Adaptation of the Diabetes Health Profile (DHP-1) for use with patients with Type 2 diabetes mellitus: psychometric evaluation and cross-cultural comparison

Validation of the Chinese version of the diabetes health profile to predict the impact of mobile health education on quality of life in type 2 diabetes patients

Purpose

The Diabetes Health Profile (DHP18), initially created in the United Kingdom, currently lacks a Chinese version. This study endeavors to authenticate the Chinese adaptation of the DHP18 and assess the influence of mobile health (mHealth) education intervention on the quality of life of individuals living with diabetes.

Patients and methods

The study included 470 Type 2 diabetes Mellitus (T2DM) patients (204 men, 266 women), spanning an age range of 19-79 years, with an average age of 54 ± 12.40 years. Data analysis employed Jamovie and Mplus software. Moreover, test-retest reliability was evaluated in 52 hospitalized T2DM patients through two repeated measurements taken 4 weeks apart.

Results

The Chinese version DHP18 scale exhibited high reliability, evidenced by a Cronbach's alpha of 0.88, and coefficient of test-retest reliability of 0.84. Individual subscales also demonstrated strong reliability, ranging from 0.76 to 0.84, with test-retest reliability spanning from 0.71 to 0.74. Confirmatory Factor Analysis (CFA) employing a three-factor structure (χ2 = 294.69, GFI = 0.92, TLI = 0.91, RMSEA = 0.05, SRMR = 0.06) validated the scale's construct validity. Notably, there was a statistically significant difference (p < 0.05) in the quality of life between Type 2 diabetes patients using mHealth education intervention and those without mHealth education intervention. Mediation analysis revealed that Appraisal of Diabetes (ADS) and Self-Management Efficacy (SED) mediated the effects of Psychological Distress (PD) and Behavior Adherence (BA) on quality of life, both significant direct and indirect effects (p < 0.001). In addition, Dietary Abstinence (DE) displayed significant overall impact (β = -0.13, p < 0.001) and indirect influence (β = -0.10, p < 0.01) on diabetic patients' quality of life, though lacking a significant direct effect (β = -0.03, p = 0.38).

Conclusion

The Chinese version of the Diabetes Health Profile Scale meets stringent psychometric standards and stands as an appropriate measurement tool for Chinese T2DM patients, maintaining comparable results to the original scale's structure. The mHealth education intervention yielded a notably positive impact on the quality of life among T2DM patients. Mediation analysis revealed that the three dimensions of the DHP were mediated by Appraisal of Diabetes and Diabetes Self-Management Efficacy, partially mediated by Psychological Distress and Behavior Adherence, and fully mediated by Dietary Abstinence, providing insight into the positive effects of the mHealth model on the quality of life of diabetic patients.

Validation and Cultural Adaptation of the Problem Areas in Diabetes-5 (PAID-5) Scale to European Portuguese

INTRODUCTION

Diabetes distress syndrome (DDS) can lead to poor outcomes and should be assessed with adapted and validated tools. One of these tools is the Problem Areas in Diabetes (PAID) scale, which assesses diabetes distress in people suffering from diabetes (PsD). A short five-item form, PAID-5, is an easier and quicker alternative to be used in clinical and research practices, than the previous one with 20-items and has been validated by the original authors. This study intended to perform the cultural adaptation and validation of the PAID-5 scale in European Portuguese.

METHODS

To create the Portuguese version of PAID-5, translation-back translation, a clinical review, and a cognitive debriefing panel were performed. A convenience sample of 90 PsD was studied in three primary healthcare units for reliability and validity tests. Reliability was studied by the internal consistency (Cronbach's alpha) and the interval coefficient correlation (ICC) under a test-retest design. Structural validity was studied by principal component analysis. The construct validity was tested by the sensitivity of the PAID-5 total score with age, most recent HbA1c test, and socioeconomic class by the Socio-Economic Deprivation Index (SEDI). Criterion validity was tested by correlating the PAID-5 total score with the psychological distress questions of the Diabetes Health Profile 18 Questions (DHP-PDQ).

RESULTS

A Cronbach's alpha coefficient value of 0.905 and an ICC of 0.905 were computed. In a sample of n = 90 PsD, 55.6% were males, 63.3% aged 65 years or more, SEDI was 5.2 ± 0.8 [3 to 6], 44.4% studied for less than 4 years, and 18.9% were living alone. The Spearman correlation between PAID-5 and DHP-PDQ total scores was ρ = 0.382, p < 0.001, between PAID-5 total score and age was ρ = -0.207, p = 0.050 and between PAID-5 total score and most recent HbA1c knowledge was ρ = 0.275, p = 0.040. There was no significant relationship between PAID-5 total score and SEDI ρ = 0.080, p = 0.452.

