Health Behavior Change in Managed Care
A S TAT US R E P O R T
Selected Evidence for Behavioral Approaches to Chronic Disease Management in Clinical Settings:
Diabetes
Acknowledgments
We are grateful to these individuals for their many contributions to this project Our thanks to the following researchers and writers for their work on the reports and evidence tables: Thomas Babor, PhD; Elizabeth Eakin, PhD; Edwin Fisher, PhD; Cynthia Gibson; Karen Glanz, PhD, MPH; Russell Glasgow, PhD; John Higgins-Biddle, PhD; Evette Ludman, PhD; John Piette, PhD; Paul Rohde, PhD; C Barr Taylor, MD; Dennis Turk, PhD; and Cheryl Ulmer, MS The following individuals provided valued contributions as well, and we are grateful for their expertise and commitment: Lisa Benz Scott, Naana Boakye, Jonathan Wade Bress, Carrie Cannon, Enesha Cobb, Gloria Cohen, Michelle Connatser, Suzanne Connaughton, Maria Dittrich, Steve Garfinkel, William Gerin, Brooke Hamilton, Laura Johnson Hurst, Jill Lipidis, Mary Mannix, Catherine Maule, Karen McDonnell, Susan Reneau, Mark Schlesinger, Amy R Schwartz, Sumi Tripuraneni, and Sharon Loube Zack The Center for the Advancement of Health extends special thanks to John Pinney
and J Michael McGinnis for their involvement in this project from its initial conceptual development through its completion Finally, we wish to thank C Tracy Orleans and the Robert Wood Johnson Foundation for its generous support of this project The Foundations commitment to these ideas and to the translation of health and behavior research into the delivery of health care is crucial to improving the nations health
2000 Center for the Advancement of Health Center for the Advancement of Health 2000 Florida Avenue, NW, Suite 210 Washington, DC 200091231 http://wwwcfahorg All rights reserved No part of this publication may be reproduced, stored in any retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopied, recorded, or otherwise without prior permission
Contents
Advisory Committee 4 Introduction 5 Selecting the Evidence for Behavior Change in Clinical Settings 7 Evidence for Behavior Change in Managed Care 7 What the Literature Says 9 Alcohol Misuse 9 Nutrition 11 Physical Activity 13 Smoking Cessation 14 Asthma 16 Cardiovascular Disease 17 Depression 19 Diabetes 21 Low Back Pain 22 Common Themes 24 Selected Evidence:
Diabetes Management 27 Brief Interventions 27 Intensive Interventions 42 Literature Reviews 79 System Changes 85 Reference List: Key Words and Index 89 Publications Request Form 95
Center for the Advancement of Health
Health Behavior Change in Managed Care Advisory Committee
The following persons are listed according to their affiliation at the time of their participation Affiliations are for identification purposes only
David Abrams, PhD Center for Behavioral and Preventive Medicine Brown University School of Medicine and The Miriam Hospital Lynda Anderson, PhD Division of STD Prevention Health Services Research and Evaluation Centers for Disease Control Prevention Michael Bailit, MBA Bailit Health Purchasing, LLC Barbara Cooper Health Care Financing Administration Susan Curry, PhD Center for Health Studies Group Health Cooperative of Puget Sound Edwin Fisher, PhD Division of Health Behavioral Research Washington University School of Medicine Jed Goldart, MD, MPH Value Behavioral Health, Inc Robert G Harmon, MD, MPH Optum Division UnitedHealth Group Laura Hayman, PhD, FAAN Frances Payne Bolton School of Nursing Case Western Reserve University George Isham, MD
HealthPartners Nancy Kennedy, DrPH Center for Substance Abuse Prevention Substance Abuse Mental Health Services Administration Barbara Lardy American Association of Health Plans
Joseph Maloney CHI Mountain Region Foundation J Michael McGinnis, MD National Academy of Sciences Christopher OFlinn Global Benefits Mobil Corporation C Tracy Orleans, PhD Robert Wood Johnson Foundation John Pinney Pinney Associates Nicolaas Pronk, PhD Center for Health Promotion HealthPartners Mark S Rappoport, MD Oxford Health Plans Bill Rosenberg Global Human Resource Solutions PricewaterhouseCoopers LLP James Sabin, MD Department of Mental Health Harvard Pilgrim Healthcare Robert St Peter, MD Kansas Health Institute L David Taylor Alpha Health Plan Edward Wagner, MD, MPH Sandy McColl Institute Group Health Cooperative of Puget Sound DAnn Whitehead, PsyD Preventive Health Services Chevron Corporation Daniel Wolfson, MHSA Alliance of Community Health Plans
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Introduction
Nearly half of the nations premature deaths from the 10 leading causes of mortality are attributable to controllable behavioral factors such as unhealthy diet, lack of exercise, tobacco use,
alcohol and drug abuse, and risky sexual practices Behavioral health risks are also associated with higher ambulatory care and hospitalization costs — accounting for as much as 70 percent of all medical care spending Managed care plans can stem these costs by incorporating evidence-based behavior change interventions that encourage healthy people and those with chronic illness to modify their behavior to reduce health risks and maintain that behavior over time Evidence Evidence shows that there is a range of services shows that there is a range of services and programs and programs that can help individuals change that can help individuals change the behavior patterns that contribute to the onset and progression the behavior patterns that contribute to the of chronic diseases, disability, and premature death onset and progression of chronic diseases, The integration of these interventions into clinical disability, and premature death care, however, continues to be limited and piecemeal This is true even in managed care organizations — in which there are powerful reasons to apply the lessons that have accrued from decades of behavioral research The managed care enterprise was
established on the premise that the health of individuals can be improved in a cost-effective manner through the strategic application of knowledge about disease prevention and management Under this premise, consumers, payers, providers, and plans all benefit from health plan members remaining as healthy as possible Well-designed and widely available behavior change services could, if fully implemented, make a significant contribution to this aim by improving health outcomes In many cases, such services could also reduce health care utilization in the short- and long-term Given the overlap of interests and incentives — and consumers growing desire for high-quality services that allow them to take greater control of their health — this is a critical time for managed care systems to consider incorporating behavioral interventions and programs into their service delivery protocols Managed care is still a young and expanding industry, constantly being reassessed, redirected, and reorganized to deliver better health outcomes at lower costs Such ongoing expansion and modification creates an unprecedented opportunity for organized health care to address the behaviors that drive health
care costs up and compromise the health and productivity of the nation Meanwhile, this expansion and modification can also reclaim the philosophical and scientific foundation upon which managed care was built
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Assessing Health Behavior Change Efforts in Managed Care
Any attempt to recommend strategies for incorporating behavioral change interventions into managed care must begin with an assessment of the efforts managed care plans already have undertaken and the gaps that remain In 1999, the Center for the Advancement of Health CAH conducted such an assessment through a series of studies and analyses designed to ascertain the factors influencing the availability, access, and integration of health-related behavior change strategies in managed health care settings Information was collected from three sources: 1 Health maintenance organization HMO medical directors in five states and the District of Columbia were surveyed about the availability, intensity, and integration of behavior change strategies within standard health care in their plans The directors were asked to describe their attitudes and beliefs about the effectiveness of such
strategies Specifically, interviewees provided information about their health plans provision of services to help members change four of the leading behavioral risk factors that contribute to the development of chronic disease: smoking physical inactivity unhealthy dietary habits misuse of alcohol and/or other drugs
Medical directors also provided information about their plans provision of services to improve patient management of five conditions that are among the leading causes of morbidity and mortality: 2 asthma back pain cardiovascular disease depression diabetes
Public and private health care purchasers, insurance brokers, and benefits consultants were interviewed about their attitudes toward behavior change services and the extent to which they negotiate for and purchase these services Literature reviews of randomized controlled trials, quasi-experimental studies, systematic reviews, and metaanalyses were conducted These reviews summarize brief and intensive behavioral interventions, their effect on outcomes, cost impact, and consumer satisfaction, as well as the availability of evidence-based protocols and standards for each of the four risk behaviors and five
chronic conditions
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Selecting the Evidence for Behavior Change in Clinical Settings
CAH searched and reviewed the published peer-reviewed scientific literature on the following topics: 3 Behavioral Risk Reduction in Clinical Settings1 alcohol and other drug misuse dietary practices physical inactivity smoking Behavioral Approaches to Chronic Disease Management in Clinical Settings asthma back pain cardiovascular disease depression diabetes
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Each topic was searched in the following databases all years indexed through September, 1999: 3 3 3 3 3 Medline PsychInfo / PsychLit Sociofile HealthStar The Cochrane Library
The inclusion criteria limited the evidence to: 3 3 3 3 3 Randomized or quasi-experimental control or comparison studies Research conducted in a clinical setting primary care, inpatient and outpatient, home-based self-management, community-based vendors and worksite clinics Research that tested the effect of a behavioral intervention individual or multi-component in at least one experimental group Research that measured behavior change, health indicators, and/or economic indicators absenteeism, return to work,
cost-benefit, cost-effectiveness, cost-offset Meta-analyses or systematic reviews of literature meeting the above criteria
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Clinical settings includes interventions delivered to individuals and small groups; excluded were mass media, community-based, and environmental interventions
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Behavioral scientists at CAH reviewed the full text of each study that was identified by an initial search Senior content area experts were contracted to assess the initial search results and provide additional studies that were missed The reference lists of recent meta-analyses and systematic reviews also were used to determine gaps in the evidence base2 The final collection of selected evidence for each topic was abstracted to a table Abstracted articles were independently reviewed by 2 to 3 behavioral scientists The abstraction categories are:3 3 3 3 3 3 3 Principal Investigators, Year and Title of Publication Study Design: Randomized Control Trial RCT and Follow-up period FU, Systemic Review, Meta-Analysis Sample Description: Eligibility/ Diagnosis, Age, Gender, Ethnicity; Setting Interventions: Main components, providers, duration, intensity, sample size
Measures: Behavioral, psychosocial, physiological, economic Outcomes: Main findings
Abstracted articles were organized chronologically descending and alphabetically ascending within categories that were identified by senior content area experts To simplify searching for abstracted studies, the final section of this report features a complete list of references as well as an index indicating the page on which each study appears within this document
The body of work contained in this document does not necessarily represent an exhaustive collection of all that exists in the peer-reviewed scientific literature Abstraction was based on a careful review of full text articles but was limited by the content of the published worked reviewed The varying levels of detail provided by the abstracts are a reflection of the information available from the original articles
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What the Literature Says
CAH commissioned experts in health behavior change theory, research, and practice to synthesize evidence about 3 four of the leading behavioral risk factors that contribute to chronic disease–smoking, physical inactivity, unhealthy nutrition behaviors,
and alcohol and other drug misuse/dependency preventing and/or managing five of the leading causes of morbidity and/or mortality–asthma, back pain, cardiovascular disease, depression, and diabetes
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Each of the following reviews summarizes research about 3 3 3 3 state-of-the-art behavior change technologies as applied in both brief and intensive interventions the essential elements for behavior change recommendations for best practice short- and/or long-term costs of providing or not providing behavior change interventions eg, cost-benefit, cost-effectiveness, and cost-offset
Wherever available, outcomes evidence–pertaining to both health eg, blood pressure, blood glucose, and weight management and quality of life eg, decreased pain and worker absenteeism, increased functional status, and patient satisfaction–is also included Studies selected for the reviews were based on randomized controlled trials and quasi-experimental studies At least one experimental group was used to assess the effectiveness of an individual or multifactorial behavioral intervention Also included are meta-analyses and systematic reviews that synthesize study results, as well as studies that compare
different providers effectiveness eg, nurse practitioner vs primary care physician and/or system changes eg, comparison of a plan that uses a proactive system to identify and follow up vs usual care
Alcohol Misuse
Alcohol misuse, as defined by the World Health Organization, includes alcohol consumption that places people at risk for problems, as well as clinical alcohol abuse and dependence Approximately 20 percent of the American population consumes alcohol in ways that lead to increased risk, about 35 percent drinks within guidelines for moderate alcohol use, and less than 5 percent meets the criteria for alcohol dependence Alcohol misuse is currently the third leading risk factor for mortality in the United States, accounting for as many as 100,000 deaths each year Specific alcohol-related causes of death include cancers, cirrhosis,
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pancreatitis, motor vehicle accidents, falls, drowning, fires, suicide, and homicide Alcohol also contributes to such common and significant health problems as hypertension, stroke, cardiovascular disease, trauma, depression, and gastrointestinal disorders The estimated cost of alcohol misuse in 1995 was
166 billion Alcohol consumption lies at the root of all alcohol-related problems, and the amount and intensity of consumption, in general, relate directly to the level of medical, social, and other kinds of problems drinkers experience However, the quantity and pattern of drinking vary both among drinkers and within individuals over time Therefore, the critical issue in determining appropriate care for alcohol misuse is the presence or absence of alcohol dependence Alcohol dependence is a chronic disorder characterized by a cluster of three or more symptoms within a 12month period These symptoms include alcohol tolerance, withdrawal, loss of control, and continued use despite knowledge of having a physical or psychological problem Alcohol abuse is a less severe pattern evidenced by one or more recurrent, adverse consequences, such as the failure to fulfill important obligations or the repeated use of alcohol in Screening, brief interventions, and more intensive physically dangerous situations At-risk use is the interventions based on differential assessment and consumption of alcohol in a way and for a purpose diagnosis of alcohol abuse and dependence are all that is not consistent
with legal or medical guidelines and that is likely to present risks of acute and/ or chronic medical, behavioral, and social harm to the user or others critical elements of the treatment of alcohol misuse
Screening, brief interventions, and more intensive interventions based on differential assessment and diagnosis of alcohol abuse and dependence are all critical elements of the treatment of alcohol misuse Screening instruments that rely on patients self-reports are available for use with general medical populations Perhaps the most widely used screening instrument is the CAGE acronym for Attempts to Cut down; Annoyance with criticisms; Guilt; Using alcohol as an Eye opener, which has limited usefulness because it fails to ask about alcohol consumption Another self-report measure, the 10item AUDIT Alcohol Use Disorders Identification Test, asks about consumption, related problems, and signs of dependence It was designed for early detection of both at-risk drinkers and alcoholics Despite the availability of these and other instruments and evidence of the feasibility of screening in primary care, hospital, and emergency settings, most primary care physicians do not screen for
alcohol misuse When such screening does occur, it creates opportunities for intervention The results of over 40 clinical trials indicate that brief interventions are effective in reducing alcohol consumption Brief interventions typically include feedback from screening, health advice to reduce consumption and risk, guidelines for sensible drinking, involvement of the patient in goal setting, and strategies to increase motivation The goal of brief interventions may be moderate drinking rather than total abstinence, and the interventions may involve only one session lasting 3 to
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5 minutes or as many as several 20-minute sessions Brief interventions are usually provided to individuals who are at-risk drinkers rather than active or recovering alcoholics and take place in settings such as primary care settings that are not specifically oriented toward the treatment of alcoholism An appropriate alcohol screening and brief intervention program for the general medical population will also identify patients who are likely to be alcohol-dependent Such patients are typically referred for specialty care An important first step of the more intensive
interventions that characterize specialty care is differential assessment Differential assessment, which includes detailed evaluation of the patients problem in terms of etiology, presenting symptoms, use of substances, and other associated features including the social, psychological, and physical consequences of substance use, should be conducted through use of a standard diagnostic interview Among the wide variety of services and settings established for the treatment of alcohol problems, 12-step treatment programs derived from Alcoholics Anonymous continue to dominate the field However, new treatment approaches eg, relapse prevention and motivational enhancement therapy and older approaches have been refined to the point where the treatments can be standardized and widely disseminated Significant advances have been noted in pharmacotherapy, family and social support therapy, and behavior-oriented controlled drinking interventions Intensive treatment for alcohol dependence should include, among other services, detoxification for patients with moderate to severe withdrawal The purpose of detoxification is to minimize symptoms, prevent or manage seizures or delirium, and
facilitate acceptance of therapy that addresses dependence The identification, management, and reduction of health risks associated with substance misuse are critical features of any comprehensive health system The prevalence and cost of substance-related problems are powerful indicators that patients and health plans would benefit from better integration of substance misuse care with primary medicine
Nutrition
Nutrition plays an integral role in the etiology, progression, and sequelae of cardiovascular disease, diabetes, obesity, and some cancers and can be a key risk factor in chronic diseases, especially high blood cholesterol and hypertension Nutrition interventions usually take the form of education or advice about ways to implement health-enhancing dietary changes Changing eating patterns can be quite complex for several reasons: 1 2 Most diet-related risk factors are asymptomatic and do not present immediate or dramatic symptoms Health-enhancing dietary changes require qualitative change, not just modification of the amount of food consumed
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3
Information acquisition and processing may be more complex for dietary change than for
other behaviors, such as smoking or exercise Because nutrition intervention leads to meaningful improvements in cardiovascular health only when longterm change is achieved, both providers and patients need to look down the road when formulating expectations and setting goals Even after goals are achieved, new dietary habits must be maintained
4
Nutrition intervention best practices require the participation of physicians and other providers in promoting healthful eating behaviors Physicians have a critical responsibility to communicate to patients the importance of nutrition to health, provide credible nutrition advice, and understand the challenges of adherence to long-term nutritional changes Physicians should also coordinate with other professionals, including dietitians, nurses, psychologists, and other qualified health educators and aides An increasing body of evidence indicates that brief, minimal-contact interventions can effectively improve nutrition For example, self-help guides and personalized, tailored materials can help reduce dietary fat intake and increase fruit and vegetable intake It is less clear whether brief interventions achieve significant results for
cholesterol reduction, diabetes management, or weight loss To date, there are no established, evidence-based protocols for brief nutrition intervention, although studies suggest the most successful interventions include an authoritative medical source; personalized feedback; motivational messages; and concrete advice, such as food substitution lists and recipes Longer-term nutrition interventions usually involve several meetings per month for at least three to six months, with less frequent maintenance or booster sessions for up to a year or more These have been used for cholesterol reduction, diabetes management, weight reduction, and primary prevention Comprehensive nutrition intervention for chronic disease management requires a cyclical sequence of activities: 3 Assessment–diagnostic evaluation of lipids, blood pressure, body mass index, glycemic control, and other risk factors; dietary evaluation; and assessment of other factors such as physical activity, readiness to change, self-efficacy, knowledge level, prior experiences with dietary change, and barriers to change Treatment–nutrition counseling, dietary advice, referrals, and provision of educational or supporting
materials Evaluation, monitoring, and follow-up–assessments of adherence and treatment efficacy, negotiating new goals, and periodic monitoring once risk factor control is achieved Follow-up should focus on helping patients become more comfortable with self-monitoring and self-management techniques
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The majority of these activities can be accomplished in 5 to 15 minutes during an office visit or through telephone counseling sessions They can be administered by auxiliary providers Most important, these activities must be done consistently and sustained over a period of time, since long-term change requires long-term intervention
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Physical Activity
