Change is possible: How increased patient activation is associated with favorable changes in well-being, self-management and health outcomes among people with type 2 diabetes mellitus: A prospective longitudinal study

Impacts of Diabetes Stigma on Acute Health Care Utilization Among Adults With Type 2 Diabetes

PurposeThe purpose of this study was to examine the relationships between diabetes stigma, patient activation, and acute health care use. It was predicted that greater diabetes stigma would be associated with lower patient activation and greater likelihood of acute health care utilization.MethodsPrimary data were collected cross-sectionally using a web-based panel of US adults with type 2 diabetes (N = 371). Participants were screened for eligibility by providing informed consent, reporting a type 2 diabetes diagnosis from a health care provider, and passing an end-of-survey check to corroborate participants' initial self-reported diagnosis of type 2 diabetes. The Diabetes Stigma Assessment Scale, with its 3 subscales, assessed blame and judgment, perceived discrimination, and self-stigma associated with having diabetes. Patient activation was measured using the Patient Activation Measure. The frequency of diabetes-related emergency department visits and hospitalizations during the prior 12 months measured acute health care use.ResultsSelf-stigma was significantly associated with lower levels of patient activation, and blame and judgment and perceived discrimination were not. Perceived discrimination was also significantly associated with greater risk of emergency department visits and hospitalizations, and self-stigma and blame and judgment were not associated with either indicator of acute health care use.ConclusionsResults suggest self-stigma is associated with lower levels of patient activation and that perceived discrimination is related to increased use of acute health care. Future research may examine avenues to reduce diabetes stigma and its effect on patient activation and acute health care utilization.

Association between patient activation, self-management behaviours and clinical outcomes in adults with type 2 diabetes: a systematic review with narrative synthesis

OBJECTIVES

Patient activation (PAct)-a measure assessing an individual's perceived knowledge, skills and confidence in managing their health and well-being-is often used to personalise and evaluate care, although its causal link to self-management behaviours (SMBs) and clinical outcomes remains uncertain. We aimed to synthesise the evidence on the causal association between PAct, SMBs and clinical outcomes in type 2 diabetes (T2D).

DESIGN

Systematic review and narrative synthesis of data summarised in a harvest plot.

DATA SOURCES

We searched Medline, Embase, CENTRAL, PsycInfo, Web of Science and CINAHL up to April 2024 for relevant English articles.

ELIGIBILITY CRITERIA

We included studies of any quantitative design that reported on the association of PAct with clinical outcomes or SMBs in adult patients with T2D.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers were involved, and any disagreements were discussed and resolved collaboratively. Risk-of-bias (RoB) was assessed using an adapted RoB Assessment Tool for Nonrandomised Studies. Levels of evidence were evaluated for each T2D-related outcome.

RESULTS

We identified 21 studies published between 2009 and 2023, including 15 cross-sectional studies and no randomised controlled trials. Eleven studies were conducted in the USA. Seventeen studies used the Patient Activation Measure questionnaire. There is moderate evidence that higher PAct scores are associated with better glycated haemoglobin levels (studies reporting on this association, n=14). There is very limited evidence that PAct improves diet (n=5) and physical activity (n=6). All other clinical outcomes and SMBs had inconclusive results due to either inconsistent or insufficient evidence, or both.

CONCLUSION

A causal relationship between PAct, clinical outcomes and SMBs in T2D cannot be established due to inconsistent evidence and a lack of high-quality studies. Thus, the use of PAct scores as a tailoring tool and an outcome measure in healthcare services requires further evaluation.

PROSPERO REGISTRATION NUMBER

CRD42021230727.

How a nation's well-being influences its health profile: an analysis of critical indicators

This study examines the impact of macroeconomic well-being indicators-GDP, health spending as a percentage of GDP, and the unemployment rate-on the prevalence of chronic diseases, including circulatory and respiratory diseases and diabetes mellitus, across 27 European Union countries over 21 years. Utilizing advanced econometric methods like General Method of Moments, Structural Equation Modeling, and wavelet coherence analysis, the research reveals that higher GDP correlates with increased disease prevalence, while greater health spending reduces it. The unemployment rate significantly affects diabetes prevalence. The study introduces the "Economic Prosperity and Chronic Disease Paradox," theory, which suggests that economic growth, while improving healthcare access and living standards, paradoxically increases chronic disease rates due to lifestyle changes such as unhealthy diets, sedentary behavior, and pollution. This theory highlights the need for strategic public health policies to counteract these adverse effects and promote sustainable health outcomes amidst economic development.