CONCLUSION

DDS can now be assessed in the Portuguese context, accounting for better intervention by primary care teams. PAID-5 has good psychometric properties and is a reliable scale to identify diabetes-specific distress in the Portuguese diabetic population.

Patient-reported outcomes for people with diabetes: what and how to measure? A narrative review

Patient-reported outcomes (PROs) are valuable for shared decision making and research. Patient-reported outcome measures (PROMs) are questionnaires used to measure PROs, such as health-related quality of life (HRQL). Although core outcome sets for trials and clinical practice have been developed separately, they, as well as other initiatives, recommend different PROs and PROMs. In research and clinical practice, different PROMs are used (some generic, some disease-specific), which measure many different things. This is a threat to the validity of research and clinical findings in the field of diabetes. In this narrative review, we aim to provide recommendations for the selection of relevant PROs and psychometrically sound PROMs for people with diabetes for use in clinical practice and research. Based on a general conceptual framework of PROs, we suggest that relevant PROs to measure in people with diabetes are: disease-specific symptoms (e.g. worries about hypoglycaemia and diabetes distress), general symptoms (e.g. fatigue and depression), functional status, general health perceptions and overall quality of life. Generic PROMs such as the 36-Item Short Form Health Survey (SF-36), WHO Disability Assessment Schedule (WHODAS 2.0), or Patient-Reported Outcomes Measurement Information System (PROMIS) measures could be considered to measure commonly relevant PROs, supplemented with disease-specific PROMs where needed. However, none of the existing diabetes-specific PROM scales has been sufficiently validated, although the Diabetes Symptom Self-Care Inventory (DSSCI) for measuring diabetes-specific symptoms and the Diabetes Distress Scale (DDS) and Problem Areas in Diabetes (PAID) for measuring distress showed sufficient content validity. Standardisation and use of relevant PROs and psychometrically sound PROMs can help inform people with diabetes about the expected course of disease and treatment, for shared decision making, to monitor outcomes and to improve healthcare. We recommend further validation studies of diabetes-specific PROMs that have sufficient content validity for measuring disease-specific symptoms and consider generic item banks developed based on item response theory for measuring commonly relevant PROs.

Patient-reported outcome measures for assessing health-related quality of life in people with type 2 diabetes: A systematic review

Patient-Reported Outcome Measures (PROMs) are important tools to assess outcomes relevant to patients, with Health-Related Quality Of Life (HRQOL) as an important construct to be measured. Many different HRQOL PROMs are used in the type 2 diabetes field, however a complete overview of these PROMs is currently lacking. We therefore aimed to systematically describe and classify the content of all PROMs that have specifically been developed or validated to measure (aspects of) HRQOL in people with type 2 diabetes. A literature search was performed in PubMed and EMBASE until 31 December 2021. Studies on the development or validation of a PROM measuring HRQOL, or aspects of HRQOL, in people with type 2 diabetes were included. Title and abstract and full-text screening were conducted by two independent researchers and data extraction was performed independently by one of the researchers. Data were extracted on language in which the PROM was developed, target population, construct(s) being measured, names of (sub)scales and number of items per (sub)scale. In addition, all PROMs and subscales were classified according to specific aspects of HRQOL based on the Wilson & Cleary model (symptom status, functional status, general health perceptions) to aid researchers in PROM selection. In total 220 studies were identified that developed or validated PROMs that measure (aspects of) HRQOL in people with type 2 diabetes. Of the 116 unique HRQOL PROMs, 91 (of the subscales) measured symptom status, 60 measured functional status and 26 measured general health perceptions. In addition, 16 of the PROMs (subscales) measured global quality of life. 61 of the 116 PROMs (subscales) also include characteristics of the individual (e.g. aspects of personality, coping) or environment (e.g. social or financial support) and patient-reported experience measures (PREMs, e.g. measure of a patient's perception of their personal experience of the healthcare they have received, e.g. treatment satisfaction), which are not part of the HRQOL construct. Only 9 of the 116 PROMs measure all aspects of HRQOL based on the Wilson & Cleary model. Finally, 8 of the 116 PROMs stating to measure HRQOL, measured no HRQOL construct. In conclusion, a large number of PROMs are available for people with type 2 diabetes, which intend to measure (aspects of) HRQOL. These PROMs measure a large variety of (sub)constructs, which are not all HRQOL constructs, with a small amount of PROMs not measuring HRQOL at all. There is a need for consensus on which aspects of HRQOL should be measured in people with type 2 diabetes and which PROMs to use in research and daily practice. PROSPERO: CRD42017071012. COMET database: http://www.comet-initiative.org/studies/details/956 .