Research indicates that regular physical activity reduces risk of coronary heart disease CHD, diabetes, colon cancer, hypertension, and obesity It also promotes psychological well-being; builds and maintains healthy bones, muscles, and joints, reducing the risk of severe injury from falls; and increases functional independence Physical activity is also an important part of the self-care regimen of many chronic conditions Inactivity, for example, is a major CHD risk factor and is similar
in magnitude to risks associated with smoking, hypertension, and hypercholesterolemia National guidelines from the US Centers for Disease Control and Prevention and the American College of Sports Medicine recommend that all adults should accumulate at least 30 minutes of moderate physical activity per day for five or more days per week However, surveys indicate that approximately 68 percent of adults do not achieve this level of activity, and activity levels decrease with age Moreover, care regarding physical inactivity is inconsistent, with only half of a national sample of internists saying they counseled all patients about exercise and only 15 percent of those saying they counseled inactive patients for at least five minutes during routine office visits Best practice guidelines from the US Department of Health and Human Services stipulate that all physically inactive patients should be counseled The guidelines specify that information should be provided about the role of physical activity in disease prevention, and patients should be assisted in selecting appropriate physical activity Key elements of effective, brief, primary carebased interventions include the following: 3 3
assessment of the patients current level of physical activity collaborative goal setting between patient and provider that takes into account the patients preferences and lifestyle problem solving with the patient about barriers to physical activity identifying supports that will help the patient maintain an increased level of physical activity eg, repeat visits, telephone follow-up, mailings, and community resources
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As with other health-related behaviors, this intervention is enhanced when there is a system in place that facilitates the identification and assessment of eligible patients, that has trained and motivated staff, and that allows for population-based patient tracking One example of an effective intervention is encouraging home-based physical activity, such as in exercise groups or classes Intervention usually begins with a clinic visit with a health educator who can help patients set goals for activities they can perform on their own Patients track their progress on activity logs, and the health educator provides ongoing support via telephone calls This model has been particularly successful in promoting as well as maintaining physical activity in older adults and
has demonstrated increases in physical activity and fitness comparable to higher-intensity, group-based exercise programs
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For extremely frail patients, as well as those recovering from a heart attack or who have not benefited from brief intervention, a variety of more intensive programs are available that take place outside the primary care setting Among these are multicomponent and multisession cardiac and pulmonary rehabilitation programs led by multidisciplinary professionals, as well as community-based exercise programs eg, those offered at fitness, recreation, or senior centers While these interventions appear effective in producing short-term changes in physical activity, maintenance continues to be a challenge and is an area in need of further research A recent review of primary care-based physical activity interventions, for example, found only seven studies with outcomes of one year or more Of these, only three reported that initial increases in physical activity had been maintained These findings suggest a need for longer-term follow-up support after the initial intervention
Smoking Cessation
Cigarette smoking represents the
greatest health risk of all the behaviors discussed in this report Despite scores of well-publicized educational campaigns about the health risks of smoking, nearly one-quarter of the entire adult population and 28 percent of 16- and 17year-olds continue to smoke Given the enormous health consequences of smoking, smoking cessation has been the focus of considerable research attention over the past 35 years Numerous studies, for example, have shown quitting smoking is associated with decreased use of both inpatient and outpatient health care services over a five-year period Quitting smoking also leads to reduced risk for cardiovascular and cardiopulmonary disease, low-birth-weight babies, and workrelated absenteeism Cigarette smoking represents the greatest health risk of all the behaviors discussed in this report Despite scores of well-publicized educational campaigns about the health risks of smoking, nearly one-quarter of the entire adult population and 28 percent of 16- and 17-year-olds continue to smoke
Smoking cessation research has generated the most advanced and effective brief and intensive behavioral intervention protocols Generally, these programs help patients to 3 3 3
3 3 3 set a target date and specific plan for quitting identify and cope with temptations likely to provoke relapse effectively utilize nicotine replacement or other medications solicit support from family or friends secure continued follow-up and support services prevent relapse
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Based on exhaustive reviews of published literature, the Agency for Health Care Policy and Research AHCPR guidelines provide a clear protocol for brief smoking cessation interventions that can be delivered by a variety of health care professionals: 3 During every office visit, patients should be questioned about whether they smoke and, if they do, about their smoking habits These results should be noted among vital signs Patients should be educated and advised about the dangers of smoking and the importance of quitting This information should be personalized, whenever possible, to the needs and habits of the individual patient Patients should be encouraged to set a quit date; assisted in identifying possible temptations and strategies for overcoming them; and encouraged to consider medications, including nicotine replacement Providers should be able to refer
patients for follow-up services and, for patients who have difficulty stopping, provide or arrange for more intensive counseling and assistance
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Intensive interventions should be used with individuals who have been unable to quit on their own or with brief assistance, or those who are facing an immediate health imperative eg, pregnancy or heart attack These interventions may entail counseling, group support, education, and skills training eg, problem solving over, on average, a six- to eight-week period Most of these services can be provided via telephone or computer, as well as in person Clinical data indicate that both brief and intensive interventions can be effective in helping people quit A recent meta-analysis of 86 smoking cessation studies, for example, indicates that people who receive one brief intervention to promote nonsmoking are 148 times more likely to quit than those who receive none Those who receive two or more of these treatments are 148 times more likely to quit than those who received only one When nicotine replacement therapy NRT is combined with a variety of interventions eg, brief counseling or group cessation programs, the rate of abstinence
doubles A meta-analysis of 19 intensive group programs found participants were 21 times more likely to quit than those receiving only self-help materials and 191 times more likely to quit than those receiving minimal or no contact Coverage of costs for smoking cessation services also has an impact on their ability to promote cessation A recent study revealed that charging for some portion of the cost of cessation services led to higher quit rates, but offering services at no charge led to higher participation rates Therefore, offering cessation services at no charge resulted in a higher net percentage of quitters among all smokers in a plan 28 percent in comparison to quit rates of 07 to 17 percent of all smokers when partial or full payment by users was required There are a number of effective approaches to smoking cessation, with no intervention significantly more effective than another Also, different interventions may fulfill similar functions Counseling offered as part of primary care or educational materials tailored to individuals not yet ready to quit may help motivate them toward cessation, and individual counseling or group programs may help people plan their quits and
master behavioral selfmanagement skills to avoid relapse From the literature, a critical theme emerges Across numerous studies, cost analyses, and meta-analyses, the more extended and comprehensive the treatment, the more likely cessation will be achieved Additions to the
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briefest counseling will increase the efficacy of that counseling, and additions of comprehensive behavioral interventions and follow-up to more intensive programs increase their efficacy as well
Asthma
Asthma is characterized by chronic inflammation of the bronchial tubes due to allergens and other irritants that compromise breathing An estimated 14 million people have asthma; it is particularly prevalent among children, especially low-income and minority pediatric populations Today, asthma is the most commonly experienced chronic disease in childhood, responsible for the most lost days of school about 10 million per year Asthma also affects adults and accounts for 3 million lost workdays annually, or an average of five workdays missed per year Estimates of direct medical expenditures and indirect costs attributed to asthma totaled approximately 126 billion in 1993
Psychosocial factors play a role in the onset and progression of asthma Anxiety disorders and depression, for example, are more prevalent among those with asthma than in the general population Additionally, a variety of individual and family psychological and social distress factors have been implicated in frequency of attacks and high risk for death from asthma Key elements of asthma treatment are 3 avoiding crises by treating the inflammation, usually through inhaled medications taken several times daily, even when the patient does not feel ill avoiding or limiting exposure to allergens or other asthma triggers treating acute crises with rescue medications monitoring asthma either with a peak flow meter that measures air flow or by monitoring symptoms so that medication dosage can be adjusted to avoid worsening of symptoms
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Failure to take asthma medication regularly and/or inadequate response to symptoms is responsible for much unnecessary morbidity Adherence to asthma therapies is only around 50 percent, leaving patients vulnerable to exacerbations According to the National Asthma Education and Prevention Programs Guidelines for the Diagnosis and Management of Asthma,
usual care should include regular use of medications to reduce airway inflammation and prevent attacks This should be followed by rescue medications when symptoms emerge and timely acute care when symptoms do not abate It should also include three to four regular outpatient care visits per year to monitor progress and adjust medication and behavior management plans Patients and parents of children with asthma need what the National Asthma Education and Prevention Program calls a partnership with a primary care provider Also needed are skills and confidence for using rescue medications, as well as knowledge of indicators and procedures for accessing acute care
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Research has identified a core set of skills and objectives for educational or behavioral programs for asthma management These are also reflected in the Guidelines for the Diagnosis and Management of Asthma Core skills and objectives include the following: 3 identifying and avoiding allergens or asthma triggers, including dust, allergens from cockroaches and other pests, allergens from pets, and secondary tobacco smoke identifying and acting on early signs of attacks including
monitoring symptoms–with peak flow meters, for example managing attacks including use of rescue medications and adhering to medication including preventive medications
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Other common elements of asthma management programs include learning relaxation skills, seeking acute care when symptoms worsen or fail to improve, and learning how to communicate better with health care providers and other people in the patients life Because smoking–including second-hand smoke–exacerbates asthma, best practices in asthma management often include smoking cessation services for patients and family members Clinical and educational objectives can often be accomplished through routine primary care and available print, video, and other educational resources Time required for such care is generally three to four regular outpatient visits per year Visits should include review of the patients records of symptoms or peak flow measures of lung function, assessment of the patients medication adherence, and adjustment of medications and plans for managing acute symptoms This care would also include occasional education delivered by physicians or other professionals through print or electronic media or
in face-to-face meetings Effective intensive interventions cover the same basic objectives as brief interventions but offer more opportunity for review, rehearsal, and monitoring of behavior change over time and attention to individual barriers to adoption and adherence Offered in either individual or group formats, intensive interventions may be supplemented by relaxation training and other stress-management procedures, counseling, or cognitive behavior therapy to address psychosocial issues that may be barriers to care and adherence
Cardiovascular Disease
Nearly 60 million Americans have one or more types of cardiovascular disease CVD, including an estimated 50 million people with hypertension, 137 million with CHD, and nearly 4 million who have had a stroke About 15 million Americans have a new or recurrent myocardial infarction MI each year, and about one-third of them will die Heart failure is the major hospital diagnosis for older patients, with over 800,000 patients discharged with this diagnosis each year Common comorbidities include hypertension, hypercholesterolemia, diabetes, and depression CVD is often rooted in unhealthful lifestyle factors, such as smoking, poor
diet, or inactivity Psychosocial factors also play a role Depression, hostility, and social isolation, for example, all have been shown to contribute independently to mortality and morbidity in patients with CVD The evidence is particularly compelling for
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depression Anger and hostility are strongly associated with the development of CHD, and anger has been shown to trigger acute MI Effective treatment of CVD therefore requires considerable attention to psychosocial and behavioral issues that contribute significantly to the progress of the disease Smoking cessation alone can reduce the risk of recurrent disease by about 30 percent Exercise may reduce total and coronary mortality by as much as 25 percent It is estimated that if pharmacological and behavioral approaches were combined, five-year mortality could be reduced by as much as 50 percent Brief interventions should include screening and feedback about smoking habits, diet, weight, exercise, and psychosocial factors, as well as measurement of blood pressure and lipid levels Screening should be followed by counseling that explains the results of the screening, provides recommendations
for change, determines motivation, sets goals, and arranges for follow-up Educational materials, referrals, and/or access to self-help/selfmanagement groups and follow-up also should be available to patients Minimal intervention programs are relatively inexpensive and require about 20 to 30 minutes of provider time, supplemented by 60 to 90 minutes of additional education/counseling by other health care providers The British Family Heart Study, for example, estimated the cost of provider advice with follow-up to be 400 per patient per year Computer-based or videotape interventions cost even less per patient Brief interventions are most likely to be effective for patients who are highly motivated, have self-management skills, have less comorbidity, have more social support, and are better educated
More intensive interventions have been shown to produce a greater effect than brief interventions Such interventions are particularly useful for patients who need more motivation, support, or skill training than a brief intervention can provide
More intensive interventions have been shown to produce a greater effect than brief interventions Such interventions are particularly useful for
patients who need more motivation, support, or skill training than a brief intervention can provide The MULTIFITSM intervention, developed by Robert DeBusk, MD, and colleagues at Stanford University, is a best practice model through which providers usually nurse care-managers follow patients and provide clear advice about the need for multifactorial risk reduction Scheduled interactions between nurse care-managers include the following: 3 3 3 nurse-initiated telephone contacts computer-generated progress reports mailed to patients, based on questionnaires completed by patients visits for initial assessment and counseling, treadmill exercise testing, and initiation of lipid-lowering drug therapy
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Patients begin the process with an assessment by the nurse care-manager of their risk factors They are then shown a series of videotapes that address the nature of CVD and are invited to discuss with the provider the contribution of psychosocial factors to the disease Separate videos are available that address smoking, diet, and exercise Patients also complete a checklist, workbook, and questionnaires Follow-up consists of 14 nurse-initiated
telephone calls and two or three outpatient contacts Training materials for nurse care-managers, providers, and specialists psychiatrists, psychologists, and dieticians are available from MULTIFITSM One nurse care-manager can treat approximately 250 patients per year, spending an average of about nine hours per patient A cost analysis reveals that the cost per patient is about 500 annually, with patient-related materials costing 5
Depression
Depression costs the US economy about 44 billion per year Depression is associated with high utilization of medical care, increased work absenteeism, decreased vocational productivity, and negative effects on family functioning and quality of life Among primary care patients, major depressive disorder MDD and minor depression are among the most commonly reported illnesses, affecting about 5 to 10 percent of this population Recent evidence indicates that for a significant proportion of depressed individuals, depressive disorders are chronic and recurrent conditions Although primary care physicians provide most of the treatment for depression mostly using antidepressant medication, depression is recognized and accurately diagnosed in only about
half of primary care patients Most depressed patients in primary care settings, however–perhaps up to 90 percent–fail to receive adequate doses of empirically supported treatment ie, either adequate dose and duration of guideline-level medication or empirically Most depressed patients in primary care settings supported depression-specific psychotherapies fail to receive adequate doses of empirically A variety of psychosocial interventions have been supported treatment ie, either adequate dose developed based on the assumption that depressed and duration of guideline-level medication or patients have acquired maladaptive behavior patterns that can be unlearned All empirically supported empirically supported depression-specific psychotherapies for depression are structured and psychotherapies time-limited and have manuals to guide their implementation; many can be provided in a group format Cognitive therapy, for example, helps depressed patients become aware of and change thinking patterns Behavior therapy helps increase behaviors that elicit positive reinforcements, specifically by teaching social and other coping skills Interpersonal therapy addresses interpersonal conflicts or
deficits that may cause depression
Center for the Advancement of Health 3 19
Therapy can be short- or long-term, but increasingly, brief interventions are preferred A variety of brief interventions, focusing on improved identification and enhanced self-management, can be integrated into routine primary care Many of these brief interventions are adjuncts to pharmacotherapy They provide medication adherence support through education, counseling, and proactive follow-up delivered by physician extenders either over the phone or in person Some include elements of brief psychotherapy as well Several collaborative care models, which emphasize active collaboration between the primary care physician and a consulting mental health professional either psychiatrist or psychologist, have been shown to enhance treatment adherence, clinical outcome, and patient satisfaction In 1993, the Depression Guideline Panel of the AHCPR published recommendations for treating MDD in primary care practice Specifically, the panel recommended that medication be the acute-phase treatment for severe depression but that either medication or psychotherapy could serve as the initial treatment for primary care
patients with mild or moderate depression A recent qualitative review examining available reports published between 1992 and 1998 of randomized clinical trials conducted in primary care settings concluded that evidence supported the efficacy of both antidepressant pharmacotherapy and psychotherapy that was time-limited and depression-targeted The review also concluded that, in most cases, the choice between these treatments should depend on patient preference Evidence for superiority of combined psychotherapy and pharmacotherapy relative to either antidepressant medication or psychotherapy has been somewhat limited The AHCPR guidelines recommend combined pharmacotherapy-psychotherapy only for certain cases eg, patients who have partial response to either treatment alone or those with a more chronic history of depression More recent studies provide additional support for the superiority of combined therapy over psychotherapy alone for the treatment of more severely depressed outpatients For less severely depressed patients, combined treatment had no additive effect Given the high rates of relapse and the often chronic nature of depression, ongoing care interventions can
significantly reduce the prevalence and burden of depression The AHCPR guidelines strongly recommend maintenance-phase antidepressant treatment for patients with multiple past episodes of depression, a positive family history of mood disorder, or early depression onset Psychotherapy, especially cognitive-behavioral therapy and psychotherapy used in combination with medication, appears to be a very promising treatment for chronic or drug-treatment resistant depression A clear consensus regarding best practice for the treatment of depression is still being actively debated Nonetheless, two points are clear: 1 2 The gap between usual care and best practice in the management of depression is wide Regardless of whether pharmacotherapy or psychosocial treatment is selected, the treatment, to be effective, must be empirically supported and provided in an adequate dose
20 3 Health Behavior Change in Managed Care
Diabetes
Among adults, diabetes is the leading cause of end-stage renal disease, blindness, and amputations not resulting from trauma Costs of care for diabetic members of managed care plans are as much as four times the costs for nondiabetic members As a result, several major
