Online patient education interventions in type 2 diabetes or cardiovascular disease: A systematic review of systematic reviews

doi:10.1016/j.pcd.2018.07.011

Primary Care Diabetes

Volume 13, Issue 1, February 2019, Pages 16-27

https://doi.org/10.1016/j.pcd.2018.07.011 Get rights and content

Highlights

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This study synthesises data from 23 systematic reviews of online patient education in type 2 diabetes and cardiovascular disease.
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The contained reviews incorporate 87 distinct primary studies.
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The technology can target biological, behavioural, cognitive and psychological measures.
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Outcomes most consistently benefitting were knowledge and social support.

Abstract

Aims

Online patient education is a growing form of support to patients with chronic conditions, including type 2 diabetes (Type 2 DM) and cardiovascular disease (CVD). Multiple systematic reviews have been undertaken on this topic with conflicting results. We aim to explore the applications of online patient education in Type 2 DM and CVD and synthesise current evidence.

Methods

A systematic review of systematic reviews was performed. Ovid Medline, EMBASE and Cochrane Database were searched between January 2005 and May 2018. Systematic reviews considering patient outcomes of online education interventions for adults with Type 2 DM and/or CVD were included. Quality assessment and data extraction was carried out in duplicate, and data combined using narrative synthesis. The PROSPERO registration number is CRD42016034018.

Results

Twenty-three systematic reviews were eligible, synthesizing evidence from 87 distinct primary studies. Six reviews were high quality, nine used meta-analysis. Biological, behavioural, psychological, knowledge and self-efficacy measures are all potential targets. The outcomes most consistently showing benefits were knowledge and social support.

Conclusions

Online patient education has wide ranging benefits for people with Type 2 DM or CVD. Strengths of this review include its comprehensive synthesis of the large amount of literature on this topic.

Introduction

Type 2 diabetes (Type 2 DM) and cardiovascular disease (CVD) are two of the largest causes of ill health and mortality globally [1]. Whilst pharmacological therapy is a key management component, lifestyle factors significantly impact the trajectory. Making adjustments requires patients to learn about the importance of these factors in their condition [2]. Furthermore, enabling patients to better understand their conditions can improve coping strategies and reduce health related anxiety and depression [3].

Education is available for patients in a wide variety of formats, including printed information, group based structured education and telephone helplines. The internet is an information exchange modality that has come to predominance in the past 10–15 years and several authors have proposed that it might provide a useful modality to reach patients, including geographically or socioeconomically isolated groups [4]. There are 4.6 billion mobile broadband users globally and more than 84% of households in developed countries are now connected to the internet [5]. Other postulated benefits have included cost-efficacy, convenient 24-h access and home use during illness recovery, which may be the time when the patient is most open to lifestyle change. It is argued that whilst on an individual patient level only modest benefits might be seen, the wide reaching potential of these technologies could have a large overall public health impact [6].

A number of studies have evaluated internet based educational interventions for patients with Type 2 DM and CVD, prompting several systematic reviews on this subject [7], [8]. These have drawn conflicting conclusions, and frequently include a different pool of studies despite attempting to address the same research question. The aim of this review of reviews is therefore to explore the effectiveness and scope of online patient education in Type 2 DM and CVD on patient outcomes and to synthesise the current evidence from all studies conducted to date.

Section snippets

Protocol registration

The protocol for this systematic review is registered on the PROSPERO register. The registration number is CRD42016034018.

Inclusion criteria

Only completed published systematic reviews were included. They considered interventions delivered over the internet and including web-based education for participants aged 18 years and over with established CVD and/or Type 2 DM. Studies reported effects on patient outcomes, defined as a change in an aspect of individual patient health status or behaviour, as a result of the

Study selection

The initial search strategy 6418 papers. Following title review and removal of duplicates, 168 abstracts were identified, of which 47 were considered potentially relevant after screening. Twenty-three reviews met all inclusion criteria and are included in this review [3], [4], [7], [8], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. Reference searching did not identify any further reviews. The PRISMA diagram depicting the

Summary of main results

The 23 reviews summarised here have considered a wide range of different online education interventions. Biological, behavioural, psychological outcomes, knowledge and self-efficacy for patients with Type 2 DM and CVD have all shown examples of benefits from online patient education despite a mixed overall picture. Where available, effect sizes suggest that the overlap between outcomes in the control and intervention groups remained substantial or observed benefits were inconsistent between

Conclusions

This review provides a comprehensive synthesis of the plethora of research undertaken in the field of online patient education in Type 2 DM and CVD. We have highlighted the types of patient outcomes that may benefit from this technology, discussed their relative successes, and the factors influencing them. The technology shows examples of possible benefits in many different aspects of these conditions however the evidence remains conflicting between individual trials and we have attempted to

Conflict of interest

Dr Angharad Woolley and Dr Michelle Hadjiconstantinou have no duality of interests to declare.

