How can clinical practices pragmatically increase physical activity for patients with type 2 diabetes? A systematic review

Abstract

Although regular physical activity (PA) is a cornerstone of treatment for type 2 diabetes (T2D), most adults with T2D are sedentary. Randomized controlled trials (RCTs) have proven the effectiveness of PA behavioral interventions for adults with T2D but have rarely been conducted in healthcare settings. We sought to identify PA interventions that are effective and practical to implement in clinical practice settings. Our first aim was to use the valid Pragmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool to assess the potential for future implementation of PA interventions in clinical practice settings. Our second aim was to identify interventions that effectively increased PA and glycemic control among the interventions in the top tertile of PRECIS-2 scores. We searched PubMed MED-LINE from January 1980 through May 2015 for RCTs of behavioral PA interventions coordinated by clinical practices for patients with T2D. Dual investigators assessed pragmatism by PRECIS-2 scores, and study effectiveness was extracted from original RCT publications. The PRECIS-2 scores of the 46 behavioral interventions (n = 13,575 participants) ranged from 3.0 to 4.8, where 5 is the most pragmatic score. In the most pragmatic tertile of interventions (n = 16) by PRECIS-2 scores, 30.8 and 31.3% of interventions improved PA outcomes and hemoglobin A1c, respectively. A minority of published evidence-based PA interventions for adults with T2D were both effective and pragmatic for clinical implementation. These should be tested for dissemination using implementation trial designs.

Excellent multi-stakeholder acceptability and reimbursable costs in a pilot pragmatic trial of an evidence-based physical activity counseling intervention for patients with type 2 diabetes

“…Key elements of these pragmatic EBPs included the use of simple tools to operationalize effective behavioral counseling, such as a checklist, motivational interviewing approaches, and use of a coach/care manager to guide patients to set and monitor PA goals. Our review also found that even pragmatic and effective programs were rarely sustained after grant funding ceased, thus identifying a pressing need for implementation strategies addressing costs and financial reimbursement (7). So, the key question emerging from this review was: how can pragmatic PA EBPs be adapted to work in real-world primary care?…”

“…Conversely, regular PA improves physical function, quality of life, glycemic control, and cardiovascular risk (7)(8)(9)(10)(11)(12)(13)(14). However, changing sedentary behavior has been difficult for patients with T2D outside a formal PA behavioral intervention (7,(15)(16)(17). Prior PA behavioral interventions delivered in health systems were often too time and resource-intensive to be practical for clinical practices (7).…”

“…However, changing sedentary behavior has been difficult for patients with T2D outside a formal PA behavioral intervention (7,(15)(16)(17). Prior PA behavioral interventions delivered in health systems were often too time and resource-intensive to be practical for clinical practices (7). To move towards integrating PA interventions into clinical practice, we need evidence-based PA interventions that are simple enough to be feasible, replicable, and effective.…”

“…Our recent systematic review identified several PA counseling programs that were delivered in health systems, improved PA for adults with T2D, and were rated as highly pragmatic for real-world health system use, hereafter termed "pragmatic evidence-based programs (EBPs)" (7). Key elements of these pragmatic EBPs included the use of simple tools to operationalize effective behavioral counseling, such as a checklist, motivational interviewing approaches, and use of a coach/care manager to guide patients to set and monitor PA goals.…”

A comparison of meta-analytic methods for synthesizing evidence from explanatory and pragmatic trials

“…More recently, Jordan et al [ 23 ] also demonstrated the potential benefit of using the PRECIS-2 instrument for aiding systematic review and meta-analysis of studies in hepatitis C virus care. Louma et al [ 24 ] used PRECIS-2 to identify interventions that effectively increased physical activity and glycemic controls among patients with type 2 diabetes and assess the potential use of PRECIS-2 for implementing physical activity interventions in clinical practice settings.…”