Aslak Steinsbekk

Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis

BackgroundDiabetes self-management education (DSME) can be delivered in many forms. Group based DSME is widespread due to being a cheaper method and the added advantages of having patient meet and discuss with each other. assess effects of group-based DSME compared to routine treatment on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients.MethodsA systematic review with meta-analysis. Computerised bibliographic database were searched up to January 2008 for randomised controlled trials evaluating group-based DSME for adult type-2 diabetics versus routine treatment where the intervention had at least one session and =/>6 months follow-up. At least two reviewers independently extracted data and assessed study quality.ResultsIn total 21 studies (26 publications, 2833 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 60 years, BMI 31.6, HbA1c 8.23%, diabetes duration 8 years and 82% used medication. For the main clinical outcomes, HbA1c was significantly reduced at 6 months (0.44% points; P = 0.0006, 13 studies, 1883 participants), 12 months (0.46% points; P = 0.001, 11 studies, 1503 participants) and 2 years (0.87% points; P < 0.00001, 3 studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12 months (1.26 mmol/l; P < 0.00001, 5 studies, 690 participants) but not at 6 months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at 6 months (SMD 0.83; P = 0.00001, 6 studies, 768 participants), 12 months (SMD 0.85; P < 0.00001, 5 studies, 955 participants) and 2 years (SMD 1.59; P = 0.03, 2 studies, 355 participants) and self-management skills also improved significantly at 6 months (SMD 0.55; P = 0.01, 4 studies, 534 participants). For the main psychosocial outcomes, there were significant improvement for empowerment/self-efficacy (SMD 0.28, P = 0.01, 2 studies, 326 participants) after 6 months. For quality of life no conclusion could be drawn due to high heterogeneity. For the secondary outcomes there were significant improvements in patient satisfaction and body weight at 12 months for the intervention group. There were no differences between the groups in mortality rate, body mass index, blood pressure and lipid profile.ConclusionsGroup-based DSME in people with type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes.

Use of complementary and alternative medicine by children in Europe: Published data and expert perspectives

INTRODUCTION Few data document the use of complementary and alternative medicine (CAM) in Europe, with even fewer investigating use by children. METHODS A narrative, non-systematic review of CAM use in Europe was performed by combining data from published surveys with expert perspectives. Limitations created by a lack of representative studies, varying definitions of CAM use, and what qualifies as CAM in different countries was partially overcome by integrating local experts to summarise information available only in the national language and provide their perspectives about CAM availability, quality, use and popularity in their countries using a semi-structured questionnaire. Local and international published surveys were summarised, and the prevalence of CAM use was extrapolated. RESULTS Data from 20 European countries were available, representing 69% of the European population. Some data about CAM use by the general population were available for 90% of the examined countries, whereas peer-reviewed published surveys were available for only 60%. We extrapolated that 56% (range: 10-90%, adjusted for population size) of the European population in general had used CAM at least once in the past year. Surveys in CAM use by children were available for 55% of the investigated countries. The extrapolated prevalence of CAM use by children in Europe was 52% (range: 5-90%, adjusted for population size). Paediatric CAM experts reported an increasing awareness for and use of CAM in healthcare institutions. CONCLUSION This precursor for further surveys indicates that CAM appears to be popular not only among adults in Europe, but also for children. Development of a pan-European definition of CAM use and CAM therapies are required to achieve surveys comparable between European countries. Additionally, more research investigating the efficacy and potential adverse effects of CAM therapies is needed because of increasing CAM use by children in Europe.

Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial

OBJECTIVE To evaluate the efficacy of ongoing group based diabetes self-management education (DSME) for patients with type 2 diabetes. METHODS 146 patients were randomised to either group education or waiting list control. Primary outcomes were A1C and patient activation measured with patient activation measure (PAM). RESULTS There were no differences in the primary outcomes between the groups at 12 months, but the control group had an increase in A1C of 0.3% points during follow-up. Diabetes knowledge and some self-management skills improved significantly in the intervention group compared to the control group. A sub group analysis was conducted for the quartile with the highest A1C at baseline (>7.7, n=18 in both groups). There were significant improvements within the intervention group at 12 month follow-up for both A1C and PAM and a trend for better outcome in the intervention group compared to the control. CONCLUSIONS The locally developed ongoing diabetes self-management education programs prevented an increase in A1C and can have an effect on A1C in patients with higher A1C level. PRACTICE IMPLICATIONS Locally developed programs may be less effective than programs developed for studies.

Same description, different values. How service users and providers define patient and public involvement in health care.

Background  Patient and public involvement in health care is important, but the existing definitions of the concept do not integrate the stakeholders’ own perceptions.

Development of a patient-centred care pathway across healthcare providers: a qualitative study

BackgroundDifferent models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway.MethodsThis qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants.ResultsThe development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient’s functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals.ConclusionsDisease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.

Herbal use among cancer patients during palliative or curative chemotherapy treatment in Norway

Goals of workThis survey aims to explore the differences between cancer patients undergoing chemotherapeutic treatment with palliative or curative intention with respect to concurrent herbal use, experiences of adverse effects, motives of herbal intake, and communication about herbal use with health care providers.Materials and methodsOne hundred and twelve adult cancer patients from the west coast of Central Norway, currently undergoing chemotherapeutic treatment, were recruited to a cross-sectional descriptive survey.Main resultsPalliative and curative patients used herbal remedies concurrent with chemotherapy equally frequent (37% and 38%). One palliative patient reported adverse effects when doubling the dose of injected mistletoe used. Garlic was only used by palliative patients (p = 0.009) who also tended to have a more frequent everyday herbal use (78% vs 67%, respectively) than curative patients (p = 0.075). Curative patients, however, used herbal remedies more often to counteract adverse reactions (31% vs 3%, respectively; p = 0.026). A bivariate logistic regression, which was adjusted for age, showed that palliative patients used herbal remedies more frequently to improve their immune system (adjusted OR = 7.5, 95% CI = 1.1–49.7).ConclusionsThis is the first survey comparing concurrent herbal use between cancer patients undergoing palliative or curative chemotherapy. Both groups frequently use herbal remedies concurrent with chemotherapy, but with a slightly different intent. The frequent concurrent use emphasizes the need for clinicians to include questions on complementary and alternative medicine in routine history taking and for further studies on possible herb–drug interactions among the cancer patient.

The effect of an educational programme consisting of group and individual arthritis education for patients with polyarthritis—A randomised controlled trial §

OBJECTIVE The aim of this study was to investigate the effect of an educational programme for patients with polyarthritis compared to usual care. METHODS Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to the intervention (n=71) or usual care (n=70). The intervention consisted of three group educational sessions followed by one individual educational session. The primary outcomes were a patients global well-being and arthritis self-efficacy. Secondary outcomes were patient activation, physical and psychological health status, educational needs and disease activity. RESULTS After four months the intervention group had significantly better global well-being, 95% CI (2.3-14.1), p=0.01, and self-efficacy, 95% CI (0.2-8.1), p=0.04, than the control group. There were also trends for improved disease activity, and a statistically significant improvement in patient activation and pain in the intervention group. CONCLUSION This patient educational programme consisting of group sessions and nurse-delivered individual education has statistically significant benefits for global well-being and maintaining a level of self-efficacy in managing other symptoms in patients with polyarthritis. PRACTICE IMPLICATIONS This educational programme allows patients to learn from each other in addition to addressing individual educational needs.