third-party payers and professional organizations, including the Health Care Financing Administration HCFA and the American Association of Health Plans AAHP, have targeted improvements in diabetes care, and NCQA will release new HEDIS performance standards for the disease Diabetes self-management is extremely complex and challenging, involving the following: 3 3 3 frequent self-monitoring of blood glucose levels and medication taking and adjustments regular checks for early signs of foot problems ongoing dietary and physical activity regimens
These self-care activities such as coping with signs of hyper- or hypoglycemia, as well as the emotional issues that often accompany the illness must be attended to in an ongoing and integrated manner for the remainder of the patients life Patients and families–rather than health care providers–are responsible for more than 95 percent of diabetes management Interventions that help facilitate self-management have been proven effective and sometimes even cost-effective Major randomized clinical trials are now demonstrating that carefully coordinated diabetes care that entails proactive follow-up support can markedly improve glycemic and blood
pressure control, reduce complications, and decrease the likelihood of mortality Effective self-management interventions require the following: 3 a population-based approach including a diabetes registry that is regularly updated and used to provide feedback in managing a panel of patients planned and proactive health care visits rather than working only with those who present complaints collaborative goal setting between patients and providers identification of the barriers and supports in patients social environments patient-centered, personalized problem solving and education systematic follow-up support integration with other health care and community resources
3 3 3 3 3 3
A range of staff members eg, nurses, dieticians, and health educators who have been trained in self-management techniques can provide brief interventions Having an agreed-upon protocol is essential In many cases, the primary interventionist is a nurse who coordinates care, delivers the interventions often via telephone follow-up, and ensures that needed services and screenings are performed
Center for the Advancement of Health 3 21
A randomized study found that counseling patients for as little as 20
minutes immediately prior to an office visit led to significant improvements in both glycemic control and quality of life This intervention included reviewing the patients medical record and working with the patient to identify key issues that he or she wished to discuss Patient-centered empowerment and behavioral, Long-term diabetes care entails the following: 3 3 3 3 goal setting an agreed-upon intervention protocol regular, planned visits periodic collection of outcome measures and corrective action by both patients and professionals based on this feedback frequent follow-up contact problem-solving skills-training interventions produce results superior to both usual care and to more traditional knowledge-based diabetes education sessions
3
Patient-centered empowerment and behavioral, problem-solving skills-training interventions usually conducted in groups produce results superior to both usual care and to more traditional knowledge-based diabetes education sessions Impressive data regarding outcomes and cost-effectiveness have begun to emerge from randomized trials of group-based interventions These interventions also increase patients satisfaction with overall care Monthly
group visits bringing together 8 to 12 patients and their spouses to solve problems and share experiences, co-led by a nurse coordinator and the patients physician, are particularly effective Recently, several population-based intervention strategies involving systematic care management have been studied in managed care settings These studies usually involve a strong patient self-management component in addition to proactive, ongoing protocol-based care, practice redesign, and systematic follow-up The studies have demonstrated impressive outcomes and cost-effectiveness, in some cases over a period of a few years
Low Back Pain
Back pain is the most frequent cause of activity limitation in people ages 45 and under It is the second most frequent reason for physician visits and the fifth most frequent reason for hospitalization Surgery for back pain is the third-ranking surgical procedure in the United States Chronic back disorders cost the American people approximately 75 to 100 billion per year The tendency for recurrence exacerbates these costs Recurrence is more likely to occur in patients treated by HMOs than by other facilities–a recidivism that may be due to HMOs lack of
information about recurrence, prevention, or selfmanagement strategies
22 3 Health Behavior Change in Managed Care
AHCPR clinical practice guidelines suggest that there are three critical points in treating adults with low back problems: 1 2 3 when symptoms are initially presented when symptoms persist beyond four weeks when there is persistent pain beyond four weeks but for less than 12 weeks
Initial assessment of back pain should include ruling out red flags such as signs of fracture, infection, or trauma If none of these conditions exists, and pain and intolerance of activity persist beyond four weeks, a physician should address psychosocial issues or refer the patient for a psychosocial evaluation The reason: Many studies indicate psychological distress or psychiatric disorders are more important risk factors for back pain than are physical problems When pain persists beyond 12 weeks, back problems should be considered chronic rather than acute Psychosocial factors are especially important to consider if back pain is evident after three to six months following the initial onset of pain Many outcome studies, for example, indicate that surgical interventions, implantation of
spinal cord stimulators, and long-term use of opioids for chronic pain are effective only for a small proportion of patients Other studies indicate that many patients with chronic back pain do not respond well to treatments such as modifying physical activities that focus solely on physical pathology Brief interventions, such as the provision of educational booklets emphasizing self-care, instruction in posture, and/or brief counseling sessions also do not have any effect on long-term outcomes for people with back pain This finding again suggests that a failure to address patients beliefs and attitudes, job satisfaction, or stress levels could result in ineffective treatment and continual chronic pain Longer-term interventions are thus recommended for chronic back pain The content of these interventions varies, as does the make-up of the professional staff involved, which can include physicians, psychologists, physical therapists, nurses, and vocational counselors Comprehensive rehabilitation programs physical therapy, medication, etc that include behavioral or psychosocial components appear to be the most successful in returning to work a significant proportion of patients with
back pain Such programs are more successful than physical therapy or surgery A meta-analysis of 65 studies, in fact, concluded that comprehensive programs are 17 times more cost-effective, with the potential to save billions of dollars in health care costs Despite these data, many third-party payers are still reluctant to cover such rehabilitation programs This reluctance appears to stem at least in part from long-term familiarity with invasive–and often expensive– procedures, such as surgery, that have been used extensively in the hope of fixing the broken body and thereby curing back pain The reality, however, is that chronic pain is hardly ever cured, which means that rehabilitation services may be the best option for patients and payers One study, for example, found that HMOs with physicians on staff who had been trained specifically in providing behavioral interventions reported substantial savings, including 42 percent fewer consultations, 59 percent fewer physical therapy referrals, and 33 percent fewer diagnostic imaging procedures
Center for the Advancement of Health 3 23
In short, there is growing evidence that the multidisciplinary treatment of chronic pain in pain
management and functional restoration programs can be both clinically effective and cost-effective, despite the complexity of the problem Although surgical and pharmacological approaches to chronic pain can lead to significant reductions in pain severity, comprehensive programs that incorporate cognitive-behavioral approaches appear to have at least as good a result in pain reduction and better outcomes on criteria such as a reduction in health care utilization, increased activity, and return to work This evidence suggests that billions of dollars in medical care and indemnity costs could be saved through a shift in the treatment of back pain from reliance on invasive procedures to the widespread implementation of comprehensive approaches to rehabilitation that have been documented to be effective
Common Themes
While the literature shows each of the aforementioned conditions to be associated with a diverse array of effective behavior change interventions, it also reveals common findings across behaviors and conditions: 3 Behavior change interventions delivered in health care settings yield positive outcomes Studies measured the effects of intervention on a wide variety of outcomes
These ranged from sustained behavior change to physiological changes with clinical significance glycosylated hemoglobin, peak flow rates, and blood pressure to reductions in health service utilization Generally, the effects are quite positive in the short term and, in the absence of effective maintenance efforts, taper off over time
Behavior change interventions delivered in health care settings yield positive outcomes Studies measured the effects of intervention on a wide variety of outcomes
3
The economic impact of interventions in clinical settings to change health behavior is not clear Measurement of the cost of behavior change interventions varies widely among intervention targets For example, there is a wealth of reliable information demonstrating the economic impact of interventions for smoking cessation For most health behavior change interventions, however, measurement of economic impact has been rudimentary and incomplete Effective intervention protocols are available There is some form of publicly available evidence-based guideline, protocol, standard, or best practice document available for changing each of the four risk behaviors and for patient management of the
five chronic conditions However, the sophistication of the evidence review and comprehensiveness of the guidance offered in these documents vary considerably
3
24 3 Health Behavior Change in Managed Care
Common themes emerged across interventions in all behavioral risk reduction and disease management topics: 3 The primary care providers role is brief but critical All effective interventions include some form of review and collaborative planning between primary care provider and patient While more intensive interventions may be better delivered by other trained professionals, the authority of the primary care provider role and that roles attendant coordination functions appear to be important elements in initiating and sustaining patient behavior change Collaborative planning between the primary care provider and the patient is essential Individuals with chronic conditions and those who are otherwise at risk often are faced with changing multiple, longstanding habits Common elements of effective discussions between primary care provider and patient include the following: a brief, personalized review of health status and risks collaborative decision-making and priority-setting
about what to do mutual development of a treatment plan, including referral to specific behavior change support services, if needed arrangements to follow up on progress
3
3
A wide range of behavior change supports should be available Brief standard screening and behavior change counseling exist and can be integrated into routine primary care For more intensive intervention, however, the wider the selection of evidence-based services and supports available, the higher the likelihood that patients will choose approaches that will help them successfully achieve and maintain change A range of health care professionals coordinate access and deliver behavior change services in most trials reviewed The discipline of the therapist appears to be far less important than the extent of training in effective behavior change strategies Managing health risk and chronic conditions requires a lifelong series of course corrections Data show that changing any longstanding health habit often requires ongoing and sustained treatment efforts similar to those provided for managing chronic conditions Realistic expectations about the effectiveness of any intervention on the part of purchasers,
providers, and consumers are key for planning and maintaining commitment to change Health care interventions oriented toward providing advice, collaborative planning, choices among effective self-management support services, and follow-up that continues over time can encourage continued engagement on the part of both patients and providers
3
Center for the Advancement of Health 3 25
Selected Evidence: Diabetes Management1
SMBG Self Monitoring of Blood Glucose RCT Randomized Control or Comparative Trial FU Follow Up
Brief Interventions
Brief Interventions
Principal Investigators
3 papers, 1 study: Initial study: 3 Glasgow RE, Toobert DJ, et al 1995 A brief office-based intervention to facilitate diabetes dietary self-management Short-term results: 3 Glasgow RE, Toobert DJ, et al 1996 Effects of a brief office-based intervention to facilitate diabetes dietary self-management Follow-up study: 3 Glasgow RE, LaChance PA, et al 1997 Long term effects and costs of brief behavioral dietary intervention for patients with diabetes delivered from the medical officeA
Study Design
RCT with FU at 3 and 12 months
Sample Description
3 Subjects were patients with Type I or II diabetes n
206, 616 female, mean age 624 3 Office based outpatient setting
Interventions
3 E: Brief Intervention BI In addition to receiving usual care, subjects completed an additional dietary assessment, received personalized feedback, met with staff for goal setting and strategy planning, viewed interactive videos, and received follow-up phone calls at weeks 1 and 3 post-intervention Intervention took approximately one hour n 108; vs 3 C: Usual Care UC Subjects received their regular physician appointment n 98 3 Both groups were reassessed after 3 months and 12 months
Selected Measures
3 Food Habits Questionnaire FHQ 3 4day food record 3 Serum cholesterol 3 HbA1c glycated hemoglobin 3 Body mass index BMI 3 Patient satisfaction 3 Cost effectiveness
Selected Outcomes
12 month FU results: 3 Greater overall dietary improvement was found by BI than by UC group 3 Significantly larger reductions in serum cholesterol were found among BI than UC group 3 No significant differences were found in either HbA1c or BMI 3 BI group reported significantly higher overall satisfaction with the office visit than did UC group 3 Program was found to be more cost effective in participants with lower fat and
cholesterol intake
1 Errors may have occurred during abstraction, therefore, we do not guarantee the complete accuracy of information contained in this document The ultimate authority for accuracy is the original publication References are provided
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 27
Brief Interventions
Brief Interventions, Continued
Principal Investigators
Franz M, Splett P, et al 1995 Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin dependent diabetes mellitusA
Study Design
RCT — six month study with six month FU
Sample Description
3 n 179 adults with NIDDM aged 38 to 78 years who were free from any serious diabetic complications 3 3 Diabetes Clinics 3 United States
Interventions
3 E1: Medical Nutrition Therapy MNT Nutrition care according to Practice Guidelines Group met with a dietician three times Dietician selected appropriate nutrition prescription and educational interventions n 94; vs 3 E2: Basic Nutrition Care BC consisted of one visit with a dietician
during which data from the patient and referring physician were used to develop a nutrition plan Nutrition interventions designed to improve gylcemic control were introduced and general principles of nutrition management were discussed n 85
Selected Measures
3 Glycated hemoglobin 3 Fasting Plasma Glucose 3 Cost-effectiveness ratios expressed as cost per unit of improvements in glycemic control fasting plasma glucose and HbA1 levels in 1993 dollars
Selected Outcomes
3 E2 spent 65 20 minutes with a dietician, but times varied significantly among the three sites The mean time for E1 was 151 53 minutes, and also varied significantly among the three sites The mean cost of supplies for E2 was 77 48 E1 mean cost of supplies was 10569 The total cost of providing care to E2 was 4195 per patient vs E1 11207 per patient E2 reduction of fasting plasma glucose level was 427 mmol/L, and 69 167 reduction in HbA1 levels E1 mean reduction in fasting plasma glucose level was 11 28 mmol/L, with a 93 163 reduction in HbA1 levels 3 Overall, when fasting plasma glucose level was the outcome indicator, the cost-effectiveness of the two nutrition therapy approaches was similar However, for net
cost-effectiveness ratio, E1 had the advantage The cost-effectiveness of glycated hemoglobin outcome revealed a cost efficiency advantage for the BC approach
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
28 3 Health Behavior Change in Managed Care
Brief Interventions, Continued
Principal Investigators
2 papers, 1 study: Intervention description: 3 Stott NCH, Rollnick S, et al 1995 Innovation in clinical method, diabetes care and negotiating skills D Follow-up study: 3 Pill R, Stott NCH, et al 1998 A randomized controlled trial of an intervention designed to improve the care given in general practice to Type II diabetic patients: patient outcomes and professional ability to change behaviorD
Brief Interventions
Study Design
RCT pre/post-test with 18 month FU
Sample Description
3 Subjects were non-insulin dependent diabetics n 180, mean age 581, 50 male 3 Outpatient general practice 3 United Kingdom
Interventions
3 E: Innovative intervention Physicians were trained to encourage active patient participation in delivery of diabetic care Patients were allowed to air
personal concerns about medical condition, select personally relevant topics to discuss, and set specific goals for themselves n 95; vs 3 C: Standard care Standard British Diabetic Association leaflets were distributed n 95
Selected Measures
3 Glyco-Hb glycosylated hemoglobin 3 Body mass index 3 Blood pressure 3 Clinical complications 3 Medication use 3 SF36 questionnaire, used to provide information on health status, diabetes-specific measures of well being, and treatment satisfaction
Selected Outcomes
3 C group improved significantly at FU on patient satisfaction and physical functioning 3 No other significant findings
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 29
Brief Interventions
Brief Interventions, Continued
Principal Investigators
Litzelman DK, Slemenda CW, et al 1993 Reduction of lower extremity clinical abnormalities in patients with non-insulin dependent diabetes mellitusB
Study Design
RCT with one year FU
Sample Description
3 Subjects were non-insulin dependent diabetics n 352, mean age 604, 81 female 3
Academic general medicine practice
Interventions
3 E: Intervention group Foot care education was administered and then reinforced by telephone and postcard reminders Behavioral contracts were negotiated Coded folders prompted health care providers to do foot exams, and review foot care at each visit n 191; vs 3 C: Control group No information given, except usual care n 205 3 12 month intervention, telephone follow up 2 weeks after education sessions, postcards sent one month and three months into treatment
Selected Measures
3 Many foot care behaviors eg, washing and lubricating feet, filing calluses, drying between toes 3 Foot ailments eg, lesions, dry skin, calluses 3 Practice patterns of health care providers
Selected Outcomes
3 E group was more likely to report appropriate self-foot-care behaviors p001 and receive foot education from health providers p001 3 E group was less likely than C group to have serious foot lesions or other skin abnormalities 3 Physicians assigned to E group were more likely to examine patients feet for abnormalities and make referrals to the podiatry clinic p04
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions
– Glucose D Brief Interventions — Multiple Risk Factors E Youth
30 3 Health Behavior Change in Managed Care
Brief Interventions, Continued
Principal Investigators
Tu KS, McDaniel G, et al 1993 Diabetes self-care knowledge, behaviors, and metabolic control of older adults — the effect of a posteducational follow-up programD
Brief Interventions
Study Design
RCT pre/post-test
Sample Description
3 Subjects were hospitalized elderly diabetics who had completed an inpatient diabetes education program n 27, mean age 654 years, 667 female 3 Outpatient follow-up program
Interventions
3 E: Regularly scheduled telephone follow-up calls were conducted to assess deficits in self care knowledge and behaviors When deficits were recorded, instructions and counseling were given Health maintenance and exercise suggestions were given, and adherence to making and keeping clinic appts was emphasized n 15; vs 3 C: No calls were placed until post-intervention n 12 3 First call to E group was placed within 48 hours of discharge, and calls were repeated once/week for three more weeks Post-measurement calls were made one week after the final call was made to E group
Selected Measures
3
Diabetes Knowledge Scale 3 HbA1c glycosylated hemoglobin 3 Behavioral deficits defined as an omission or irregularity of self-care practice
Selected Outcomes
3 Significantly more C group subjects reported irregular practice of self-monitoring of blood glucose and record keeping 3 Significantly more C group subjects had deficits in behaviors related to hypoglycemia prevention and to following their dietary regime 3 In the E group, there was a significant decrease over the course of the intervention in deficits relevant to dietary therapy and symptom reporting
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 31
Brief Interventions
Brief Interventions, Continued
Principal Investigators
Anderson BJ, Wolf FM, et al 1989 Effects of peer-group intervention on metabolic control of adolescents with IDDM: randomized outpatient studyD, E
Study Design
RCT with 18 month FU
Sample Description
3 Adolescents from diabetes clinic at least 1 year post-diagnosis n 60, mean age 127 years, 533 female 3 University Hospitals 3 United
States
Interventions
3 E: Problem-solving intervention Five 15 hour sessions of education about self-monitoring of blood glucose SMBG, in addition to standard care n 30; vs 3 C: Standard care Routine clinic care provided by pediatric endocrinologists and a diabetes nurse educator; focused on information and instruction n 30
Selected Measures
3 HbA1 glycosylated hemoglobin 3 Use of SMBG during self-care behaviors exercise, adjustment of insulin dose, diet as assessed by an adapted version of the Diabetes-Care Profile, a validated self-report measure designed to assess a range of diabetesrelated variables
Selected Outcomes
3 At FU, HbA1 was significantly lower for the intervention group E experienced mean decrease in HbA1 of 037 and C experienced mean increase of 062 Significantly greater percentage of E than C adolescents reported use of SMBG when exercising; no differences for diet or insulin dose adjustment
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
32 3 Health Behavior Change in Managed Care
Brief Interventions, Continued
Principal Investigators
Fontbonne A,
Billault B, et al 1989 Is glucose self-monitoring beneficial in non-insulin-treated diabetic patients? Results of a randomized comparative trialC
Brief Interventions
Study Design
RCT and six month FU
Sample Description
3 Subjects were non-insulin-treated, poorly controlled diabetic patients n 208, mean age 55, 62 males 3 Diabetes clinic 3 France
Interventions
3 E1: Regular HbA1c determinations, no self-monitoring n 68; vs 3 E2: Self-urine glucose monitoring, twice every other day n 72; vs 3 E3: Self monitoring of blood glucose SMBG, twice every other day n 68 3 All patients were assessed in a pre-entry visit, an entry visit, and three-bimonthly FU visits
