title: Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus.
abstract: BACKGROUND
  Diabetes is one of the commonest chronic medical conditions, affecting around 347 million adults worldwide. Structured patient education programmes reduce the risk of diabetes-related complications four-fold. Internet-based self-management programmes have been shown to be effective for a number of long-term conditions, but it is unclear what are the essential or effective components of such programmes. If computer-based self-management interventions improve outcomes in type 2 diabetes, they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition.
  
  
  OBJECTIVE
  To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus.
  
  
  METHODS
  We searched six electronic bibliographic databases for published articles and conference proceedings and three online databases for theses (all up to November 2011). Reference lists of relevant reports and reviews were also screened.
  
  
  METHODS
  Randomised controlled trials of computer-based self-management interventions for adults with type 2 diabetes, i.e. computer-based software applications that respond to user input and aim to generate tailored content to improve one or more self-management domains through feedback, tailored advice, reinforcement and rewards, patient decision support, goal setting or reminders.
  
  
  METHODS
  Two review authors independently screened the abstracts and extracted data. A taxonomy for behaviour change techniques was used to describe the active ingredients of the intervention.
  
  
  RESULTS
  We identified 16 randomised controlled trials with 3578 participants that fitted our inclusion criteria. These studies included a wide spectrum of interventions covering clinic-based brief interventions, Internet-based interventions that could be used from home and mobile phone-based interventions. The mean age of participants was between 46 to 67 years old and mean time since diagnosis was 6 to 13 years. The duration of the interventions varied between 1 to 12 months. There were three reported deaths out of 3578 participants.Computer-based diabetes self-management interventions currently have limited effectiveness. They appear to have small benefits on glycaemic control (pooled effect on glycosylated haemoglobin A1c (HbA1c): -2.3 mmol/mol or -0.2% (95% confidence interval (CI) -0.4 to -0.1; P = 0.009; 2637 participants; 11 trials). The effect size on HbA1c was larger in the mobile phone subgroup (subgroup analysis: mean difference in HbA1c -5.5 mmol/mol or -0.5% (95% CI -0.7 to -0.3); P < 0.00001; 280 participants; three trials). Current interventions do not show adequate evidence for improving depression, health-related quality of life or weight. Four (out of 10) interventions showed beneficial effects on lipid profile.One participant withdrew because of anxiety but there were no other documented adverse effects. Two studies provided limited cost-effectiveness data - with one study suggesting costs per patient of less than $140 (in 1997) or 105 EURO and another study showed no change in health behaviour and resource utilisation.
  
  
  CONCLUSIONS
  Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup. There is no evidence to show benefits in other biological outcomes or any cognitive, behavioural or emotional outcomes.
authors.affiliation: Research Department of Primary Care and Population Health, University College London, London, UK. k.pal@ucl.ac.uk
authors.forename: Kingshuk
authors.initials: K
authors.lastname: Pal
authors.forename: Sophie V
authors.initials: SV
authors.lastname: Eastwood
authors.forename: Susan
authors.initials: S
authors.lastname: Michie
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Farmer
authors.forename: Maria L
authors.initials: ML
authors.lastname: Barnard
authors.forename: Richard
authors.initials: R
authors.lastname: Peacock
authors.forename: Bindie
authors.initials: B
authors.lastname: Wood
authors.forename: Joni D
authors.initials: JD
authors.lastname: Inniss
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Murray