Making and Maintaining Lifestyle Changes after Participating in Group Based Type 2 Diabetes Self-Management Educations: A Qualitative Study

Background Disease management is crucial in type 2 diabetes. Diabetes self-management education aims to provide the knowledge necessary to make and maintain lifestyle changes. However, few studies have investigated the processes after such courses. The aim of this study was to investigate how participants make and maintain lifestyle changes after participating in group-based type 2 diabetes self-management education. Methods Data was collected through qualitative semi-structured interviews with 23 patients who attended educational group programs in Central Norway. The participants were asked how they had used the advice given and what they had changed after the course. Results Knowledge was essential for making lifestyle changes following education. Three factors affected whether lifestyle changes were implemented: obtaining new knowledge, taking responsibility, and receiving confirmation of an already healthy lifestyle. Four factors motivated individuals to maintain changes: support from others, experiencing an effect, fear of complications, and the formation of new habits. Conclusion Knowledge was used to make and maintain changes in diet, medication and physical activity. Knowledge also acted as confirmation of an already adequate lifestyle. Knowledge led to no changes if diabetes appeared “not that scary” or if changes appeared too time consuming. Those involved in diabetes education need to be aware of the challenges in convincing asymptomatic patients about the benefits of adherence to self-management behaviour.

The profiles of adults who consult alternative health practitioners and/or general practitioners

Objective. To compare the profiles of people visiting only a general practitioner (GP), those visiting only a practitioner of complementary and alternative medicine (CAM), and those visiting both (GP&CAM). Design. A comparative total population health survey in central Norway (HUNT 2). Subjects. A total of 54 448 persons 20 years of age and over who answered questions about their use of health services during the previous 12 months. Variables. Sociodemographic characteristics, self-perceived health, subjective health complaints, and a variety of common diseases. Results. Some 34 854 (64.0%) of those who answered the health service use question had visited only a GP, 837 (1.5%) only a CAM practitioner, and 4563 (8.4%) both during the last 12 months. The likelihood of being a CAM-only user as compared to a GP-only user was significantly increased (p < 0.005) if the participant was male; aged between 30 and 69; and without cardiovascular disease. The likelihood of being a GP&CAM user compared with a GP-only user was significantly increased (p < 0.005) for those who were female; aged between 30–59; had a higher education level; were non-smokers; had lower perceived global health; had a limiting chronic complaint; had experienced a health complaint during the last 12 months; had musculoskeletal disease; had a psychiatric complaint; and had hay fever. Conclusion. There were few CAM-only users and they differ from GP-only users by being male, aged 30–69, and without cardiovascular disease. Users of both GP&CAM were less healthy with more complaints and poorer self-reported health than GP- and CAM-only users.

Empowering the Cancer Patient or Controlling the Tumor? A Qualitative Study of How Cancer Patients Experience Consultations With Complementary and Alternative Medicine Practitioners and Physicians, Respectively

Objectives: The authors describe how patients with cancer, who have had consultations with both a conventional physician and a complementary and alternative medicine (CAM) practitioner, experience these consultations. The theoretical background of this study is inspired by a description of 2 models of principles of treatment. In the first model, the instrumental intervention (eg, the medicine) is defined as the causal factor for outcome. In the second model, the patient is defined as the causal factor; the outcomes of the treatment are dependent on the resources of the patient (eg, the body’s ability to heal itself) and the impact of the patient’s situation. Methods: Semistructured, in-depth interviews were conducted with 17 Norwegian cancer patients who had visited both a CAM practitioner and a physician. The patients were recruited from both an oncology department at a university hospital and a newspaper advertisement in the area of Trondheim in central Norway. Methods of data analysis used were open coding, relational coding, and categorizing of themes. Results: The cancer patients have experienced 2 different modes of consultations: one characterized by practitioners focusing on controlling the tumor and another characterized by practitioners focusing on the patient. The patients’ accounts of these 2 modes of consultation differ in a number of ways: which issues are discussed during the consultation, who is in control of the consultation agenda, what are the patients’ perceptions of the practitioners’ health and disease understanding (ontology), what are the practitioners’ communication skills, and how empowered the patient feels during the consultation. Conclusions: Patients in this study ask for a consultation style that conveys a focus on both the disease and the whole patient. The results of this study point to a possible connection between the practitioners’ understanding of health and disease and the content and form of the consultations. Future research should test this connection.