Selected Measures
3 HbA1c glycated hemoglobin 3 Body weight 3 Number of used reactive strips reported in diary E2 and E3 only
Selected Outcomes
3 No significant differences between groups on any outcome measures 3 In E3, SMBG appeared to relate to the outcome measure of number of used reactive strips compliance
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 33
Brief
Interventions
Brief Interventions, Continued
Principal Investigators
Marrero DG, Kronz KK, et al 1989 Clinical evaluation of computer-assisted self-monitoring of blood glucose systemC, E
Study Design
RCT with data gathered at baseline, 2 months, and 4 months
Sample Description
3 Subjects were insulin-dependent diabetics between the ages of 10 and 18 years n 57, mean age 144, 614 male 3 University hospital
Interventions
3 E: patients used a Glucometer M reflectance meter with memory to record their self-monitoring of blood glucose levels SMBG for 4 months n 29; vs 3 C: patients used reflectance meters without memory, recording SMBG levels in a logbook n 28 3 Both groups reviewed their SMBG data with physicians at 2 months and 4 months E group reviews were conducted with computer-generated data formats C group reviews used traditional logbooks
Selected Measures
3 HbA1 glycosylated hemoglobin 3 Amount of SMBG 3 Number of minutes spent with physician reviewing SMBG 3 Perceived quality of physician interaction
Selected Outcomes
3 Both groups showed significant decrease in HbA1 3 Significantly more time was spent by physicians with the E group than the C group 3 E group
experienced significant increase in quality of interaction with physician, understanding of diabetes and treatment, and perceived importance of testing
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
34 3 Health Behavior Change in Managed Care
Brief Interventions, Continued
Principal Investigators
Miley WM 1989 Reduction of blood glucose levels in chronically ill Type II diabetics by brief biofeedbackassisted relaxation training D
Brief Interventions
Study Design
RCT with data gathered at baseline, 1 week and 2 weeks
Sample Description
3 Subjects were Type II insulin dependent diabetic inpatients treated primarily for something other than diabetes n 37, mean age 136, 48 male 3 Rehabilitation hospital
Interventions
3 E1: Biofeedback-relaxation BR 45 minutes of biofeedback-assisted training in which subjects attempted to turn off both an auditory and a visual signal using relaxation n 7; vs 3 E2: Non-directive, patient-centered insight therapy I 45 minute session in which subjects were encouraged to discuss any areas of difficulty they were experiencing n 7; vs 3 C:
Control C 45 minutes of sitting quietly or resting n 7 3 All subjects were monitored for blood glucose levels before and after the 45minute sessions Sessions took place at 10:00 am once a week for 3 weeks All patients received standard medical treatment in addition to procedures for the study
Selected Measures
3 Blood glucose BG
Selected Outcomes
3 BR group BG levels decreased significantly more than groups I and C 3 Groups I and C did not differ significantly in their BG levels
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 35
Brief Interventions
Brief Interventions, Continued
Principal Investigators
Ardron M, MacFarlane IA, et al 1988 Anti-smoking advice for young diabetic smokers: Is it a waste of breath? D
Study Design
RCT with 3 and 6 month FU
Sample Description
3 4 groups: 1 diabetic smokers 2 diabetic nonsmokers 3 non-diabetic smokers 4 non-diabetic nonsmokers 3 n 60, mean age 281 years, 523 female 3 Adult diabetic clinic 3 United Kingdom
Interventions
3 E: Intensive advice IA consisted of same 5 minute talk as C group
received, as well as a stop smoking leaflet and home visits by a diabetes health facilitator within 2 weeks of initial clinic attendance Family was encouraged to play a supportive role n 30; vs 3 C: Routine advice RA consisted of standard 5minute talk stressing the general hazards of smoking, as well as the associated diabetic complications Patients were advised to give up smoking completely and that major impetus to do so must come from self n 30 3 Patients were evaluated at 3 and 6 months post-baseline Only diabetic smokers underwent intervention All other subjects were assessed only at baseline
Selected Measures
3 Breath carbon monoxide BCO 3 Urinary cotinine : creatinine ratio UC
Selected Outcomes
3 BCO levels were significantly lower in the E group compared to the C group at 6 months post-baseline 3 No other significant results
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
36 3 Health Behavior Change in Managed Care
Brief Interventions, Continued
Principal Investigators
Greenfield S, Kaplan SH, et al 1988 Patients participation in medical care: Effects on blood
sugar control and quality of life in diabetesD
Brief Interventions
Study Design
RCT pre/post-test
Sample Description
3 Subjects were non-insulin dependent diabetics n 59, 498 female, mean age 497 3 University hospital outpatient clinic
Interventions
3 E: 20 minute session before regular doctor visit spent going over patients chart, discussing what medical decisions may be made during visit, rehearsing negotiation skills, and practicing asking focused questions of the physician n 33; vs 3 C: 20 minute session before regular doctor visit spent reviewing standardized educational materials about diabetes treatment n 26 3 Both groups were enrolled in the study during a regular office visit, at which time they completed pre-test measures At the next scheduled visit, they were randomly assigned to one condition or the other, and administered the corresponding intervention At the next scheduled visit, the intervention was repeated At the final visit, typically 12 weeks later, post-test measures were obtained
Selected Measures
3 HbA1 glycosylated hemoglobin 3 Disease severity 3 Quality of life QL measures 3 Physician-patient interaction 3 Patient satisfaction rating 3 Knowledge of
disease
Selected Outcomes
3 Mean HbA1 level decreased significantly in E group 3 A significantly greater percent of E than C group experienced a change or decrease in their treatment regimen 3 Significant differences were found favoring the E group over the C group regarding the QL measures 3 After intervention, E group was significantly more active during doctor visit than C group, including increased conversation, greater mean number of questions/minute, and more control-taking 3 No significant difference between E and C groups after intervention on measures of patient satisfaction or knowledge of disease
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 37
Brief Interventions
Brief Interventions, Continued
Principal Investigators
Smith DM, Norton JA, et al 1986 Increasing prescribed office visits: a controlled trial in patients with diabetes mellitusD
Study Design
RCT with 1 year FU
Sample Description
3 Subjects were outpatient diabetics at least 15 years old n 859, mean age 591, 744 female, 70 Black 3 Medical clinic
based
Interventions
3 E: Patients were provided with a number of interventions designed to increase compliance: Information cards with clinic information, details of medical complications, a self-care booklet, and appointment reminder postcards were sent, and phone calls or home visits were made when necessary to schedule routine visits Information cards were resent every 6 months n 429; vs 3 C: Usual care: information cards were available upon request No other interventions were performed, and reschedule reminders were not attempted until 4 months after a failed visit n 430 3 Data were analyzed based on an average one year FU for all patients
Selected Measures
3 Incidence of hospitalization 3 Kept/failed appointments 3 Walk-in visits 3 Prescription refills
Selected Outcomes
3 E group kept significantly more scheduled visits than C group 3 Total overall contacts with clinic were significantly greater in E group than C group 3 E group scheduled significantly more appointments with clinic than C group 3 The intervention did not appear to lose its effectiveness at FU
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief
Interventions — Multiple Risk Factors E Youth
38 3 Health Behavior Change in Managed Care
Brief Interventions, Continued
Principal Investigators
Kaplan RM, Chadwick MW, et al 1985 Social learning intervention to promote metabolic control in Type I diabetes mellitus: Pilot experiment resultsD, E
Brief Interventions
Study Design
RCT with 4 month FU
Sample Description
3 Participants were diabetic youth between the ages of 13 and 18 n 21, mean age 14 3 Outpatient 3 United States
Interventions
3 E: Participants were assigned to a social learning intervention where over a course of 3 weeks, they identified social situations in which peer influence might lead to variation from the diabetes regimen A psychology graduate student led the groups All subjects participated in rehearsal exercises where problem situations and their solutions were enacted A series of video tapes of these situations was created mean age 149, 46 female; vs 3 C: The control group was assigned to discuss medical information relevant to diabetes over the course of a 3week period in a small group format Participants discussed medical knowledge gained during the lecture portions of the program and learned facts
about diabetes from an interactive computer system and by watching educational films Participants also were asked to identify facts that were most important for diabetic teenagers to learn mean age 14, 538 female
Selected Measures
3 Glycosylated hemoglobin 3 Diabetes knowledge, attitudes and behavior 3 Sarason Social Support Questionnaire 3 Means End Problem Solving Test
Selected Outcomes
3 Results showed that diabetes knowledge and changes to diabetes knowledge were unrelated to metabolic control as assessed by the glycosylated hemoglobin assay Those variables associated with poor diabetes control included social problem-solving ability and satisfaction with social support
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 39
Brief Interventions
Brief Interventions, Continued
Principal Investigators
Hopper SV, Miller P, et al 1984 A randomized study of the impact of home health aides on diabetic control and utilization patternsD
Study Design
RCT pre/post-test
Sample Description
3 Subjects were adult diabetics n 227, mean age 58,
73 female 3 Hospital-affiliated diabetes clinic
Interventions
3 E: Group was offered home health aide services consisting of insulin instruction and administration, bathing, feeding, monitoring vital signs, and dietary planning n 114; vs 3 C: Group continued to receive routine care n 113 3 Routine care was not defined, nor was the schedule of aide service described Of the 114 in E group, only 44 accepted and received aide services for the duration of the 18month study
Selected Measures
3 Mean fasting blood glucose FBS 3 Number of eye clinic visits 3 Negative utilization index determined by number of emergency room visits and number of missed appointments
Selected Outcomes
3 FBS levels dropped significantly in the E group 3 Those in the E group who accepted home health aide services increased their eye clinic attendance significantly 3 Overall, the negative utilization index showed a slight increase in the C group and a slight decrease in the E group
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
40 3 Health Behavior Change in Managed Care
Brief Interventions,
Continued
Principal Investigators
DeBont AJ, Bker IA, et al 1981 A randomised controlled trial of the effect of low fat diet advice on dietary response in insulin dependent diabetic women A
Brief Interventions
Study Design
RCT with 6 month FU
Sample Description
3 Subjects were Type II diabetic women n 136, mean age 55 3 Hospital clinics
Interventions
3 E1: Dietary advice — low fat diet Dieticians reviewed current diets and attempted to reduce fat to 30 of total energy intake Focused on reducing dairy and fat from meats, substituting margarines, and increasing proportion of carbohydrates to maintain total caloric intake n 71; vs 3 E2: Dietary advice — low carbohydrate diet Same review as E1 but focus was to limit carbohydrate intake to no more than 40 of total caloric intake 3 All participants received 3 home visits from a single nutritionist to reinforce adaptation of diets according to group assignment Diets were reviewed using one-day weighed inventory method Scales to weigh food portions were provided
Selected Measures
3 Mean plasma glucose BG 3 HbA1 3 Triglycerides/ total cholesterol TC 3 Body weight 3 1 day food intake 3 Weighed food
Selected Outcomes
3 Weight loss
in both groups, but especially for obese subjects in low fat group 3 Mean plasma TC fell significantly in low fat group, but no significant difference between groups in HDL 3 Evidence suggests that adherence to low fat diets occurred with benefit for weight and TC, and without deterioration of diabetes
A B
Brief Interventions — Diet Brief Interventions — Foot Care C Brief Interventions — Glucose D Brief Interventions — Multiple Risk Factors E Youth
Center for the Advancement of Health 3 41
Intensive Interventions
Principal Investigators
Anderson BJ, Ho J, et al 1999 An Office-Based Intervention to Maintain Parent-Adolescent Teamwork in Diabetes ManagementD,E
Study Design
RCT with FU at 12 months
Sample Description
3 n 85; Type I diabetics mean age is 126 years; Range 1015 years; 50 female 3 Mean diabetes duration 55 years, mean HbA1c 85 3 Office-based
Intensive Interventions
Interventions
3 E1: Teamwork Intervention Group met four times over 12 months E1 focused on parent team responsibility, sharing diabetes tasks and ways to avoid conflicts that undermine such teamwork The tasks were divided into insulin injections, drawing up insulin, doing injections, and BG
monitoring n 28; 79 had two parents, 21 had one parent; vs 3 E2: Attention Control Group met four times over 12 months during routine call E2 provided traditional diabetes education with no focus on parental involvement n 30; 80 had two parents, 20 had one parent; vs 3 C: Standard Care Condition did not have any interventions with the research assistant n 24; 85 had two parents, 15 had one parent 3 Research Assistant encouraged active family discussion and provided brief written materials 3 After 12 months, E2 and C were combined to form the comparison group
Selected Measures
3 Parental involvement in diabetes management tasks 3 Diabetes family checklist 3 Family conflict scale 3 glycemic control HbA1 and HbA1c
Selected Outcomes
3 No major deterioration in the parental involvement in any family in E1 compared with 11 p07 of parents in E2 who showed major deterioration in parental involvement with glucose monitoring E2 and C combined demonstrated a 16 p 03 deterioration in parent involvement in insulin administration than E1 3 No significant change in the level of conflict in E2 3 Parents in E1 reported a significantly greater decrease in their negative behavior than did
parents in E2 3 During follow-up E1 improved HBA1c levels compared to E2 and C combined p07
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
42 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Noel P, Larme AC, et al 1998 Patient choice in diabetes education curriculum D
Study Design
RCT with nested design
Sample Description
3 Participants were adults with Type II diabetes They were either physician or self-referred, were 18 years of age or older, and had not attended or completed diabetes education classes within the previous 12 months n 596; 62 female 3 Outpatient 3 United States
Intensive Interventions
Interventions
3 E1: Patients were allowed to choose one of two curriculums They were provided with written neutral descriptions of two curricula and were assigned to the curriculum of their choice n 305; vs 3 E2: Patients in the no choice condition were randomly assigned to one of the two curricula n 291 3 Curriculum 1: This was an experimental nutritional
program which devoted 60 of its content to nutritional management practices and 40 of its content to non-nutritional management It recommended that patients use the food pyramid as a guideline and promoted gradual, continuous changes in eating habits n 383 3 Curriculum 2: This was a control curriculum and consisted of patients receiving a usual care diabetes education program Participants were given a meal plan and advised to make dietary changes at once n 213 3 Both curricula consisted of a 5class sequence 3 Measures were given to all patients at 14 weeks before attending classes Physiological measures were also taken at this time
Selected Measures
3 Diabetes Treatment Satisfaction Questionnaire 3 Factors affecting class attendance 3 Michigan Diabetes Knowledge Tests 3 Self-care behaviors 3 SF36 to measure functional health status 3 Importance of diabetes care 3 Metabolic control 3 Fasting serum cholesterol 3 BMI
Selected Outcomes
3 When patients were given a choice, they chose the nutrition curriculum almost 4 times more frequently than the standard curriculum Patients who were allowed to choose their curriculum did not have significantly higher attendance rates or
significantly better improvements in diabetes knowledge or other clinical outcomes compared with patients who were randomly assigned to the two different curriculum types Patients appeared equally satisfied in their ratings of the two different curricula by the end of the classes
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 43
Intensive Interventions, Continued
Principal Investigators
Agurs-Collins TD, Have TRT, et al 1997 A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjectsD
Study Design
RCT pre/post-test with 3 and 6 month FU
Sample Description
3 Overweight African-Americans with NIDDM n 64, aged 5579, 23 male 3 Hospital clinic 3 United States
Intensive Interventions
Interventions
3 E: Intervention group Promoted adherence to proper diet, weight loss of 10 lbs over 6 months, 18 sessions, 90 minutes 60 minutes of nutrition education and 30 minutes of exercise/physical therapy A behavioral component
was included relapse prevention, weight maintenance, strategies — goal setting, avoiding triggers, food diaries n 32; vs 3 C: Usual care One class on methods of glycemic control and 2 mailings about nutrition information Received baseline, mid- and post-treatment measurement on same schedule as the intervention group n 32
Selected Measures
3 HbA1c glycemic levels 3 Blood pressure BP 3 Weight 3 Nutrition knowledge, food frequency, and activity levels 3 Self-efficacy for diabetes management
Selected Outcomes
3 The intervention group significantly decreased the HbA1c levels 3 BP decreased significantly among the intervention group compared to the control group 3 Mean weight decreased in the intervention group and increased in the control group 3 Nutrition knowledge and activity level increased in the intervention group but not in the control group 3 Change in self-efficacy was not assessed, but self-efficacy did not significantly predict any outcome 3 Improvements in HbA1c may not reflect changes in knowledge, diet, or weight An appropriately designed program for older African-Americans can result in improvements in NIDDM management
A B
Intensive Interventions — Diet Intensive
Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
44 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Mazzuca KB, Farris NA, et al 1997 Demonstrating the Added Value of Community Health Nursing for Clients With Insulin-Dependent DiabetesD
Study Design
RCT
Sample Description
3 n 22 77 female, age range 4983, equal distribution of African-American and White subjects 3 Community-Based
Interventions
3 E: Community Health Nursing Intervention CHNI Baseline, received community health nursing home visits by senior undergraduate community health nursing students under the supervision of faculty investigator After baseline, E received traditional and individualized community health nursing weekly or biweekly for 8 months Intervention included health teaching and guidance, health referrals, coordination of care, and client advocacy Major areas of teaching included nutrition, exercise, foot care, and blood glucose monitoring n 11; vs 3 C: Usual Care No community health nursing intervention was provided to this group n
11
Intensive Interventions
Selected Measures
3 Dietary adherence weight and a 3day dietary record-recall combination 3 Blood glucose finger-stick method and blood glucose monitor with memory 3 General diabetes knowledge test 3 Glycosylated hemoglobin 3 Medical Outcome, Short-Form Health Survey
Selected Outcomes
3 E: CHNI significantly enhanced the self-reported self-care behaviors of blood glucose testing, complication management, nutrition regimen adherence, and foot changes 3 No outcome differences were found between E and C for dietary adherence, foot care, blood glucose levels, overall diabetes knowledge, metabolic control, or functional health status 3 The findings suggest that the CHNI improves self-care competency in the area of self-care behaviors, but does not increase the health status with insulin-treated diabetes
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 45
Intensive Interventions, Continued
Principal Investigators
Mendez FJ, Belendez M 1997 Effects of a
behavioral intervention on treatment adherence and stress management in adolescents with IDDMD,E
Study Design
Quasi-experimental pre/post-test with 13 month FU
Sample Description
3 Subjects were IDDM adolescents between the ages of 11 and 18 n 37, mean age 136, 48 male 3 Health center based 3 Spain
Intensive Interventions
Interventions
3 E: Behavioral group intervention consisting of review of previous concepts, information on diabetes, diet, and stress, role playing social situations, preparing menus, and keeping self-monitoring records n 18; vs 3 C: Normal medical care not fully described n 19 3 E group had 12 sessions once per week 2 with parents, 2 assessment, and 8 treatment lasting 90140 minutes each
Selected Measures
3 Self-monitoring of diet, exercise, and blood glucose 3 Self-report questionnaires: Diabetes Information Survey for Children Barriers to Adherence Questionnaire Diabetic Daily Hassles Scale Diabetes Family Behavior Checklist DFBC Diabetic Adolescents Social Skills Inventory Blood Glucose Testing Skills Observation Test External Cues Questionnaire
Selected Outcomes
3 Results showed significant changes in the E group in variables related to
diabetes: information patients and their parents, adherence, daily hassles, uneasiness and likelihood of response in social interactions, skills and frequency of glycemic analyses, blood glucose estimate errors, and negative family support The intervention had no effect on either dietary and physical exercise or glycemic control
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
46 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Campbell EM, Redman S, et al 1996 The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: A randomized trialD
Study Design
RCT with FU at 3, 6, and 12 months
Sample Description
3 Subjects were non-insulin dependent diabetics less than 80 years old n 238, mean age 583, 521 female 3 Outpatient diabetes education program 3 Australia
Interventions
3 E1: Group education GE Consisted of at least 2 individual sessions and a 3day small group education course involving lectures, small group
exercises, and practical sessions Two hour group FUs were scheduled at 3 and 9 months after the course n 66; vs 3 E2: Individual education IE Consisted of 2 sessions in the first 2 weeks, then monthly sessions which covered diabetes information such as causes, symptoms, and complications n 57; vs 3 E3: Behavioral B Based on cognitive-behavioral strategies and emphasized cardiovascular risks Three visits were scheduled in the first month, then were made as needed, minimally at 3, 6, and 12 months n 56; vs 3 C: Minimal instruction MI Consisted of two one-hour sessions during first two weeks Covered the same topics but in less detail: oral hypoglycemics, urine testing, foot care, and the importance of consulting diabetes specialists n 59 3 Metabolic measures for all subjects were taken at baseline and after 3, 6, and 12 months
Intensive Interventions
Selected Measures
Physiological measures: 3 HbA1 glycosylated hemoglobin 3 Body mass index BMI 3 Blood lipids: total cholesterol TC, HDL, and cholesterol risk ratio CRR 3 Blood pressure BP Additional Measures: 3 Diabetes treatment intensity: type and dosage of current meds 3 Smoking 3 Diabetes Knowledge Scale DKNA 3 Patient
