Loveman, E., Cave, C. (Carolyn), Green , C., Royle, Pamela, Dunn, N. and Waugh, Norman. (2003) The clinical and cost-effectiveness of patient education models for diabetes : a systematic review and economic evaluation. Health Technology Assessment, Vol.7 (No.22). ISSN 1366-5278

Preview	Text WRAP_Waugh_Education TAR.pdf - Published Version Download (666Kb) | Preview
Preview	Text WRAP_waugh15_Coversheet_FinalVersion.pdf Download (168Kb) | Preview

Abstract

Description of the proposed service This systematic review examines the clinical and cost-effectiveness of patient education models for adults with Type 1 or Type 2 diabetes. Epidemiology and background Diabetes mellitus (diabetes) is characterised by a state of chronic hyperglycaemia (raised blood sugar). There are two main types of diabetes: Type 1 and Type 2. Type 1 diabetes is an autoimmune condition involving a process of destruction of the beta cells of the pancreas, leading to severe insulin deficiency. About one-fifth of patients with diabetes in England and Wales have Type 1 diabetes. Type 2 diabetes is characterised by insulin resistance and relative insulin deficiency and is linked to being overweight or obese, and to physical inactivity. Type 2 diabetes primarily affects people aged over 40 years. The basic target in the treatment of diabetes is the normalisation of blood glucose levels. Poor control of diabetes can in the short term result in diabetic ketoacidosis, a serious and potentially fatal condition, and in the long term can increase the risk of complications such as diabetic retinopathy and nephropathy. However, studies have shown that good diabetic control is associated with a reduced risk of these complications. Diabetic control is affected by both lifestyle factors such as diet, and by pharmacological treatments, and the management of diabetes is largely the responsibility of patients. A key component in empowering patients to manage their own diabetes is education. Education of patients with diabetes is considered a fundamental aspect of diabetes care and aims to empower patients by improving knowledge and skills. Structured educational programmes for diabetes self-management are often multifaceted interventions providing patients with information not only about diabetes but also management issues such as diet, exercise, self-monitoring of blood glucose and medication use. Methods A systematic review of the literature and an economic evaluation were undertaken. Data sources Electronic databases were searched, including the Cochrane Library, MEDLINE, EMBASE, PubMed, Science Citation Index, Web of Science Proceedings, DARE and HTA databases, PsychINFO, CINAHL, NHS Economic Evaluation Database and EconLit. References of all retrieved articles were checked for relevant studies, and experts were contacted for advice and peer review and to identify additional published and unpublished references. Sponsor submissions to the National Institute for Clinical Excellence were reviewed. Study selection Studies were included if they fulfilled the following criteria: Interventions: educational interventions compared with usual care or another educational intervention. Participants: adults with Type 1 or Type 2 diabetes mellitus. Outcomes: must report glycated haemoglobin, hypoglycaemic episodes, diabetic complications or quality of life. Other reported outcomes from included studies were discussed. Evaluation of outcomes >12 months from inception of intervention. Design: randomised clinical trials (RCTs), and controlled clinical trial (CCTs) with a concurrent control were included. Reporting: studies were only included if they reported sufficient detail of the intervention to be reproducible (e.g. topics covered, who provided the education, how many sessions were available). Studies in non-English language or available only as abstracts were excluded. Titles and abstracts were checked by two reviewers. Full texts of selected studies were assessed for inclusion by one reviewer and checked by a second. Differences in opinion were