Content Validity of Patient-Reported Outcome Measures Developed for Assessing Health-Related Quality of Life in People with Type 2 Diabetes Mellitus: a Systematic Review

PURPOSE OF REVIEW

We aimed to systematically evaluate the content validity of patient-reported outcome measures (PROMs) specifically developed to measure (aspects of) health-related quality of life (HRQOL) in people with type 2 diabetes. A systematic review was performed in PubMed and Embase of PROMs measuring perceived symptoms, physical function, mental function, social function/participation, and general health perceptions, and that were validated to at least some extent. Content validity (relevance, comprehensiveness, and comprehensibility) was evaluated using COSMIN methodology.

RECENT FINDINGS

We identified 54 (different versions of) PROMs, containing 150 subscales. We found evidence for sufficient content validity for only 41/150 (27%) (subscales of) PROMs. The quality of evidence was generally very low. We found 66 out of 150 (44%) (subscales of) PROMs with evidence for either insufficient relevance, insufficient comprehensiveness, or insufficient comprehensibility. For measuring diabetes-specific symptoms, physical function, mental function, social function/participation, and general health perceptions, we identified one to 11 (subscales of) PROMs with sufficient content validity, although quality of the evidence was generally low. For measuring depressive symptoms, no PROM with sufficient content validity was identified. For each aspect of HRQL, we found at least one PROM with sufficient content validity, except for depressive symptoms. The quality of the evidence was mostly very low.

Psychometric validation of diabetes distress scale in Bangladeshi population

Diabetes Distress (DD)-an emotional or affective state arise from challenge of living with diabetes and the burden of self-care-negatively impact diabetes management and quality of life of T2DM patients. Early detection and management of DD is key to efficient T2DM management. The study aimed at developing a valid and reliable instrument for Bangladeshi patients as unavailability such a tool posing challenge in diabetes care. Linguistically adapted, widely used, 17-item Diabetes Distress Scale (DDS), developed through forward-backward translation from English to Bengali, was administered on 1184 T2DM patients, from four diabetes hospitals in Bangladesh. Psychometric assessment of the instrument included, construct validity using principal component factor analysis, internal consistency using Cronbach's α and discriminative validity through independent t-test and test-retest reliability using intraclass-correlation coefficient (ICC) and Kappa statistics. Factor analysis extracted 4 components similar to original DDS domains, confirms the construct validity. The scale demonstrated satisfactory internal consistency (α = 0.838), stability (test-retest ICC = 0.941) and good agreement across repeated measurements (Kappa = 0.584). Discriminative validity revealed that patients with complication (p < 0.001) and those are on insulin (p < 0.001) had significantly higher distress scores in all domains. Bengali version of DDS is a valid and reliable tool for assessing distress among Bangladeshi T2DM patients.

Patient-Reported Experience and Outcome Measures in People Living with Diabetes: A Scoping Review of Instruments

BACKGROUND

Diabetes mellitus is a global public health concern, with over 463 million people living with this chronic disease. Pathology complexity, management difficulty, and limited participation in care has resulted in healthcare systems seeking new strategies to engage people living with diabetes. Patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) were developed to address the gap between the healthcare system expectation and patient preference.

OBJECTIVE

This study aimed to review the existing literature on PREMs and PROMs specific to type 1 and 2 diabetes, and report the dimensions report the dimensions they have measured.

METHODS

A scoping review was conducted from January 1985 to March 2020 of six databases, MEDLINE, EMBASE, PsycINFO, CINHAL, Scopus, and BiblioPro, to identify PREM and PROM instruments specific for type 1 and 2 diabetes.

RESULTS

Overall, 34 instruments were identified, 32 PROMs and two PREMs. The most common instrument included outcomes related to quality of life at 44% (n = 15), followed by satisfaction (whether with treatment, device, and healthy habits) at 26% (n = 9). Furthermore, instruments regarding personal well-being accounted for 15% (n = 5). For instruments that measure experiences of persons with diabetes, there were two scales of symptoms, and one related to the attitude patients have toward the disease.

CONCLUSIONS

Diabetes-specific validated instruments mainly focus on quality of life, education, and treatment, and sometimes overlap each other, in their subscales and assessment dimensions. Constructs such as cultural and religious beliefs, leisure, and work life may need more attention. There appears to be a gap in instruments to measure experiences of individuals who "live with diabetes" and seek to lead a "normal life."

Measurement Properties of Patient-Reported Outcome Measures for Diabetes: Systematic Review

BACKGROUND

The management of diabetes is complex. There is growing recognition of the use of patient-reported outcome measures (PROMs) as a standardized method of obtaining an outlook on patients' functional status and well-being. However, no systematic reviews have summarized the studies that investigate the measurement properties of diabetes PROMs.

