title: Effectiveness and safety of patient activation interventions for adults with type 2 diabetes: systematic review, meta-analysis, and meta-regression.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37 %, CI 0.28-0.45 %, I (2) 83 %; SBP: WMD 2.2 mmHg, CI 1.0-3.5 mmHg, I (2) 72 %; body weight: WMD 2.3 lbs, CI 1.3-3.2 lbs, I (2) 64 %; and LDL-c: WMD 4.2 mg/dL, CI 1.5-6.9 mg/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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Center for Health Care Research and Policy, MetroHealth Medical Center, Cleveland, OH, USA, sdb73@case.edu.
authors.forename: Shari D
authors.initials: SD
authors.lastname: Bolen
authors.forename: Apoorva
authors.initials: A
authors.lastname: Chandar
authors.forename: Corinna
authors.initials: C
authors.lastname: Falck-Ytter
authors.forename: Carl
authors.initials: C
authors.lastname: Tyler
authors.forename: Adam T
authors.initials: AT
authors.lastname: Perzynski
authors.forename: Alida M
authors.initials: AM
authors.lastname: Gertz
authors.forename: Paulette
authors.initials: P
authors.lastname: Sage
authors.forename: Steven
authors.initials: S
authors.lastname: Lewis
authors.forename: Maurine
authors.initials: M
authors.lastname: Cobabe
authors.forename: Ying
authors.initials: Y
authors.lastname: Ye
authors.forename: Michelle
authors.initials: M
authors.lastname: Menegay
authors.forename: Donna M
authors.initials: DM
authors.lastname: Windish
mesh_terms: D000328:Adult; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D061345:Early Medical Intervention / Q000379:methods*; D006801:Humans; D010358:Patient Participation / Q000379:methods*; D061214:Patient Safety; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D012648:Self Care / Q000379:methods*; D016896:Treatment Outcome
references.citation: Diabetes Care. 2011 Feb;34(2):262-7
references.pmid: 21270183
references.citation: Am J Manag Care. 2011 Feb;17(2):105-13
references.pmid: 21473660
references.citation: Patient Educ Couns. 2012 Jan;86(1):98-105
references.pmid: 21592715
references.citation: BMJ. 2012 Apr 26;344:e2333
references.pmid: 22539172
references.citation: Cochrane Database Syst Rev. 2012 Jun 13;(6):CD000259
references.pmid: 22696318
references.citation: Health Aff (Millwood). 2012 Oct;31(10):2168-75
references.pmid: 23048092
references.citation: Control Clin Trials. 1986 Sep;7(3):177-88
references.pmid: 3802833
references.citation: Diabetes Care. 2008 Mar;31(3):408-14
references.pmid: 18096810
references.citation: Diabetes Care. 2010 Apr;33(4):745-7
references.pmid: 20103547
references.citation: Diabetes Care. 2002 Sep;25(9):1576-83
references.pmid: 12196430
references.citation: Arch Intern Med. 2007 Jun 25;167(12):1277-83
references.pmid: 17592101
references.citation: Diabetes Care. 2008 Mar;31(3):596-615
references.pmid: 18308683
references.citation: Diabetes Educ. 2010 Mar-Apr;36(2):301-9
references.pmid: 20200284
references.citation: Ann Intern Med. 2008 Feb 19;148(4):295-309
references.pmid: 18283207
references.citation: Vasc Health Risk Manag. 2009;5:705-11
references.pmid: 19756162
references.citation: Health Expect. 2010 Mar;13(1):65-72
references.pmid: 19906211
references.citation: J Negat Results Biomed. 2011 Oct 11;10:13
references.pmid: 21988865
references.citation: Telemed J E Health. 2011 May;17(4):254-61
references.pmid: 21476945
references.citation: Diabetologia. 2008 Nov;51(11):1954-61
references.pmid: 18758747
references.citation: Diabetes Res Clin Pract. 2011 Sep;93(3):328-36
references.pmid: 21640424
references.citation: Am J Med. 2005 Mar;118(3):276-84
references.pmid: 15745726
references.citation: Diabetes Care. 2009 Dec;32(12):2149-55
references.pmid: 19741187
references.citation: BMJ. 2008 Apr 26;336(7650):924-6
references.pmid: 18436948
references.citation: Biometrics. 1994 Dec;50(4):1088-101
references.pmid: 7786990
references.citation: Diabetes Res Clin Pract. 2007 May;76(2):265-8
references.pmid: 17049662
references.citation: Control Clin Trials. 1996 Feb;17(1):1-12
references.pmid: 8721797
references.citation: Diabetes Educ. 1995 May-Jun;21(3):203-10
references.pmid: 7758387
references.citation: Int J Nurs Stud. 2008 Jul;45(7):986-94
references.pmid: 17822705
references.citation: Ther Patient Educ. 2009 Jun 1;1(1):3-11
references.pmid: 20076768
references.citation: Prog Cardiovasc Dis. 1985 Mar-Apr;27(5):335-71
references.pmid: 2858114
references.citation: Diabetes Care. 2011 Jan;34(1):2-7