Patient-Centered Communication and Mental Health of Sexual Minority Adults: A Moderated Mediation Model

Health and health care disparities confronting sexual minority (i.e. non-heterosexual identified) adults are well-documented. Meanwhile, patient-centered communication (PCC) is shown to be effective for health care delivery and health promotion among sexual minority individuals. However, there remains a dearth of research that links PCC and sexual minority adults' mental health. This study examines the relationship between PCC and mental health among sexual minority adults by focusing on the mediating role of health self-efficacy and the moderating role of eHealth. Data from all non-heterosexual identified respondents (N = 350; mean age = 56.23 years; 65.7% female) of the Health Information National Trends Survey collected in 2017 (HINTS 5 Cycle 1) were analyzed. Results indicate that after controlling for respondents' age, gender, and education, health self-efficacy mediated the relationship between PCC and mental health. Meanwhile, the mediating effect of health self-efficacy was moderated by eHealth. Findings from this study provide a more precise understanding of the mechanism that underlies the relationship between PCC and sexual minority adults' mental health as well as inform the development of interventions to address their health care disparities.

Assessing the Impact of Community Health Coaching on Self-Management of Chronic Illness Among Older Adults: A Cross-Sectional Approach

Background

Chronic illnesses among older adults require effective self-management strategies. Community health coaching, which provides personalized guidance and support, has shown promise in improving self-management behaviors and patient activation. This study examines the impact of health coaching on self-management among older adults and investigates the mediating role of patient activation.

Methods

A cross-sectional study was conducted with 200 older adults with chronic illnesses attending primary healthcare centers in Riyadh, Saudi Arabia. Data were collected using the Patient Activation Measure (PAM-13), Self-Management Behavior Scale (SMBS), and Health Coaching Perception Questionnaire (HCPQ). Multiple regression and mediation analyses were conducted to assess the relationships between health coaching, patient activation, and self-management behaviors.

Results

Health coaching was significantly associated with improved self-management behaviors (β = 0.42, p < 0.001). Higher satisfaction with coaching was related to better medication adherence and dietary modification. Patient activation partially mediated the relationship between health coaching and self-management, with an indirect effect coefficient of 0.22 (p < 0.01). The results highlight the role of activation in enhancing health coaching effectiveness.

Conclusion

Community health coaching positively influences self-management behaviors in older adults, with patient activation serving as a critical mediator. Integrating health coaching into primary care could improve chronic illness management and support healthy aging.

Patient activation and support needs in patients after ICU discharge: A UK survey of critical illness survivors

Background

Understanding the degree to which patients are actively involved, confident and capable of engaging with self-management and rehabilitation could be an initial step in guiding individualised supportive strategies for people after critical illness.

Aims

To assess the levels of active involvement with self management among ICU survivors using the Patient Activation Measure (PAM), explore associations between patient characteristics and PAM results, and investigate its relationship with patients' support needs at key transition points during the recovery process.

Methods

Eligible participants received both the PAM and Support Needs After Critical care (SNAC) questionnaires by post. The return of the completed questionnaires was considered as consent to participate. Ethical approval was obtained (17/NI/0236). Descriptive statistics were used to summarise the data and Pearson's coefficient for correlations between variables.

Findings

There were 200 completed PAM and SNAC questionnaires. PAM scores showed that levels of active involvement with self management fell into level 1 (n = 64; disengaged and overwhelmed, low confidence to self manage) and 2 (n = 70; still struggling), with considerably less participants achieving scores in level 3 (n = 51; taking action) and 4 (n = 15; pushing further). Lower patient activation levels were associated with higher support needs (r = -0.16, p = 0.02).

Conclusion

We found that patient activation levels are low implying low knowledge, skills and confidence to self-manage after critical illness, and also that patients have support needs at various timepoints during recovery. Future research should focus on a longitudinal study to track changes in activation and support needs in the same patients over time and identify effective strategies to optimise recovery after critical illness.