resolved through discussion. Data extraction and quality assessment Data extraction and quality assessment were undertaken by one reviewer and checked by a second, with any disagreement resolved through discussion involving a third reviewer if necessary. The quality of included studies was assessed in accordance with Centre for Reviews and Dissemination Report 4. Data synthesis Data on clinical effectiveness were synthesised through a narrative review with tabulation of results from included studies. Studies were too diverse to be combined in a meta-analysis. Cost-effectiveness analyses were reported in a narrative review. Number and quality of studies Searches identified 24 studies comparing education with either a control group or with another educational intervention. These were 18 RCTs and six CCTs. Four studies included adults with Type 1 diabetes, 16 studies included adults with Type 2 diabetes and four studies included adults with either Type 1 or Type 2 diabetes. The quality of reporting and methodology of the studies was generally poor by today’s standards with only two RCTs reporting adequate randomisation procedures and none demonstrating adequate allocation concealment. Economic evaluations Literature searches identified only two studies reporting cost-effectiveness results: one cost-utility analysis and one cost-effectiveness analysis using intermediate outcomes only. Summary of benefits Studies of education in Type 1 diabetes suggest that education programmes offered as a part of intensified treatment interventions can result in significant and long-lasting improvements in metabolic control and reductions in complications. These are studies in which education is part of a package of care also including treatment changes (for example diet and insulin) and therefore it is not possible to draw conclusions about potential effects of education per se in Type 1 diabetes. Diverse educational programmes in Type 2 diabetes did not yield consistent results. Although some trials reported significant improvements in metabolic control and/or quality of life or other psychological outcomes, many others did not report significant effects of educational interventions. No clear characterisation is possible as to what features of education may be beneficial in this patient group. Studies that included patients with either Type 1 or Type 2 diabetes also produced mixed results with only poorer quality studies reporting significant effects. Costs Literature searches identified a small number of studies offering cost data in relation to patient education models. These were all studies undertaken outside the UK and they covered a variety of methodologies. We are not able to generalise from these studies as to the cost-effectiveness of patient education models. Patient education models will predominantly consist of direct costs for resource inputs to particular education packages, for example staff time (diabetes specialist nurse, dietitian and/or consultant) and education materials. The Dose Adjustment for Normal Eating (DAFNE) intervention is estimated to cost approximately £545 per person attending. Costs per life year gained Owing to the absence of accurate data on health outcomes, we are not able to provide cost-effectiveness summary statistics. The evidence base does indicate that improved glycaemic control is likely to have a positive impact on the incidence of long-term diabetic complications. Therefore, where the costs associated with patient education are assumed to be in the region of £500–600 per patient, the benefits over time would have to be very modest to offer an attractive cost-effectiveness profile for the intervention. The submission from the DAFNE study group predicts a scenario in which the DAFNE intervention results in cost savings and added health benefits over time, when compared with usual practice. Implications The main implication for the NHS would be staff time, particularly of diabetes specialist nurses, but also dietitians. Provision of increased education may be hindered by a shortage of trained specialist nurses, which will take some years to resolve. Future research needs The paucity of high-quality trials that have tested education per se in diabetes reveals a need for more research. Such research should focus on RCTs with clear designs based on explicit hypotheses and with a range of outcomes evaluated after long follow-up intervals. In order to draw conclusions about the effects of education alone, such trials should manipulate only education rather than confounding education with other factors.

