Effectiveness and safety of patient activation interventions for adults with type 2 diabetes: systematic review, meta-analysis, and meta-regression.

Abstract

Patient activation interventions (PAIs) engage patients in care by promoting increased knowledge, confidence, and/or skills for disease self-management. However, little is known about the impact of these interventions on a wide range of outcomes for adults with type 2 diabetes (DM2), or which of these interventions, if any, have the greatest impact on glycemic control. Electronic databases were searched from inception through November 2011. Of 16,290 citations, two independent reviewers identified 138 randomized trials comparing PAIs to usual care/control groups in adults with DM2 that reported intermediate or long-term outcomes or harms. For meta-analyses of continuous outcomes, we used a random-effects model to derive pooled weighted mean differences (WMD). For all-cause mortality, we calculated the pooled odds ratio (OR) using Peto's method. We assessed statistical heterogeneity using the I (2) statistic and conducted meta-regression using a random-effects model when I (2) > 50%. A priori meta-regression primary variables included: intervention strategies, intervention leader, baseline outcome value, quality, and study duration. PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37%, CI 0.28-0.45%, I (2) 83%; SBP: WMD 2.2mmHg, CI 1.0-3.5mmHg, I (2) 72%; body weight: WMD 2.3lbs, CI 1.3-3.2lbs, I (2) 64%; and LDL-c: WMD 4.2mg/dL, CI 1.5-6.9mg/dL, I (2) 64%]. The evidence was moderate for A1c, low/very low for other intermediate outcomes, low for long-term mortality and very low for complications. Interventions had no effect on hypoglycemia (evidence: low) or short-term mortality (evidence: moderate). Higher baseline A1c, pharmacist-led interventions, and longer follow-up were associated with larger A1c improvements. No intervention strategy outperformed any other in adjusted meta-regression. PAIs modestly improve A1c in adults with DM2 without increasing short-term mortality. These results support integration of these interventions into primary care for adults with uncontrolled glycemia, and provide evidence to insurers who do not yet cover these programs.