references.pmid: 21193619
references.citation: Diabet Med. 2009 Jun;26(6):628-35
references.pmid: 19538239
references.citation: Health Technol Assess. 2009 Feb;13(15):iii-iv, ix-xi, 1-50
references.pmid: 19254484
references.citation: Prev Chronic Dis. 2008 Jan;5(1):A16
references.pmid: 18082005
references.citation: Biometrics. 2000 Jun;56(2):455-63
references.pmid: 10877304
references.citation: Diabetes Care. 2011 Feb;34(2):308-13
references.pmid: 21270188
references.citation: Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78
references.pmid: 11816692
references.citation: Prev Med. 2003 Jul;37(1):23-32
references.pmid: 12799126
references.citation: Patient Educ Couns. 2004 Jun;53(3):291-8
references.pmid: 15186866
references.citation: Psychol Health. 2009 Mar;24(3):237-54
references.pmid: 20204991
references.citation: Diabetes Care. 2005 Dec;28(12):2819-22
references.pmid: 16306539
references.citation: Diabetes Res Clin Pract. 2011 Aug;93(2):179-186
references.pmid: 21570146
references.citation: Diabetes Care. 1991 Apr;14(4):308-17
references.pmid: 2060433
references.citation: Diabetes Care. 2004 Jan;27(1):95-103
references.pmid: 14693973
references.citation: BMJ. 2011 Feb 15;342:d715
references.pmid: 21324992
references.citation: Popul Health Manag. 2012 Jun;15(3):144-8
references.pmid: 22313442
references.citation: Diabetes Care. 2003 Feb;26(2):404-8
references.pmid: 12547870
references.citation: Diabetes Care. 2012 Jan;35 Suppl 1:S101-8
references.pmid: 22187467
references.citation: Diabetes Educ. 2007 May-Jun;33(3):493-502
references.pmid: 17570880
references.citation: Am J Public Health. 2011 Dec;101(12):2253-60
references.pmid: 21680932
references.citation: BMJ. 1997 Sep 13;315(7109):629-34
references.pmid: 9310563
references.citation: Diabetes Educ. 2009 Jul-Aug;35(4):641-51
references.pmid: 19407333
references.citation: Diabetes Res Clin Pract. 2008 Nov;82(2):165-71
references.pmid: 18804887
references.citation: N Engl J Med. 2013 Jul 11;369(2):145-54
references.pmid: 23796131
references.citation: Disabil Rehabil. 2010;32(19):1558-67
references.pmid: 20590506
references.citation: Diabetes Educ. 2011 Nov-Dec;37(6):801-12
references.pmid: 22021025
references.citation: J Am Soc Nephrol. 2005 Mar;16 Suppl 1:S22-6
references.pmid: 15938028
references.citation: Br J Health Psychol. 2004 Sep;9(Pt 3):365-79
references.pmid: 15296683
references.citation: J Behav Med. 2009 Aug;32(4):349-59
references.pmid: 19365719
references.citation: Telemed J E Health. 2011 Apr;17(3):153-63
references.pmid: 21375410
references.citation: Diabetes Care. 2003 Apr;26(4):1058-63
references.pmid: 12663573
references.citation: Lancet. 2011 Jul 9;378(9786):129-39
references.pmid: 21705068
references.citation: Diabetes Educ. 2003 May-Jun;29(3):488-501
references.pmid: 12854339
references.citation: Diabetes Care. 2004 Mar;27(3):670-5
references.pmid: 14988283
references.citation: JAMA. 2006 Jul 26;296(4):427-40
references.pmid: 16868301
references.citation: Diabetes Care. 2001 Mar;24(3):561-87
references.pmid: 11289485
references.citation: Arch Intern Med. 2009 Oct 26;169(19):1788-94
references.pmid: 19858437
references.citation: Diabetes Res Clin Pract. 2011 Mar;91(3):286-92
references.pmid: 21168231
references.citation: Diabet Med. 1988 Sep;5(6):552-6
references.pmid: 2974778
references.citation: J Ambul Care Manage. 2009 Oct-Dec;32(4):320-7
references.pmid: 19888008
references.citation: BMJ. 2000 Aug 12;321(7258):405-12
references.pmid: 10938048
references.citation: Pharm World Sci. 2006 Apr;28(2):65-72
references.pmid: 16791717
references.citation: J Gen Intern Med. 2010 Oct;25(10):1116-22
references.pmid: 20556536
references.citation: N Engl J Med. 2008 Feb 7;358(6):580-91
references.pmid: 18256393
references.citation: Diabet Med. 2011 Jul;28(7):789-96
references.pmid: 21342243
references.citation: Scand J Prim Health Care. 2001 Mar;19(1):25-30
references.pmid: 11303543
references.citation: J Diabetes. 2010 Sep;2(3):203-11
references.pmid: 20923485
references.citation: Diabetes Care. 2010 Nov;33(11):2333-5
references.pmid: 20980426
references.citation: Diabetes Technol Ther. 2009 Jul;11(7):431-7
references.pmid: 19580356
references.citation: Ann Intern Med. 2010 Jun 1;152(11):689-96
references.pmid: 20513826
references.citation: Diabetes Educ. 2009 May-Jun;35(3):439-54
references.pmid: 19383882
references.citation: BMJ. 2003 Sep 6;327(7414):557-60
references.pmid: 12958120