Dr Samuel Seidu has received honoraria for speaking at meetings and serving on Advisory Boards for Novartis, Sanofi-Aventis, Novo Nordisk, Janssen, Merck Sharp & Dohme, AstraZeneca, Lilly And Boehringer Ingelheim.

Professor Melanie Davies has acted as consultant, advisory board member and speaker for Novo Nordisk, Sanofi-Aventis, Lilly, Merck Sharp & Dohme, Boehringer Ingelheim, AstraZeneca and Janssen,

Funding

Dr Angharad Woolley is a National Institute for Health Research (NIHR) clinical research fellow in General Practice whose time is funded by the NIHR. This research was supported by CLAHRC-EM and Leicester NIHR BRC.

References (32)

L. Beatty et al.
A systematic review of internet-based self-help therapeutic interventions to improve distress and disease-control among adults with chronic health conditions
Clin. Psychol. Rev.
(2013)
A. Cotter et al.
Internet interventions to support lifestyle modification for diabetes management: a systematic review of the evidence
J. Diabetes Complications
(2014)
M. Mignerat et al.
Using telecare for diabetic patients: a mixed systematic review
Health Policy Technol.
(2014)
A. Ramadas et al.
Web-based interventions for the management of type 2 diabetes mellitus: a systematic review of recent evidence
Int. J. Med. Inform.
(2011)
E. Beranova et al.
A systematic review of computer-based softwares for educating patients with coronary heart disease
Patient Educ. Couns.
(2007)
World Health Organisation 2014, The top 10 causes of death, World Health Organisation Fact sheet number 310, Updated...
M. VanVugt et al.
Use of behavioural change techniques in web-based self-management programs for type 2 diabetes patients: systematic review
J. Med. Internet Res.
(2013)
K. Pal et al.
Computer-based interventions to improve self-management in adults with type 2 diabetes (review)
Cochrane Database Syst. Rev.
(2013)
S. Fredericks et al.
A systematic review of web-based educational interventions
Clin. Nurs. Res.
(2015)
ICT Facts and Figures 2017 International Telecommunications...

W. Kroeze et al.

A systematic review of randomised trials on the effectiveness of computer-tailored education on physical activity and dietary behaviours

Ann. Behav. Med.

(2006)

R. Devi et al.

Internet-based interventions for the secondary prevention of coronary heart disease

Cochrane Database Syst. Rev.

(2015)

K. Pal et al.

Computer-based interventions to improve self-management in adults with type 2 diabetes: a systematic review and meta-analysis

Diabetes Care

(2014)

B.J. Shea et al.

Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews

BMC Med. Res. Methodol.

(2007)

C.R.L. Beishuizen et al.

Web-based interventions targeting cardiovascular risk factors in middle-aged and older people: a systematic review and meta-analysis

J. Med. Internet Res.

(2016)

D. Bossen et al.

The effectiveness of self-guided web-based physical activity interventions among patients with a chronic disease: a systematic review

J. Phys. Act. Health

(2014)