Item Type:	Journal Article
Subjects:	R Medicine > RC Internal medicine
Divisions:	Faculty of Medicine > Warwick Medical School > Health Sciences
Library of Congress Subject Headings (LCSH):	Health education, Diabetes -- Treatment, Non-insulin-dependent diabetes -- Treatment, Metabolism -- Regulation, Self-care, Health
Journal or Publication Title:	Health Technology Assessment
Publisher:	National Coordinating Centre for Health Technology Assessment
ISSN:	1366-5278
Date:	2003
Volume:	Vol.7
Number:	No.22
Status:	Peer Reviewed
Publication Status:	Published
Funder:	NIHR Health Technology Assessment Programme (Great Britain)
References:	1. Bell J, Hockaday T. Diabetes mellitus. In Ledingham J, Warrell D, editors. Concise Oxford textbook of medicine. Oxford: Oxford University Press; 2000. pp. 734–70. 2. British Diabetic Association (now Diabetes UK). Diabetes in the United Kingdom – 1996. London: British Diabetic Association; 1995. 3. Drake AJ, Smith A, Betts PR, Crowne EC, Shield J-PH. Type 2 diabetes in obese white children. Arch Dis Child 2002;86:207–8. 4. Ehtisham S, Kirk J, McEvilly A, Shaw N, Jones S, Rose S, et al. Prevalence of type 2 diabetes in children in Birmingham. BMJ 2001;322:1428. 5. Fuller JH, Elford J, Goldblatt P, Adelstein AM. Diabetes mortality: new light on an underestimated public health problem. Diabetologia 1983;24:336–41. 6. Wong JS, Pearson DW, Murchison LE, Williams MJ, Narayan V. Mortality in diabetes mellitus: experience of a geographically defined population. Diabet Med 1991;8:135–9. 7. Waugh NR, Dallas JH, Jung RT, Newton RW. Mortality in a cohort of diabetic patients. Causes and relative risks. Diabetologia 1989;32:103–4. 8. Gatling W, Williams Z, Houston AC, Walters D, Campbell M, Hill RD. Ten year follow-up of a community based diabetic population reveals an excess mortality in middle-aged female diabetic patients. Diabet Med 1990;6:11a. 9. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–53. 10. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977–86. 11. Diabetes UK. Fact sheet No 2 – Diabetes: the figures. URL: http://www.diabetes.org.uk/ infocentre/fact/fact2.htm (accessed 11 February 2002). 12. Davies M, Day J. Screening for non-insulindependent diabetes mellitus (NIDDM): how often should it be performed? J Med Screen 1994; 1:78–81. 13. Audit Commission. Testing times: a review of diabetes services in England and Wales. London: Audit Commission; 2000. 14. Diabetes UK. Patient education for effective diabetes self-management. Diabetes UK: London; 2002. 15. Department of Health. National Service Framework for Diabetes: Standards. London: Department of Health; 2002. 16. Mensing C, Boucher J, Cypress M, Weinger K, Mulcahy K, Barta P, et al. National standards for diabetes self-management education. Diabetes Care 2002;25 Suppl 1:S140–7. 17. American Association of Diabetes Educators. The 1999 Scope of Practice for Diabetes Educators and the Standards of Practice for Diabetes Educators. Diabetes Educ 2000;26:519–25. 18. European Diabetes Policy Group. A guide to type 2 diabetes mellitus 1998–1999. URL: http://www.diabetesguidelines.com/health/dwk/pro/ guidelines/type2/3.1htm (accessed 22 January 2002). 19. CRD. Undertaking Systematic Reviews of Research on Effectiveness. York: Centre for Reviews and Dissemination; 2001. No. 4. 20. Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ 1996;313:275-83. 21. Reichard P, Britz A, Cars I, Nilsson BY, Sobocinsky- Olsson B, Rosenqvist U. The Stockholm Diabetes Intervention Study (SDIS): 18 months’ results. Acta Med Scand 1988;224:115–22. 