Tailoring nursing interventions to empower patients: personal coping strategies and self-management in type 2 diabetes care

BACKGROUND

Diabetes is one of the most common chronic diseases that severely reduce a patient's quality of life. Effective self-care and management are critical for maintaining blood glucose levels and preventing complications.

AIM

This study evaluates the effectiveness of a structured diabetes self-management education program on patients' self-management behaviors, empowerment, and activation levels.

METHODS

This study employed a quasi-experimental design involving 100 participants aged 30-65 to improve diabetes self-management and empowerment. Over 16 weeks, the program included three phases: a two-week pre-test phase for recruitment and baseline assessments using the Diabetes Self-Management Questionnaire (DSMQ), Diabetes Empowerment Scale (DES), and Patient Activation Measure (PAM); a 12-week intervention phase featuring weekly 90-minute educational sessions on topics such as diet, exercise, medication adherence, stress management, and self-empowerment; and a two-week post-test phase for follow-up assessments using the same tools. Data were analyzed using descriptive statistics, chi-square tests for PAM levels, and paired t-tests for DSMQ and DES scores, with statistical significance set at p < 0.05.

RESULTS

The study demonstrated significant improvements in participants' self-management, empowerment, and activation levels after the intervention. DSMQ scores increased from 64.5 to 68.6 (p < 0.001), DES scores rose from 65.4 to 70.0 (p = 0.001), and the number of participants at the highest PAM activation level (Level 4) grew from 30 to 50 (p = 0.016). Positive correlations among DSMQ, DES, and PAM scores suggest these improvements are interrelated.

CONCLUSION

The structured diabetes self-management education programme significantly impacted participants' self-management behaviors, empowerment, and activation levels. The findings underscore healthcare professionals' need to implement targeted interventions that facilitate patient engagement in diabetes care.

RECOMMENDATION

Future interventions should be designed to address the specific needs of diverse populations, paying attention to those facing socio-economic challenges. It is vital to facilitate greater access to diabetes self-management education to enhance health outcomes for these demographic groups.

Enhancing patient activation: a controlled implementation study of an interprofessional evidence-based counseling program for complementary and integrative healthcare in cancer patients ('CCC-Integrativ')

Complementary and integrative healthcare (CIH) is increasingly recognized as a valuable approach to empowering and activating cancer patients. Studies have shown that higher patient activation is positively associated with improved health outcomes and reduced healthcare costs. The CCC-Integrativ study aimed to assess the implementation of an evidence-based counseling service on CIH at four Comprehensive Cancer Centers (CCC) in Germany. In this controlled implementation study, the patient-level intervention included three CIH consultations within a 3-month period delivered by interprofessional teams of physicians and nurses. The primary endpoint was patient activation using the PAM-13 at baseline (T1) and post-intervention (T2), and compared between control (CO, receiving routine care) and the intervention group (IG) using an analysis of covariance. Missing data were handled with multiple imputations. Maintenance effects at 6-month follow-up (T3) were investigated using a linear mixed model. A total of n = 1128 oncology patients (CO = 443, IG = 685) with diverse tumor entities and cancer stages were included in the study. The overall mean baseline PAM-13 score was 69.74 (SD = 14.24) (n = 959 (85.0%)). A statistically significant between-group difference in post-intervention PAM-13 scores was observed (Fgroup(1, 1866.82) = 8.634, P = 0.003), with an adjusted mean difference of 2.22 PAM-points. Age, gender, tumor entity, disease stage, or CCC study site did not significantly predict post-treatment PAM-13 scores. The maintenance effect of the intervention was not statistically significant (FtimeXgroup(1, 3316.04) = 2.337, P = 0.096). Individually tailored counseling on CIH, offered by specifically trained, interprofessional teams, significantly improved patient activation. Given the established positive effects of higher patient activation, the implementation of such a program at cancer centers may yield beneficial outcomes for both patients and the healthcare system.

