The clinical and cost-effectiveness of patient education models for diabetes : a systematic review and economic evaluation

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

Classification of Polarimetric SAR Data Using Dictionary Learning

End-user development (EUD) research has yielded a variety of novel environments and techniques, often accompanied by lab-based usability studies that test their effectiveness in the completion of representative real-world tasks. While lab studies play an important role in resolving frustrations and demonstrating the potential of novel tools, they are insufficient to accurately determine the acceptance of a technology in its intended context of use, which is highly dependent on the diverse and dynamic requirements of its users, as we show here. As such, usability in the lab is unlikely to represent usability in the field. To demonstrate this, we first describe the results of a think-aloud usability study of our EUD tool “Jeeves”, followed by two case studies where Jeeves was used by psychologists in their work practices. Common issues in the artificial setting were seldom encountered in the real context of use, which instead unearthed new usability issues through unanticipated user needs. We conclude with considerations for usability evaluation of EUD tools that enable development of software for other users, including planning for collaborative activities, supporting developers to evaluate their own tools, and incorporating longitudinal methods of evaluation.Postprin

Distributed situation awareness in dynamic systems: Theoretical development and application of an ergonomics methodology

The purpose of this paper is to propose foundations for a theory of situation awareness based on the analysis of interactions between agents (i.e., both human and non-human) in subsystems. This approach may help promote a better understanding of technology-mediated interaction in systems, as well as helping in the formulation of hypotheses and predictions concerning distributed situation awareness. It is proposed that agents within a system each hold their own situation awareness which may be very different from (although compatible with) other agents. It is argued that we should not always hope for, or indeed want, sharing of this awareness, as different system agents have different purposes. This view marks situation awareness as a 1 dynamic and collaborative process that binds agents together on tasks on a moment-by-moment basis. Implications of this viewpoint for development of a new theory of, and accompanying methodology for, distributed situation awareness are offered

Periconception onset diabetes is associated with embryopathy and fetal growth retardation, reproductive tract hyperglycosylation and impaired immune adaptation to pregnancy

Diabetes has been linked with impaired fertility but the underlying mechanisms are not well defined. Here we use a streptozotocin-induced diabetes mouse model to investigate the cellular and biochemical changes in conceptus and maternal tissues that accompany hyperglycaemia. We report that streptozotocin treatment before conception induces profound intra-cellular protein β-O-glycosylation (O-GlcNAc) in the oviduct and uterine epithelium, prominent in early pregnancy. Diabetic mice have impaired blastocyst development and reduced embryo implantation rates, and delayed mid-gestation growth and development. Peri-conception changes are accompanied by increased expression of pro-inflammatory cytokine Trail, and a trend towards increased Il1a, Tnf and Ifng in the uterus, and changes in local T-cell dynamics that skew the adaptive immune response to pregnancy, resulting in 60% fewer anti-inflammatory regulatory T-cells within the uterus-draining lymph nodes. Activation of the heat shock chaperones, a mechanism for stress deflection, was evident in the reproductive tract. Additionally, we show that the embryo exhibits elevated hyper-O-GlcNAcylation of both cytoplasmic and nuclear proteins, associated with activation of DNA damage (ɣH2AX) pathways. These results advance understanding of the impact of peri-conception diabetes, and provide a foundation for designing interventions to support healthy conception without propagation of disease legacy to offspring.Hannah M. Brown, Ella S. Green, Tiffany C.Y. Tan, Macarena B. Gonzalez, Alice R. Rumbold, M. Louise Hull, Robert J. Norman, Nicolle H. Packer, Sarah A. Robertson, Jeremy G. Thompso

Exploring the affordances of smart toys and connected play in practice

What does children’s play look like in the smart toy era? What conceptual frameworks help make sense of the changing practices of children’s connected play worlds? Responding to these questions, this article re-frames discussions about children’s smart toy play within wider theoretical debates about the affordances of new digital materialities. To understand recent transformations of children’s play practices, we propose it is necessary to think of toys as increasingly media-like in their affordances and as connected to wider digital material ecosystems. To demonstrate the potential of this conceptual approach, we explore illustrative examples of two popular smart ‘care toys’. Our analysis identifies three examples of affordances that smart care toys share with other forms of mobile and robotic media: liveliness, affective stickiness and portability. We argue that locating discussions of smart toys within wider conceptual debates about digital materialities can provide new insights into the changing landscape of children’s play

HST STIS Observations of PG 0946+301: the Highest Quality UV Spectrum of a BALQSO

We describe deep (40 orbits) HST/STIS observations of the BALQSO PG 0946+301 and make them available to the community. These observations are the major part of a multi-wavelength campaign on this object aimed at determining the ionization equilibrium and abundances (IEA) in broad absorption line (BAL) QSOs. We present simple template fits to the entire data set, which yield firm identifications for more than two dozen BALs from 18 ions and give lower limits for the ionic column densities. We find that the outflow's metalicity is consistent with being solar, while the abundance ratio of phosphorus to other metals is at least ten times solar. These findings are based on diagnostics that are not sensitive to saturation and partial covering effects in the BALs, which considerably weakened previous claims for enhanced metalicity. Ample evidence for these effects is seen in the spectrum. We also discuss several options for extracting tighter IEA constraints in future analyses, and present the significant temporal changes which are detected between these spectra and those taken by the HST/FOS in 1992.Comment: 32 pages, 7 figures, to appear in ApJ. See also companion paper by Arav, Korista and De Koo

Systems, interactions and macrotheory

A significant proportion of early HCI research was guided by one very clear vision: that the existing theory base in psychology and cognitive science could be developed to yield engineering tools for use in the interdisciplinary context of HCI design. While interface technologies and heuristic methods for behavioral evaluation have rapidly advanced in both capability and breadth of application, progress toward deeper theory has been modest, and some now believe it to be unnecessary. A case is presented for developing new forms of theory, based around generic “systems of interactors.” An overlapping, layered structure of macro- and microtheories could then serve an explanatory role, and could also bind together contributions from the different disciplines. Novel routes to formalizing and applying such theories provide a host of interesting and tractable problems for future basic research in HCI