患者的伴侶一起參與、改善糖尿病控制


  【24drs.com】新研究顯示,對於第二型糖尿病控制不佳的成人,納入他們的配偶或其他承諾參與之夥伴的行為電話訪談,會使結果有所差異。
  
  雪城紐約上州醫科大學、州立大學精神病學暨行為科學教授Paula M Trief博士等人進行的此篇隨機試驗結果,線上發表於7月25日的糖尿病照護期刊。
  
  Trief博士表示,納入有意願的夥伴,可以在幾個方面有所助益。合作的雙方都須同意,介入的目的是幫助他們瞭解糖尿病對他們本身與他們彼此的關係有何影響。
  
  她表示,這個想法是朝向他們如何展開相互幫助之溝通而努力,而不只是監督功能的教練。
  
  醫師或其他醫療保健人員可以詢問患者是否想要夥伴參與,以及他們如何共同應對糖尿病與此疾病對他們的影響。
  
  這篇研究是多中心、歷時12個月的隨機控制試驗,共280組,其中一人的第二型糖尿病控制不佳(HbA1c > 7.5%),他們被隨機分組到三種介入方式之一,都是由糖尿病衛教師進行電話訪談:行為介入雙人通話、行為介入個別通話、個別糖尿病介入通話。
  
  這三組都接到2次初次的75分鐘綜合糖尿病衛教通話,而教育組這組就沒有後續的介入;其他兩組各接到另外10次通話,每次約1小時以內。
  
  這兩組的行為介入包括目標設定、自我監督、行為承諾與促進飲食改變、運動、藥物順從性、血糖監測。
  
  在夥伴介入這組中,夥伴積極參與通話,並鼓勵互相支持改變,使用合作解決問題的技巧,並體認彼此的相互影響,還有兩堂重點在於溝通與衝突管理之課程。
  
  三分之二的患者是男性,約三分之一自述為弱勢族群,他們的平均年齡為57歲、患有糖尿病的時間為12年,有固定關係25.5年,開始時的平均HbA1c是9.1%。
  
  三組的平均HbA1c都顯著降低,整體在任何追蹤時間點皆無顯著差異。
  
  不過, 對於那些開始時的HbA1c居於三分位中間者—也就是8.3% -9.2%者 —只有夥伴組在1年時 HbA1c 顯著降低,從平均8.7%降到8.0% (P < .05)。
  
  開始時的HbA1c低於8.3%者,三個介入組都無改變,而那些開始時的HbA1c大於9.2%者,三個介入組都產生改善。
  
  相較於開始時,只有夥伴組的身體質量指數有些微的顯著減少(12個月時,P = 0.021),而夥伴組和糖尿病教育介入組的腰圍比開始時顯著降低。
  
  不過,個別介入組的收縮壓和舒張壓實際改善最多(8個月時與教育組相比,收縮壓P = 0.021、舒張壓P = 0.032)。
  
  但是,夥伴介入組在一些社會心理檢測有比較好的結果,例如:糖尿病壓力在12個月時顯著低於教育組(P = .009),也顯著低於開始時(P = .03),另外,夥伴組在8個月時的憂鬱症分數也低於開始時(P = .014)。
  
  在對收到的服務程度的滿意度這個問題方面, 83.5%的夥伴組、70.3% 的個別介入組、41.3%的教育組表示非常滿意。
  
  夥伴組的差異顯著高於個別介入組(P = .05),這兩組則是顯著優於教育組(P < .001)。
  
  Trief博士表示,事實是,HbA1c值最高的患者對於糖尿病衛教的反應影響了結果。
  
  另外,夥伴介入組和可比較之個別介入組的比較方面,肯定是一個挑戰,因為任何行為介入都會有很多影響,使它難以釐清兩種行為介入的差異。
  
  她觀察發現,其他研究大部份使用一般照護作為比較。
  
  這就表示,我認為對居於三分位中間者的影響是相當驚人的,特別是這些人大部份是醫師在實務上所診治的患者。雖然這些討論要花一點時間,如果可以讓夥伴積極配合,它就值得了。
  
  本篇研究接受國家健康研究院(NIH)資助,第一年的資金是由NIH多樣性獎學金補助。Trief博士無相關財務關係;其他共同作者的相關宣告列於文中。
  
  資料來源:http://www.24drs.com/
  
  Native link:Involving Patient's Partner May Improve Diabetes Control
  

Involving Patient's Partner May Improve Diabetes Control

By Miriam E Tucker
Medscape Medical News

For adults with poorly controlled type 2 diabetes, a behavioral telephone intervention that includes their spouse or other committed partner may make a difference, new research shows.