22. Terent A, Hagfall O, Cederholm U. The effect of education and self-monitoring of blood glucose on glycosylated hemoglobin in type I diabetes. A controlled 18-month trial in a representative population. Acta Med Scand 1985;217:47–53. 23. Mühlhauser I, Bruckner I, Berger M, Cheta D, Jorgens V, Ionescu-Tirgoviste C, et al. Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest–Düsseldorf Study. Diabetologia 1987;30:681–90. 24. Starostina EG, Antsiferov M, Galstyan GR, Trautner C, Jorgens V, Bott U, et al. Effectiveness and cost–benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow – blood glucose versus urine glucose self-monitoring. Diabetologia 1994;37:170–6. 25. Greenfield S, Kaplan SH, Ware J-EJ, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448–57. 26. The Diabetes Control and Complications Trial Research Group. Adverse events and their association with treatment regimens in the Diabetes Control and Complications Trial. Diabetes Care 1995;18:1415–27. 27. Glasgow RE, Osteen VL. Evaluating diabetes education. Are we measuring the most important outcomes? Diabetes Care 1992;15:1423–32. 28. Brown SA, Kouzekanani K, Garcia AA, Hanis CL. Culturally competent diabetes self-management education for Mexican Americans – The Starr County Border Health Initiative. Diabetes Care 2002;25:259–68. 29. Campbell EM, Redman S, Moffitt PS, Sanson- Fisher RW. The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: a randomized trial. Diabetes Educator 1996;22:379–86. 30. Trento M, Passera P, Tomalino M, Bajardi M, Pomero F, Allione A, et al. Group visits improve metabolic control in type 2 diabetes: a 2-year follow-up. Diabetes Care 2001;24:995–1000. 31. Heller SR, Clarke P, Daly H, Davis I, McCulloch DK, Allison SP, et al. Group education for obese patients with type 2 diabetes: greater success at less cost. Diabet Med 1988;5:552–6. 32. Raz I, Soskolne V, Stein P. Influence of small-group education sessions on glucose homeostasis in NIDDM. Diabetes Care 1988;11:67–71. 33. Domenech MI, Assad D, Mazzei ME, Kronsbein P, Gagliardino JJ. Evaluation of the effectiveness of an ambulatory teaching/treatment programme for non-insulin dependent (type 2) diabetic patients. Acta Diabetol 1995;32:143–7. 34. Kronsbein P, Jorgens V, Muhlhauser I, Scholz V, Venhaus A, Berger M. Evaluation of a structured treatment and teaching programme on noninsulin- dependent diabetes. Lancet 1988;2:1407–11. 35. Kaplan RM, Hartwell SL, Wilson DK, Wallace JP. Effects of diet and exercise interventions on control and quality of life in non-insulindependent diabetes mellitus. J Gen Intern Med 1987;2:220–8. 36. Uusitupa M, Laitinen J, Siitonen O, Vanninen E, Pyorala K. The maintenance of improved metabolic control after intensified diet therapy in recent type 2 diabetes. Diabetes Res Clin Pract 1993;19:227–38. 37. Ridgeway NA, Harvill DR, Harvill LM, Falin TM, Forester GM, Gose OD. Improved control of type 2 diabetes mellitus: a practical education/behavior modification program in a primary care clinic. South Med J 1999;92:667–72. 38. Wing RR, Epstein LH, Nowalk MP, Koeske R, Hagg S. Behavior change, weight loss, and physiological improvements in type II diabetic patients. J Consult Clin Psychol 1985;53:111–22. 39. Wing RR, Epstein LH, Nowalk MP, Scott N, Koeske R, Hagg S. Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes? Am J Med 1986;81:830–6. 40. Samaras K, Ashwell S, Mackintosh AM, Fleury AC, Campbell LV, Chisholm DJ. Will older sedentary people with non-insulin-dependent diabetes mellitus start exercising? A health promotion model. Diabetes Res Clin Pract 1997;37:121–8. 41. Wing RR, Epstein LH, Nowalk MP, Scott N. Selfregulation in the treatment of type II diabetes. Behav Ther 1988;19:11–23. 42. Gilliland S, Perez G, Azen S, Carter J. Strong in body and spirit: lifestyle intervention for Native American adults with diabetes in New Mexico. Diabetes Care 2002;25:78–83. 43. Green LW, Kreuter MW. Health Promotion Planning: an educational and ecological approach. Mountain View, CA: Mayfield; 1999. 