Lifelong Management (LM) is an empowerment-based model ideally-suited for long-term DSMS because it is designed to be patient-driven and flexible to the unique needs, priorities, and life circumstances of each individual. This study examined the long-term impact of the 24-month LM intervention on sustaining the self-management gains achieved from previous DSME and a short-term, 6-month DSME enhancement period.
According to our findings, not only did the LM intervention sustain improvements achieved from the 6-month DSME enhancement period, but it also led to additional gains in self-care behaviors and psychosocial functioning. Considering that two key components of the LM intervention were (1) providing face-to-face group-based social support and (2) encouraging participants to set behavioral goals and make action plans, it is not surprising the DSMS intervention was associated with further enhancements in quality of life and three self-care practices (e.g., making healthy dietary decisions, spacing out carbohydrates, and using insulin as prescribed). These findings are consistent with those of previous studies that have found participation in self-management and goal-setting interventions to be associated with improvements in quality of life25
and self-care behaviors [25
Participation in the 24-month LM intervention was not associated with any changes in glycemic control. According to the UKPDS study [27
], without medical treatment, the natural progression of diabetes would result in approximately 0.2% increase in A1C each year (i.e., 12 months). Based on this information, we would expect to see a 0.4% increase in A1C at the end of 24 months. Because glycemic control remained relatively unchanged over the course of the 24-month LM intervention, it is possible that the intervention exerted a stabilizing effect, which is the goal of our DSMS model.
Our study also presented an ideal opportunity to observe natural patterns of attendance over a long period of time. Not surprisingly, the average attendance rate was lower for the last 12 months of the study (m=29%) compared to the first 12 months (m=34%). Notwithstanding, the attendance for the latter half of the intervention is higher than our attendance expectation (i.e., to attract 15–20% of total sample each week) and, therefore, suggests that participants remained engaged in the intervention
We found no relationship between frequency of attendance and improvements (i.e., no dosage effect). Contrary to our findings, a study by Thompson and colleagues  showed that participants who reported more weekly contacts with a community health worker (CHW) showed greater improvements in glycemic control. In Thompson et al’s study [28
], there were several contexts in which a “contact” could occur in any given week (e.g., telephone counseling, face-to-face encounters, walking club, DSME classes, or depression support group etc.). In two of these contexts “contact” was initiated by CHWs rather than the patient. In contrast, in our study, a “contact” was defined as attending a weekly group session with attendance being initiated by the participant. In “real-world” settings, there is neither the time nor resources for healthcare providers to proactively initiate weekly contacts with every individual patient. Furthermore, patients may differ in the type and amount of support they need. Our finding that the frequency of attendance was not related to outcomes suggests that participants do have different support needs and, thereby, seek support (i.e., attend sessions) accordingly. In other words, participants who only need to come to sessions when in crisis may receive the same benefit as participants who need to come every week.
Given that this study was conducted over a period of 30 months, a retention rate of 67% is reasonable. It is not surprising that completers were significantly older than dropouts as older participants are more likely to be retired with more free-time and fewer competing demands (e.g., employed, managing a household) than younger participants. Furthermore, dropouts were more likely to fall into lower income brackets and subsequently, may not have the type of employment that is flexible enough to attend a group being conducted during work hours (10AM and 3PM groups). This finding underscores the challenge of designing an intervention that can accommodate the circumstances of all patients regardless of age, socioeconomic background, ethnicity, etc.
Our results suggest that this type of intervention can have a more expansive reach without additional cost. Typical group-based interventions recruit approximately 8 participants per group and each group is usually facilitated by one or two health care professionals. Based on this traditional model, we would need to conduct 7 or 8 groups to accommodate 60 participants. Alternatively, the LM intervention can accommodate 60 participants while conducting only 2 groups. Future investigations should include a formal cost-effectiveness evaluation.
There were several limitations to this study. Our inclusion criterion for previous DSME was loosely defined. Clearly, a participant who recently completed a 10-hour ADA accredited DSME program has received more intensive education than a participant who raised one or two self-management questions with his/her provider during a 15-minute health care visit. While we attempted to equalize these differences by employing a 6-month DSME enhancement period, it is unlikely that participants, as a whole, started the 24-month DSMS intervention with the maximum self-management benefits derived from participating in a comprehensive DSME program. Given that a high-intensity, face-to-face DSME intervention with active mechanisms for interaction and social support would likely yield greater improvements across more variables (e.g., clinical, behavioral, and psychosocial), subsequent investigations of this DSMS model should include a formal DSME component. While the LM intervention was associated with sustained and enhanced improvements, this study did not use a randomized controlled trial (RCT) design. Therefore, we cannot conclude with certainty that the diabetes-related health improvements were due to the intervention and not for other reasons such as study effects.
Given the chronic nature of diabetes, short-term DSME is not sufficient to produce enduring self-management improvements. To meet the long-term challenges of living with diabetes, newly-designed models for ongoing DSMS need to be flexible enough to accommodate different self-management needs across individuals and be responsive enough to adapt to the ever-changing needs within each individual.