Effectiveness of interventions for reducing diabetes and cardiovascular disease risk in people with metabolic syndrome: systematic review and mixed treatment comparison meta-analysis.

AIMS: To review the evidence on interventions for reversing metabolic syndrome or preventing development of type 2 diabetes and cardiovascular disease in people with metabolic syndrome. METHODS: A systematic review and Bayesian mixed treatment comparison meta-analysis was conducted. Relevant electronic bibliographic databases were searched up to January 2010. Included studies were randomized controlled trials with a follow-up of ≥24 weeks and outcomes comparing incidence of diabetes and/or cardiovascular disease, or reversal of metabolic syndrome. RESULTS: A total of 16 studies met the inclusion criteria. Thirteen studies with outcome data for reversal of metabolic syndrome, involving 3907 participants, were included in the meta-analysis. Insufficient trials reported cardiovascular events/mortality, or incidence of type 2 diabetes, to conduct a meta-analysis for these outcomes. Interventions, alone or in combination, included lifestyle (diet and/or exercise) and pharmacological therapy. Using random-effect models, both lifestyle (odds ratio, OR 3.81; 95% confidence interval, CI 2.47-5.88) and pharmacological interventions (OR 1.59; 95% CI 1.04-2.45) were statistically superior compared with control for reversing metabolic syndrome. Using mixed treatment comparison methods, the probability that lifestyle interventions were the most clinically effective was 87%. CONCLUSIONS: Evidence suggests that both lifestyle and pharmacological interventions can reverse metabolic syndrome. However, there is a lack of data on whether these benefits are sustained and translate into longer term prevention of diabetes and/or cardiovascular disease.

Potentially avoidable emergency department attendance: interview study of patients' reasons for attendance.

OBJECTIVES: To explore the reasons for attendance at the emergency department (ED) by patients who could have been managed in an alternative service and the rate of acute admissions to one acute hospital. DESIGN: Interview study. SETTING: One acute hospital (University Hospitals of Leicester) in the East Midlands. PARTICIPANTS: 23 patients and/or their carers. METHODS: A purposive sample of patients attending the ED and the linked urgent care centre was identified and recruited. Patients in the sample were approached by a clinician and a researcher and invited to take part in an interview. Patients of different ethnicities and from different age groups, arriving at the ED via different referral routes (self-referral, emergency ambulance, GP referral, out-of-hours services) and attending at different times of the day and night were included. The interviews were recorded and transcribed with the individuals' permission and analysed using the framework analysis approach. RESULTS: Patients' anxiety or concern about the presenting problem, the range of services available to the ED and the perceived efficacy of these services, patients' perceptions of access to alternative services including general practice and lack of alternative pathways were factors that influenced the decision to use the ED. CONCLUSIONS: Access to general practice, anxiety about the presenting problem, awareness and perceptions of the efficacy of the services available in the ED and lack of alternative pathways are important predictors of attendance rates.

Patient safety systems in the primary health care of diabetes­a story of missed opportunities?

AIMS: Key elements of a patient safety system include mechanisms for identifying errors or safety events, methods for investigating the events and processes for acting on the findings of the investigations. A patient safety system for management of diabetes in primary care might help to reduce adverse outcomes. The aims of this study were to review the current state of research into patient safety systems for people with diabetes in primary care. METHODS: MEDLINE, EMBASE and nine other biomedical and health management databases were searched for articles published up to April 2009. Selection and review of abstracts were carried out independently by two authors. RESULTS: Abstracts of 1659 articles were identified, of which only three fulfilled the selection criteria, and these did not appear in mainstream primary care journals. These papers covered the applications of root cause analysis, videoconferencing and automated telephone support to patient safety systems for managing diabetes in primary care. CONCLUSIONS: There is very little evidence on how patient safety systems for the management of primary care diabetes can be implemented, or on how the effectiveness of such systems can be maximized. If patient safety systems do have potential to improve the processes and outcomes of care, the lack of relevant research may be regarded as a missed opportunity­investigation into the reasons for the situation is needed, with the aim of motivating and enabling further research on a range of problems identified here.