mesh_terms: D000328:Adult; D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000628:therapy*; D006442:Glycated Hemoglobin / Q000378:metabolism; D006304:Health Status; D006801:Humans; D020407:Internet; D008875:Middle Aged; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D012648:Self Care / Q000379:methods*; D013813:Therapy, Computer-Assisted / Q000379:methods*
chemical_list: D006442:Glycated Hemoglobin
references.citation: Diabetes Care. 2007 May;30(5):1266-8
references.pmid: 17325261
references.citation: Diabetes Res Clin Pract. 2008 Feb;79(2):256-61
references.pmid: 17988756
references.citation: ANS Adv Nurs Sci. 2009 Jul-Sep;32(3):E42-57
references.pmid: 19707086
references.citation: Diabetes Technol Ther. 2009 Mar;11(3):181-6
references.pmid: 19216685
references.citation: N Engl J Med. 1993 Sep 30;329(14):977-86
references.pmid: 8366922
references.citation: Diabetes Care. 2011 Sep;34(9):1934-42
references.pmid: 21788632
references.citation: Diabetes Technol Ther. 2010 Aug;12(8):663-9
references.pmid: 20615108
references.citation: AMIA Annu Symp Proc. 2006;:1080
references.pmid: 17238699
references.citation: Health Educ Res. 1995 Dec;10(4):467-78
references.pmid: 10159676
references.citation: Stat Med. 2002 Jun 15;21(11):1539-58
references.pmid: 12111919
references.citation: Diabetes Care. 2010 Apr;33(4):745-7
references.pmid: 20103547
references.citation: Lancet. 2011 Jul 2;378(9785):31-40
references.pmid: 21705069
references.citation: Diabetes Technol Ther. 2005 Oct;7(5):710-8; discussion 719-20
references.pmid: 16241873
references.citation: Patient Educ Couns. 2002 Oct -Nov;48(2):115-22
references.pmid: 12401414
references.citation: J Telemed Telecare. 2006;12 Suppl 1:13-5
references.pmid: 16884565
references.citation: Diabetes Technol Ther. 2007 Jun;9(3):254-64
references.pmid: 17561796
references.citation: Milbank Mem Fund Q. 1966 Jul;44(3):Suppl:94-127
references.pmid: 5967464
references.citation: Diabetes Technol Ther. 2010 Mar;12(3):213-20
references.pmid: 20151772
references.citation: Int J Med Inform. 1998 Aug-Sep;51(2-3):117-25
references.pmid: 9794328
references.citation: Diabetes Technol Ther. 2010 May;12(5):333-7
references.pmid: 20388042
references.citation: PLoS Med. 2009 Jul 21;6(7):e1000100
references.pmid: 19621070
references.citation: Telemed J E Health. 2011 May;17(4):254-61
references.pmid: 21476945
references.citation: Health Educ Res. 2005 Jun;20(3):275-90
references.pmid: 15632099
references.citation: Diabetes Care. 2009 Apr;32(4):559-66
references.pmid: 19131469
references.citation: CMAJ. 2009 Jul 7;181(1-2):37-44
references.pmid: 19581618
references.citation: Int J Med Inform. 2007 Sep;76(9):655-63
references.pmid: 16815741
references.citation: J Eval Clin Pract. 2008 Jun;14(3):465-9
references.pmid: 18373577
references.citation: BMC Public Health. 2007 Jun 11;7:104
references.pmid: 17561997
references.citation: Radiographics. 2004 Sep-Oct;24(5):1483-9
references.pmid: 15371622
references.citation: J Gen Intern Med. 2006 Feb;21(2):105-10
references.pmid: 16390512
references.citation: J Nurs Care Qual. 2005 Oct-Dec;20(4):335-40
references.pmid: 16177585
references.citation: J Am Med Inform Assoc. 2006 Jan-Feb;13(1):40-51
references.pmid: 16221935
references.citation: J Telemed Telecare. 2009;15(2):77-82
references.pmid: 19246607
references.citation: Patient Educ Couns. 1997 Nov;32(3):175-84
references.pmid: 9423499
references.citation: Med Care. 2006 Nov;44(11):964-71
references.pmid: 17063127
references.citation: Prev Med. 2003 Apr;36(4):410-9
references.pmid: 12649049
references.citation: Diabetes Educ. 2000 Jul-Aug;26(4):645-55
references.pmid: 11140073
references.citation: Contemp Clin Trials. 2009 Jul;30(4):334-46
references.pmid: 19250979
references.citation: Diabetes Educ. 1999 Nov-Dec;25(6 Suppl):52-61
references.pmid: 10711085
references.citation: J Med Internet Res. 2006 Jun 23;8(2):e10
references.pmid: 16867965
references.citation: J Psychol. 1975 Sep;91(1):93-114
references.pmid: 28136248
references.citation: Diabetes Care. 2009 Jan;32 Suppl 1:S87-94