satisfaction 3 Consulting diabetes specialists self-report 3 Other utilization of medical services
Selected Outcomes
3 No significant differences between programs on any of the physiological measures, except diastolic BP At 3 months: 3 Subjects in the B group had significantly greater reduction in CRR and were more likely to have consulted with a podiatrist than other groups 3 Both B and GE groups improved DKNA scores over MI group, and B group improved more than IE group At 6 months: 3 MI group was more likely to have increased diabetes treatment intensity than those in other groups 3 B group was more likely to have consulted with a podiatrist and to have higher satisfaction than MI or IE groups 3 Both B and GE groups had greater improvements in DKNA scores than MI or IE groups At 12 months: 3 B group had greater reductions in diastolic BP than GE or IE groups
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
Center for the Advancement of Health 3 47
Intensive Interventions, Continued
Principal
Investigators
Uusitupa MIJ 1996 Early lifestyle intervention in patients with non-insulin-dependent diabetes mellitus and impaired glucose toleranceD
Study Design
RCT pre/post-test, 12 month intervention with 12month FU
Sample Description
3 Patients were recently diagnosed non-insulin-dependent diabetics n 86, age range 4064 3 Outpatient clinic 3 Finland
Intensive Interventions
Interventions
3 E: Intensified therapy aimed at weight reduction, glycemic control, and normalizing elevated blood pressure Patients also received exercise training, and recommendations to exercise 34 times/week for 3060 minutes Dietary compliance and physical activity were monitored daily n 43; vs 3 C: Conventional treatment — no counseling beyond initial 3months of basic diabetes education n 43 3 E group met at outpatient clinic every 2 months for a year, for a total of 6 visits Before randomization, both groups received 3 months of basic diabetes education, including dietary advice aimed at losing weight and reducing fat and cholesterol intake
Selected Measures
3 VO2max endurance 3 Dietary fat intake 3 Weight loss 3 Fasting blood glucose FBG 3 HbA1c glycosylated hemoglobin 3 Cholesterol and
trigylcerides 3 Blood pressure BP
Selected Outcomes
3 Intervention resulted in better metabolic control and a moderate reduction in BP, cholesterol, and trigylcerides as compared to the C group 3 At FU, significantly less of the E group received oral antidiabetic drugs as compared to the C group 3 FBG was significantly reduced in the E group at the end of the 12month intervention 3 Improvement in insulin resistance and secretion were detected in both groups
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
48 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Wing R, Anglin K 1996 Effectiveness of behavioral weight control program for Blacks and Whites with NIDDM A
Study Design
RCT, 1 year FU
Sample Description
3 Subjects had NIDDM and were 30 or 18 kg above ideal weight based on 1983 Metropolitan Life Insurance norms 3 n 91 16 Blacks and 75 Whites 3 Ranged in age from 30 to 70: Black mean age 494 90, White mean age 524 94
Intensive
Interventions
Interventions
3 E1: Low Calorie Diet LCD A calorie goal of 1,0001,200 kcal/day and 30 fat; vs 3 E2: Very Low Calorie Diet VLCD On the diet from 112 and 2436 weeks Individuals ate about 500 kcal/ day After each VLCD dieting period, other foods were gradually re-introduced until subjects were eating about equal to E1 consumption 3 Sessions led by a multidisciplinary team All groups attended weekly classes for one year Participants were weighed, self-monitoring records were reviewed, and lecture/discussion was presented on nutrition, behavioral techniques, or exercise Encouraged two miles per day of physical activity, five days a week
Selected Measures
3 Weight baseline, 6 months, and 1 year 3 BMI 3 Paffenbarger Activity Questionnaire 3 Gylcemic Control 3 HbA1 3 Plasma glucose 3 Insulin
Selected Outcomes
3 Faster weight regain in Blacks than in Whites: during the latter six months, Blacks regained 545 kg compared to Whites who regained 17 kg p 02 3 Overall weight loss was significantly less in Blacks than Whites 71 kg vs 135 kg p02 3 During follow-up weight loss between Blacks and Whites remained significant -71 vs -115 kg, p 02 3 Blacks and Whites increased their
exercise from baseline to six months p001 and maintained improvement at one year Mood improved for both groups p004 3 No significant differences in calories consumed between the two groups 3 Blacks tended to be more likely to require medication to control glucose levels However, change in glucose, insulin, and HbA1 at baseline to six months or baseline to 1 year were similar in each group Suggests that changes in glycemic control are only moderately associated with changes in body weight 3 VLCD did not affect the difference between Blacks and Whites
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 49
Intensive Interventions, Continued
Principal Investigators
Anderson RM, Arnold MS, et al 1995 Patient empowerment Results of a randomized controlled trialD
Study Design
Randomized Waiting-list Controlled Trial, pre/post-test
Sample Description
3 Patients recruited from media and local clinics and either used insulin or not to control their diabetes n 64, mean age 50 years, 70
women
Interventions Intensive Interventions
3 E: Empowerment Program 6 weekly 2hour group sessions — individual self-assessment and planning worksheets, large and small group discussion n 32; vs 3 C: Waiting-list control Completed the intervention program after the E group completed the program n 32
Selected Measures
3 Self-efficacy 3 Diabetes Attitude Scale DAS 3 Diabetes Care Profile DCP 3 Blood glucose
Selected Outcomes
3 The intervention group gained points on the following self-efficacy subscales: setting goals, managing stress, obtaining support, and making decisions There were only group differences on one subscale of the DAS attitude concerning the impact of diabetes on quality of life, with the intervention group showing a slight improvement The intervention group significantly declined in negative attitude toward living with diabetes a subscale on the DCP The intervention group also showed a larger reduction in glycated hemoglobin at 6week FU than the control group measured directly following program intervention
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive
Interventions — Multiple Risk Factors E Intensive Interventions — Youth
50 3 Health Behavior Change in Managed Care
Intensive Interventions with Multiple Risk Factors, Continued
Principal Investigators
Cox D, Gonder-Frederick L, et al 1995 A Multicenter Evaluation of Blood Glucose Awareness Training IIB
Study Design
3 Multi-center evaluation, repeated baseline design with a FU at 1 month 3 Centers were blind to assignment
Sample Description
3 Eligibility: 1 diabetes for at least two years 2 insulin dependent since time of diagnosis 3 routinely measure BG with a meter 2 times/day 4 no clinical history of depression or substance abuse 3 n 78 women 64; mean age: 38290 years 3 22 participants did not complete all pre/post-treatment assessments
Intensive Interventions
Interventions
3 E: Blood Glucose Awareness Training BGAT Classes focused on how to predict combined effects of insulin regimens, high and low levels for insulin, and how to extrapolate the vulnerability of BG level extremes The intervention involved seven 15 hour classes that followed a standardized training manual, BGAT II; vs 3 C: Usual Care No BGAT, but did receive BGAT II 3 E and C were assessed by using
Pison hand-held computers for 50 trials over a 34 week interval before their routine self-monitoring blood glucose SMBG Subjects entered an estimated BG level, computer then presented symptoms, subjects rated symptoms based on computer prompt, and then performed SMBG Each time, computer stored information 3 Four therapists taught BGAT BG profiles were developed six months before, immediately before, and one month after BGAT
Selected Measures
3 BG estimation accuracy of low 389 mmol/l and high 10 mmol/l BG levels 3 BG index frequency and degree of extreme BG levels in SMBG 3 HbA1 3 Symptom Checklist
Selected Outcomes
3 E participants were less accurate at baseline, but showed the greatest benefit from BGAT II Both groups illustrated significant pre- to post-improvement in accuracy index F 5391, p 0001 3 BGAT II improved overall BG estimation accuracy, and detection of high BG in both C and E F 507, p 02 However, only E displayed a significant improvement in detection of low BG F 159, p 0001 3 C showed significant pre- to post-improvement in their low BG indexes F 369, P 055 E demonstrated a significant pre to post-improvement in high BG index
A B
Intensive Interventions
– Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 51
Intensive Interventions, Continued
Principal Investigators
Cox D, Gonder-Frederick L, et al 1994 Long-term follow-up evaluation of blood glucose awareness trainingB
Study Design
RCT, Follow-up at 5 years
Sample Description
3 n 41 insulin dependent diabetics; 27 of these were followed up 3 Range of disease duration 1221 years
Interventions
3 E1: Blood Glucose Awareness Training BGAT Patient education designed to teach Insulin Dependent Diabetes Mellitus IDDM patients to accurately estimate blood glucose BG Main elements: symptom identification and interpretation and amounts and timing of insulin, food and exercise to better anticipate extreme BG levels Average of seven weekly classes, use of training manual, daily homework n 14; vs 3 E2: BGAT Plus Booster Training to refresh patient memory regarding BGAT procedures Diaries were given to record any BG relevant symptoms and information about insulin, food, and/or exercise for two weeks before
evaluation n 14; vs 3 C: General Diabetes education classes; no additional information given Did not have a no treatment control group 3 All subjects were given hand-held computers to self-monitor BG levels, and were instructed to use the computer during routine measurements and whenever BG was perceived as low or high Recorded BG levels between 5080 times during 34 week period during their daily routine Computer tracked date and time of entry, and elapsed time of computer prompt vs subjects actual BG measurements
Intensive Interventions
Selected Measures
3 Self-report blood glucose rating without a device on a scale from 0 to 6, where 6 was extreme 3 Self-reported of car accidents 3 Ability to recognize BG fluctuations 3 Lost work days 3 Glycosylated hemoglobin
Selected Outcomes
3 E1 group was superior in estimation of BG levels compared to both E2 and C p 001 E1 subjects were more accurately able to estimate their BG levels compared to control subjects E1 increased awareness of low BG levels allowing patients to be more aware of when not to drive 3 E2 was significantly more aware of hypoglycemia than E1 participants p 02; E2 was significantly more aware of their
hypoglycemia and more accurate in general than the control group p 01 3 At long-term FU, E1 had significantly fewer car crashes than C However, E1 did not lead to fewer lost work days 3 Conclusion: BGAT has long-term benefits, which can be enhanced with booster training May result in long-term reduction of severe hypoglycemic events and car crashes
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
52 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
3 Diabetes Control and Complications Trial Research Group 1994 Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial 3 Diabetes Control and Complications Trial Research Group 1995 Implementation of treatment protocols in the Diabetes Control and Complications TrialD
Study Design
RCT with FU every three months for an average of 74 years
Sample Description
3 Subjects were
adolescents who were insulin-dependent diabetics n 195, 514 female, mean age 15 at baseline 3 Diabetes clinics
Intensive Interventions
Interventions
3 Subjects were first divided into 2 groups based on absence primary prevention cohort or presence secondary intervention cohort of retinopathy, then both groups were randomly assigned to E1 or E2 3 E1: Intensive therapy IT Administration of insulin 3 or more times daily by injection or by external pump Shortacting insulin was given before meals, with dosage adjusted according to planned dietary intake, anticipated exercise, and SMBG Monthly visits by clinic staff and frequent telephone calls were conducted to review and adjust regimens Goal: to achieve glycemic control as close to the nondiabetic range as possible n 92; vs 3 E2: Conventional therapy CT One or two daily insulin injections, once-daily self-monitoring of urinary or blood glucose levels, and diet and exercise education Goal: to eliminate symptoms of high or low blood glucose without specified targets n 103
Selected Measures
3 Program adherence 3 HbA1c 3 Blood glucose BG 3 Overall levels of severity of retinopathy 3 Incidence of microalbuminaria 3 Total cholesterol
TC 3 Frequency of diabetic ketoacidosis 3 Incidence of severe hypoglycemia 3 Body mass index BMI 3 Body height
Selected Outcomes
3 Overall, average percentage of time spent in assigned treatment was 95 3 IT group showed significantly lower HbA1c and BG levels over the course of the study than the CT group These differences were achieved by 6 to 12 months and maintained through the remainder of the trial 3 IT significantly reduced the risk of retinopathic progression and incidence of microalbuminaria in the SI cohort 3 TC was significantly higher in CT group than in IT group 3 In CT group, adolescents had a significantly greater frequency of diabetic ketoacidosis than did adults 3 Incidence of severe hypoglycemia was 24 times more frequent in IT than in CT group 3 Significantly greater increase in BMI for IT group
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
Center for the Advancement of Health 3 53
Intensive Interventions, Continued
Principal Investigators
Manning RM, Jung RT, et al 1994 The comparison of four
weight reduction strategies aimed at overweight diabetic patientsA
Study Design
RCT with 1 year FU All subjects were randomly assigned, except for the no treatment control group who were a control group of convenience
Sample Description
3 Diabetics who were not motivated to lose weight n 205, 51 male, mean age 56 years 3 Outpatient diabetic clinic 3 Scotland
Intensive Interventions
Interventions
3 E1: Regular clinic visits Individual sessions with a dietetic consultant every 6 weeks for 6 months, then once every 2 months for the next 6 months n 37; vs 3 E2: Behavioral group therapy Group behavioral therapy sessions once every 2 weeks for 3 months, then once a month for 9 months Sessions were with a physiotherapist, clinical psychologist, and a dietitian n 38; vs 3 E3: Dexfenfluramine Sessions as in E1 plus 15 mg of dexfenfluramine twice per day for the first 3 months n 37; vs 3 E4: Combined home and clinic visits Sessions as in E1, except that the first and fourth sessions were conducted in the subjects home; all other visits were in the clinic n 35; vs 3 C: Regular diabetic care No contact with a dietician during the study period n 58
Selected Measures
3 Weight 3 HbA1C
3 BMI
Selected Outcomes
3 At post-treatment, one year after the study began, all experimental groups lost significantly more weight than the control group, but there were no significant differences between experimental groups The control group gained an average of 12 kg, while the experimental groups lost from 275 to 114 kg at 1year post-treatment The behavioral therapy group was the best at losing weight and keeping it off at the 1year post-treatment mark, in those whom did not drop out 3 For those who did not drop out n 103, not including control subjects weight loss was associated with loss of fat 3 There were no significant differences in HbA1C levels between the experimental and control groups at posttreatment 3 Forty percent of the dexfenfluramine stopped taking the drug before the 3month allotted time constraint because of side effects 3 Home visits did not offer any added effect of treatment
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
54 3 Health Behavior Change in Managed Care
Intensive
Interventions, Continued
Principal Investigators
McNabb WL, Quinn MT, et al 1994 Increasing childrens responsibility for diabetes self-care: The In Control studyD,E
Study Design
RCT pre/post-test with 12 week FU pilot study
Sample Description
3 Subjects were insulin-dependent diabetic children ages 812 n 24, mean age 99, 54 male 3 Diabetes clinic of large metropolitan hospital
Interventions
3 E: Behavior-oriented, diabetes self-management education program called In Control consisted of discussion of self-care concepts, learning and practicing self-care behaviors, and setting behavioral goals with parents The goal of the program is to promote self-care independence E group met for 6 weeks, 1 hour/week n 12; vs 3 C: Usual diabetes care, including routine physician visits, team care typically provided by clinic, and instruction as needed n 12
Intensive Interventions
Selected Measures
3 Childrens Diabetes Inventory frequency with which child performs specific self-care duties, yields a responsibility score 3 Glycohemoglobin levels
Selected Outcomes
3 E group children showed significantly higher overall responsibility for self-care than C group 3 Mean glycohemoglobin levels
were higher in the C group than in the E group at both baseline and post-test The difference was significant when using a 2sample t-test, but not when using a repeated measures ANCOVA
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 55
Intensive Interventions, Continued
Principal Investigators
DEramo-Melkus GA, Wylie-Rosett J, et al 1992 Metabolic impact of education in NIDDMD
Study Design
RCT with FU at 3 and 6 months
Sample Description
3 Subjects were obese non-insulin-dependent diabetics n 49, mean age 573, 449 male
Interventions Intensive Interventions
3 E1: 11 week diabetes education and weight reduction group intervention with one individual session by week 4 to clarify content n 15; vs 3 E2: Same 11 week program plus 2 individual follow-up counseling sessions at weeks 12 and 18 post-group intervention n 19; vs 3 C: no further education than is received through customary medical care single individual educational session n 15 3 11 week group intervention
consisted of a 2hour weekly session 1st hour was lecture and slide presentation, 2nd hour was discussion focused on changing behavior related to eating, physical activity, and blood glucose control
Selected Measures
3 Fasting blood glucose FBG 3 HbA1 3 Body weight 3 Locus of control rating scale combining the Multidimensional Health LC and Rotters LC Scales 3 25item diabetes knowledge test 3 49item dietary knowledge test
Selected Outcomes
3 At the 3month FU, FBG and HbA1 were lowest for E1; however, by the end of the 6month FU, FBG, HbA1 and body weight were all lowest in E2
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
56 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Glasgow RE, Toobert DJ, et al 1992 Improving self-care among older patients with Type II diabetes: The Sixty Something studyD
Study Design
RCT pre/post-test with delayed intervention for control group; 6 month FU
Sample Description
3 Subjects were Type II diabetics at least 60 years of age n
102, 628 female, mean age 671 3 Oregon Research Institute
Interventions
3 E: Immediate Intervention Participation in education program focusing on review and discussion of diabetes self-care topics n 52; vs 3 C: Delayed Intervention No participation until 6 month FU of E group n 50 3 10 weekly sessions, supervised walking sessions 2x/week, and encouragement to exercise on own time
Intensive Interventions
Selected Measures
3 Dietary history 3 3day food record 3 Stanford 7day recall physical activity 3 Body weight 3 GHb glycosylated hemoglobin 3 Mood assessments 3 Social desirability 3 Problem solving skills
Selected Outcomes
3 Regarding body weight, E produced significant improvements compared to C, as well as compared to baseline 3 GHb levels significantly decreased for both E and C, but there were no significant between-group differences 3 No significant improvements on mood level, but there were consistent and large improvements associated with E on measures of problem solving 3 Six-month FU results were generally encouraging, and the post-test of the C group yielded similar results, adding further support for the validity of the findings
A B
Intensive Interventions –
Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 57
Intensive Interventions, Continued
Principal Investigators
Delamater AM, Bubb J, et al 1990 Randomized prospective study of self-management training with newly diagnosed diabetic childrenD,E
Study Design
RCT with 2 year FU
Sample Description
3 Subjects were insulin-dependent diabetic IDDM children n 36, mean age 93, 53 male 3 Childrens Hospital 3 United States
Intensive Interventions
Interventions
3 E1: Conventional follow-up CF Outpatient visits 1 and 3 months post-diagnosis and every three months thereafter, individualized meal planning, managed by physicians and dieticians; vs 3 E2: CF Supportive counseling SC Same as CF, plus 7 parent-child sessions at 6 and 12 months The sessions were led by a medical social worker and focused on coping with a regimen, family involvement, and adjustment; vs 3 E3: CF Self-management training SMT Same as CF, plus 7 parent-child sessions within 4 months Emphasis was on self-management techniques, reinforcement of
accurate monitoring and recording, and behavior change such as diet and daily life adjustments Additional review and reinforcement occurred at 6 and 12 months post-diagnosis SMT and SC conducted by same social worker
Selected Measures
3 HbA1 glycosylated hemoglobin
Selected Outcomes
3 SMT had significantly lower HbA1 levels than conventional patients did at 1year and 2year post-diagnosis Evidence suggests that a SMT program during first few months post-diagnosis helps to avoid deterioration in metabolic control in IDDM children 6 and 24 months after diagnosis
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
58 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Estey AL, Tan MH, et al 1990 Follow-up intervention: Its effect on compliance behavior to a diabetes regimenD
Study Design
RCT pre/post-test
Sample Description
3 Subjects were non-insulin dependent diabetics n 53, mean age 553, 472 males 3 University-affiliated teaching hospital 3 Canada
Intensive
Interventions
Interventions
3 E: Standard 3day education program plus 10 weeks of follow-up calls 4 per patient and home visits 1 per patient intending to reinforce previously learned knowledge and to provide support and encouragement Contacts were made by a registered nurse n 28; vs 3 C: Standard 3day education program and a brief phone call at 10 weeks to arrange for post-testing n 25 3 The behaviorally oriented educational program was identical for both groups and consisted of primarily didactic instruction and interactive small group settings Both groups attended a brief review session one-month after the educational program was conducted
Selected Measures
Compliance to prescribed regimens was determined by: 3 HbA1 glycosylated hemoglobin 3 Self-monitoring of blood glucose SMBG self-report records 3 Body weight
Selected Outcomes
3 SMBG was significantly better in the E group than in the C group 3 No significant differences in post-HbA1 and weight changes between groups 3 Conclusion: FU intervention by telephone calls and home visit can enhance patient compliance to certain aspects of diabetes care
A B
Intensive Interventions — Diet Intensive Interventions — Glucose
Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 59
Intensive Interventions, Continued
Principal Investigators
Horan PP, Yarborough MC, et al 1990 Computer-assisted self-control of diabetes by adolescentsD,E
Study Design
RCT pre/post-test with 15 week FU
Sample Description
3 Subjects were insulin-dependent diabetics ages 1219 n 20, mean grade level 99, 70 female 3 University-based laboratory
Interventions Intensive Interventions
3 E: Diabetes in Self-Control DISC, an interdisciplinary program which allows for management of blood glucose, insulin, weight, diet, exercise and stress data, computer assisted diabetes education, and problem solving and goal setting to improve self-care and glycemic control Self-care data were entered into the computer database; vs 3 C: Conventional education CE utilizing an educational booklet All diabetes education was administered in print form, and written records were kept of self-care data Goal setting phase was replaced by continued recording of self-care data 3 Study design consisted of 3 major phases:
