A new study examining individual counseling for self-care in patients with diabetes vs group education has found that the latter is associated with better outcomes. The research was carried out in a real-world situation in Ontario, with more than 75,000 patients.
"We were pleased to find that not only is group education more efficient in terms of resource utilization, it actually leads to better care and better patient outcomes, so it's a win-win situation: you can save money and improve care," senior author Baiju Shah, MD, PhD, of the Institute for Clinical Evaluative Sciences, Toronto, Ontario, told Medscape Medical News.
"There's been a little bit of clinical-trial data that compare different ways of delivering diabetes education, but there really hasn't been very much literature published in this area," Dr. Shah explained.
"So we wanted to investigate in our population cohort what the differences were, based on individual appointments vs the group-class approach, recognizing that the ministry of health and payers are pushing toward group programs because they're cheaper — you can treat more people with the same staff. We wanted to look at whether there was a clinical justification for that."
Compared with those attending individual counseling, patients who went to group classes were less likely to visit the emergency room, be hospitalized for hypo- or hyperglycemia, or develop foot ulcers/cellulitis. Group-therapy recipients were also more likely to have adequate HbA1c and lipid testing and to receive statins than those getting one-on-one care.
The research is published by Jeremiah Hwee, MSc, also of the Institute for Clinical Evaluative Sciences, and colleagues in the May/June issue of the Canadian Journal of Public Health.
Most Patients Getting Individual Care
To conduct the study, the researchers identified all patients in Ontario who attended diabetes education programs in 2006 who were grouped according to the type of program they attended. They found the vast majority of people were seen on an individual-appointment basis (n = 55,761), with fewer attending group classes (n = 12,234), and some getting a mixture of both (n = 9829).
In the following year, they compared acute complications and quality of care between the groups.
They note they were unable to distinguish type 1 from type 2 diabetes, so the analyses could not be stratified by diabetes type. "However, the overwhelming majority of patients with diabetes in the population have type 2," they observe.
Diabetes self-education is primarily provided by nurses and dieticians in Ontario, Dr. Shah explained. He said that the size of group classes "was very variable" across the population studied, although most would contain, on average, 5 to 10 patients plus family members.
"But there were some centers in smaller towns, for example, where a group program would only be run once a month, and all 50 patients in the town with diabetes would attend," he noted.
Group Education Halves Rate of Hypo-, Hyperglycemia
Compared with those attending individual counseling, patients who attended group classes were significantly less likely to have emergency-department visits for hypo-/hyperglycemia (odds ratio [OR], 0.54), hypo-/hyperglycemia hospitalizations (OR, 0.49), or foot ulcers/cellulitis (OR, 0.64) (all P < .001).
They were also more likely to receive adequate HbA1c testing (OR, 1.10; P < .001) and lipid testing (OR, 1.25; P < .001) and to get statin therapy (OR, 1.22; P = .004).
"This is the first study able to evaluate the effectiveness, not just efficacy, of group diabetes self-management education in actual clinical practice," the researchers say, noting that the benefits they observed in real-world heterogeneous clinical care "mirror those of randomized efficacy trials."
Group classes are a more efficient use of self-management education resources, because providers can deliver care to multiple patients simultaneously, Dr. Shah noted.
Asked if he had theories as to why the group classes had better clinical outcomes, he said: "We were using secondary data, so we didn't have direct access to patients, but other studies that have been published suggest visits tend to be longer — a full day or a half day compared with 20 minutes or half an hour [for individual counseling] — so there is certainly more time spent."
Previous research has also shown that information received from group classes is rated as more "useful" by patients than that received at individual counseling, he said. This likely includes the importance of discussing feelings with others with diabetes.
"Developing that sense of community and talking to others with the same experience and being able to share stories does have some value," he said.
Yet fewer than 1 in 7 self-management education program attendees in Ontario went to group classes, Dr. Shah noted.
"In a time of increasing pressure to find efficiencies in healthcare delivery…the finding that [group classes] reduce acute complications and improve quality of care suggests that they should be the preferred method of delivering self-management [diabetes] education support where it is feasible to do so," he and his colleagues conclude.
The authors have reported no relevant financial relationships.
Can J Public Health. 2004;105: e192-e197. Abstract