Incorrect and incomplete coding and classification of diabetes: a systematic review.

AIMS: To conduct a systematic review to identify types and implications of incorrect or incomplete coding or classification within diabetes or between diabetes and other conditions; also to determine the availability of evidence regarding frequency of occurrence. METHODS: Medical Subject Headings (MeSH) and free-text terms were used to search relevant electronic databases for papers published to the end of August 2008. Two researchers independently reviewed titles and abstracts and, subsequently, the full text of potential papers. Reference lists of selected papers were also reviewed and authors consulted. Three reviewers independently extracted data. RESULTS: Seventeen eligible studies were identified, including five concerned with distinguishing between Type 1 and Type 2 diabetes. Evidence was also identified regarding: the distinction between diabetes and no-diabetes, failure to specify type of diabetes, and diagnostic errors or difficulties involving maturity-onset diabetes of the young, latent autoimmune diabetes in adults, pancreatic diabetes, persistence of foetal haemoglobin and acquired immune deficiency syndrome (AIDS). The sample was too heterogeneous to derive accurate information about frequency, but our findings suggested that misclassification occurs most commonly in young people. Implications relating to treatment options and risk management were highlighted, in addition to psychological and financial implications and the potential impact on the validity of quality of care evaluations and research. CONCLUSIONS: This review draws attention to the occurrence and implications of incorrect or incomplete coding or classification of diabetes, particularly in young people. A pragmatic and clinically relevant approach to classification is needed to assist those involved in making decisions about types of diabetes.

Educational interventions for migrant South Asians with Type 2 diabetes: a systematic review.

AIMS: To conduct a systematic review to determine the scope of published assessments of educational initiatives for South Asians with Type 2 diabetes living in Western countries and to consider the effectiveness of reported interventions. METHODS: A range of electronic databases was searched using Medical Subject Headings (MeSH) and free text terms; papers published up to the end of 2007 were considered. Two researchers independently reviewed titles and abstracts and the full text of selected citations. Reference list review and consultation with experts in the field were used to check for completeness of the final sample of studies prior to data extraction. RESULTS: Only nine studies, including five randomized controlled trials with a combined total of 1004 cases, met our inclusion criteria. The quality of reporting in some studies was limited, e.g. omission of detailed information about ethnicity. Selected studies included a range of group and one-to-one interventions with varied knowledge, psychological and biomedical outcome measures. The effectiveness of the interventions was also variable, and the low number and heterogeneity of the studies made identification of factors linked to effectiveness difficult and meta-analysis inappropriate. However, it appeared that improvements in knowledge levels may be easier to achieve than positive biomedical outcomes, and the need for tailored approaches was suggested. CONCLUSIONS: Our findings confirm the difficulty of designing, assessing and achieving an impact through educational interventions for migrant South Asians with Type 2 diabetes and emphasize the need for good-quality studies in these high-risk populations.

Self-management education for adults with epilepsy.

