Clinical Issue
The clinical issue being addressed is diabetes, a major health concern in the country due to the high risk of morbidity and mortality and the high care costs. Diabetes management is essential in reducing the disease’s negative effects, especially for patients newly diagnosed with diabetes. Self-management can be effective in reducing complications, which increases hospitalization and visits to the emergency room. A patient’s A1c levels are essential in reducing the risks of complications and other negative effects. Self-management to control A1c levels requires comprehensive care comprising of usual care, diabetes education, and case management. The following is the developed PICOT question to guide the review: Among newly diagnosed diabetic patients with A1c levels of nine (9) or greater (P), how does primary care, matched with nurse case managers and diabetic educators (I), compared to no case management (C), contribute to lower A1c levels and fewer emergency room visits and hospitalizations (O) over one year (T)?
Search Methods
Major databases utilized in the article search were CINAHL and PubMed. The search was completed using key phrases such as ‘diabetes-related education,’ ‘case management in diabetes care, ‘education interventions, ‘ and ‘technology-based education.’ The phrases were typed separately in the first search and then combined to make complete sentences. Exclusion criteria used included articles over five years old, systematic reviews, reports or summary articles, those published in other languages, and those available only in abstracts. The articles selected were those relevant to the PICOT questions with evidence supporting the question.
Synthesis of the Literature
One of the articles selected was a case-control study that aimed to assess the impact of health education on attitude, knowledge levels, practices, and glycemic control in patients diagnosed with type 2 diabetes mellitus. The study occurred in the Medicine department of a tertiary care teaching hospital in India and involved 100 diabetic subjects aged above 40 years. The intervention group received education on lifestyle modification and drugs and was issued a leaflet. The intervention group achieved significant changes in knowledge levels, practice, attitude, and HbA1C levels (Chawla et al., 2019). The findings support the PICOT as they show that diabetic-related education significantly reduces A1c levels.
Another article selected is a quasi-experimental study that compared the effects of an intensive 360 min educational intervention on HBA1c parameters in diabetic patients to the usual 90-min intervention. The study involved 249 participants, with 171 assigned to the control groups and 78 to the intervention group. The intervention group received more intense patient education covering many areas. The intervention group reported a decrease in HbA1c mean value from 8.97 to 8.06, while the control group reduction was from 6.97 to 6.75 (Martos-Cabrera et al., 2021). There was a statistically significant mean difference between the two groups, with the intervention group reporting a higher reduction in HbA1c levels. The findings support the PICOT question as the intensive educational intervention reduced A1c levels significantly.
The third article is a pilot observational study conducted for 12 months with a sample size of 40 participants. The study evaluated the contribution of community pharmacists as case managers in improving adherence to the individual care plan. The researchers reported increased adherence to individual treatment plans and improvements in clinical and biological parameters, including LDL-cholesterol, systolic and diastolic blood pressure, and HBA1c levels. A -4% reduction in A1c levels was attained by the end of 12 months (La Regina et al., 2020). The findings support the PICOT question that case management contributes to reduced A1c levels. Having community pharmacists as case managers and increased collaboration between physicians and pharmacists increased patient adherence to treatment plans resulting in improvements in reducing hospitalization and emergency visits.
The fourth article is a randomized controlled trial that examined the cost-effectiveness of technology-assisted case management (TACM). A total of 113 participants were randomized to the usual care and intervention group. The TACM intervention capitalized on information technology to link a case manager to diabetic patients with poorly controlled diabetes. All data analyses were done using Stata/SE 15 and R, with the study’s statistical significance being considered at p<0.05. The findings indicated a standardized cost saving of $1000 to $4,000 for a 1% change in HbA1c per year (Egede et al., 2021). Improvements in glycemic control are also associated with improved outcomes, less hospitalization, and fewer complications. The article supports the PICOT as the evidence shows that case management reduces HbA1c levels, associated with significant cost-saving due to less demand for care, including emergency visits.