Challenges experienced by those with polycystic ovary syndrome in healthcare interactions: a qualitative evidence synthesis

Studies report interaction difficulties between patients with polycystic ovary syndrome (PCOS) and healthcare professionals (HCP). This systematic review and qualitative evidence synthesis aimed to collate and synthesize the existing peer-reviewed literature investigating challenges for people with PCOS when interacting with HCP. Medline, PsycInfo, EMBASE, All EBM and CINAHL were searched from 1990 to September 2022. Study risk of bias (RoB) was performed and all textual data relevant to challenging interactions between patients with PCOS and HCP were extracted and analysed using thematic synthesis. Of the 6353 studies identified, 28 were included. Two were appraised as high, four as moderate and 22 as low RoB. Four analytic themes were derived illustrating that interactions were challenging when: (i) medical information (PCOS, its management) was not shared in the best way; (ii) information provision and deliberation opportunities were insufficient to achieve outcomes that mattered to patients; (iii) interactions prompted but did not support patient activation; and (iv) health system-level barriers (e.g. policies and guidelines) were present or made worse by HCP behaviour. Future research should examine methods for the implementation and evaluation of established frameworks for sharing medical information and supporting patient agency in the context of PCOS care.

Research status and hotspots of patient engagement: A bibliometric analysis

OBJECTIVE

This analysis aimed to examine current global trends in patient engagement research and identify critical focus areas.

METHODS

We searched the Web of Science Core Collection database for pertinent literature from January 1, 2000 to December 31, 2022. CiteSpace and VOSviewer were used for information analysis.

RESULTS

The bibliometric analysis covered 11,386 documents from 140 countries/regions, featuring contributions from 12,731 organizations and 45,489 authors. The United States and The University of Toronto were the most prolific country and institution. Leading researchers in publications and citations included Hibbard JH, Elwyn G, Legare F, and Street RL. Patient Education and Counseling led among journals.

CONCLUSION

Patient engagement research has experienced significant growth over the past two decades. The core of patient engagement research includes concepts, content, practical frameworks, impact assessment, and barriers. The current research focal points revolve around interventions for chronic disease patients, integrating digital health technologies to improve engagement, and incorporating patient-reported outcomes (PROs) into healthcare delivery.

PRACTICE IMPLICATIONS

This study unveils key trends and emphasizes global collaboration, strategic focus on chronic disease interventions, integration of digital health technologies, and the pivotal role of PROs. Embracing these insights promises to optimize healthcare practices and empower patients on a global scale.

Determinants associated with activation in patients with oral anticoagulant treatment: A cross-sectional study

AIMS

The terms "patient activation" and "patient empowerment" are used to describe the extent to which individuals are able to manage their own healthcare. Health outcomes and quality of life improve in patients who are more active in health care. The aim of this study was to identify sociodemographic, clinical, sociological and psychological determinants associated with activation in a group of chronically anticoagulated patients.

METHODS

Cross-sectional study of patients treated with oral antivitamin-k drugs attended at a specialized outpatient anticoagulant unit between November 2021 and June 2022. The main dependent variable was the level of patient activation according to the 13-item Patient Activation Measure (PAM-13). Simple and multiple linear regression models were conducted to identify the determinants associated with PAM-13 score.

RESULTS

A total of 137 patients who met all the inclusion criteria were recruited for the study. The mean age was 59.6 years (SD 13.8; range 22-86) and 60.6% were male. Sixty per cent presented a level IV of activation according to the PAM-13 scale. Mean patient activation score was 73.9 (SD 15.4). The factors independently associated with significantly lower activation were: emergency department visits in the past 12 months, intermediate social risk, anxiety symptoms, stress symptoms and low self-efficacy.

CONCLUSIONS

Five determinants were found to be associated with activation. Knowing the factors that modify the level of activation can help to identify subgroups of chronic anticoagulated patients who are less likely to engage in self-management and are therefore candidates for tailored educational interventions.

Text messaging intervention for fatigue self-management in people with stroke, spinal cord injury, and multiple sclerosis: A pilot study

BACKGROUND

Fatigue negatively impacts the function and quality of life of people with disabilities (PwD). Mobile health (mHealth) platforms are recognized as effective and accessible approaches to delivering health interventions and may show higher satisfaction by tailoring the information toward personalized needs for PwD.

