................................................................................................. 123 School Performance .................................................................................................... 124

Chapter 4. Discussion .................................................................................................... 127 Grading the Body of Evidence.................................................................................... 127 Discussion of Key Questions ...................................................................................... 130 Limitations .................................................................................................................. 135 Conclusions................................................................................................................. 136 Future Research Opportunities ................................................................................... 136

References and Included Studies .................................................................................... 139

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Tables

Table 1. Summary table for diabetes education for children with type 1 diabetes ......... 7 Table 2. Inclusion and exclusion criteria for studies assessing the effectiveness of

diabetes education for children and their families .......................................... 25 Table 3. Methodological quality and source of funding of randomized controlled trials

assessing the effectiveness of diabetes education for children with type 1 diabetes and their families .............................................................................. 35 Table 4. Methodological quality and source of funding for controlled clinical trials assessing the effectiveness of diabetes education for children with type 1 diabetes and their families .............................................................................. 37 Table 5. Methodological quality of before-and-after studies and cohort studies.......... 38 Table 6. Summary of results for studies assessing the effect of diabetes education on HbA1c ............................................................................................................. 53 Table 7. Summary of results for studies assessing the effect of diabetes education on health services utilization................................................................................ 61 Table 8. Summary of results of studies assessing the effect of diabetes education on short-term complications ................................................................................ 68 Table 9. Summary of results of studies assessing the effect of diabetes education on knowledge ....................................................................................................... 77 Table 10. Summary of results of studies assessing the effect of diabetes education on skills ................................................................................................................ 83 Table 11. Summary of results of studies assessing the effect of diabetes education on self-management/regimen adherence.............................................................. 92 Table 12. Summary of results of studies assessing the effect of diabetes education on family/social relationships .............................................................................. 99 Table 13. Summary of results of studies assessing the effect of diabetes education on family and social support .............................................................................. 104 Table 14. Summary of results of studies assessing the effect of diabetes education on social skills.................................................................................................... 107 Table 15. Summary of results of studies assessing the effect of diabetes education on coping............................................................................................................ 111 Table 16. Summary of results of studies assessing the effect of diabetes education on self-perception............................................................................................... 115 Table 17. Summary of results of studies assessing the effect of diabetes education on self-efficacy................................................................................................... 118 Table 18. Summary of results of studies assessing the effect of diabetes education on stress.............................................................................................................. 119 Table 19. Summary of results of studies assessing the effect of diabetes education on anxiety and depression.................................................................................. 122 Table 20. Summary of results of studies assessing the effect of diabetes education on quality of life................................................................................................. 124 Table 21. Summary of results of studies assessing the effect of diabetes education on school performance....................................................................................... 125 Table 22. Grading the strength of evidence .................................................................. 127

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