title: Interventions to improve patients' compliance with therapies aimed at lowering glycated hemoglobin (HbA1c) in type 1 diabetes: systematic review and meta-analyses of randomized controlled clinical trials of psychological, telecare, and educational interventions.
abstract: BACKGROUND
  Brazilian records on glycemic control in patients with type 1 diabetes show treatment efficacy. Poor patient adherence to therapeutic proposals influences these results and can be associated with social, psychological, and economic aspects, besides others factors. The aim of this study was to evaluate the efficacy of psychological, telecare, and educational interventions to improve treatment compliance among patients with type 1 diabetes. Compliance was assessed indirectly using reduction of glycated hemoglobin (HbA1c) as the principal outcome measure.
  
  
  METHODS
  Systematic review and meta-analyses of randomized controlled clinical trials (RCTs) were performed using Medline, Embase, Cochrane and Scopus databases up to April 2015. The following medical subject headings were used: Diabetes Mellitus, Type 1, Patient Compliance or Adherence, Hemoglobin A, glycated, and Randomized Controlled Trial. The principal outcome was change in HbA1c between baseline and follow-up. Where appropriate, trials were combined in meta-analysis using fixed effects models.
  
  
  RESULTS
  From 191 articles initially identified, 57 were full text reviewed, and 19 articles met the inclusion criteria providing data from 1782 patients (49.4 % males, age 18 years). The RCTs (2 to 24 months in duration) were divided into four groups according to type of intervention: psychology (seven studies; 818 patients), telecare (six studies; 494 patients); education (five studies; 349 patients), and psychoeducation (one study; 153 patients). All studies reported some type of adherence measurement of the interventions. Decrease in HbA1c was observed after psychology (MD -0.310; 95 % CI, -0.599 to -0.0210, P = 0.035) but not after telecare (MD -0.124 %; 95 % CI, -0.268, 0.020; P = 0.090) or educational (MD -0.001; 95 % CI, -0.202, 0.200; P = 0.990) interventions.
  
  
  CONCLUSIONS
  Psychological approaches to improve adherence to diabetes care treatment modestly reduced HbA1c in patients with type 1 diabetes; telecare and education interventions did not change glycemic control. However, the limited number of studies included as well as their methodological quality should be taken into account.
authors.affiliation: Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4° andar, 90035-003, Porto Alegre, RS, Brazil. vercoza@yahoo.com.
authors.forename: Luciana Verçoza
authors.initials: LV
authors.lastname: Viana
authors.affiliation: Unit of Diabetes, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil. mariliabgomes@gmail.com.
authors.forename: Marilia Brito
authors.initials: MB
authors.lastname: Gomes
authors.affiliation: Internal Medicine Department, Diabetes Division, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. lenitazaj@gmail.com.
authors.forename: Lenita
authors.initials: L
authors.lastname: Zajdenverg
authors.affiliation: Department of Clinical Medicine, Universidade Estadual de Campinas, Campinas, Brazil. ejpavin@gamil.com.
authors.forename: Elizabeth Joao
authors.initials: EJ
authors.lastname: Pavin
authors.affiliation: Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4° andar, 90035-003, Porto Alegre, RS, Brazil. mjazevedo@gmail.com.
authors.forename: Mirela Jobim
authors.initials: MJ
authors.lastname: Azevedo
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000523:psychology / Q000628:therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D010353:Patient Education as Topic; D017216:Telemedicine
chemical_list: D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human