More residents perceived that sleep loss and fatigue had major impact on their personal lives during residency, leaving many personal and social activities and meaningful personal pleasures deferred or postponed. Sleep loss and fatigue also had major impact on residents' abilities to perform their work. This finding further substantiates the growing concern about the potential impact on professional development. These observations should be taken into account in developing new training guidelines and educational interventions for housestaff.
BACKGROUND: Patient activation interventions (PAIs) engage patients in care by promoting increased knowledge, confidence, and/or skills for disease self-management. However, little is known about the impact of these interventions on a wide range of outcomes for adults with type 2 diabetes (DM2), or which of these interventions, if any, have the greatest impact on glycemic control. METHODS: Electronic databases were searched from inception through November 2011. Of 16,290 citations, two independent reviewers identified 138 randomized trials comparing PAIs to usual care/control groups in adults with DM2 that reported intermediate or longterm outcomes or harms. For meta-analyses of continuous outcomes, we used a random-effects model to derive pooled weighted mean differences (WMD). For allcause mortality, we calculated the pooled odds ratio (OR) using Peto's method. We assessed statistical heterogeneity using the I 2 statistic and conducted meta-regression using a random-effects model when I 2 >50 %. A priori meta-regression primary variables included: intervention strategies, intervention leader, baseline outcome value, quality, and study duration. RESULTS: PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37 %, CI 0.28-0.45 %, I 2 83 %; SBP: WMD 2.2 mmHg, CI 1.0-3.5 mmHg, I 2 72 %; body weight: WMD 2.3 lbs, CI 1.3-3.2 lbs, I 2 64 %; and LDLc: WMD 4.2 mg/dL, CI 1.5-6.9 mg/dL, I 2 64 %]. The evidence was moderate for A1c, low/very low for other intermediate outcomes, low for long-term mortality and very low for complications. Interventions had no effect on hypoglycemia (evidence: low) or short-term mortality (evidence: moderate). Higher baseline A1c, pharmacistled interventions, and longer follow-up were associated with larger A1c improvements. No intervention strategy outperformed any other in adjusted meta-regression. CONCLUSIONS: PAIs modestly improve A1c in adults with DM2 without increasing short-term mortality. These results support integration of these interventions into primary care for adults with uncontrolled glycemia, and provide evidence to insurers who do not yet cover these programs. INTRODUCTIONType 2 diabetes is common and contributes to excess morbidity, mortality, and health care costs, accounting for approximately one in five U.S. health care dollars. 1,2 Behavioral interventions are one important way to improve patient outcomes, 3 yet less is known about a subset of novel behavioral interventions focused on engaging patients in care 4-6 (often termed "patient activation" 7,8 ). Hibbard et al. 7,9 have described patient activation interventions as those that promote motivation, knowledge, and disease self-management skills. 7,9 Despite the growing evidence suggesting improved patient outcomes by engaging patients, 4-6,10 these interventions are often not integrated into practice due to uncertainty about benefit, lack of resources needed for integration, lack of health insurance coverage across insurers, and lack of clarity on the best strategies to incorporate. 11,12 Understanding the imp...
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