44. Bloomgarden ZT, Karmally W, Metzger J, Brothers M, Nechemias C, Bookman J, et al. Randomised controlled trial of diabetic patient education: improved knowledge without improved metabolic status. Diabetes Care 1987;10:263–72. 45. Glasgow RE, La Chance PA, Toobert DJ, Brown J, Hampson SE, Riddle MC. Long-term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office. Patient Educ Couns 1997;32:175–84. 46. Raji A, Gomes H, Beard J, MacDonald P, Conlin PR. A randomised trial comparing intensive and passive education in patients with diabetes mellitus. Arch Intern Med 2002;162:1301–4. 47. Gilden JL, Hendryx MS, Clar S, Casia C, Singh SP. Diabetes support groups improve health care of older diabetic patients. J Am Geriatr Soc 1992; 40:147–50. 48. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561–87. 49. Norris S, Lau J, Smith S, Schmid C, Engelgau M. Self-management education for adults with type 2 diabetes. Diabetes Care 2002;25:1159–71. 50. Norris S, Nichols P, Caspersen C, Glasgow R, Engelgau M, Jack L, et al. Increasing diabetes self-management education in community settings: a systematic review. Am J Prev Med 2002;22:39–66. 51. Corabian P, Harstall C. Patient diabetes education in the management of adult type 2 diabetes. Alberta Heritage Foundation for Medical Research; 2001. HTA 23: Series A. 52. Huang ES, Meigs JB, Singer DE. The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes mellitus. Am J Med 2001;111:633–42. 53. Brown SA. Effects of educational interventions in diabetes care: a meta-analysis of findings. Nurs Res 1988;37:223–30. 54. Brown SA. Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited. Patient Educ Couns 1990;16:189–215. 55. Brown SA. Meta-analysis of diabetes patient education research: variations in intervention effects across studies. Res Nurs Health 1992; 15:409–19. 56. Padgett D, Mumford E, Hynes M, Carter R. Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus. J Clin Epidemiol 1988; 41:1007–30. 57. Brown SA, Hedges LV. Predicting metabolic control in diabetes: a pilot study using metaanalysis to estimate a linear model. Nurs Res 1994;43:362–8. 58. Albano MG, Jacquemet SP. Patient education and diabetes research: a failure. Going beyond the empirical approaches. Acta Diabetol 1998; 35:207–14. 59. Griffin S, Kinmouth AL, Skinner C, Kelly J. Educational and psychological interventions for adults with diabetes. London: British Diabetic Association; 1998. 60. Montani S, Bellazzi R, Quaglini S, D’Annunzio G. Meta-analysis of the effect of the use of computerbased systems on the metabolic control of patients with diabetes mellitus. Diabetes Technol Ther 2001; 3:347–56. 61. Fain JA, Nettles A, Funnell MM, Charron D. Diabetes patient education research: an integrative literature review. Diabetes Educator 1999;25:7–15. 62. Whittemore R. Strategies to facilitate lifestyle change associated with diabetes mellitus. J Nurs Scholarsh 2000;32:225–32. 63. Krishna S, Balas EA, Spencer DC, Griffin JZ, Boren SA. Clinical trials of interactive computerized patient education: implications for family practice. J Fam Pract 1997;45:25–33. 64. Berger M, Mühlhauser I. Implementation of intensified insulin therapy – a European perspective. Diabet Med 1995;12:201–8. 65. Kaplan RM, Atkins CJ, Wilson DK. The cost–utility of diet and exercise interventions in non-insulindependent diabetes mellitus. Health Promot 1987; 2:331–40. 66. Gagliardino JJ, Etchegoyen G. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Diabetes Care 2001;24:1001–7. 67. Pieber TR, Holler A, Siebenhofer A, Brunner GA, Semlitsch B, Schattenberg S, et al. Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria. Diabet Med 1995;12:349–54. 68. de Weerdt I, Visser AP, Kok GJ, de Weerdt O, van der Veen EA. Randomized controlled multicentre evaluation of an education programme for insulin-treated diabetic patients: effects on metabolic control, quality of life, and costs of therapy. Diabet Med 1991;8:338–45. 