OBJECTIVE

To evaluate the acceptability, feasibility, and participant engagement with a Short Message Service (SMS) text messaging intervention for fatigue self-management and to explore the pre- and post-score health changes in PwD.

METHODS

A total of 27 PwD (multiple sclerosis = 9, spinal cord injury = 9, or stroke = 9) experiencing fatigue in their daily lives participated in a 12-week self-management text messaging intervention. Participants completed a demographic survey and health outcome measures, including patient activation, self-efficacy for managing symptoms, fatigue, sleep, and satisfaction with participation in social roles before and after the intervention. Participants also completed a client satisfaction questionnaire after the intervention. We also tracked the program retention and SMS response rates over the 12-week intervention period.

RESULTS

Twenty-five participants completed the entire intervention (93% retention rate), and the overall SMS response rate was 84.67%, indicating high acceptability and adherence to the intervention. The mean satisfaction score was 3.18, indicating high satisfaction with the intervention. Despite finding a negligible effect on patient activation, we found a small intervention effect on self-efficacy for managing symptoms (η2 = 0.04) and moderate effects on fatigue (η2 = 0.06-0.12), sleep (η2 = 0.11), and satisfaction with participation in social roles (η2 = 0.08).

CONCLUSIONS

This study provides initial feasibility and health outcome change evidence to support an SMS text messaging intervention to manage fatigue in PwD.

Applying the Patient Empowerment, Engagement, and Activation Survey to Improve Patient Outcomes

This article focuses on applying the patient empowerment, engagement, and activation (PEEA) model as an implementation strategy to achieve patient- or person-centered care. There is substantial evidence linking PEEA to improved patient care outcomes and reduced healthcare costs. Interrelationships among the 3 concepts are discussed and how the PEEA survey can be used to evaluate patients' activation for self-care postdischarge and their perceptions of nurses' empowering and engaging them during the care encounter.

A codesigned integrated kidney and diabetes model of care improves patient activation among patients from culturally and linguistically diverse backgrounds

BACKGROUND

Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD.

METHODS

This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non-CALD backgrounds spoke English only as their primary language. Paired t-tests compared baseline and 12-month patient activation scores by CALD status.

RESULTS

Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non-CALD backgrounds (58.5 ± 14.6) at baseline. Within-group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow-up (52.1 ± 17.6-59.4 ± 14.7), and no significant change was observed for those from non-CALD backgrounds (58.5 ± 14.6-58.8 ± 13.6).

CONCLUSIONS

Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi-structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

Mental well-being and patient activation during the first eight months of the COVID-19 pandemic in Denmark - a cohort study among 710 Danish adults with chronic conditions

BACKGROUND

COVID-19 has highlighted the importance of patient activation in managing chronic conditions and promoting resilience during times of crisis. Patient activation refers to an individual's knowledge, skills, and confidence in managing their own health and healthcare. Previous research has shown that people with higher levels of patient activation are better prepared to navigate the challenges of chronic illness and are more likely to engage in healthy behaviors. However, the impact of patient activation on COVID-19-related concerns and mental well-being among people with chronic conditions during the pandemic remains unclear. This study aims to investigate the possible role of patient activation in shaping COVID-19-related concerns and to describe changes in mental well-being among Danish adults with one or more chronic conditions during the early months of the pandemic.

METHODS

Danish adults with chronic conditions (e.g. diabetes, coronary heart disease, obstructive pulmonary lung disease, cancer) who had participated in a municipal health education program prior to the COVID-19 outbreak were asked to participate in this prospective questionnaire study in May 2020 and November 2020. Sociodemographic (sex, age, living status, educational attainment, employment status) and disease-related information (diagnosis, one or more chronic conditions) along with the Patient Activation Measure were collected before the outbreak and were obtained from a clinical database used for monitoring and evaluation of municipal health education programs. In contrast, the two questionnaires collected six months apart consisted of single items related to concerns about COVID-19 and the WHO-5 well-being index.

RESULTS

A total of 710 people with chronic conditions (mean age 60.9 years; 55.8% female) participated at both time points. In bivariate analyses, patient activation was associated with COVID-19-related concern and well-being. At follow-up, participants experienced a significant decrease in well-being. The decrease was associated with poorer well-being measured six months earlier, a greater perception that it had become more challenging to take care of one's health due to the pandemic, and finally, feeling lonely. The association between patient activation and well-being ceased to be significant in the multivariate regression model.