references.pmid: 19118294
references.citation: Zhejiang Da Xue Xue Bao Yi Xue Ban. 2003 Jun;32(3):244-8
references.pmid: 12881874
references.citation: Am J Manag Care. 2009 Jul;15(7):425-31
references.pmid: 19589010
references.citation: Int J Nurs Stud. 2007 Jul;44(5):687-92
references.pmid: 16618486
references.citation: Lancet. 1998 Sep 12;352(9131):837-53
references.pmid: 9742976
references.citation: Ann Behav Med. 2003 Aug;26(1):1-7
references.pmid: 12867348
references.citation: Diabet Med. 2009 Jun;26(6):628-35
references.pmid: 19538239
references.citation: Diabetes Res Clin Pract. 2008 Oct;82(1):73-9
references.pmid: 18701183
references.citation: Diabetes Care. 1992 Feb;15(2):204-12
references.pmid: 1547677
references.citation: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003417
references.pmid: 15846663
references.citation: Implement Sci. 2009 Jul 16;4:40
references.pmid: 19607700
references.citation: Psychol Health. 2011 Nov;26(11):1479-98
references.pmid: 21678185
references.citation: Diabetes Care. 2005 Jul;28(7):1624-9
references.pmid: 15983311
references.citation: Comput Inform Nurs. 2011 Feb;29(2):101-6
references.pmid: 21099675
references.citation: Diabetes Care. 1986 Sep-Oct;9(5):504-8
references.pmid: 3533475
references.citation: Trans Am Clin Climatol Assoc. 2007;118:289-304
references.pmid: 18528511
references.citation: Patient Educ Couns. 2011 Jul;84(1):49-55
references.pmid: 20619577
references.citation: Diabetes Care. 2011 Feb;34(2):308-13
references.pmid: 21270188
references.citation: Diabetes Care. 2001 Feb;24(2):202-8
references.pmid: 11213866
references.citation: Ann Behav Med. 2006 Apr;31(2):128-37
references.pmid: 16542127
references.citation: Diabetes Res. 1992 Mar;19(3):97-105
references.pmid: 1344707
references.citation: Diabetes Educ. 2000 Nov-Dec;26(6):929-36
references.pmid: 11912805
references.citation: N Engl J Med. 2003 Jan 30;348(5):383-93
references.pmid: 12556541
references.citation: Health Technol Assess. 2011 Oct;15(37):1-160
references.pmid: 22030014
references.citation: J Epidemiol Community Health. 2007 Mar;61(3):254-61
references.pmid: 17325405
references.citation: Diabetes Care. 1991 Feb;14(2):130-4
references.pmid: 2060415
references.citation: Aust J Adv Nurs. 1996 Winter;13(4):19-27
references.pmid: 8900703
references.citation: Comput Inform Nurs. 2006 Nov-Dec;24(6):337-45
references.pmid: 17108753
references.citation: BMC Public Health. 2010 Apr 23;10:204
references.pmid: 20416042
references.citation: Diabet Med. 2011 Apr;28(4):455-63
references.pmid: 21392066
references.citation: J Gen Intern Med. 2008 Apr;23(4):459-65
references.pmid: 18373145
references.citation: Stud Health Technol Inform. 2006;122:172-5
references.pmid: 17102242
references.citation: Diabetes Technol Ther. 2004 Dec;6(6):828-35
references.pmid: 15684636
references.citation: Diabetes Educ. 2010 May-Jun;36(3):446-56
references.pmid: 20375351
references.citation: Telemed J E Health. 2004 Summer;10(2):170-83
references.pmid: 15319047
references.citation: Ann Behav Med. 2010 Aug;40(1):40-8
references.pmid: 20411443
references.citation: Nurs Health Sci. 2009 Sep;11(3):277-84
references.pmid: 19689636
references.citation: Diabetes Care. 2008 Jan;31 Suppl 1:S12-54
references.pmid: 18165335
references.citation: Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005268
references.pmid: 19160249
references.citation: Diabetes Technol Ther. 2007 Feb;9(1):52-9
references.pmid: 17316098
references.citation: J Clin Psychol. 2004 Feb;60(2):209-20
references.pmid: 14724928
references.citation: Arch Intern Med. 2008 Jan 28;168(2):141-6
references.pmid: 18227359
references.citation: J Telemed Telecare. 2001;7(1):47-50
references.pmid: 11265938
references.citation: Diabetes Technol Ther. 2008 Jun;10(3):160-8
references.pmid: 18473689
references.citation: Yonsei Med J. 2003 Feb;44(1):1-8
references.pmid: 12619168
references.citation: Diabetes Care. 2011 Feb;34(2):320-5
references.pmid: 21216855
references.citation: Diabetes Technol Ther. 2010 Jul;12(7):575-9
references.pmid: 20597833