69. Gruesser M, Bott U, Ellerman P, Kronsbein P, Joergens V. Evaluation of a structured treatment and teaching program for non-insulin-treated type II diabetic outpatients in Germany after the nationwide introduction of reimbursement policy for physicians. Diabetes Care 1993;16:1268–75. 70. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–65. 71. Chilcott J, Wight J, Lloyd Jones M, Tappenden P. The clinical effectiveness and cost-effectiveness of pioglitazone for type 2 diabetes mellitus: a rapid and systematic review. Health Technol Assess 2002;5 (19). 72. The Diabetes Control and Complications Trial Research Group. Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial. JAMA 1996;276:1409–15. 73. Palmer AJ, Weiss C, Sendi PP, Neeser K, Brandt A, Singh G, et al. The cost-effectiveness of different management strategies for type I diabetes: a Swiss perspective. Diabetologia 2000;43:13–26. 74. Tomar R, Lee S, Wu S, Klein R, Moss SE, Fryback DG, et al. Disease progression and cost of insulin dependent diabetes mellitus: development and application of simulation model. J Soc Health Syst 1998;5:24–37. 75. Eastman RC, Javitt JC, Herman WH, Dasbach EJ, Zbrozek AS, Dong F, et al. Model of complications of NIDDM. I. Model construction and assumptions. Diabetes Care 1997;20:725–34. 76. Klein R, Klein BE, Moss SE, Cruickshanks KJ. The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 1998; 105:1801–15. 77. Eastman RC, Javitt JC, Herman WH, Dasbach EJ, Copley-Merriman C, Maier W, et al. Model of complications of NIDDM. II. Analysis of the health benefits and cost-effectiveness of treating NIDDM with the goal of normoglycemia. Diabetes Care 1997;20:735–44. 78. The Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes 1995;44:968–83. 79. UK Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:713. 80. Klein R, Klein BE, Moss SE, Cruickshanks KJ. Prevalence of self-reported erectile dysfunction in people with long-term IDDM. Diabetes Care 2002; 19:135–41. 81. NHS. NHS Reference Costs. London: Stationery Office; 2000. 82. Bagust A, Wilson E, Downs KE, Perry AS, Harrison DJ. Utility and quality of life in the CODE-2 study for type 2 diabetes. Diabetes Forthcoming. 83. Dolan P. The effect of experience of illness on health state valuations. J Clini Epidemiol 1996;49:551–64. 84. Dolan P. Effect of age on health state valuations. J Health Serv Res Policy 2000;5:17–21. 85. Dolan P. Whose preferences count? Med Decis Making 1999;19:482–6. 86. Redekop WK, Koopmanschap MA, Stolk RP, Rutten GEHM, Wolffenbuttel BHR, Niessen LW. Health-related quality of life and treatment satisfaction in Dutch patients with type 2 diabetes. Diabetes Care 2002;25:458–63. 87. Dolan P. Modelling valuations for EuroQol health states. Med Care 1997;35:1095–108. 88. Wu S, Sainfort F, Tomar R, et al. Development and application of a model to estimate the impact of type 1 diabetes on health-related quality of life. Diabetes Care 1998;21:725–31. 89. Brown MM, Brown GC, Sharma S, Shah G. Utility values and diabetic retinopathy. Am J Ophthalmol 1999;128:324–30. 90. Kiberd BA, Jindal KK. Screening to prevent renal failure in insulin dependent diabetic patients: an economic evaluation. BMJ 1995;311:1595–9. 91. Klein R, Klein BE. Relation of glycemic control to diabetic complications and health outcomes. Diabetes Care 1998;21 Suppl 3:C39–43. 92. The Diabetes Control and Complications Trial Research Group. Influence of intensive diabetes treatment on quality-of-life outcomes in the diabetes control and complications trial. Diabetes Care 1996;19:195–203. 93. Rossing P, Hougaard P, Borch-Johnsen K, Parving HH. Predictors of mortality in insulin dependent diabetes: 10 year observational follow up study. BMJ 1996;313:779–84. 94. Blonde L. Management of type 2 diabetes: update on new pharmacological options. Manag Care 2000;9 (8 Suppl):11–17. 95. Tildesley HD, Mair K, Sharpe J, Piaseczny M. Diabetes teaching – outcome analysis. Patient Educ Couns 1996;29:59–65. 96. Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. URL: http://www.mrc.ac.uk/; 2000. 