Diabetes education programs show mixed results

Educational programs for patients with uncontrolled diabetes showed some success but overall had mixed results in three recent trials.

The most successful of the programs randomized 222 patients with a mean A1c of 9.0% (half type 1 diabetics and half type 2) to one of three arms: (1) a five-session manual-based, educator-led structured group intervention with cognitive behavioral strategies; (2) an educator-led group education program; or (3) unlimited individual nurse and dietitian education sessions for six months. All of the groups showed significant improvements in A1c, but the patients who received structured behavioral education made the greatest improvements: an A1c drop of 0.8% compared to 0.4% in the other groups (P=0.04 for group x time interaction). The study authors concluded that the structured behavioral intervention was effective and could successfully be implemented by nurses and dieticians, although they noted that sustainability of the results should be investigated.

However, another study, also published online by Archives of Internal Medicine on Oct. 10, found greater success with individual education than group education. This trial included 623 type diabetics with an A1c of at least 7%. They were randomized to group education using the US Diabetes Conversation Map program (totaling eight hours), three hours of individual education or usual care. Again, all of the groups lowered their A1cs, but the individual group had a significantly bigger drop (−0.51% compared to −0.27% with group education and −0.24% with usual care; P=0.01 for difference between groups). The authors concluded that the results support existing Medicare reimbursements for individual education, and they noted that the type of group education, and the educators' lack of experience with conversation maps, may have been one cause of the difference.

The final study enrolled 201 patients and randomized them to either a 24-minute video and five sessions of telephone coaching by a trained diabetes nurse or a 20-page brochure from the National Diabetes Education Program. The mean A1c at the start of the study was 9.6%, and it decreased to 9.1% six months after the intervention, but no significant difference was found between the groups. The authors noted that their study population was particularly difficult to treat; in addition to having a high baseline A1c, the patients were predominately poor and uninsured, and the study was undertaken at the start of the recession. They concluded that the telephone coaching was insufficient and that more intensive interventions may be necessary, particularly for disadvantaged patients.

A commentary that accompanied the three studies struggled to pull overarching conclusions from the differing findings. The education strategies can't really be directly compared, especially since the amount of time educators spent with patients varied dramatically, with more time investment apparently being associated with greater success. Also, none of the findings should lead to rejection of these approaches for newly diagnosed patients, the commentary said, since most trial participants had already had the disease for many years. Another accompanying commentary said that the studies point to the need for a more standardized definition of health coaching, with training requirements and credentialing standards for health and wellness coaches.