The other article reviewed was a quasi-experimental study that explored the effectiveness of a health education intervention implemented in a public school in Pakistan. The researchers randomly selected 136 respondents from a secondary school. The intervention was a health education session for diabetes prevention and continued for 100 minutes. There was pre-test and post-test data collection. Paired t-test was used in data analysis. Findings indicated an increase in diabetes knowledge from 20.03 to 49.11 and statistically significant changes (P<0.05) in diabetes symptoms, preventive practices, complications, and overall score (Kumar et al., 2022). The study’s findings support the PICOT as they support the effectiveness of diabetes education in improving symptoms, reducing complications, and preventive practices, which can be associated with decreased hospitalization and visits to the ED.
The other study included is a quantitative study that compared processes and outcomes of diabetic care provided to older patients by primary care physicians only versus team care offered by physician assistants (PAs) and nurse practitioners (NPs). The researchers studied 3,524 primary care practices and used 2015 Medicare claims. Findings indicated that patients in care teams with NPs or PAs were provided with more guideline-recommended care than care from PCPs-only teams regarding eye examination, nephropathy, and HbA1c testing. Patients in all teams achieved comparable clinical outcomes regarding preventable hospitalization (Guo et al., 2020). The findings support the PICOT question as it shows the need for NPs and PAs in case management for diabetes as they facilitate the delivery of holistic care.
Another study that was found relevant focused on describing patient experiences of group-based education for diabetes based on the Taking Charge of One’s Life with Type 2 Diabetes model. The study adopted a qualitative approach and conducted group and individual interviews. The education comprised five two-hour sessions with 12 participants. The intervention was effective as patients could learn through reflections on their own and others’ experiences and were motivated to be more responsible for their treatment (Kjellsdotter et al., 2020). These findings support the PICOT by demonstrating the effectiveness and capacity of diabetes-related education in improving outcomes, especially the HbA1c levels.
The last article reviewed is a multinational investigation that aimed to identify common barriers to effective diabetes self-management and identify the enablers. The researchers conducted an international online survey and telephone interviews with patients diagnosed with type 1 and type 2 diabetes. Data analysis was conducted using descriptive and inferential statistics. Identified gaps included the inability to exercise diet planning to avoid hypoglycemia, inability to interpret blood glucose pattern levels, and managing stress impact on diabetes. Enablers included the will to prevent diabetes-related complications and use technological devices (Adu et al., 2019). The study highlights educational reinforcement as an enabler of self-management with significant improvement in outcomes, providing the basis for the PICOT question.
Comparison of Articles
The researchers in the eight studies reviewed focus on different aspects, but all relate to diabetes management through education and the significance of case management in improving outcomes. Researchers have adopted various approaches, including qualitative and quantitative approaches, and different methodologies, including randomized control trials, quasi-experimental studies, case-control, and observational approaches. Some of the common themes identified include the effectiveness of educational programs in increasing diabetes-related knowledge, skills for self-management, and reducing HbA1c levels (Chawla et al., 2019: Egede et al., 2021: Kjellsdotter et al., 2020: Kumar et al., 2022: Martos-Cabrera et al., 2021). Some educational interventions implemented by researchers include group-based education, intensive and structured patient education, nursing-intense health education, verbal sessions, and leaflets. Three articles focus on case management and its impacts on diabetes. One of the two studies focused on community pharmacists as case managers, which led to increased adherence to the treatment plan reducing hospitalization and visits to the ED (La Regina et al., 2020). The other article focused on technology-assisted case management, which was found to be cost-effective with a reduction of HbA1c levels (Egede et al.,2021). The third article highlighted differences in team care depending on team composition. Team care involving NPs and PAs recorded better outcomes compared PCPs only teams (Guo et al., 2020).
