title: Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis.
abstract: BACKGROUND
  Diabetes self-management education is an essential part of diabetes care, but its impact on all-cause mortality risk of type 2 diabetes patients is unclear. A systematic review and meta-analysis aiming to elucidate the impact of diabetes self-management education on all-cause mortality risk of type 2 diabetes patients was performed.
  
  
  METHODS
  Randomised controlled trials were identified though literature search in Medline, Embase, CENTRAL, conference abstracts, and reference lists. Only randomised controlled trials comparing diabetes self-management education with usual care in type 2 diabetes patients and reporting outcomes after a follow-up of at least 12 months were considered eligible. Risk ratios with 95 %CIs were pooled. This study was registered at PROSPERO with the number of CRD42016043911.
  
  
  RESULTS
  42 randomised controlled trials containing 13,017 participants were included. The mean time of follow-up was 1.5 years. There was no heterogeneity among those included studies (I2= 0 %). Mortality occurred in 159 participants (2.3 %) in the diabetes self-management education group and in 187 (3.1 %) in the usual care group, and diabetes self-management education significantly reduced risk of all-cause mortality in type 2 diabetes patients (pooled risk ratios : 0.74, 95 %CI 0.60-0.90, P = 0.003; absolute risk difference: -0.8 %, 95 %CI -1.4 to -0.3). Both multidisciplinary team education and nurse-led education could significantly reduce mortality risk in type 2 diabetes patients, and the pooled risk ratios were 0.66 (95 %CI 0.46-0.96, P = 0.02; I2= 0 %) and 0.64 (95 % CI 0.47- 0.88, P = 0.005; I2= 0 %), respectively. Subgroup analyses of studies with longer duration of follow-up (≥1.5 years) or larger sample size (≥300) also found a significant effect of diabetes self-management education in reducing mortality risk among type 2 diabetes. Significant effect of diabetes self-management education in reducing mortality risk was also found in those patients receiving diabetes self-management education with contact hours more than 10 h (pooled risk ratio: 0.60, 95 %CI 0.44-0.82, P = 0.001; I2= 0 %), those receiving repeated diabetes self-management education (pooled RR: 0.71, P = 0.001; I2= 0 %), those receiving diabetes self-management education using structured curriculum (pooled risk ratio: 0.72, P = 0.01; I2= 0 %) and those receiving diabetes self-management education using in-person communication (pooled risk ratio: 0.75, P = 0.02; I2= 0 %). The quality of evidence for the effect of diabetes self-management education in reducing all-cause mortality risk among type 2 diabetes patients was rated as moderate according to the Grading of Recommendations Assessment, Development, and Evaluation method, and the absolute risk reduction of all-cause mortality of type 2 diabetic patients by diabetes self-management education was estimated to be 4 fewer per 1000 person-years (from 1 fewer to 6 fewer).
  
  
  CONCLUSIONS
  The available evidence suggests that diabetes self-management education can reduce all-cause mortality risk in type 2 diabetes patients. Further clinical trials with longer time of follow-up are needed to validate the finding above.
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China.|Shanghai Medical College, Fudan University, Shanghai, 200032, China.
authors.forename: Xiaoqin
authors.initials: X
authors.lastname: He
authors.affiliation: Department of Nephrology, Xi'an Central Hospital, Xi'an, 710003, China.
authors.forename: Jie
authors.initials: J
authors.lastname: Li
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China.
authors.forename: Bin
authors.initials: B
authors.lastname: Wang
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China.
authors.forename: Qiuming
authors.initials: Q
authors.lastname: Yao
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China.
authors.forename: Ling
authors.initials: L
authors.lastname: Li
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China.
authors.forename: Ronghua
authors.initials: R
authors.lastname: Song
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China.
authors.forename: Xiaohong
authors.initials: X
authors.lastname: Shi
authors.affiliation: Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, 201508, China. zhangjinan@hotmail.com.
authors.forename: Jin-An
authors.initials: JA
authors.lastname: Zhang
mesh_terms: D003924:Diabetes Mellitus, Type 2 / Q000401:mortality* / Q000628:therapy*; D006801:Humans; D010353:Patient Education as Topic; D012648:Self Care; D016896:Treatment Outcome
keywords: All-cause mortality; Diabetes self-management education; Meta-analysis; Type 2 diabetes