Evidence Based Practice
Critical Appraisal Topic (CAT)
Self-Managed Diabetic Program
Date: July 2 2015
Appraised by: Megan Johns BSN, RN, FNP-S
The management of diabetics can be an overwhelming and daunting for both the patient
and their provider. Education on glucose monitoring, proper insulin administration, and lifestyle
changes are necessary for the newly diagnosed patient to understand and properly apply to their
daily lives. Self-managed diabetic programs are being implemented across primary care clinics
to give the patient control over their diagnosis and empower them to tightly control their
glycemic index without the daily supervision of a provider. “The overall objectives of DSME
(diabetic self-management education) are to support informed decision-making, self-care
behaviors, problem-solving and active collaboration with the health care team and to improve
clinical outcomes, health status, and quality of life” (Funnel et al., 2010).
Case Scenario:
K.S. is a 65-year-old obese man recently diagnosed with type 2 Diabetes Mellitus and associated
Hypertension, Hyperlipidemia, and Depression. He presents with uncontrolled hgb A1C of
10.8%, undocumented blood sugar recordings, and feelings of fatigue, drowsiness, and
lightheadedness. He currently takes Metformin 500mg ER 2 tabs PO at bedtime, Lantus 50 units
daily subcutaneous at bedtime, and Novolog 10units subcutaneous before meals. He is compliant
with his medications but does not monitor or log his blood sugar readings. After education on
side effects and consequences of poorly controlled blood sugars, the patient is willing to take
control of his symptoms and management.
PICO:
Do adult patients with type 2 diabetes have better glycemic control with lower glycated
hemoglobin levels if placed on a self-managed blood sugar-insulin program versus a health care
provider protocol?
Summary and Appraisal of Key Evidence:
Norris et al., sought to discover the effectiveness of self-managed training in type 2
diabetics with a systematic review of 72 studies (2001). They sought to discover how training
diabetics on “knowledge, frequency and accuracy of self-monitoring of blood glucose, selfreported dietary habits, and glycemic control were demonstrated in studies with a short follow-up
(<6 months)” (Norris et al., 2001). This study had maximum validity with randomly selecting
controlled trials that reviewed subjects with type 2 diabetes. These patients were >18 years of
age with any degree of disease severity and any comorbidities. “Self-management training
interventions were classified into one of the following categories by primary educational focus:
knowledge or information; lifestyle behaviors, including diet and physical activity; skill
development, including skills to improve glycemic control such as self-monitoring of blood
glucose, as well as skills to prevent and identify complications and coping skills, including
interventions using empowerment techniques or promoting relaxation or self-efficacy” (Norris et
al., 2001). Results of this study found with a follow-up period of between 6-12 months the
glycemic index was more tightly controlled. Providers found that interventions with regular
reinforcement were more effective in the patient’s glycemic control and overall understanding of
the diagnosis.
Another study by Hou et al., sought to discover the efficacy of blood glucose selfmonitoring on glycemic control in patients with non-insulin treated type 2 diabetes with a metaanalysis of 7 randomized controlled trials (2014). The results of the study found that individuals
with type 2 diabetes had a significant reduction in glycated hemoglobin levels by self-monitoring
their blood glucose levels. “Subgroup analysis showed that while implementation of a diabetes
management regimen based on the blood glucose self-monitoring results effectively reduced the
HbA1c level by 0.42%, no significant improvement in HbA1c level control was observed with
the implementation of blood glucose self-monitoring alone” (Hou, 2014).
Delamater (2006), conducted a randomized study of 597 patients with type 2 diabetes to
examine the “effects of rapid hgbA1c feedback on clinical decision making and subsequent
glycemic control in patients in a primary care setting.” The study found that a rapid feedback of
the A1C levels resulted in a better intensification of therapy when the patient’s level was >7%.
This showed that when patients are involved in the numerical and graphical improvements of
their glycemic control efforts, that they adhered to their programs on a stricter level.
Clinical Bottom Line:
In conclusion, involving diabetic patients in the implementation and monitoring of their
care proved greater glycemic control as evidence by their glycated hemoglobin levels. Providing
proper training through a diabetic self-management education program gave the patient control
over their blood sugar readings and subsequently their diabetic oral agents and insulin
management requirements. This proves that providing patient training on self-management and
self-advocacy of a chronic disease like diabetes can decrease complications, improve self worth,
and provide greater patient outcomes.
References:
Delamater, A. (2006). Clinical Diabetes. Retrieved July 3, 2015, from
http://clinical.diabetesjournals.org/content/24/1/6.full
Funnell, M., Brown, T., Childs, B., Haas, L., Hosey, G., Jensen, B., . . . Weiss, M. (2010).
National Standards for Diabetes Self-Management Education. Retrieved July 3, 2015,
from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797385/
Hou, Y., Li, W., Qiu, J., & Wang, X. (2014, June 1). Efficacy of blood glucose self-monitoring
on glycemic control in patients with non-insulin-treated type 2 diabetes: A meta-analysis.
Retrieved July 3, 2015, from
http://www.sciencedirect.com/science/article/pii/S2352013214000386
Norris, S., Engelgau, M., & Narayan, V. (2001, March 1). Diabetes Care. Retrieved July 3, 2015,
from http://care.diabetesjournals.org/content/24/3/561.full