One of the articles reviewed highlighted enablers and barriers to self-management, information that case managers can utilize to increase effectiveness (Adu et al., 2019). The studies conclude that diabetes-related education and case management are key to improving health and clinical outcomes. Major limitations highlighted include small sample size, limited generalizability, and bias due to self-reported data (Egede et al., 2021: Guo et al., 2020; La Regina et al., 2020).
Suggestions For Future Research
Future research can seek to replicate the results with improvements based on the limitations of previous studies. For example, using a bigger sample size. There should also be research to identify solutions to barriers to diabetes self-management. Other areas that may require additional research include the role of technology in diabetes-related patient education and the most effective health education intervention. For example, comparing group versus individual interventions.
Conclusion
The articles reviewed support the PICOT question as they present evidence on how diabetes educators and case managers lower A1c levels and reduce hospitalization and visits to the emergency room. Diabetes educators equip the patients with knowledge and skills that motivate and empower them to practice healthy lifestyles, including monitoring their diet, blood sugar levels, physical exercise, and adherence to treatment. Case managers also increase adherence to individual treatment plans. However, educators and case managers should identify enablers and barriers to improve patient participation. Technology is also essential in education and case management.

References
Adu, M. D., Malabu, U. H., Malau-Aduli, A. E., & Malau-Aduli, B. S. (2019). Enablers and barriers to effective diabetes self-management: A multinational investigation. PloS One, 14(6), e0217771. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217771
Chawla, S. P. S., Kaur, S., Bharti, A., Garg, R., Kaur, M., Soin, D., & Pal, R. (2019). Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. Journal of Family Medicine and Primary Care, 8(1), 261. https://doi.org/10.4103/jfmpc.jfmpc_228_18
Egede, L. E., Dismuke, C. E., Walker, R. J., Williams, J. S., & Eiler, C. (2021). Cost-Effectiveness of Technology-Assisted Case Management in Low-Income, Rural Adults with Type 2 Diabetes. Health Equity, 5(1), 503-511. https://pubmed.ncbi.nlm.nih.gov/34327293/
Guo, F., Lin, Y. L., Raji, M., Leonard, B., Chou, L. N., & Kuo, Y. F. (2020). Processes and outcomes of diabetes mellitus care by different types of team primary care models. Plos One, 15(11), e0241516. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241516
Kjellsdotter, A., Berglund, M., Jebens, E., Kvick, J., & Andersson, S. (2020). To take charge of one’s life-group-based education for patients with type 2 diabetes in the primary care-a lifeworld approach. International Journal of Qualitative Studies on Health and Well-Being, 15(1), 1726856. https://www.tandfonline.com/doi/abs/10.1080/17482631.2020.1726856
Kumar, R., Rehman, S., Baloch, G. M., Vankwani, M., Somrongthong, R., & Pongpanich, S. (2022). Effectiveness of health education intervention on diabetes mellitus among the teachers working in public sector schools of Pakistan. BMC Endocrine Disorders, 22(1), 1-6.
https://bmcendocrdisord.biomedcentral.com/articles/10.1186/s12902-022-01110-7
La Regina, R., Pandolfi, D., Stabile, N., Beloni, L., Glisenti, F., Griggio, P., … & La Regina, G. (2020). A New Case Manager for Diabetic Patients: A Pilot Observational Study of the Role of Community Pharmacists and Pharmacy Services in the Case Management of Diabetic Patients. Pharmacy (Basel, Switzerland), 8(4), 193. https://pubmed.ncbi.nlm.nih.gov/33086680/
Martos-Cabrera, M. B., Gómez-Urquiza, J. L., Cañadas-González, G., Romero-Bejar, J. L., Suleiman-Martos, N., Cañadas-De la Fuente, G. A., & Albendín-García, L. (2021). Nursing-Intense Health Education Intervention for Persons with Type 2 Diabetes: A Quasi-Experimental Study. In Healthcare (Vol. 9, No. 7, p. 832). MDPI AG. https://doi.org/10.3390/healthcare9070832