CONCLUSIONS

A considerable proportion of people with chronic conditions participating in this study have been mentally burdened during COVID-19. Although lower levels of patient activation were associated with greater COVID-19-related concerns, it did not have a significant impact on mental well-being over time.

The mediating effect of self-efficacy on the relationship between diabetes self-management ability and patient activation in older adults with type 2 diabetes

OBJECTIVE

The aim of this study was to investigate the level of diabetes self-management ability in older patients with type 2 diabetes and analyse its relationship with patient activation. Besides, the mediating effect of self-efficacy on the relationship between the two was assessed in the study.

METHODS

Using a cross-sectional design, 200 elderly patients with type 2 diabetes were recruited from the community of Yangzhou, China. The Patient Activation Measure (PAM), The Self-efficacy for Diabetes (SED), and The Summary of Diabetes Self-Care Activities Measure (SDSCA) were used in the questionnaires. Data analysis was performed using SPSS 27.0 and PROCESS macro.

RESULTS

Pearson correlation analysis revealed a significant positive correlation (p< 0.01) between diabetes self-management ability and patient activation (r=0.312) and self-efficacy (r=0.367). Self-efficacy partially mediated the effect between patient activation and self-management ability in older patients with type 2 diabetes, and the mediating effect accounted for 49.33% of the total effect (p< 0.001).

CONCLUSIONS

Older patients with type 2 diabetes in the community have a moderate level of self-management ability. Patient activation can improve patients' self-management ability through self-efficacy.

Recommendations for Early and Comprehensive Management of Type 2 Diabetes and Its Related Cardio-Renal Complications

Type 2 diabetes (T2D) is a global health problem accompanied by an elevated risk of complications, the most common being cardiac and renal diseases. In Lebanon, the prevalence of T2D is estimated at 8-13%. Local medical practice generally suffers from clinical inertia, with gaps in the yearly assessment of clinical manifestations and suboptimal screening for major complications. The joint statement presented here, endorsed by five Lebanese scientific medical societies, aims at providing physicians in Lebanon with a tool for early, effective, and comprehensive care of patients with T2D. Findings from major randomized clinical trials of antidiabetic medications with cardio-renal benefits are presented, together with recommendations from international medical societies. Optimal care should be multidisciplinary and should include a multifactorial risk assessment, lifestyle modifications, and a regular evaluation of risks, including the risks for cardiovascular (CV) and renal complications. With international guidelines supporting a shift in T2D management from glucose-lowering agents to disease-modifying drugs, the present statement recommends treatment initiation with metformin, followed by the addition of sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists due to their CV and renal protection properties, whenever possible. In addition to the selection of the most appropriate pharmacological therapy, efforts should be made to provide continuous education to patients about their disease, with the aim to achieve a patient-centered approach and to foster self-management and adherence to the medical plan. Increasing the level of patient engagement is expected to be associated with favorable health outcomes. Finally, this statement recommends setting an achievable individualized management plan and conducting regular follow-ups to monitor the patients' glycemic status and assess their risks every 3-6 months.

Association between medication regimen complexity and glycemic control among patients with type 2 diabetes

INTRODUCTION

Type 2 diabetes mellitus (T2DM) and comorbid conditions require patients to take complex medication regimens. Greater regimen complexity has been associated with poorer T2DM management; however, the relationship between overall regimen complexity and glycemic control is unclear.

OBJECTIVES

Our objectives were: (1) to examine associations between regimen complexity (with the Medication Regimen Complexity Index [MRCI]) and glycemic control (A1C), and (2) to compare overall MRCI with other measures of regimen complexity (overall and diabetes-specific medication count) and diabetes-specific MRCI.

METHODS

This was a secondary data analysis of cross-sectional data from a parent trial. Participants were patients with T2DM taking at least 3 chronic medications followed in safety net clinics in the Chicago area. The MRCI measures complexity based on dosing frequency, route of administration, and special instructions for prescribed medications. MRCI scores were created for overall regimens and diabetes-specific medications. Sociodemographics and outpatient visit utilization were included in models as covariates. Linear regression was used to examine the associations between variables of interest and hemoglobin A1C.