97. Dunn SM, Bryson JM, Hoskins PL, et al. Development of the diabetes knowledge (DKN) scales: forms DKNA, DKNB, and DKNC. Diabetes Care 1984;7:36–41. 98. Reichard P, Berglund A, Britz A, Levander S, Rosenqvist U. Hypoglycaemic episodes during intensified insulin treatment: increased frequency but no effect on cognitive function. J Intern Med 1991;229:9–16. 99. Reichard P, Britz A, Carlsson P, Cars I, Lindblad L, Nilsson BY, et al. Metabolic control and complications of 3 years in patients with insulin dependent diabetes (IDDM): The Stockholm Diabetes Intervention Study (SDIS). J Intern Med 1990;228:511–17. 100. Reichard P, Rosenqvist U. Nephropathy is delayed by intensified insulin treatment in patients with insulin-dependent diabetes mellitus and retinopathy. J Intern Med 1989;226:81–7. 101. Reichard P, Pihl M. Mortality and treatment sideeffects during long-term intensified conventional insulin treatment in the Stockholm Diabetes Intervention Study. Diabetes 1994;43:313–17. 102. Reichard P, Britz A, Rosenqvist U. Intensified conventional insulin treatment and neuropsychological impairment. BMJ 1991; 303:1439–42. 103. Reichard P, Berglund B, Britz A, Cars I, Nilsson BY, Rosenqvist U. Intensified conventional insulin treatment retards the microvascular complications of insulin-dependent diabetes mellitus (IDDM): the Stockholm Diabetes Intervention Study (SDIS) after 5 years. J Intern Med 1991;230:101–18. 104. Reichard P, Toomingas B, Rosenqvist U. Changes in conceptions and attitudes during five years of intensified conventional insulin treatment in the Stockholm Diabetes Intervention Study (SDIS). Diabetes Educ 1994;20:503–8. 105. Reichard P, Nilsson BY, Rosenqvist U. The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus. N Engl J Med 1993;329:304–9. 106. Reichard P, Pihl M, Rosenqvist U, Sule J. Complications in IDDM are caused by elevated blood glucose level: the Stockholm Diabetes Intervention Study (SDIS) at 10-year follow up. Diabetologia 1996;39:1483–8. 107. Reichard P. To be a teacher, a tutor and a friend: the physician’s role according to the Stockholm Diabetes Intervention Study (SDIS). Patient Educ Couns 1996;29:231–5. 108. Brown SA, Hanis CL. Culturally competent diabetes education for Mexican Americans: the Starr County Study. Diabetes Educ 1999;25:226–36. 109. Laitinen JH, Ahola IE, Sarkkinen ES, Winberg RL, Harmaakorpi-Iivonen PA, Uusitupa MI. Impact of intensified dietary therapy on energy and nutrient intakes and fatty acid composition of serum lipids in patients with recently diagnosed non-insulindependent diabetes mellitus. J Am Diet Assoc 1993;93:276–83. 110. Laitinen J, Uusitupa M, Ahola I, Laakso M, Siitonen O. Metabolic and dietary variables associated with glycaemic control in patients with recently diagnosed type II diabetes mellitus. Diabetes Nutr Metab Clin Exp 1994;7:77–87. 111. Uusitupa MI. Early lifestyle intervention in patients with non-insulin-dependent diabetes mellitus and impaired glucose tolerance. Ann Med 1996;28:445–9. 112. Vanninen E, Uusitupa M, Lansimies E, Siitonen O, Laitinen J. Effect of metabolic control on autonomic function in obese patients with newly diagnosed type 2 diabetes. Diabetic Med 1993;10:66–73. 113. Vanninen E, Uusitupa M, Siitonen O, Laitinen J, Lansimies E. Habitual physical activity, aerobic capacity and metabolic control in patients with newly-diagnosed type 2 (non-insulin-dependent) diabetes mellitus: effect of 1-year diet and exercise intervention. Diabetologia 1992;35:340–6. 114. Vijan S, Hofer TP, Hayward RA. Estimated benefits of glycemic control in microvascular complications in type 2 diabetes. Ann Intern Med 1997;127:788–95. 115. DAFNE Study Group. DAFNE (Dose Adjustment for Normal Eating): its clinical and cost effectiveness for education people with type 1 diabetes mellitus in diabetes self-management. 2002. 116. Netten A, Rees T, Harrison G. Unit Costs of Health and Social Care, 2001. Canterbury: Personal Social Services Research Unit, University of Kent at Canterbury; 2002.
URI:	http://wrap.warwick.ac.uk/id/eprint/52144

Request changes to a record

Actions (login required)

View Item