references.citation: Med Inform (Lond). 1996 Oct-Dec;21(4):297-316
references.pmid: 9179834
references.citation: Perspect Health Inf Manag. 2011 Jan 01;8:1b
references.pmid: 21307985
references.citation: Soc Sci Med. 2003 Feb;56(4):671-84
references.pmid: 12560003
references.citation: J Clin Nurs. 2007 Jun;16(6):1082-7
references.pmid: 17518883
references.citation: Patient Educ Couns. 2010 Jul;80(1):29-41
references.pmid: 19906503
references.citation: Popul Health Manag. 2009 Aug;12(4):197-204
references.pmid: 19663622
references.citation: Diabetes Care. 2009 Feb;32(2):234-9
references.pmid: 19017773
references.citation: Diabet Med. 2006 Sep;23(9):944-54
references.pmid: 16922700
references.citation: Diabetes Care. 2003 Jan;26 Suppl 1:S5-20
references.pmid: 12502614
references.citation: J Am Med Inform Assoc. 2010 Mar-Apr;17(2):196-202
references.pmid: 20190064
references.citation: Proc Annu Symp Comput Appl Med Care. 1991;:53-7
references.pmid: 1807657
references.citation: Diabetes Care. 2011 Aug;34(8):1794-8
references.pmid: 21680723
references.citation: Diabetes Care. 2010 Jun;33(6):1275-81
references.pmid: 20299481
references.citation: Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004274
references.pmid: 16235356
references.citation: Telemed J E Health. 2011 Apr;17(3):153-63
references.pmid: 21375410
references.citation: AIDS Behav. 2008 May;12(3):335-53
references.pmid: 17896176
references.citation: Diabetes Care. 2005 Jan;28(1):33-9
references.pmid: 15616230
references.citation: Ann Fam Med. 2008 Nov-Dec;6(6):512-8
references.pmid: 19001303
references.citation: J Telemed Telecare. 2008;14(1):32-6
references.pmid: 18318927
references.citation: Clin Trials. 2004;1(6):532-44
references.pmid: 16279294
references.citation: Ann Intern Med. 2002 Apr 16;136(8):565-74
references.pmid: 11955024
references.citation: Addiction. 2012 Aug;107(8):1431-40
references.pmid: 22340523
references.citation: Diabetes Care. 2006 Dec;29(12):2625-31
references.pmid: 17130195
references.citation: Diabet Med. 1998 Jul;15(7):539-53
references.pmid: 9686693
references.citation: BMC Fam Pract. 2009 Nov 17;10:72
references.pmid: 19917136
references.citation: Diabetes Care. 2004 Feb;27(2):478-83
references.pmid: 14747232
references.citation: Diabetes Care. 2010 Mar;33(3):478-84
references.pmid: 20009091
references.citation: Appl Nurs Res. 2008 May;21(2):84-9
references.pmid: 18457747
references.citation: Diabet Med. 1989 Sep-Oct;6(7):591-4
references.pmid: 2527699
references.citation: Chronic Illn. 2006 Mar;2(1):27-38
references.pmid: 17175680
references.citation: Health Psychol. 2009 Nov;28(6):690-701
references.pmid: 19916637
references.citation: Diabetes Care. 1991 Oct;14(10):875-80
references.pmid: 1773685
references.citation: Prev Med. 2008 Jul;47(1):3-16
references.pmid: 18403003
references.citation: Int J Behav Nutr Phys Act. 2009 Mar 27;6:18
references.pmid: 19327141
references.citation: Scand J Prim Health Care. 2000 Dec;18(4):252-3
references.pmid: 11205096
references.citation: Med Care. 2001 Nov;39(11):1217-23
references.pmid: 11606875
references.citation: BMJ. 2008 Mar 1;336(7642):491-5
references.pmid: 18276664
references.citation: Diabetes Care. 1996 Jun;19(6):601-6
references.pmid: 8725859
references.citation: Diabetes Technol Ther. 2009 Jul;11(7):431-7
references.pmid: 19580356
references.citation: J Gen Intern Med. 2010 Dec;25(12):1315-22
references.pmid: 20714820
references.citation: Med Care. 2000 Nov;38(11):1062-73
references.pmid: 11078048
references.citation: J Am Med Inform Assoc. 2009 Jul-Aug;16(4):446-56
references.pmid: 19390093
references.citation: Med Care. 2000 Feb;38(2):218-30
references.pmid: 10659695
references.citation: BMJ. 2002 Oct 5;325(7367):746
references.pmid: 12364302
references.citation: Psychol Bull. 1982 Jul;92(1):111-35
references.pmid: 7134324
references.citation: Health Psychol. 2009 Nov;28(6):668-74
references.pmid: 19916634
references.citation: Am J Med Qual. 2006 Nov-Dec;21(6):401-7
references.pmid: 17077422
references.citation: BMJ. 2003 Sep 6;327(7414):557-60
references.pmid: 12958120