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The diabetes education material on diabetes for website: Results of a validation process
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To validate an educational material on diabetes through an expert consensus for its implementation into a web site.
An observational study was carried out in a group of health professionals, for which an educational material was developed for patients with diabetes. Topics included nutrition, physical exercise, control indicators, complications, pharmacological treatment, among others. The language, text and figures were focused on easy comprehension, additionally, a section of didactic activities to be answered by the patient with diabetes at the end of each module was included. To evaluate the educational material by health professionals, an instrument was designed and validated. Once all the educational material was available, each of the modules was sent by e-mail to at least three clinical experts in the assigned topic, as well as the instrument for the evaluation of the module.
Thirty-seven experts were included in the study, 76% rated the educational modules evaluated as highly adequate, while only 24% rated them as adequate. The instrument used obtained a good level of internal consistency, with a Cronbach's alpha coefficient of 0.92. In the dimensions of the instrument, the lowest Cronbach's alpha score was that of “call-to-action”, with a value of 0.71.
The diabetes educational material was rated as highly appropriate by the clinical experts. The developed instrument has an adequate content validity, as well as a good level of internal consistency.
Validar un material educativo en diabetes a través de un consenso de expertos para su implementación en un sitio web.
Se realizó un estudio observacional en un grupo de profesionales de la salud, para ello se desarrolló un material educativo para pacientes con diabetes. Se incluyeron temas de nutrición, ejercicio físico, indicadores de control, complicaciones, tratamiento farmacológico, entre otros. El lenguaje, texto y figuras fueron enfocadas a una fácil comprensión, además de una sección de actividades didácticas a responder por el paciente con diabetes al finalizar cada módulo. Para evaluar el material educativo por los profesionales de la salud, se diseñó y validó un instrumento. Una vez que se contó con todo el material educativo, se envió cada uno de los módulos por correo electrónico al menos a tres expertos clínicos en el tema asignado, así como el instrumento para la evaluación del módulo.
Se incluyeron 37 expertos en el estudio, 76% calificó los módulos educativos evaluados como altamente adecuados, mientras que solo 24% lo evaluó como adecuados. El instrumento utilizado obtuvo un buen nivel de consistencia interna, con un coeficiente alfa de Cronbach de 0,92. En las dimensiones del instrumento, la puntuación del alfa de Cronbach más baja fue la de «llamada a la acción», con un valor de 0,71.
El material educativo en diabetes fue calificado como altamente apropiado por los expertos clínicos. El instrumento desarrollado tiene una adecuada validez de contenido, así como buen nivel de consistencia interna.
Educational preferences in individuals with cardiometabolic disease differs with age, ethnicity and educational status
2022, Patient Education and Counseling
Citation Excerpt :
The role of education in stroke and CVD focusses on rehabilitation, physical symptom management and enhancing quality of life, but the evidence base is less well established [10]. In the digital age, online education programmes, websites, and standalone modules are increasingly implemented to increase access, and reduce associated costs, in addition to clinical benefit [11–14]. Despite the broad range of educational modalities available, of the 90% of adults with type 2 diabetes mellitus offered structured education in the UK, less than 10% had recorded attendance [15].
To evaluate how sociodemographic factors influence educational modality preferences in people with cardiometabolic disease.
This was a cross-sectional study performed in people with diabetes and cardiovascular disease, who completed a questionnaire to denote their previous experience and ranked preferences for different educational modalities.
The questionnaire was completed by 3751 people, of whom 59% were men, median (interquartile range) age was 68 (59−76) years, and 78% were White European. In total, 73% had diabetes, 35% had heart disease, and 10% had history of stroke; the majority (83.4%) had one of these conditions. Overall preference was for one-to-one education (77% ranked first choice), and telephone education ranked the lowest. People tended to prefer modalities they had previously experienced.
We highlight the importance of considering factors that could influence selection of educational modalities including age, ethnicity, gender and educational level. We anticipate this approach will aid in the design, delivery and tailoring of educational programmes that are accessible to the diverse cohort of people living with chronic diseases, including diabetes and cardiovascular disease.
Given the influence of multiple demographic factors and previous experiences on expressed preferences, providers should support individuals to make informed decisions about educational interventions to maximise engagement.
Revisiting secondary prevention in coronary heart disease
2022, Indian Heart Journal
Secondary prevention in coronary heart disease is the prevention of occurrence of recurrent coronary events after clinical diagnosis. High level of adherence to secondary prevention interventions, especially aggressive lifestyle changes and pharmacotherapy can lead to significant decline in recurrent coronary events. Both international and Indian studies have reported low adherence to such therapies. Evidence-based useful interventions include regular physical activity, yoga, intake of healthy diet, smoking and tobacco use cessation and weight management. Pharmacotherapeutic interventions useful are anti-platelet therapy, target oriented lipid lowering therapy with statins, beta blockers and angiotensin converting enzyme inhibitors in patients with impaired left ventricular function. Hypertension and diabetes management with control to targets is important. Novel strategies include use of anticoagulants, anti-inflammatory drugs, and triglyceride lowering for residual risk. Physician and patient level interventions using multifaceted educational, socioeconomic and technological innovations are important to promote life-long adherence to these strategies.
Digital interventions self-management education for type 1 and 2 diabetes: A systematic review and meta-analysis
2021, Computer Methods and Programs in Biomedicine
Citation Excerpt :
Mobile health interventions on the other hand, are widely used in DSMES with varying effects [8–10]. Web-based interventions in DSMES have also demonstrated effectiveness in improving various clinical and psychosocial outcomes [5]. Despite the aforementioned advantages, some evidence shows that digital health-led DSMES is not always effective in improving health outcomes, especially if there are no personal interactions incorporated.
Objective: To describe and assess digital health-led diabetes self-management education and support (DSMES) effectiveness in improving glycosylated hemoglobin, diabetes knowledge, and health-related quality of life (HrQoL) of Type 1 and 2 Diabetes in the past 10 years.
Design: Systematic Review and Meta-Analysis. The protocol was registered on PROSPERO registration number CRD42019139884.
Data Sources: PubMed, EMBASE, Cochrane library, Web of Science, and Scopus between January 2010 and August 2019.
Study Selection and Appraisal: Randomized control trials of digital health-led DSMES for Type 1 (T1DM) or 2 (T2DM) diabetes compared to usual care were included. Outcomes were change in HbA1c, diabetes knowledge, and HrQoL. Cochrane Risk of Bias 2.0 tool was used to assess bias and GRADEpro for overall quality. The analysis involved narrative synthesis, subgroup and pooled meta-analyses.
Results: From 4286 articles, 39 studies (6861 participants) were included. Mean age was 51.62 years, range (13–70). Meta-analysis revealed intervention effects on HbA1c for T2DM with difference in means (MD) from baseline -0.480% (-0.661, -0.299), I²75% (6 months), -0.457% (-0.761, -0.151), I² 81% (12 months), and for T1DM -0.41% (-1.022, 0.208) I² 83% (6 months), -0.03% (-0.210, 0.142) I² 0% (12 months). Few reported HrQoL with Hedges’ g 0.183 (-0.039, 0.405), I² 0% (6 months), 0.153 (-0.060, 0.366), I² 0% (12 months) and diabetes knowledge with Hedges’ g 1.003 (0.068, 1.938), I² 87% (3 months).
Conclusion: Digital health-led DSMES are effective in improving HbA1c and diabetes knowledge, notably for T2DM. Research shows non-significant changes in HrQoL. Intervention effect on HbA1c was more impressive if delivered through mobile apps or patient portals. Further research is needed on the impact of DSMES on these outcomes, especially for newly diagnosed diabetes patients.
Digital enabled learning for people with diabetes post COVID-19 pandemic
2023, Practical Diabetes
Effects of Using Websites on Physical Activity and Diet Quality for Adults Living With Chronic Health Conditions: Systematic Review and Meta-Analysis
2023, Journal of Medical Internet Research