baseline 3 weeks, diabetes education 7 weeks, and goal setting/ problem solving 8 weeks
Selected Measures
3 HbA1c and HbA1 glycosylated hemoglobin 3 Blood glucose levels BG 3 Frequency of BG testing 3 Diabetes knowledge 3 Self-care frequency self-report
Selected Outcomes
3 Pre-lunch BG levels were significantly lower for the DISC group than the CE group 3 Improvement in pre-dinner BG levels was significant for DISC group from baseline to FU 3 DISC subjects tested BG levels more frequently than did CE subjects 3 DISC group significantly increased BG testing frequency from baseline to FU 3 DISC subjects reported more behavioral change more involvement in controlling IDDM as a function of what was learned
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
60 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Jones PM 1990 Use of a course on self-control behavior techniques to increase adherence to prescribed frequency for self-monitoring blood glucoseB
Study Design
RCT
pre/post-test
Sample Description
3 Subjects were insulin-treated diabetics n 25, mean age 369, 44 male 3 University-based laboratory
Interventions
3 E: Self-control behavior techniques SCBT course A six-unit course on self-monitoring of blood glucose SMBG and other health behaviors, including a study guide, written assignments, and a post-test n 11; vs 3 C: Control group kept a record of SMBG, but received no further instruction n 14 3 Subjects completed same pre-test instruments, E participated in SCBT for four weeks, both groups took post-test, and both groups continued recording SMBG for 8 more weeks
Intensive Interventions
Selected Measures
3 SCBT pre/post-test 3 Maintaining Behavior Change Questionnaire 3 Adherence to goal 3 Course evaluation E group only
Selected Outcomes
3 E group SCBT scores changed significantly more from pre to post than did C group scores 3 E group increased adherence by 22 and C group decreased adherence by 12 3 All but one subject reported that the study was either moderately or extremely helpful in increasing the frequency of blood glucose testing 3 Most subjects rated the course as useful for learning the SCBT, and found the format easy to
follow Suggestions included adding group meetings and meeting more often with instructors
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 61
Intensive Interventions, Continued
Principal Investigators
DeWeerdt I, Visser AP, et al 1989 Randomized controlled evaluation of an education program for insulin treated patients with diabetes: effects on psychosocial variablesD
Study Design
3 RCT pre/post-test with 1 and 6month FU for experimental groups 3 Outpatients from 15 randomly selected hospitals 3 Netherlands
Sample Description
3 Subjects were insulin treated diabetics n 558, 50 female, mean age 44
Intensive Interventions
Interventions
3 E1: Education program led by a health care worker from the hospital n 183; vs 3 E2: Education program led by a fellow patient n 172; vs 3 C: no extra education n 203 3 Program consisted of four weekly group sessions of 3 hours each Sessions consisted of watching films, answering questions from the film, reading a book, group discussion,
and practice materials 3 Patients in E1 and E2 were evaluated 4 times pre/post-program and 2 FUs
Selected Measures
3 Frequency of home blood glucose monitoring HBGM 3 Questionnaire measuring patient knowledge of general aspects of diabetes 3 Diabetes health locus of control LOC 3 Spielberger State-Trait Anxiety Inventory 3 Questionnaire measuring attitudes and social norms re: active diabetes self-care
Selected Outcomes
3 HBGM increased significantly in E1 and E2 and remained during FU 3 Scores on knowledge and LOC increased significantly in E1 and E2 3 No significant changes in anxiety were found in any group 3 Attitude to HBGM improved significantly in E1 and E2, but social norms improved only marginally 3 Other behavioral aspects of self-care increased significantly in E1 and E2, including carrying sugar, having glucagon at home, using short-acting insulin, and keeping a record diary
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
62 3 Health Behavior Change in Managed Care
Intensive Interventions,
Continued
Principal Investigators
Huttunen N-P, Lankela S-L, et al 1989 Effect of once-a-week training program on physical fitness and metabolic control in children with IDDMC,E
Study Design
RCT with 3 months FU
Sample Description
3 Insulin dependent patients, ages 817 years n 32, mean age 119, 56 males 3 Diabetes clinic 3 Finland
Intensive Interventions
Interventions
3 E: Exercise group 13 weekly 1hour sessions led by nursing students in physiotherapy Jogging, running, gymnastics, and games were used Goal heart rate 150 beats/minute for 45 minutes; vs 3 C: 13 weekly 1hour sessions, activities that did not require physical effort
Selected Measures
3 HbA1c glycosylated hemoglobin 3 VO2 — peak oxygen uptake 3 Endurance measured by bike pedaling time 3 Urinary glucose UG 3 Blood glucose BG
Selected Outcomes
3 Physical fitness as judged by VO2 and pedaling time improved significantly in the E group but not in the C group 3 HbA1c increased significantly in the E group negative outcome 3 Authors concluded that guided exercise is of little value for managing diabetes in children because those who have poor glycemic control are not motivated to take part in an exercise program,
and those who are motivated already have good metabolic control
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 63
Intensive Interventions, Continued
Principal Investigators
Massouh SR, Steele TMO, et al 1989 The effect of social learning intervention on metabolic control of insulindependent diabetes mellitus in adolescentsD,E
Study Design
RCT with 35 month FU
Sample Description
3 Subjects were insulin-dependent diabetic adolescents ages 12 15 n 33, mean age 128, 55 female 3 Diabetes camp for adolescents
Intensive Interventions
Interventions
3 E: Daily one hour teaching sessions about self-care and the physiology of diabetes, plus social learning intervention SLI consisting of role modeling to help avoid peer pressure n 17; vs 3 C: Daily one hour teaching sessions about self-care and the physiology of diabetes n 16 3 8day program with review sessions conducted for C group during the period that E group received SLI
Selected Measures
3 HbA1 glycosylated
hemoglobin
Selected Outcomes
3 C group showed no significant difference in pre and FU levels of HbA1 3 E group showed significantly higher levels of HbA1 after SLI negative outcome
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
64 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Satin W, LaGreca AM, et al 1989 Diabetes in adolescence: Effects of multifamily group intervention and parent simulation of diabetesD,E
Study Design
RCT with 6 month FU
Sample Description
3 Subjects were insulin dependent diabetics n 32, mean age 146, 375 male 3 University-based laboratory
Interventions
3 E1: Multifamily MF group Families met together for 6 weekly sessions of 90 minutes each to discuss diabetes management and to receive guidance and support from each other n 11 subjects and their families, 29 total; vs 3 E2: Multifamily plus parent simulation MFS group Same as MF, except that beginning with week 3, the subjects taught their parents diabetes management skills n 12
subjects and their families, 31 total; vs 3 C: No specific intervention was provided These families participated in all phases of assessment, and were offered intervention at conclusion of study n 9 subjects and their families, 22 total 3 All families received identical psychosocial and family evaluations at baseline and 6 weeks later In addition, metabolic control was assessed at baseline, and 3 and 6 months after study enrollment
Intensive Interventions
Selected Measures
3 HbA1 glycosylated hemoglobin 3 Attitudes about diabetes, as measured by a set of 10 semantic differentials 3 Parents estimates of childs self care — self report questionnaire 3 Family Environment Scale
Selected Outcomes
3 Subjects in the MFS group demonstrated significant improvements in HbA1 relative to C group Also, subjects in the 2 MF groups combined showed similar improvement which were maintained at FU 3 Subjects attitudes toward a teenager with diabetes improved significantly for those in both MF groups
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive
Interventions — Youth
Center for the Advancement of Health 3 65
Intensive Interventions, Continued
Principal Investigators
Wood, ER 1989 Evaluation of a hospital-based education program for patients with diabetesD
Study Design
RCT with 1 and 4 months FU
Sample Description
3 Subjects were hospitalized patients with a primary or secondary diagnosis of diabetes mellitus n 93, mean age 60, 471 male 3 Inpatient hospital setting
Intensive Interventions
Interventions
3 E: Living with Diabetes program Conducted by nurses and a dietician, focus was on pathology and physiology of diabetes, SMBG, self-care behaviors, diet planning, and initiation of an exercise program n 53; vs 3 C: No educational program was offered; patients were given information upon request n 40 3 Program was 2 hours/day for 2 days; average attendance was 4 to 6 patients
Selected Measures
3 Timeliness of insulin injections 3 Exercise frequency 3 Insulin level 3 Fasting blood sugar FBS 3 Emergency room visits
Selected Outcomes
3 At both 1 and 4 month FUs, a significantly greater percentage of the E group maintained an exercise program than did the C group 3 E group showed significantly greater compliance
regarding administering insulin at the prescribed time than did the C group 3 E group showed a significantly greater decrease in blood glucose than did the C group 3 E group showed a significantly lower emergency room visitation rate than did the C group
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
66 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Heller SR, Clarke P, et al 1988 Group education for obese patients with Type II diabetes: Greater success at less costD
Study Design
RCT with FU at 3, 6, and 12 months
Sample Description
3 Subjects were newly diagnosed Type II diabetics n 75, 48 male 3 Diabetes clinic
Interventions
3 E: Group education GE consisted of 3 90minute weekly sessions Goal of intervention was to lose weight, learn about proper nutrition, diabetes care, and glucose measuring n 36; vs 3 C: Usual care clinic CG consisted of FU at 3, 6 and 12 months, but no written protocol or standard diet was followed n 39
Intensive
Interventions
Selected Measures
3 Body weight 3 HbA1 glycosylated hemoglobin 3 Fasting blood glucose FBG 3 General and dietary knowledge of diabetes
Selected Outcomes
3 GE group lost significantly more weight than did CG after 3 months, and maintained this difference at 12 month FU 3 HbA1 was significantly lower in GE group than in CG after 3 months, a difference maintained at 6 months but not 12 months 3 GE group had significantly higher diabetes knowledge scores than did CG 3 There was a slight but significant association between diabetes knowledge score and weight loss at 12 months
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 67
Intensive Interventions, Continued
Principal Investigators
Wing RR, Epstein LH, et al 1988 Exercise in a behavioural weight control programme for obese patients with Type II non-insulin-dependent diabetesD
Study Design
RCT with 1year FU
Sample Description
3 Study 1: non-insulin dependent obese diabetic patients n 25, 16 male, mean age 54
years 3 Study 2: Obese diabetics n 30, 30 male, mean age 555 years 3 Outpatient clinic 3 United States
Interventions
Study 1: 3 The following applied to all subjects in Study 1: All subjects were given a daily calorie goal designed to result in 1 kg/week weight loss Calorie books and self-monitoring diaries were distributed, and subjects monitored their caloric intake Subjects were taught to increase complex carbohydrate intake, and to decrease fat intake Standard behavior modification strategies to change eating habits were taught Slowing down the rate of ingestion, decreasing eating signals in the environment, dealing with social pressures, planning in advance for high-risk situations, and refunds of a deposit for weight loss, meeting attendance, and exercise were used All subjects exercised 2x/week as a group, and once a week alone Each group exercise session 1 hour Treatment lasted 10 weeks with 1year FU 3 E1: Diet plus Moderate Exercise DPME Moderate exercise geared towards walking Distance and speed were increased until subjects were walking 3 miles in 1 hour session n 12; vs 3 E2: Diet plus Placebo Exercise DPPE Low intensity exercise of light calisthenics and
flexibility exercises set to music aka flexercise n 13 Study 2: 3 Same as above, except that all subjects in Study 2 met 3x/week for 10 weeks, then once a week for 10 weeks, then once a month for 1 year 3 E1: Diet only Subjects were told to not change their activity level Sessions involved demonstrating low-calorie cooking techniques, role playing asking for low-calorie options, dinners at restaurants, and group trips to food stores n 15; vs 3 E2: Diet plus exercise Subjects walked 3 miles at each session and were told to exercise one other time per week alone n 15
Intensive Interventions
Selected Measures
3 Weight, BMI 3 Fasting blood glucose, HbA1 3 Blood Pressure 3 Cholesterol and triglycerides 3 Paffenbarger Activity questionnaire
Selected Outcomes
3 Study 1: At post-treatment n 22 all subjects lost weight and improved on physiological measures, but there were no significant group differences At 1 year FU n 18 subjects maintained weight loss but not improved physiological changes, and there were no significant group differences 3 Study 2: Subjects in the E2 group lost significantly more weight than those in E1 at post-treatment, 10week FU, and 1year FU Subjects in the
E2 group also had greater changes in BMI, greater decreases in cholesterol and triglycerides at all FU points, and reduced their medication more frequently and in greater quantity 3 Both Studies: Self-reported exercise was associated with weight loss and improved HbA1 levels
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
68 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Kaplan RM, Hartwell SL, et al 1987 Effects of diet and exercise intervention on control and quality of life in non-insulin-dependent diabetes mellitusD
Study Design
RCT with 18 month FU
Sample Description
3 Adults with NIDDM were recruited through the media n 76, mean age 55 years, 42 male 3 Outpatient clinic 3 United States
Interventions
3 All subjects were given a 1200 cal/day exchange diet and an individualized exercise program developed from an exercise test All sessions were 2 hours once a week for 10 weeks, and all subjects gave a deposit of 40, part of which was returned as a reward
depending upon group assignment 3 E1: Diet Subjects used behavior modification, cognitive restructuring, and the principles of modern learning theory to modify their diet and change their cognitions Dietician taught subjects to use a food diary Relaxation exercises were taught as a coping strategy; vs 3 E2: Exercise 10 sessions, including goal setting, self-monitoring strategies, stretching exercises, group discussion, and completing an exercise diary During the week results were graphed at each session so subjects could see group progress; vs 3 E3: Diet and Exercise 10 sessions, including a modified program of E1 with individualized exercise program, self-monitoring, foot care, group discussion, and stretching; vs 3 C: Education Health care specialists gave 2hour presentations Personnel included an endocrinologist, a podiatrist, an ophthalmologist, a psychologist, a registered dietician, a representative of the ADA, a representative of a company that makes home glucose monitoring equipment, and an exercise physiologist
Intensive Interventions
Selected Measures
3 Fasting blood glucose 3 Glycosylated hemoglobin HbA1C 3 Blood lipids 3 Weight 3 Exercise tolerance 3 Quality of
life
Selected Outcomes
3 At the 18month FU there were no significant differences between groups in weight loss At the 3 and 6 month FUs the Diet group had lost a significant amount of weight The Diet group regained this weight by the 18 month FU The Exercise group was not able to maintain their weight loss, and the Diet and Exercise group maintained the same weight throughout the program 3 The Diet and Exercise group decreased their HbA1C levels by 148, significantly different from the control group The Diet alone and Exercise alone groups decreased their HbA1C levels, but not significantly more than the control group whose levels increased by 036 3 The E1 and E3 groups significantly improved on the quality of life measures at 18 months, while the E2 and C groups remained the same as the baseline measure and declined slightly from baseline, respectively 3 Cost Analysis: The combined diet and exercise program was estimated to cost 1000 per patient in 1986 dollars, which would produce 47 well years for every 100 participants 3 A combined diet and exercise program produces significant health benefits over 18 months
A B
Intensive Interventions — Diet Intensive Interventions –
Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 69
Intensive Interventions, Continued
Principal Investigators
Mulrow C, Bailey S, et al 1987 Evaluation of an audiovisual diabetes education program: Negative results of a randomized trial of patients with non-insulin dependent diabetes mellitusD
Study Design
RCT pre/post-test, with 1month FU
Sample Description
3 Subjects were obese non- insulin dependent diabetics who were diagnosed after the age of 29 n 120, mean age 53, 55 female, 49 Black 3 Hospital-based outpatient diabetes clinic 3 England
Intensive Interventions
Interventions
3 E1: Videotaped lessons on diabetes education were used, with printed handouts Topics included dietary regimen, diabetes complications, urine testing, physical exercise, and goal setting Weight and blood glucose BG were also measured monthly n 40; vs 3 E2: One diabetes information session covering the topics of diabetes, diet, and urine testing followed by monthly sessions for open discussion and weight/BG measurement No videotapes, intended
standardization, or handouts were utilized n 40; vs 3 C: Only one diabetes information session covering the topics of diabetes, diet, and urine testing was given n 40 3 Information session was one hour, and training sessions were 30 minutes each, once/month for 5 months At 7 and 11 months, outcome measure data were collected from all subjects
Selected Measures
3 Body weight 3 HbA1 glycosylated hemoglobin 3 Triglyceride level 3 Cholesterol level
Selected Outcomes
3 E1 lost significantly more weight than E2 and C, but loss was not maintained at FU 3 None of the other measures differed significantly between groups
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
70 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Hartwell SL, Kaplan RM, et al 1986 Comparison of behavioral interventions for control of Type II diabetes mellitusD
Study Design
RCT with FU at 3 and 6 months
Sample Description
3 Subjects were Type II diabetics n 76, 421 male 3 University-based
laboratory
Interventions
3 E1: Diet DI — goal setting exercises, use of diary to monitor eating, altering habits cognitively, group discussion, brief relaxation exercises; vs 3 E2: Exercise EX — 2 explanatory/info sessions, then 8 sessions of stretching 20 minutes, walking 4560 minutes and group discussion 30 minutes; vs 3 E3: Diet plus exercise DE — modified DI treatment for first 5 weeks, 4 sessions of stretching 20 minutes, walking 4560 minutes and cognitive-behavioral modification 30 minutes; vs 3 C: Education control EC — traditional diabetes education class offering sessions conducted by a variety of diabetes care professionals 3 No information regarding sample size per intervention group was provided 3 10 consecutive 2hour weekly meetings, with content varying by condition All subjects received information on paper about diet and exercise, but adherence to treatment conditions was the outcome of interest
Intensive Interventions
Selected Measures
3 Weight loss 3 HbA1 glycosylated hemoglobin 3 HDL cholesterol 3 LDL cholesterol 3 Session attendance
Selected Outcomes
3 Patients assigned to the DI group experienced significantly greater reductions in weight and blood
glucose and significant increases in HDL cholesterol in comparison to other groups 3 Attendance correlated significantly with diary adherence use of a diary to record sessions, as well as a number of outcomes across groups, including HbA1 and oxygen uptake
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 71
Intensive Interventions, Continued
Principal Investigators
Vinicor F, Cohen S, et al 1986 DIABEDS: A randomized Trial of the Effects of Physician and/or Patient OutcomesD
Study Design
RCT with FU at 26 months
Sample Description
3 Eligibility: 1 Fasting Plasma Glucose FPG either 129 mg/dl on at least two occasions, or 149 mg/dl on one occasion; or 2hour post-prandial plasma glucose PPG 249 mg/dl; or random plasma glucose 299 mg/dl 2 Ability to perform at least two of the following: a draw up and administer insulin, b influence selection of food, or c test used for glucose and ketones 3 Absence of active major psychiatric illness or terminal medical disease 3 n 532 mean
age: 57 89 years; 79 female; 72 African-American 3 Hospital-based General Medical Clinic 3 United States
Intensive Interventions
Interventions
3 E1: Patient Education in which diabetes patients, but not their resident physicians, received a systematic education program Focused on target behaviors for self-management of diabetes; vs 3 E2: Physician Education consisted of residents only, and received an intensive educational program; vs 3 E3: Physician and Patient Education — both residents and their diabetes patients received training programs 3 Patients in E1 E3 had: Nurse-taught instructional units which consisted of diet, activity, and weight reduction Instructional units averaged 90 minutes/topic/patient Intervention lasted 23 to 2 months 3 Physicians from E2 E3 were assigned to a six component training program: 1 Problem-Oriented Protocols 2 Seminar 6 hours 3 Conferences with diabetes specialists 1hour small groups for 3 weeks 4 Retrospective Practice Audits of Resident Adherence to Protocols 5 Telephone hot line to Diabetes Specialist 6 Protocol Based Computer-Generated physician reminders The resident training program emphasized attitudes, beliefs, skills and
clinical support systems, as well as clinical knowledge 3 C: Usual Education — residents and their diabetic patients received only diabetes education that was routinely available in the clinic
Selected Measures
3 Glycosylated HbA1 3 Body Weight 3 Systolic Blood Pressure 3 Diastolic Blood Pressure 3 Fasting Plasma Glucose
Selected Outcomes
3 Patients in C experienced an average decrease of 27 mg/dl in fasting plasma glucose and an average increase of 35 in glycosylated HbA1 levels 3 In contrast, patients in E1 E3 groups decreased in fasting plasma glucose and glycosylated Hb by 275 mg/dl and 43 respectively p05 for both variables For a 2hour post-prandial plasma glucose the adjusted means were 3208 vs 3019, p10 C vs E1, body weight 1871 vs 1843 lb, p05 C vs E1, systolic blood pressure 1457 vs 1418 mmHg, p05 C vs E1, and diastolic blood pressure 844 vs 817 mmHg, p01 C vs E1 3 E3 outcomes were significantly improved except for systolic blood pressure Fasting plasma glucose values in E3 decreased by 39 mg/dl vs an increase of 77 mg/dl in C p01 Glycosylated Hb values revealed a similar trend, with 92 reduction in E3 patients vs 56 increase in patients from C p01 3 Also, two-hour
post-prandial blood glucose 3297 vs 2905 mg/dl, p05 C vs E3, body weight 1893 vs 1843 lb, p01 C vs E3, diastolic blood pressure 855 vs 815 mmHg, p005 C vs E3
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
72 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Wing RR, Nowalk MP, et al 1986 Calorie-counting compared to exchange system diets in the treatment of overweight patients with Type II diabetesA
Study Design
RCT pre/post-test
Sample Description
3 Participants had Type II diabetes, were ages 3070, 20 above ideal body weight for height, and their diabetes was treated only by diet or with diet plus oral hypoglycemic medication n 50; mean age 55 3 Outpatient 3 United States
Intensive Interventions
Interventions