BACKGROUND: Self-management education has been shown to improve the quality of life of people with chronic illnesses. It has been suggested that self-management education may improve seizure control and other outcomes in people with epilepsy. OBJECTIVES: To review systematically the research literature on the effectiveness of self-management education in improving health outcomes for adults with epilepsy. SEARCH STRATEGY: We searched MEDLINE (Ovid) (1966 to April 2005), EMBASE (Ovid) (1980 to April 2005), CINAHL (Dialog) (1980 to April 2005), PsycINFO (Dialog) (1887 to April 2005), and the Cochrane Epilepsy Group's Specialised Register (April 2005). We also handsearched Epilepsia and conference abstracts and proceedings. Experts in the field were contacted to identify any additional trials. We did not impose any language restriction. We re-ran the searches in February 2007 and added the identified references to the 'Studies awaiting assessment' table. SELECTION CRITERIA: Randomised trials of self-management education programmes for adults with epilepsy. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the quality of each study and extracted data. MAIN RESULTS: Two trials evaluated the effect of self-management education for adults with epilepsy, neither of which assessed as being of high quality. In total, 483 adults with epilepsy were randomised. Both trials showed improvements in seizure frequency and other outcomes, such as knowledge. However, we were not able to estimate a summary effect for seizure frequency due to a lack of data. AUTHORS' CONCLUSIONS: Self-management education programmes, based on increasing understanding through psychosocial methods, may improve knowledge about epilepsy, certain behavioural outcomes, and reduce seizure frequency. It is, however, not clear how effective self-management programmes of epilepsy would be in a more general population of adults with epilepsy, as both trials had higher proportions of people with partial seizures than would be expected in a community sample.

Self-management education for children with epilepsy.

BACKGROUND: Self-management education has been shown to improve the quality of life of children and young people with chronic illnesses. It has been suggested that self-management education may improve seizure control and other outcomes in children and young people with epilepsy. OBJECTIVES: To review systematically the research literature on the effectiveness of self-management education in improving health outcomes for children and young people with epilepsy. SEARCH STRATEGY: We searched the Cochrane Epilepsy Group's Specialised Register (April 2007), MEDLINE (Ovid) (1966 to February 2007), EMBASE (Ovid) (1980 to February 2007), CINAHL (Dialog) (1980 to February 2007), and PsycINFO (Dialog) (1887 to February 2007). We also handsearched Epilepsia and conference abstracts and proceedings. Experts in the field were contacted to identify any additional trials. No language restriction was imposed. SELECTION CRITERIA: Randomised trials of self-management education programmes for children or young people with epilepsy. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the quality of each study and extracted data. MAIN RESULTS: Only one trial involving 167 children was identified that evaluated the effect of a child-centred model of training for the self-management of two chronic illnesses, asthma and epilepsy. The trial was not assessed as being of high quality and the methods used to analyse and report the data did not enable us to precisely determine the effect of the intervention. However, improvements were seen in seizure frequency and other outcomes, such as knowledge and behaviour. AUTHORS' CONCLUSIONS: Self-management education programmes that deliver a child-centred model of training, may improve knowledge about epilepsy, certain behavioural outcomes, and reduce seizure frequency in children and young people with epilepsy. However, based on the evidence reviewed, we are not able to determine how effective it is, or what the key components of the programme should be.

Characteristics of general practices associated with emergency-department attendance rates: a cross-sectional study.

BACKGROUND: Strategies are needed to contain emergency-department attendance. Quality of care in general practice might influence the use of emergency departments, including management of patients with chronic conditions and access to consultations. AIM: The aim was to determine whether emergency-department attendance rates are lower for practices with higher quality and outcomes framework performance and lower for practices with better patient reported access. DESIGN: A cross-sectional study. SETTING: Two English primary-care trusts, Leicester City and Leicestershire County and Rutland, with 145 general practices. METHOD: Using data on attendances at emergency departments in 2006/2007 and 2007/2008, a practice attendance rate was calculated for each practice. In a hierarchical negative binomial regression model, practice population characteristics (deprivation, proportion of patients aged 65 or over, ethnicity, gender) and practice characteristics (total list size, distance from the emergency department, quality and outcomes framework points, and variables measuring satisfaction with access) were included as potential explanatory variables. RESULTS: In both years, greater deprivation, shorter distance from the central emergency department, lower practice list size, white ethnicity and lower satisfaction with practice telephone access were associated with higher emergency-department attendance rates. CONCLUSIONS: Performance as indicated by the quality and outcomes framework did not predict rates of attendance at emergency departments, but satisfaction with telephone access did. Consideration should be given to improving access to some general practices to contain the use of emergency departments.