View all citing articles on Scopus

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Original researchOnline patient education interventions in type 2 diabetes or cardiovascular disease: A systematic review of systematic reviews

Highlights

Abstract

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Protocol registration

Inclusion criteria

Study selection

Summary of main results

Conclusions

Conflict of interest

Funding

Clin. Psychol. Rev.

J. Diabetes Complications

Health Policy Technol.

Int. J. Med. Inform.

Patient Educ. Couns.

Use of behavioural change techniques in web-based self-management programs for type 2 diabetes patients: systematic review

J. Med. Internet Res.

Computer-based interventions to improve self-management in adults with type 2 diabetes (review)

Cochrane Database Syst. Rev.

A systematic review of web-based educational interventions

Clin. Nurs. Res.

A systematic review of randomised trials on the effectiveness of computer-tailored education on physical activity and dietary behaviours

Ann. Behav. Med.

Internet-based interventions for the secondary prevention of coronary heart disease

Cochrane Database Syst. Rev.

Computer-based interventions to improve self-management in adults with type 2 diabetes: a systematic review and meta-analysis

Diabetes Care

Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews

BMC Med. Res. Methodol.

Web-based interventions targeting cardiovascular risk factors in middle-aged and older people: a systematic review and meta-analysis

J. Med. Internet Res.

The effectiveness of self-guided web-based physical activity interventions among patients with a chronic disease: a systematic review

J. Phys. Act. Health

Original research
Online patient education interventions in type 2 diabetes or cardiovascular disease: A systematic review of systematic reviews