Three studies of diabetes disease management programs indicate that intensive behavioral and educational interventions may improve patient outcomes. The 3 studies analyzed different intervention programs in different patient populations, and the results were published online October 10 in the Archives of Internal Medicine as part of the journal's Health Care Reform series.
One research group, led by Katie Weiniger, EdD, from the Joslin Diabetes Center in Boston, Massachusetts, found that a structured, cognitive behavioral program was more effective than 2 control interventions in improving glycemia in adults with long-duration diabetes. The trial randomly assigned 222 adults with diabetes (49% with type 1) to 1 of 3 treatment groups: structured behavioral treatment (included a 5-session manual-based, educator-led structural intervention with cognitive behavioral strategies), group attention control (educator-led attention control group education program), and individual control (unlimited individual nurse and dietician education sessions for 6 months). All groups showed improved HbA1c levels (P < .001). The structured behavioral group, however, showed greater improvement than the group attention and individual control groups (P = .04 for group). This study thus supported educating patients with modified psychological and behavioral strategies.
JoAnn Sperl-Hillen, MD, from HealthPartners Research Foundation and HealthPartners Medical Group in Minneapolis, Minnesota, and colleagues found that individual education resulted in better glucose control outcomes than did group education in patients with established suboptimally controlled diabetes. The study evaluated a total of 623 adults from Minnesota and New Mexico with type 2 diabetes and HbA1c concentrations of 7% or higher. Although mean HbA1c concentrations decreased across all treatment groups, levels decreased significantly more in the individual education group (−0.51%) when compared with the group education using the US Diabetes Conversationl Map Program (−0.27%, P = .01) and the usual care (−0.24%, P =.01) groups. Participants in the individual education group were more likely to have HbA1c levels at or below 7% (21.2%) than participants in either the group education (13.9%) or usual care (12.8%) treatment groups (P = .03 for both comparisons) at follow up 6.8 months after enrollment. Patients receiving individual education also tended toward better psychosocial and behavioral outcomes.
Dominick L. Frosch, PhD, from the Palo Alto Medical Foundation Research Institute in California, was part of the team that conducted the third study. This last study enrolled socially and economically disadvantaged patients and found that their intervention package of video, workbook, and telephone coaching resulted in no significant effect compared with the control condition.
The study included 201 patients (72% black or Latino; 74% with annual incomes ≤$15,000) with poorly controlled type 2 diabetes. Participants were randomly assigned to receive either an intervention package consisting of a 24-minute video behavior support intervention with a workbook and 5 sessions of telephone coaching by a trained diabetes nurse (treatment group), or a 20-page brochure developed by the National Diabetes Education Program (control group). The authors found that most participants in both the treatment group (94.3%) and control group (93.5%) had received the assigned treatment materials, and the majority (88.5% in the treatment group and 89.8% in the control group) rated the clarity of the information presented as good, very good, or excellent at the 1-month follow-up. Although mean (± standard deviation) HbA1c in both groups decreased from 9.6% ± 2.0% to 9.1% ± 1.9% (P < .001), there was not a significant difference in HbA1c between groups.
Dr. Frosch and colleagues noted that "[m]ore intensive and therefore more expensive interventions may be a worthwhile investment to lower the high costs associated with poorly managed diabetes in the long term; however, larger structural interventions also may be necessary to overcome the many challenges faced by these severely disadvantaged patients."
Two accompanying invited commentaries noted that much work still needs to be done to establish coaching standards and best practices. Ruth Q Wolever, PhD, and David M. Eisenberg, MD, from Duke University Medical Center in Durham, North Carolina, explained in one commentary that coaching assumes that humans desire to realize positive change and will do so when treated with respect while being challenged and supported to shift their worldview. Health coaches use this foundation to select goals and relate the goals to the individual's core values. Research has shown that health coaching can increase physical activity and aid in dietary changes when behavioral change interventions are provided through the telephone.
Unfortunately, although studies have been able to quantify the effect of dose and content on behavioral modification, the training, experience, and competency of the intervention provider remain difficult to quantify. As a consequence, there is currently no consensus on the training, credentialing, and/or licensure standards for a health coach. This lack of a minimal level of competency makes it difficult to perform clear research on health coaching. Health coaching therefore lacks a rigorous evidence base and trials evaluating coaching approaches are vulnerable to misinterpretation.
In another commentary, by Ralph Gonzales, MD, MSPH, from the Division of General Internal Medicine, Department of Medicine, and Department of Epidemiology and Biostatistics, University of California, San Francisco, and Margaret A. Handley, PhD, MPH, also from the Division of General Internal Medicine, Department of Medicine, and Department of Epidemiology and Biostatistics and the Center for Vulnerable Populations, San Francisco General Hospital, the authors note that "[a] major consideration in generalizing the results of these trials is to acknowledge that these educational programs are being applied to patients who are generally failing to achieve glycemic control targets."
"[T]the results of these trials should not be used to support or reject any of these approaches for patients with newly diagnosed diabetes," they continue.
Both Archives of Internal Medicine commentaries explain that future research should focus on determining the "essential ingredients" of the interventions with regards to health coach counseling/training, intensity of support provided, and level of individual tailoring.