3 E1: Those in the behavior modification group were seen weekly for 16 weeks and were offered a standard behavioral weight control program A calorie-counting diet was used and patients were given a daily calorie goal They were instructed to record
their intake, but they were free to eat whatever they wanted as long as they kept within their calorie goal They were encouraged to restrict simple carbohydrates and to reach specified daily goals for intake of high fiber foods; vs 3 E2: Those in the nutrition education group weekly format met for 16 weeks and were placed on an exchange system diet Patients were instructed to follow the exchange diet closest to that calorie goal; vs 3 E3: Those in the nutrition education group monthly format met for 16 weeks and were placed on an exchange system diet with similar instructions as those in E2 3 All patients were asked to record their food intake for 3 days prior to randomization and for 3 days at the end of the 16week intervention
Selected Measures
3 Self-report dietary records
Selected Outcomes
3 Results showed that changes in total caloric intake and in the specific nutrients consumed by patients who were randomly assigned to a calorie-counting diet were not significantly different from those made by patients assigned to an exchange system diet Those on both types of diet reported decreases in caloric intake and in almost all nutrients, yet the average intake continued to exceed
100 of the RDA for all nutrients except calcium
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
Center for the Advancement of Health 3 73
Intensive Interventions, Continued
Principal Investigators
Wing, RR, Epstein LH, et al 1986 Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with Type II diabetes?B,D
Study Design
RCT pre/post-test with 1year FU
Sample Description
3 Subjects were non-insulin dependent diabetics overweight by 20 or more n 50, mean age 538, 22 male 3 Medical school
Interventions Intensive Interventions
3 E1: Weight control WC Focused on weight reduction as goal of therapy using financial incentives for lost pounds and changes in eating and exercise habits; vs 3 E2: Glucose monitoring GM Focused on blood glucose control BGC by teaching how to monitor blood glucose and providing the necessary supplies to do so at home Financial incentives were provided for weight loss and improvements in BGC 3 Both groups gave 85 deposits at baseline to serve as source
of financial incentives Both groups also participated in a weight control treatment program utilizing calorie books and self-monitoring, behavior modification techniques, and introduction of specific goals Both groups attended 12 weekly meetings, then 6 monthly meetings, then FU at 9 and 12 months
Selected Measures
3 Body weight 3 Body mass index 3 Blood pressure BP 3 Cholesterol and triglycerides 3 C-peptide levels 3 Fasting blood glucose levels FBG 3 HbA1c glycosylated hemoglobin 3 Beck Depression inventory 3 Compliance: Self-report diaries and covert monitoring
Selected Outcomes
3 Weight loss was not significantly different between E1 and E2, but were significantly lower in both groups 3 Systolic BP improved significantly at post and FU 3 Triglycerides decreased at post and results were maintained at FU No difference between groups 3 C-peptide levels, FBG and HbA1c were lower at post, but results were not maintained at FU No difference between groups 3 Depression levels decreased at post and results were maintained at FU No difference between groups 3 No difference in compliance rates between groups
A B
Intensive Interventions — Diet Intensive Interventions — Glucose
Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
74 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Wing RR, Epstein LH, et al 1985 Behavior change, weight loss, and physiological improvements in Type II diabetic patientsD
Study Design
RCT with 1 year FU
Sample Description
3 Patients with Type II diabetes treated only by diet and/or oral hypoglycemic medication, recruited through the media and physicians n 53, mean age 551 years, 38 male, mean pre-treatment BMI 348 3 Outpatient weight loss clinic 3 United States
Interventions
3 All patients were given the same calorie goal throughout treatment An experienced behavioral psychologist and a nutritionist ran all groups 3 E1: Behavior Modification BM 16 weekly sessions in a small group lecture/discussion format Diet: Subjects were given a calorie book and a self-monitoring calorie diary and were instructed to avoid sugar and to increase fiber Exercise: Walking was encouraged as a form of exercise Structured, increasing goals for calorie expenditure from exercise were given, and
models of appropriate exercise and social support were also given 3/lb lost was refunded from a deposit for every pound lost limit of 6/week Changing environments and cognitions: Subjects were told to remove stimuli from the environment which was associated with eating, and were encouraged to plan ahead for risky situations using cue cards and role-playing; vs 3 E2: Nutrition Education NE 16 weekly small-group sessions to provide basic information on diabetes, nutrition, and exercise Subjects followed the Exchange List Eating Plan to match their calorie goal, and were given a pocket-sized handout of the Exchange List The Exchange List and different nutrition topics such as sugar, Fiber, Cholesterol, or Meatless meals were discussed each week Dietary and exercise goals were not set Information about exercise was given, but group exercises were not conducted Portions of the deposit were refunded for attendance at the weekly sessions; vs 3 C: Standard-care SC Four monthly group meetings over the 16week period of the E1 and E2 sessions This condition was meant to approximate the contact with a doctor usually given to subjects with diabetes All information given was identical to that
of the E2, with brief discussion Refunds of the deposit as in E2
Intensive Interventions
Selected Measures
3 Weight 3 BMI 3 BP 3 Cholesterol and triglycerides 3 Fasting blood glucose, and HbA1 3 Paffenbarger Activity Questionnaire 3 Food frequency questionnaire 3 Eating Behavior Inventory 3 Beck Depression Inventory
Selected Outcomes
3 At post-treatment, subjects in the BM group lost significantly more weight than subjects in the NE or SC groups 3 Among the 50 patients available for the 1 year FU, there were no significant differences between groups in average amount of weight loss, with an overall average loss of 28 kg There were also no group differences in physiological measures; the average blood sugar level improved significantly, as did the insulin sensitivity, total cholesterol, and blood pressure at post-treatment At the 1year FU improvements in insulin levels was the only change maintained Improvements in physiological measures were related to weight loss rather than treatment group 3 Level of depression decreased with weight loss, but returned to pre-treatment levels by 1 year FU, along with most of the weight 3 Subjects reported increasing exercise levels at
post-treatment and 1 year FU
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
C
Center for the Advancement of Health 3 75
Intensive Interventions, Continued
Principal Investigators
Campaigne BN, Gillian TB, et al 1984 Effects of a physical activity program on metabolic control and cardiovascular fitness in children with insulin-dependent diabetes mellitusC,E
Study Design
RCT pre/post-test
Sample Description
3 Insulin-dependent children with diabetes mellitus n 19, mean age 9, 63 males who were diagnosed for at least 6 months and were in stable metabolic control 3 University-based Pediatric Diabetes Clinic Unit 3 United States
Intensive Interventions
Interventions
3 E: Exercise group Three 30minute session per week for 12 weeks Running, games, and movement to music were conducted by an activity instructor All baseline and post-treatment assessments n 10; vs 3 C: Control group Baseline and post-treatment assessments only n 9
Selected Measures
3 Treadmill test 3 Fasting Blood Glucose FGB 3 HbA1
Selected
Outcomes
3 Children in the experimental group showed improvement on FGB and HbA1 levels, metabolic control Exercise was shown to mediate the decrease in HbA1 levels
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
76 3 Health Behavior Change in Managed Care
Intensive Interventions, Continued
Principal Investigators
Korhonen T, Huttunen JK, et al 1983 A controlled trial on the effects of patient education in the treatment of insulin-dependent diabetesD
Study Design
RCT with data collected every three months for 18 months
Sample Description
3 Subjects were insulin dependent diabetics n 77, mean age 448, 55 male 3 University hospital 3 Finland
Intensive Interventions
Interventions
3 E: Intensive education consisting of individual and group sessions with physicians, dieticians, and teaching nurses n 39; vs 3 C: Control group received information that corresponded to old-fashioned education that the hospital used, consisting of two 30minute meetings with a physician and a course on the practical performance of
urine tests n 38 3 5day inpatient program for C and E to give baseline measurements and to receive patient education
Selected Measures
3 Diabetic control fasting blood glucose and urinary glucose 3 Diet history 3 Diabetes knowledge
Selected Outcomes
3 E group had significantly better knowledge of diabetes management Patients in both groups significantly increased their number of home urine tests Lesser dietary knowledge correlated with poor diabetic control
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
Center for the Advancement of Health 3 77
Intensive Interventions, Continued
Principal Investigators
Rabkin SW, Boyko E, et al 1983 A randomized clinical trial comparing behavior modification and individual counseling in the nutritional therapy of non-insulin-dependent diabetes mellitus: Comparison of the effect of blood sugar, body weight, and serum lipidsA
Study Design
RCT with baseline, 6 week and 12 week FU assessments
Sample Description
3 Participants were adults with diabetes mellitus who were
non-insulin dependent, younger than 65 years, not receiving insulin, had a fasting serum glucose level over 135 mg/dl, and had stable diabetes, as assessed by their physician n 40 3 Outpatient 3 United States
Intensive Interventions
Interventions
3 E1: The behavior modification group was led by a nutritionist and was a group approach consisting of no fewer than 6 and no more than 9 patients meeting on 6 consecutive weeks for about 1 hours per session It began with more intensive discussion and graphic presentation of the pathophysiology of diabetes from lay perspectives Patients were taught to count calories and advised to consume no more than 1200 calories if female and 1500 calories if male They were asked to maintain daily eating records that were reviewed weekly by the group leader n 20; mean age 527; 65 female; vs 3 E2: The individual counseling program consisted of a brief lecture in lay terms of the pathophysiology of diabetes and its complications Participants received St Pauls diabetes guide to meal planning, and a daily food allowance aimed to reduce intake was designed, based on the individuals food intake Patients were counseled about the necessity of losing
weight as part of the treatment of diabetes They returned 6 weeks later for FU and blood tests The duration of the initial counseling session was 1 hour and the last session was 15 minutes n 20; mean age 55; 50 female
Selected Measures
3 Body weight 3 Fasting blood glucose and triglycerides 3 Skin-fold thickness
Selected Outcomes
3 Results showed that both treatment approaches were associated with significant reductions in body weight, skin-fold thickness, fasting blood glucose, and triglycerides Results also indicate that there were no consistent statistically significant differences between the individual counseling and behavior modification groups in regards to changes in fasting serum glucose and lipoproteins
A B
Intensive Interventions — Diet Intensive Interventions — Glucose Monitoring C Intensive Interventions — Physical Activity D Intensive Interventions — Multiple Risk Factors E Intensive Interventions — Youth
78 3 Health Behavior Change in Managed Care
Literature Reviews
Principal Investigators
Griffin S, Kinmouth AL 1999 Diabetes care: general practitioner or specialist? Diabetes care: the effectiveness of systems for routine surveillance for people with
diabetes
Study Design
Meta-analysis of the effectiveness of hospital versus general practice care for diabetes
Sample Description
Inclusion Criteria: 3 Either insulin or non-insulin dependent diabetics 3 Hospital-based or primary care based intervention 3 FU coordinated between hospital and primary care 3 RCT Searched all through 1996: 3 Medline 3 CINAHL 3 National Research Register 3 PsychLit 3 Healthstar 3 Embase 3 CRIB 3 Dissertation Abstracts
3 n 5 studies from Australia and the British Isles 3 Total of 1,058 diabetics; overall mean age 584 years; 442 female
Interventions
Interventions reviewed focused on: 3 Specialist care in a hospital HC vs 3 General practice GP/shared care vs 3 Prompted general practitioner/shared care featured more intensive support through a prompting system for GPs and patients System was not described
Selected Measures Literature Reviews
3 Mortality rate 3 Metabolic control HbA1 3 Hospital admissions 3 Blood pressure BP 3 Costs
Selected Outcomes
3 Significantly more patients died in general practice care than in the hospital care group Most of the deaths in GP care were accounted for by the 2 trials that did not feature prompting 3 Overall,
there was no significant difference in HbA1 of patients receiving GP and HC 3 Regarding hospital admissions, one study favored HC, one favored GP, and the third found no significant differences between prompted GP and HC 3 There were no significant differences in final readings for systolic or diastolic BP between prompted GP and HC in 2 studies, although effect sizes tended to favor HC 3 Data on costs were not comparable between studies, and were in conflict at times 3 Only one of the five trials identified lasted more than two years 3 Conclusions: Unstructured care is associated with poorer FU, greater mortality and worse glycemic control than hospital care The evidence supports use of regular prompted recall for patients and their providers which can achieve care standards as good or better than hospital outpatient care
Center for the Advancement of Health 3 79
Literature Reviews, Continued
Principal Investigators
Krishna S, Balas EA, et al 1997 Clinical trials of interactive computerized patient education: Implications for family practice
Study Design
Systematic literature review
Sample Description
Inclusion Criteria: Published articles which involved 3 Randomized
controlled clinical trials 3 Educational computer-patient interaction 3 Effect of measures on the process or outcome of care Searched: 3 Columbia Registry 3 Medline 3 Health 3 BIO-SIS 3 CINAHL
3 n 22 studies on a number of conditions, 6 on diabetes
Interventions
3 Interactive instructional computer programs on how to monitor blood glucose levels 3 Computerized health assessment and history-taking 3 Computerized information support networks
Selected Measures
3 Blood glucose BG levels 3 Level of patient involvement in self-care 3 Knowledge of diabetes and nutrition
Literature Reviews
Selected Outcomes
3 Studies that provided education on monitoring blood glucose levels reported a 10 to 20 decrease in BG levels 3 Increased involvement in self-management of diabetes was reported by 40 more subjects in intervention groups than in control groups 3 Use of instructional computer programs also resulted in increased knowledge about diabetes 40 higher and nutrition
80 3 Health Behavior Change in Managed Care
Literature Reviews, Continued
Principal Investigators
Brown S, Upchurch S, et al 1996 Promoting weight loss in Type II diabetes
Study Design
Meta-analysis
Sample
Description
Inclusion criteria: 3 Sample of obese adults with Type II diabetes 3 Strategies to promote weight loss 3 Measure of weight loss as an outcome of the intervention 3 Same setting for both treatment and control groups 3 Ex post-facto, one-group pre-test–post-test, quasiexperimental, or experimental design 3 Data that permitted calculation of effect sizes 3 n 89 studies Searched: 3 Medline 3 Combined Health Information Data Base 3 Psychological Abstracts 3 ERIC 3 Dissertation Abstracts 3 Surveys of masters degree programs in nursing, public health, and dietetics/nutrition
Interventions
Settings: 3 Outpatient settings or metabolic research units 55 Types of interventions: 3 Dietary interventions 40 3 Behavioral interventions 20 3 Exercise interventions 10 3 Drug, surgery, or combination strategies 30 3 Incomplete descriptions of interventions 20 3 Mean age 52 years 3 Mean weight 211 pounds
Literature Reviews
Selected Measures
3 BMI 3 Body weight 3 Cholesterol 3 Glycosylated hemoglobin 3 Serum insulin 3 Blood pressure
Selected Outcomes
3 Results showed that diet alone was associated with the largest weight loss Exercise alone had little effect on any outcome
variables, and when exercise was added to the behavioral and/or dietary therapies, little improvement in outcomes was noted
Center for the Advancement of Health 3 81
Literature Reviews, Continued
Principal Investigators
Clement S 1995 Diabetes self-management education
Study Design
Systematic literature review
Sample Description
Inclusion Criteria: Restricted to peer-reviewed articles that were 3 Long-term 12 months prospective randomized studies, OR 3 Studies addressing hospitalization rates, OR 3 Studies addressing cost-effectiveness of self-management education, OR 3 Short-term 12 months randomized or non-randomized studies 3 n 11 studies/13 papers
Interventions
Interventions focused on: 3 Diabetes education n 5 studies 3 Home visits n 1 study 3 Diet/nutrition counseling n 7 studies 3 Small group physical therapy n 1 study 3 Exercise instruction n 3 studies Some studies utilized more than one intervention
Selected Measures Literature Reviews
3 Fasting blood sugar FBS 3 HbA1 glycosylated hemoglobin 3 Weight change 3 Number of diabetes-related hospitalizations 3 Serious foot lesions
Selected Outcomes
Diabetes self-management education was found to be associated with:
3 FBS and HbA1 level improvement in most studies 3 no change in weight or loss of weight 3 reduction in diabetes-related hospitalizations 3 reduction in serious foot lesions 3 reduction in diabetes-related health care costs The following features appear critical to the success of self-management education: 3 Interventions must make extensive use of behavior change strategies 3 Intervention must be appropriately matched to the patient 3 Care personnel must work closely with the patients health care provider as part of an integrated team
82 3 Health Behavior Change in Managed Care
Literature Reviews, Continued
Principal Investigators
3 Brown SA 1988 Effects of educational interventions in diabetes care: a meta-analysis of findings 3 Brown SA 1990 Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited 3 Brown SA 1992 Meta-analysis of diabetes patient education research: variations in intervention effects across studies
Study Design
Meta-analysis
Sample Description
Inclusion Criteria: Published and unpublished articles that involved 3 A population of diabetic adults 3 An educational intervention 3 Research design either RCT pre-post or one
group pre-post 3 Same setting for both treatment and control groups 3 A measure of outcome that permitted calculation of effect sizes Searched: 3 Medline 3 Combined Health Information Data Base 3 Psychological Abstracts 3 ERIC 3 Dissertation Abstracts 3 n 47 studies 1988 3 n 82 studies 1990
Interventions
Interventions reviewed focused on: 3 Improvement of patient knowledge 3 Increasing self-care behaviors and compliance 1988 paper: 3 for each of these interventions was not stated, nor were details regarding the types of program materials or presentations 1990 paper: Interventions were broken down into type: 3 Group instruction — 31 studies 3 Individual instruction — 15 studies 3 Group and individual — 9 studies 3 Multidisciplinary — 22 studies 3 Inpatient programs — 1 study 3 Not stated — 3 studies 1992 paper: 3 n for each of these interventions was not stated, nor were details regarding the types of program materials or presentations
Literature Reviews
Selected Measures
3 Patient knowledge, specifically knowledge of dietary principles 1988, n 10; 1990, n 12 3 Self-care behaviors, specifically insulin injection 1988, n 3; 1990, n 5, urine testing 1988, n 5; 1990, n
7, weight loss 1988, n 16; 1990, n 28, and dietary compliance 1988, n 6; 1990, n 15 3 Metabolic control, typically measured by glycosylated hemoglobin 1988, n 13; 1990, n 27, or blood sugar 1988, n 13; 1990, n 28 3 Psychological outcomes 1990, n 14 3 Note: 1992 paper did not report Ns and used glycosylated hemoglobin as the only measure of metabolic control
Selected Outcomes
1988 paper: 3 Patient education appears to enhance patient outcomes in diabetes management for the 3 measures listed above 3 Weighted mean effect sizes were greater for one group pre-post designs than for those with control groups 1990 paper: 3 Patient knowledge effects were the highest 49 to 105, followed by self-care behavior effects 17 to 57, metabolic control effects 16 to 41 and psychological outcomes 27 3 Mean age was negatively related to knowledge of dietary principles and effect size, particularly those effects related to knowledge variables 1992 paper: 3 For increasing patient knowledge and decreasing HbA1 levels, highest effect sizes were found in pre/post-test one group designs 3 Patient education appeared to be more effective in younger adult patients than middle aged or older adults 3
For all patients, HbA1 levels improved between 1 and 6 months post-intervention, but reverted to one-month levels after six months
Center for the Advancement of Health 3 83
Literature Reviews, Continued
Principal Investigators
Padgett D, Mumford E, et al 1988 Meta-analysis of the effects of educational interventions on management of diabetes mellitus
Study Design
Meta-analysis
Sample Description
Inclusion Criteria: 3 Studies of the effects of educational and psychosocial interventions in diabetes 3 Published during 19761986 3 Either RCT or single group pre/post-design 3 Minimum sample size of 5 subjects Searched: 3 Medlars 3 Excerpta Medica 3 Dissertation Abstracts 3 NTIS 3 SSCI 3 ERIC 3 Psychological Abstracts 3 Sociological Abstracts 3 Government Printing Office
3 n 94 studies
Interventions
Interventions reviewed focused on: 3 Didactic education — standardizing formal instruction n 13 3 Enhanced education — combination of instructional and behavioral strategies, usually accompanied by diet, exercise, or self-monitoring n 22 3 Dietary behavioral instruction n 14 3 Exercise behavioral instruction n 5 3 Self-monitoring of blood glucose SMBG behavioral instruction n 13
3 Behavior modification or social learning strategies n 11 3 Relaxation and biofeedback n 9 3 Individual or group counseling n 7
Literature Reviews
Selected Measures
3 Patient knowledge of diabetes 3 Physical measures — HbA1 glycosylated hemoglobin, blood glucose BG levels 3 Psychological status 3 Compliance
Selected Outcomes
3 Moderate but significant improvements were found across selected outcome measures: Dietary interventions had the strongest effect on patient knowledge Dietary and social learning interventions had the strongest effect on physical measures Dietary interventions had the strongest effect on patient compliance 3 Studies that dealt with effects on psychological measures were inconclusive 3 Relaxation training had the only non-significant effect across outcome measures
84 3 Health Behavior Change in Managed Care
Diabetes: System Changes
Principal Investigators
Aubert RE, Herman WH, et al 1998 Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: A randomized, controlled trialA
Study Design
RCT with 12 month FU
Sample Description
3 Patients with either Type I or Type II diabetes mellitus n 138,
mean age 53 years, 399 male 3 Primary care clinics with HMO group model
Interventions
3 E: Usual care plus nurse case management Nurse-supervised adjustments in medication, meal planning, and reinforcement of exercise, along with regular communication of changes to primary care physician PCP n 71; vs 3 C: Usual care Diabetes care and follow-up from PCP, blood glucose meters and strips provided, standard HMO benefit of 5 week education program made available as patients option n 67
Selected Measures
3 HbA1c hemoglobin A1c 3 Behavior Risk Factor Surveillance System quality of life measure 3 Fasting blood glucose level 3 Body weight 3 Blood pressure 3 Lipid levels
