Version 4.0 <strong>VA</strong>/<strong>DoD</strong> <strong>Clinical</strong> <strong>Practice</strong> <strong>Guideline</strong> for the Management of Diabetes Mellitus demonstrated that there were significant improvements in 47 percent of the outcomes measured (47 of 112 outcomes). However, the improvements that occurred during the learning period were not sustained long term. Balas et al., (2004) reviewed RCTs and other study designs that evaluated the impact of various interventions including utilization of home glucose records in computer-assisted insulin dose adjustment and computer-assisted diabetes patient education. They found that small, pocket-sized dosage computers facilitated increased mobility and treatment adherence with therapy recommendations on demand and that remote diabetes control and counseling enhanced glycemic control. In a systematic review of 68 RCTs and 30 observational studies involving frail elderly, 34 of which focused on telemonitoring and diabetes, Barlow et al. (2007) determined that benefits of telemonitoring of blood glucose data and transmitting data on system outcomes (clinic time, efficiency, or workflow) were inconsistent. Four researchers found that proactive support or case management by telephone improved clinical outcomes or reduced symptoms in people with diabetes and several researchers determined that regular telephone calls from nurses reduced or delayed hospital admissions and costs in people with diabetes, but the most effective frequency of telephone support remains uncertain. Findings regarding the impact of continuing telephone follow up on treatment adherence and quality of life, as well as the effects of education and support provided via email and the Internet were also inconsistent. Proactive telephone support or case management by telephone has been found to improve clinical outcomes or reduce symptoms in people with diabetes (Kim, 2003; Piette et al., 2000; Shea et al.,, 2006; Thompson et al.,, 1999; Wong et al.,, 2005) and continuing telephone follow up is also associated with improved adherence to treatment and self efficacy in people with diabetes (Gambling & Long, 2006; Maljanian et al., 2005). However, there were no improvements in quality of life in people with diabetes receiving telephone support (Piette et al., 2000) and adding video conferencing to telephone support and home visits had no effect on knowledge and medication adherence. Botsis and Hartvigsen (2008) performed a similar review of 54 studies from 1996 to 2008, fourteen of which included elderly people with diabetes. Although not all studies measured the same outcomes, overall findings demonstrated reduced HbA1c, blood pressure and LDL cholesterol, fewer clinic visits, improved self care, lower health risk, reduction in hospitalizations, and improved quality of life when monitored and educated via telecommunication devices. Limitations in many of the studies were the small sample size and the short follow up period. Chumbler et al.,, (2004) found evidence that home telecare coordination strategies improved functional independence in veterans with chronic diseases. Elderly patients with diabetes had reduced HbA 1 c values and reduced blood pressure and LDL cholesterol when monitored and educated via telecommunication devices (Dang et al., 2007; Shea et al., 2006). Barnett et al.,, (2006) found that diabetes patients required fewer clinic visits with daily telehealth monitoring. Trief et al., (2007) confirmed findings that teleheath approaches enhanced patients’ understanding of the disease and consequently, their self-care behaviors. DELIVERY OF EDUCATION IN GROUP SETTING In a randomized trial, Rickheim et al. (2002) found that group or individualized diabetes education are equally effective methods of providing education and improving glycemic control. In a systematic review of group-based diabetes education programs for adults with type 2 diabetes, Deakin et al. (2005) found that approach to and delivery of group education was highly diverse (e.g., underlying theoretical model, numbers/hours of sessions, length of intervention, venue, and individual(s) delivering intervention). Findings, however, suggested that group education improved glycemic control as evidenced by lower HbA 1 C levels and fasting blood glucose levels and retention of diabetes knowledge at 4 to 6 months and 12 months. Additional group education sessions provided annually may extend benefits up to 2 to 4 years. Evidence also suggested that group education programs may reduce the requirement for diabetes medication, improve diabetes self-management skills, enhance patient self-empowerment skills, and improve food related aspects of quality of life. At longer term follow up (2 to 4 years), group education programs may still result in improved quality of life and reduce the progression to diabetic retinopathy. As long as the health professional is trained to provide diabetes education, there was no evidence to suggest that location, size of group, duration of program, or type of provider delivering program impacted education effectiveness. There is less evidence, however, to support the effectiveness of programs delivered by lay health workers. Programs based on therapeutic patient education using the principles of empowerment, participation and adult learning have proved to be efficacious. As stated previously, offering annual educational programs has been observed to result in long-lasting benefits to health and psychosocial outcomes. In three studies (525 patients combined) there was no effect on mortality (OR 1.2; CI 0.3 to 5.6, P = 0.77). Trento et al. (2001) found no significant difference between groups for retinopathy or foot ulcers at 2 years, but did find that Module M: Self-management Page 115
Version 4.0 <strong>VA</strong>/<strong>DoD</strong> <strong>Clinical</strong> <strong>Practice</strong> <strong>Guideline</strong> for the Management of Diabetes Mellitus retinopathy progressed significantly more slowly for intervention group at 4 years. Overall reductions in HbA 1 c varied from 0.8% to 1.6% at time points as long as 4 years, although most studies had follow-up of
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