Results from the randomized trial were published online July 25 in Diabetes Care by Paula M Trief, PhD, professor of psychiatry and behavioral sciences at State University of New York Upstate Medical University, Syracuse, and colleagues.

"It is likely to be beneficial in several ways to involve partners who are willing.…Both partners need to agree, and the intervention should be aimed at helping them see how diabetes affects each of them and their relationship," Dr Trief told Medscape Medical News.

The idea, she said, is "to strive toward opening up communication about how they can help each other, not for the partner to be a watchdog but to be a supportive coach."

Clinicians or other healthcare workers can ask if the patient would like the partner to participate and how they are working together to address diabetes and its effect on them.

Benefit Seen Among Those With HbA1c 8.3%–9.2%

The study was a multicenter, 12-month, randomized controlled trial involving 280 couples with one partner who had poorly controlled type 2 diabetes (HbA1c > 7.5%). They were randomized to one of three interventions, all delivered by telephone by diabetes educators: behavior-intervention couples calls, behavior-intervention individual calls, or individual diabetes education calls.

All three groups received two initial 75-minute calls of comprehensive diabetes education. In the education group, there was no further intervention.

The other two groups received 10 additional calls each, lasting just under an hour.

The behavioral interventions in both of those groups included goal-setting, self-monitoring, and behavioral contracting and promoted changes in diet, activity, medication adherence, and blood glucose monitoring.

In the couples' intervention, partners were actively involved in the calls and were encouraged to provide mutual support for change, using collaborative problem-solving techniques and recognizing the reciprocal effects each had on the other. Two sessions also focused on communication and conflict management.

Two-thirds of the patient participants were male, and nearly one-third were self-described minorities. They had a mean age of 57 years and diabetes duration of 12 years and had been in the committed relationship for 25.5 years, on average. The mean baseline HbA1c was 9.1%.

Significant reductions in mean HbA1c occurred in all three groups, with no significant differences overall at any follow-up.

However, for those in the middle tertile of baseline HbA1c — 8.3% to 9.2% — HbA1c was significantly lower at 1 year only in the couples group, dropping from a mean of 8.7% to 8.0% (P < .05).

There were no changes in any of the three intervention groups for those with baseline HbA1c below 8.3%, while for those starting with HbA1c above 9.2%, all three interventions produced an improvement.

Other Improvements Seen With the Different Interventions

Compared with baseline, there were small, significant reductions in body mass index only for the couples' intervention (P = 0.021 at 12 months), while both the couples and the diabetes-education interventions significantly reduced waist circumferences compared with baseline.

However, both systolic and diastolic blood pressure actually improved most in the individual intervention group (compared with the education group at 8 months, P = 0.021 for systolic and P = 0.032 for diastolic).

But the couples intervention produced superior results for some psychosocial measures, including significantly lower diabetes distress at 12 months than in the education group (P = .009) and compared with baseline (P = .03). Also, the couples group had reduced depression scores at 8 months compared with baseline (P = .014).

On a questionnaire that asked about "satisfaction with the amount of help received," 83.5% of the couples group, 70.3% of the individual intervention, and 41.3% of the education group reported being "very satisfied."

The differences were significantly higher for the couples group compared with the individual-intervention group (P = .05) and for both of those compared with the education group (P < .001).

The fact that the patients with the highest HbA1c levels responded to diabetes education affected the results, Dr Trief said.

And she noted that the comparison of the couples intervention with a comparable individual intervention "was certainly a challenge, since there's just so much effect any behavioral intervention will have, making it harder to find differences between two behavioral interventions."

Most other studies have used "usual care" as a comparison, she observed.

"That said, I think the effect on the middle-tertile group was quite striking, especially since that's the group most clinicians see in their practices.…While it can take time to have these discussions, if it positively engages the partner it can be worth it."

This study was supported by a National Institutes of Health (NIH) grant, and the first year was funded by a NIH diversity fellowship supplement. Dr Trief has no relevant financial relationships; disclosures for the coauthors are listed in the article.

    
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