RESULTS

Participants (N = 432) had a mean age of 56.9 years, most were female (66.0%), and Hispanic or Latino (73.3%). Regimen complexity was high based on overall medications (mean = 6.6 medications, SD: 3.09) and MRCI (mean = 21.4, SD: 11.3). Higher diabetes-specific MRCI was associated with higher A1C in bivariate and multivariable models. In multivariable models, overall MRCI greater than 14, fewer outpatient health care visits, male gender, and absence of health insurance were independently associated with higher A1C. The variance in A1C explained by MRCI was higher compared to medication count for overall and diabetes-specific regimen complexity.

CONCLUSIONS

More complex regimens are associated with worse A1C and measuring complexity with MRCI may have advantages. Deprescribing, increasing insurance coverage, and promoting engagement in health care may improve A1C among underserved populations with complex regimens.

Experiences of patients with multimorbidity with primary care and the association with patient activation: a cross-sectional study in Germany

OBJECTIVES

This study aimed to explore the association between patient activation and patients' experience of care among an elderly multimorbid population in Germany.

DESIGN

Cross-sectional study.

SETTING

Primary care practices in two German settings.

PARTICIPANTS

346 patients with 3 or more chronic conditions aged 65 years and over from 36 primary care practices.

OUTCOME MEASURES

Patient activation was measured with the patient activation measure (PAM). To assess patient experiences with primary care, a set of questions concerning domains of primary care were included. Multilevel regression analyses were performed to examine which domains of care were associated with patient activation.

RESULTS

Out of 1243 invited patients, a total of 346 took part in the study (participation rate 27.8 %). Mean PAM score was 76.1. Across all patients, 3.8% achieved PAM level 1, 7.5% level 2, 27.2% level 3% and 60.7% level 4. PAM scores suggest a highly activated patient group. In the regression analysis, three out ten domains of patients' experiences showed an association with patient activation. The domains 'being involved in decision as much as desired' (B=-8.56, p=0.012) and 'receiving a self-management plan' (B=6.51, p=0.051) were associated with higher patient activation scores. Patients with an up-to-date medication plan had lower patient activation scores (B=-12.01, p=0.041).

CONCLUSION

Specific domains of primary care were found to be associated with patient activation. To enhance patient activation, primary care physicians may increase involvement of patients in decisions. Future research should examine the causality of these associations.

TRIAL REGISTRATION NUMBER

DRKS00015718.

Increased Patient Empowerment Is Associated with Improvement in Anxiety and Depression Symptoms in Type 2 Diabetes Mellitus: Findings from the INDICA Study

Introduction. In cross-sectional analyses, higher levels of patient empowerment have been related to lower symptoms of anxiety and depression. The aims of this study are: (1) to assess if patient empowerment predicts anxiety and depression symptoms after 12 and 24 months among patients with type 2 diabetes mellitus, and (2) to analyze whether a change in patient empowerment is associated with a change in anxiety and depression level. Methods. This is a secondary analysis of the INDICA study, a 24 month-long, multi-arm randomized controlled trial. Patient empowerment (DES-SF), depression (BDI-II), and state-anxiety (STAI-S) were assessed at the baseline (pre-intervention) and after 12 and 24 months. Multilevel mixed linear models with a random intercept were performed to correct for our clustered data. Results. The multilevel regression models showed that the baseline empowerment did not significantly predict anxiety and depression after 12 and 24 months. However, a higher increase in patient empowerment was significantly associated with reductions of anxiety (p < 0.001) and depression levels (p < 0.001). This association was not significantly different between the two follow-ups. Conclusion. This study contributes to the knowledge on how to reduce affective symptoms in patients with uncomplicated T2DM through comprehensive patient-centered interventions, and it highlights patient empowerment as a significant contributor.