Selected Outcomes
3 E group had greater decrease in HbA1c and fasting blood glucose values than did the C group 3 No significant differences were found between E and C groups on measures of body weight, blood pressure, or lipid levels 3 Both groups reported increased quality of life, but E group was twice as likely to do so as C group
A B
System Changes: Multiple Targets System Changes: Provider Intervention
System Changes
Center for the Advancement of Health 3 85
System Changes, Continued
Principal
Investigators
Kinmonth AL, Woodcock A, et al 1998 Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease riskB
Study Design
RCT with data collected at baseline and at one year post-intervention
Sample Description
3 Subjects were recently diagnosed Type II diabetics n 250, mean age 577, 59 male 3 Medical clinic 3 England
Interventions
3 E: Intervention group Patients of doctors and nurses who received training in patient centered care n 142 vs 3 C: Comparison group Patients of doctors and nurses to whom no additional training was given n 108 3 E group practitioners received 15 days training before baseline assessment, and both groups had review/ practice sessions at 6 and 12 months after baseline
Selected Measures
3 HbA1c glycated hemoglobin 3 Cholesterol levels 3 Body mass index BMI 3 Blood pressure BP 3 Quality of life and well-being
Selected Outcomes
3 HbA1c levels were not significantly different between groups Well-being scores, patient-doctor communication, and treatment satisfaction were significantly higher in the intervention group than in the comparison group
A B
System Changes:
Multiple Targets System Changes: Provider Intervention
System Changes
86 3 Health Behavior Change in Managed Care
System Changes, Continued
Principal Investigators
Peters AL, Davidson MB 1998 Application of a diabetes managed care program: The feasibility of using nurses and a computer system to provide effective care A
Study Design
Between groups comparison non random assignment, non experimental design; FU for 1 to 3 years
Sample Description
3 Diabetics enrolled in managed care: group model HMO and IPA diabetes and lipid management
Interventions
3 E1: Comprehensive Diabetes Care Service CDCS used computerized tracking and recall system in conjunction with nurse implemented protocols that were based on clinical guidelines ADA; National Cholesterol Education Panel Provided diabetes education which consisted of 1 group meeting daily for 1 week; employed a standard of FU care that was used to stratify by compliant vs non-compliant kept 01 appointments for lab tests or treatment The comprehensive care included computer generated reminder cards to patients for lab tests and appointments Also sent monthly late notices until compliance was obtained Quarterly FU appointments were the
standard of care Referrals were given to provider team members for collaborative management eg, podiatrists, opthalmologists at least yearly Participants included in analyses were those who were continuously enrolled in CDCS for at least 1 year after diabetes education course They were physician referred diabetic patients and did not know they were in a study Average FU care was 23 plus or minus 01 years n 18 FU to 1 year only; n 27 FU to 2 years; n 47 FU to 3 years 3 E2: Group Model Health Maintenance Organization GMH Patients were those who attended a diabetes education course at a local group model HMO Education consisted of group meetings, 1 per week for 4 weeks No further details were provided Average FU care was 22 plus or minus 01 years n 16 FU to 1 year only; n 19 FU to 2 years; n 32 FU to 3 years
Selected Measures
3 SF36 Quality of Life Questionnaire 3 Glycated Hemoglobin Levels HbA1c
Selected Outcomes
3 Median HbA1c level fell in the CDCS group from 119 to 88 at year 1 and lowering was maintained for 3 years This level did not fall in GMH patients, and the median value was statistically higher than that in the CDCS group during years 2 and 3 3 There were no
statistically significant differences between groups for quality of life measures
A B
System Changes: Multiple Targets System Changes: Provider Intervention
System Changes
Center for the Advancement of Health 3 87
System Changes, Continued
Principal Investigators
DeSonnaville JJJ, Bouma M, et al 1997 Sustained good glycemic control in NIDDM patients by implementation of structured care in general practice: 2year follow up studyA
Study Design
3 Quasi-experimental, prospective, controlled cohort study 3 General practice lab 3 Netherlands
Sample Description
3 Patients with non-insulin dependent diabetes diagnosed after the age of 40 and treated for at least 6 months with diet and/or oral hypoglycemic tablets 3 Study group SG characteristics: n 350, 589 female, mean age 653 3 Control group characteristics CG: n 68, 412 female, mean age 646
Interventions
3 E: SG participated in diabetes service system consisting of supervision by a diabetologist who could be contacted 24 hour/day, a patient registration system, consultation with a dietician, podiatrist, and diabetes nurse educator, home blood glucose monitoring, and insulin therapy; vs 3 C: CG was not involved in any shared
care system 3 Both SG and CG patients were seen at 3month intervals for gylcemic control and annually for review of diabetic complications and cardiovascular risk factors 3 Within two weeks, SG patients results were sent to care providers, accompanied by advice on a step-by-step treatment plan The first step included education about self-monitoring of blood glucose and insulin therapy, and then two follow-up appointments to repeat and check education Twice weekly phone appointments were also made to adjust insulin dose as needed 3 SG data were collected after 1 and 2 years 3 CG data were collected after 15 years
Selected Measures
3 HbA1 glycated hemoglobin 3 Cholesterol levels total, HDL, and triglycerides 3 Blood pressure BP 3 Fasting plasma glucose FPG 3 Self-report questionnaires measuring general well-being and treatment satisfaction only in SG
Selected Outcomes
Between baseline and final data collection: 3 HbA1 fell significantly in SG, but not in CG 3 Total cholesterol fell significantly in SG but remained unchanged in CG 3 HDL cholesterol fell significantly in SG, but remained unchanged in CG 3 Triglycerides fell significantly in SG, but not in CG 3 Diastolic BP fell
significantly in both SG and CG 3 FPG fell significantly in SG, but not in CG 3 General well being did not show significant change 3 Treatment satisfaction tended to increase A lasting improvement in blood glucose control was achieved in primary health care as a result of implementing this structured diabetes program
System Changes
A B
System Changes: Multiple Targets System Changes: Provider Intervention
88 3 Health Behavior Change in Managed Care
Reference List: Key Words and Index
Agurs-Collins, T, Have, TRT, Kumanyika, S, Adams-Campbell, L 1997 A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjects Diabetes Care, 20, 15031511 Intensive Interventions, Multiple Risk Factors; p 44 Anderson, B, Ho, J, Brackett, J, Laffel, L 1999 An office-based intervention to maintain parent-adolescent teamwork in diabetes management Diabetes Care, 225, 713721 Intensive Interventions, Multiple Risk Factors, Youth; p 42 Anderson, B, Wolf, F, Burkhart, M, Cornell, R, Bacon, G 1989 Effects of peer-group intervention on metabolic control of adolescents with IDDM: Randomized outpatient study Diabetes Care, 123, 17983 Brief
Interventions, Multiple Risk Factors, Youth; p 32 Anderson, R, Arnold, M, Funnell, M, Fitzgerald, J, Butler, P, Feste, C 1995 Patient empowerment: Results of a randomized controlled trial Diabetes Care, 7, 943949 Intensive Interventions, Multiple Risk Factors; p 50 Ardron, M, MacFarlane, I, Robinson, C, van Heyningen, C, Calverley, P 1988 Anti-smoking advice for young diabetic smokers: Is it a waste of breath? Diabetic Medicine, 5, 667670 Brief Interventions, Multiple Risk Factors; p 36 Aubert, R, Herman, W, Waters, J, Moore, W, Sutton, D, Peterson, B, Bailey, C, Koplan, J 1998 Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: A randomized, controlled trial Annals of Internal Medicine, 1298, 605612 System Changes; p 85 Brown, S 1988 Effects of educational interventions in diabetes care: A meta-analysis of findings Nursing Research, 374, 223230 Literature Review; p 83 Brown, S 1992 Meta-analysis of diabetes patient education research: Variations in intervention effects across studies Research in Nursing and Health, 15, 409419 Literature Review; p 83 Brown, S 1990 Studies of educational intervention and outcomes in
diabetic adults: A meta-analysis revisited Patient Education and Counseling, 163, 189215 Literature Review; p 83 Brown, S, Upchurch, S, Winter, M, Ramirez, G, Anding, R 1996 Promoting weight loss in Type II diabetes Diabetes Care, 196, 613624 Literature Review; p 81 Campaigne BN, Gillian TB, Spencer ML, Lampman RM, Schork MA 1984 Effects of a physical activity program on metabolic control and cardiovascular fitness in children with insulin-dependent diabetes mellitus Diabetes Care, 71, 5762 Intensive Interventions; Physical Activity, Youth; p 76 Campbell, E, Redman, S, Moffitt, P, Sanson-Fisher, RW 1996 The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: A randomized trial The Diabetes Educator, 224, 379386 Intensive Interventions, Multiple Risk Factors; p 47
Reference List: Key Words and Index
Center for the Advancement of Health 3 89
Reference List: Key Words and Index
Clement, S 1995 Diabetes self-management education Diabetes Care, 188, 12041214 Literature Review; p 82 Cox, D, Gonder-Frederick, L, Polonsky, W, Schlundt, D, Julian, D, Clarke, W 1995 A multicenter evaluation of blood glucose awareness training-II Diabetes
Care, 184, 5238 Intensive Interventions, Glucose Monitoring; p 51 Cox, D, Gonder-Frederick, L, Julian, D, Clarke, W 1994 Long-term follow-up evaluation of blood glucose awareness training Diabetes Care, 171, 15 Intensive Interventions, Glucose Monitoring; p 52 DEramo-Melkus, G, Wylie-Rosett J, Hagan, J 1992 Metabolic impact of education in NIDDM Diabetes Care, 157, 864869 Intensive Interventions, Multiple Risk Factors; p 56 deBont, A, Baker, I, St Leger, A, et al 1981 A randomised controlled trial of the effect of low-fat diet advice on dietary response in insulin-independent diabetic women Diabetologia, 21, 529533 Brief Interventions, Diet; p 41 Delamater, A, Bubb, J, Davis, S, Smith, J, Schmidt, L, White, N, Santiago, JV 1990 Randomized prospective study of self-management training with newly diagnosed diabetic children Diabetes Care, 13, 49298 Intensive Interventions, Multiple Risk Factors, Youth; p 58 DeSonnaville, J, Bouma, M, Colly, L, Deville, W, Wijkel, D, Heine, R 1997 Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2year follow-up study Diabetologia, 4011, 13341340 System Changes, Multiple Targets; p 88
DeWeerdt, I, Visser, A, Kok, G, Van der Veen, E 1989 Randomized controlled evaluation of an education program for insulin treated patients with diabetes: Effects on psychosocial variables Patient Education and Counseling, 143, 191215 Intensive Interventions, Multiple Risk Factors; p 62 Diabetes Control and Complications Trial Research Group 1994 Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial The Journal of Pediatrics, 1252, 177188 Intensive Interventions, Multiple Risk Factors; p 53 Diabetes Control and Complications Trial Research Group 1995 Implementation of treatment protocols in the Diabetes Control and Complications Trial Diabetes Care, 183, 361376 Intensive Interventions, Multiple Risk Factors; p 53 Estey, A, Tan, M, Mann, K 1990 Follow-up intervention: Its effect on compliance behavior to a diabetes regimen The Diabetes Educator, 164, 291295 Intensive Interventions, Multiple Risk Factors; p 59 Fontbonne, A, Billault, B, Acosta, M, Percheron, C, Varenne, P, Besse, A, Eschwege, E, Monnier, L, Slama, G, Passa, P 1989 Is
glucose self-monitoring beneficial in non-insulin-treated diabetic patients? Results of a randomized comparative trial Diabète Métabolisme, 155, 255260 Brief Interventions, Glucose; p 33
90 3 Health Behavior Change in Managed Care
Reference List: Key Words and Index
Franz, M, Splett, P, Monk, A, Barry, B, et al 1995 Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus Journal of the American Dietetic Association, 95, 10181024 Brief Interventions, Diet; p 28 Glasgow, R, La Chance, P, Toobert, D, Brown, J, Hampson, S, Riddle, M 1997 Long term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office Patient Education and Counseling, 323, 175184 Brief Interventions, Diet; p 27 Glasgow, R, Toobert, D, Hampson, S 1996 Effects of a brief office-based intervention to facilitate diabetes dietary self-management Diabetes Care, 198, 835842 Brief Interventions, Diet; p 27 Glasgow, R, Toobert, D, Hampson, S, Brown, J, Lewinsohn, P, Donnelly, J 1992 Improving self-care among older patients with Type II diabetes: The Sixty Something study Patient
Education and Counseling, 191, 6174 Intensive Interventions, Multiple Risk Factors; p 57 Glasgow, R, Toobert, D, Hampson, S, Noell, JW 1995 A brief office-based intervention to facilitate diabetes dietary self-management Health Education Research, 104 , 467478 Brief Interventions, Diet; p27 Greenfield, S, Kaplan, S, Ware, Jr J, Yano, E, Frank, H 1988 Patients participation in medical care: Effects on blood sugar control and quality of life in diabetes Journal of General Internal Medicine, 35, 44857 Brief Interventions, Multiple Risk Factors; p 37 Griffin, S, Kinmonth, A 1999 Diabetes care: The effectiveness of systems for routine surveillance for people with diabetes The Cochrane Library, 1 Literature Reviews; p 79 Hartwell, S, Kaplan, R, Wallace, J 1986 Comparison of behavioral interventions for control of Type II diabetes mellitus Behavior Therapy, 174, 447461 Intensive Interventions, Multiple Risk Factors; p 71 Heller, S, Clarke, P, Daly, H, Davis, I, McCulloch, D, Allison, S, Tattersall, R 1988 Group education for obese patients with Type II diabetes: Greater success at less cost Diabetes Medicine, 56, 552556 Intensive Interventions, Multiple Risk Factors; p 67 Hopper, S,
Miller, J, Birge, C, Swift, J 1984 A randomized study of the impact of home health aides on diabetic control and utilization patterns American Journal of Public Health, 746, 600602 Brief Interventions, Multiple Risk Factors; p 40 Horan, P, Yarborough, M, Besigel, G, Carlson, D 1990 Computer-assisted self-control of diabetes by adolescents The Diabetes Educator, 163, 205211 Intensive Interventions, Multiple Risk Factors, Youth; p 60 Huttunen N-P, Lankela S-L, Knip M, Lautala P, Kaar M-L, Laasonen K, Puukka R 1989 Effect of once-a-week training program on physical fitness and metabolic control in children with IDDM Diabetes Care, 1210, 737740 Intensive Interventions, Physical Activity, Youth; p 63 Jones, P 1990 Use of a course on self-control behavior techniques to increase adherence to prescribed frequency for self-monitoring blood glucose The Diabetes Educator, 164, 296303 Intensive Interventions, Glucose Monitoring; p 61
Center for the Advancement of Health 3 91
Reference List: Key Words and Index
Kaplan, R, Chadwick, M, Schimmel, L 1985 Social learning intervention to promote metabolic control in Type I diabetes mellitus: Pilot experiment results Diabetes Care, 82, 152155
Brief Interventions, Multiple Risk Factors, Youth; p 39 Kaplan, R, Hartwell, S, Wilson, D, Wallace, J 1987 Effects of diet and exercise interventions on control and quality of life in non-insulin-dependent diabetes mellitus Journal of General Internal Medicine, 2, 220227 Intensive Interventions, Multiple Risk Factors; p 69 Kinmonth, A, Woodcock, A, Griffin, S, Spiegal, N, Campbell, M 1998 Randomised controlled trial of patient centered care of diabetes in general practice: Impact on current wellbeing and future disease risk The Diabetes Care From Diagnosis Research Team British Medical Journal, 3177167, 12021208 System Changes, Provider Interventions; p 86 Korhonen, T, Huttunen, J, AA, Hentinen, M, Ihalainen, O, Majander, H, Siitonen, O, Uusitupa, M, Pyorala, K 1983 A controlled trial on the effects of patient education in the treatment of insulin-dependent diabetes Diabetes Care, 63, 256261 Intensive Interventions, Multiple Risk Factors; p 77 Krishna, S, Balas, A, Spencer, D, Griffin, J, Boren, S 1997 Clinical trials of interactive computerized patient education: Implications for family practice Journal of Family Practice, 451, 2533 Literature Review; p 80 Litzelman, D,
Slemenda, C, Langefeld, C, Hays, L, Welch, M, Bild, D, Ford, E, Vinicor, F 1993 Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus: A randomized, controlled trial Annals of Internal Medicine, 119, 3641 Brief Interventions, Foot Care; p 30 Manning, R, Jung, R, Leese, G, Newton, R 1998 The comparison of four weight reduction strategies aimed at overweight patients with diabetes mellitus: Four-year follow-up Diabetes Medicine, 15, 497502 Intensive Interventions, Diet; p 54 Marrero, D, Kronz, K, et al 1989 Clinical evaluation of computer-assisted self-monitoring of blood glucose system Diabetes Educator, 214, 313319 Brief Intervention, Glucose, Youth; p 34 Massouh, S, Steele, T, Alseth, E, Diekmann, JM 1989 The effect of social learning intervention on metabolic control of insulin-dependent diabetes mellitus in adolescents The Diabetes Educator, 156, 518521 Intensive Interventions, Multiple Risk Factors, Youth; p 64 Mazzuca, K, Farris, N et al 1997 Demonstrating the added value of community health nursing for clients with insulin-dependent diabetes Journal of Community Health Nursing, 144, 211224 Intensive Interventions,
Multiple Risk Factors; p 45 McNabb, W, Quinn, M, Murphy, D, Thorp, F, Cook, S 1994 Increasing childrens responsibility for diabetes selfcare: The In Control study The Diabetes Educator, 202, 121124 Intensive Interventions, Multiple Risk Factors, Youth; p 55 Mendez, F, Belendez, M 1997 Effects of a behavioral intervention on treatment adherence and stress management in adolescents with IDDM Diabetes Care, 209, 13701375 Intensive Interventions, Multiple Risk Factors, Youth; p 46 Miley, W 1989 Reduction of blood glucose levels in chronically ill Type II diabetics by brief biofeedback-assisted relaxation training Rehabilitation Psychology, 341, 1724 Brief Intervention, Multiple Risk Factors; p 35
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Reference List: Key Words and Index
Mulrow, C, Bailey, S, Sonksen, P, Slavin, B 1987 Evaluation of an audiovisual diabetes education program: Negative results of a randomized trial of patients with non-insulin-dependent diabetes mellitus Journal of General Internal Medicine, 24 , 215219 Intensive Interventions, Multiple Risk Factors; p 70 Noel, P, Larme, A, Marsh, G, Correa, A, Meyer, J, Pugh, J 1998 Patient choice in diabetes education
curriculum: Nutritional versus standard content for Type II diabetes Diabetes Care, 216, 898901 Intensive Interventions, Multiple Risk Factors; p 43 Padgett, D, Mumford, E, Hynes, M, Carter, R 1988 Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus Journal of Clinical Epidemiology, 4110, 10071030 Literature Review; p 84 Peters, A, Davidson, MB 1998 Application of a diabetes managed care program: The feasibility of using nurses and a computer system to provide effective care Diabetes Care, 217, 10371043 System Changes, Multiple Targets; p 87 Pill, R, Stott, N, Rollnick, S, Rees, M 1998 A randomized controlled trial of an intervention designed to improve the care given in general practice to Type II diabetic patients: Patient outcomes and professional ability to change behaviour Family Practice 153, 229235 Brief Interventions, Multiple Risk Factors; p 29 Rabkin, S, Boyko, E, Wilson, A, Streja, D 1983 A randomized clinical trial comparing behavior modification and individual counseling in the nutritional therapy of non-insulin-dependent diabetes mellitus: Comparison of the effect on blood sugar, body weight, and serum
lipids Diabetes Care, 61, 5056 Intensive Interventions, Diet; p 78 Satin, W, LaGreca, A, Zigo, M, Skyler, JS 1989 Diabetes in adolescence: Effects of multifamily group intervention and parent simulation of diabetes Journal of Pediatric Psychology, 142, 259275 Intensive Interventions, Multiple Risk Factors, Youth; p 65 Smith, D, Norton, J, Weinberger, M, McDonald, C, Katz, BP 1986 Increasing prescribed office visits A controlled trial in patients with diabetes mellitus Medical Care, 243, 18999 Brief Interventions, Multiple Risk Factors; p 38 Stott, N, Rollnick, S, Rees, M, Pill, M 1995 Innovation in clinical method, diabetes care and negotiating skills Family Practice, 12, 413418 Brief Interventions, Multiple Risk Factors; p 29 Tu, K, McDaniel, G, Gay, J 1993 Diabetes self-care knowledge, behaviors, and metabolic control of older adults — the effect of a posteducational follow-up program The Diabetes Educator, 191, 2530 Brief Intervention, Multiple Risk Factors; p 31 Uusitupa, M I 1996 Early lifestyle intervention in patients with non-insulin-dependent diabetes mellitus and impaired glucose tolerance Annals of Medicine, 285, 445449 Intensive Interventions, Multiple Risk
Factors; p 48 Vinicor, F, Cohen, S, Mazzuca, S, et al 1987 DIABEDS: A randomized trial of the effects of physician and/or patient education on diabetes patient outcomes Journal of Chronic Diseases, 404, 345356 Intensive Interventions, Multiple Risk Factors; p 72 Wing, R, Anglin, K 1996 Effectiveness of a behavioral weight control program for Blacks and Whites with NIDDM Diabetes Care, 195, 409413 Intensive Interventions, Diet; p 49
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Reference List: Key Words and Index
Wing, R, Epstein, L, Nowalk, M, Koeske, R, Hagg, S 1985 Behavior change, weight loss, and physiological improvements in Type II diabetic patients Journal of Consulting and Clinical Psychology, 531, 111122 Intensive Interventions, Multiple Risk Factors; p 75 Wing, R, Epstein, L, Nowalk, M, Scott, N, Koeske, R, Hagg, S 1986 Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with Type II diabetes? American Journal of Medicine, 815, 830836 Intensive Interventions, Glucose Monitoring, Multiple Risk Factors; p 74 Wing, R, Epstein, L, Paternostro-Bayles, M, et al 1988 Exercise in a behavioral weight control programme for obese patients
with Type II non-insulin-dependent diabetes Diabetologia, 31, 902909 Intensive Interventions, Multiple Risk Factors; p 68 Wing, R, Nowalk, M, Epstein, L, Koeske, R 1986 Calorie-counting compared to exchange system diets in the treatment of overweight patients with Type II diabetes Addictive Behaviors, 11, 163168 Intensive Interventions, Diet; p 73 Wood, E 1989 Evaluation of a hospital-based education program for patients with diabetes Journal of the American Dietetic Association, 893, 354358 Intensive Interventions, Multiple Risk Factors; p 66
94 3 Health Behavior Change in Managed Care
Health Behavior Change in Managed Care
Publications Request Form
To request additional resources from the Health Behavior Change in Managed Care Project, please complete and fax or mail this form to: Center for the Advancement of Health 2000 Florida Avenue, NW, Suite 210 Washington, DC 20009 Fax: 202 387-2857 E-mail requests are also accepted at cfah@cfahorg
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– The full report on the Health Behavior Change in Managed Care Project Executive Summary — A brief summary of the findings of the project HMO Medical Directors Report — Results from a survey of 50 medical directors from HMOs licensed in six geographic locations Colorado, the District of Columbia, Florida, Massachusetts, Oregon, and Wisconsin Purchasers Report — Findings from 55 interviews with purchasers of health care including government purchasers; unions; purchasing and lobbying organizations; and small, mid-sized, and large businesses State Fax Number: Zip Degrees:
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Evidence Tables on the following topics: u Alcohol and other drugs u Diabetes u Asthma u Dietary practices u Cardiovascular disease u Physical inactivity u Chronic back pain u Smoking cessation u Depression
These topic-specific tables provide a detailed description of several hundred scientific papers randomized controlled trials, meta-analyses, systematic reviews, and quasi-experimental designs and are organized by themes in the behavior change literature relevant to chronic disease prevention and management in managed care eg, multiple risk factors, brief interventions, intensive interventions, and
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