Identifying Behavioural Determinants to Uptake and Adherence to a Whey Protein Supplement for the Management of Type 2 Diabetes: A Qualitative Interview Study

Interventions targeting diet and physical activity have demonstrated to be effective for improving glycaemic control in adults with type 2 diabetes. However, initiating and sustaining these changes remains a challenge. Ingestion of whey protein has shown to be effective for improving glycaemic control by increasing insulin and incretin secretion, and influencing appetite regulation; however, little is known about what influences uptake and adherence. We conducted a qualitative interview study to explore behavioural determinants of uptake and adherence to a commercially made whey protein supplementation. In total, 16/18 adults with type 2 diabetes who participated in an RCT took part in a semi-structured interview. Seven themes were generated from the data following thematic analyses. The most frequently reported determinant of uptake was the expectation that the supplement would improve health status (e.g., type 2 diabetes management), as a consequence of appetite suppression and weight loss. Determinants of adherence included palatability; the belief that the supplement was an appetite suppressant; and receiving positive reinforcement on the effects of the supplement. Frequency of consumption led to reduced adherence with some participants. Findings support that the whey protein supplement is a viable management option for adults with type 2 diabetes; however, uptake will be driven by conveying information on the positive effects of the supplement on appetite suppression and glycaemic control. Adherence will be determined by palatability, behavioural prompting, and positive reinforcement.

Psychometric Properties of the Patient Activation Measure in Community-Dwelling Adults in Singapore

Introduction

Measuring health activation in general population using valid instruments is needed to facilitate the evaluation of health education and behavioral programs in community. The 13-item Patient Activation Measure was well validated in patients with different chronic diseases but rarely validated in general population. The objective of this study was to assess the psychometric properties of the Patient Activation Measure among community-dwelling adults in Singapore.

Methods

Data of participants having valid responses to the English-version measure (N = 824) were analyzed. The psychometric properties were assessed by demonstrating evidence for uni-dimensionality using Rasch Principal Component Analysis of Residuals, known-group validity, convergent and divergent validity, and internal consistency reliability using Cronbach’s alpha.

Results

The uni-dimensionality of the Patient Activation Measure was supported by the Rasch Principal Component Analysis of Residuals results. Participants having multimorbidity or polypharmacy and being inactive in physical activity had significantly lower activation scores. The activation score was positively and moderately correlated with health confidence measured by the Health Confidence Measure (r = .38, P < .001), and negatively and weakly correlated with depressive symptoms measured by the Patient Health Questionnaire (r = − .13, P < .001). The internal reliability was good with a Cronbach’s alpha of .82.

Conclusion

The 13-item Patient Activation Measure has acceptable construct validity and good internal consistency among community-dwelling adults. It is a potential instrument to measure health activation in this population. Further research is required to investigate the expansion of response options, validate the cut-off scores for the activation levels and examine the test-retest reliability and responsiveness.

Associations between diabetes duration and self-stigma development in Japanese people with type 2 diabetes: a secondary analysis of cross-sectional data

OBJECTIVES

To examine the associations between self-stigma and diabetes duration in a sample of Japanese people with type 2 diabetes.

DESIGN

A secondary analysis of a cross-sectional study.

SETTING

Two university hospitals, one general hospital and one clinic in Tokyo, Japan.

PARTICIPANTS

Outpatients with type 2 diabetes aged 20-74 years and receiving treatment from diabetes specialist physicians (n=209) completed a self-administered questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-stigma was measured as the primary outcome. Patient Activation Measure, body mass index and haemoglobin A1c were measured as secondary outcomes.

RESULTS

One-way analysis of covariance showed significant differences in self-stigma levels between the five groups of diabetes duration (≤5 years, 6-10 years, 11-15 years, 16-21 years and 22 years or more) after controlling for age, gender, education, marital status, diabetes treatment (insulin use) and diabetes-related complications, F(4,198)=2.83, p=0.026. Multiple comparisons using Bonferroni correction showed statistically significant differences in self-stigma levels between the groups with ≤5 years (95% CI 59.63 to 69.73) and 11-15 years with diabetes (95% CI 71.12 to 80.82; p=0.020). The highest mean level of self-stigma was observed in the group having diabetes for 11-15 years.

CONCLUSIONS

Self-stigma was associated with diabetes duration and was lowest after diagnosis and gradually increased, with its highest levels being observed in those having diabetes for 11-15 years. Self-stigma takes time to develop and gradually increases in individuals as it is learnt through direct experiences of diabetes-related stigma after self-administering treatment in everyday social situations.