OBJECTIVE

Our aims were to conduct a systematic review of studies investigating the measurement properties of diabetes PROMs by evaluating the methodological quality and overall level of evidence of these PROMs and to categorize them based on the outcome measures assessed.

METHODS

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the Embase, PubMed, and PsychINFO databases. The PROMs were evaluated with the COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) guidelines.

RESULTS

A total of 363 articles evaluating the measurement properties of PROMs for diabetes in the adult population were identified, of which 238 unique PROMs from 248 studies reported in 209 articles were validated in the type 2 diabetes population. PROMs with at least a moderate level of evidence for ≥5 of 9 measurement properties include the Chinese version of the Personal Diabetes Questionnaire (C-PDQ), Diabetes Self-Management Instrument Short Form (DSMI-20), and Insulin Treatment Appraisal Scale in Hong Kong primary care patients (C-ITAS-HK), of which the C-PDQ has a "sufficient (+)" rating for >4 measurement properties. A total of 43 PROMs meet the COSMIN guidelines for recommendation for use.

CONCLUSIONS

This study identified and synthesized evidence for the measurement properties of 238 unique PROMs for patients with type 2 diabetes and categorized the PROMs according to their outcome measures. These findings may assist clinicians and researchers in selecting appropriate high-quality PROMs for clinical practice and research.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020180978; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020180978.

Impact of COVID-19 and partial lockdown on access to care, self-management and psychological well-being among people with diabetes: A cross-sectional study

BACKGROUND

The impact of lockdown measures can be widespread, affecting both clinical and psychosocial aspects of health. This study aims to assess changes in health services access, self-care, behavioural, and psychological impact of COVID-19 and partial lockdown amongst diabetes patients in Singapore.

METHODS

We conducted a cross-sectional online survey amongst people with diabetes with the Diabetes Health Profile-18 (DHP-18). Hierarchical regression analyses were performed for each DHP-18 subscale (Psychological Distress, Disinhibited Eating and Barriers to Activity) as dependent variables in separate models.

RESULTS

Among 301 respondents, 45.2% were women, 67.1% of Chinese ethnicity, 24.2% were aged 40 to 49 years, 68.4% have Type 2 diabetes and 42.2% on oral medications alone. During the pandemic and the lockdown, nearly all respondents were able to receive care safely from the clinics they attend (94%) and obtain their medications and diabetes equipment and supplies (97%) when needed. Respondents reported less frequent engagement in physical activity (38%), checking of blood pressure (29%) and blood glucose (22%). Previous diagnosis of mental health conditions (β = 9.33, P = .043), Type 1 diabetes (β = 12.92, P = .023), number of diabetes-related comorbidities (β = 3.16, P = .007) and Indian ethnicity (β = 6.65, P = .034) were associated with higher psychological distress. Comorbidities were associated with higher disinhibited eating (β = 2.49, P = .014) while ability to reach their doctor despite not going to the clinic is negatively associated with psychological distress (β = -9.50 P = .002) and barriers to activity (β = -7.53, P = .007).

CONCLUSION

Health services access were minimally affected, but COVID-19 and lockdown had mixed impacts on self-care and management behaviours. Greater clinical care and attention should be provided to people with diabetes with multiple comorbidities and previous mental health disorders during the pandemic and lockdown.

Adaptation and psychometric validation of Diabetes Health Profile (DHP-18) in patients with type 2 diabetes in Quito, Ecuador: a cross-sectional study

Introduction

The Diabetes Health Profile (DHP‐18), structured in three dimensions (psychological distress (PD), barriers to activity (BA) and disinhibited eating (DE)), assesses the psychological and behavioural burden of living with type 2 diabetes. The objectives were to adapt the DHP‐18 linguistically and culturally for use with patients with type 2 DM in Ecuador, and to evaluate its psychometric properties.

Methods

Participants were recruited using purposive sampling through patient clubs at primary health centres in Quito, Ecuador. The DHP-18 validation consisted in the linguistic validation made by two Ecuadorian doctors and eight patient interviews. And in the psychometric validation, where participants provided clinical and sociodemographic data and responded to the SF-12v2 health survey and the linguistically and culturally adapted version of the DHP-18. The original measurement model was evaluated with confirmatory factor analysis (CFA). Reliability was assessed through internal consistency using Cronbach’s alpha and test–retest reproducibility by administering DHP-18 in a random subgroup of the participants two weeks after (n = 75) using intraclass correlation coefficient (ICC). Convergent validity was assessed by establishing previous hypotheses of the expected correlations with the SF12v2 using Spearman’s coefficient.

Results

Firstly, the DHP-18 was linguistically and culturally adapted. Secondly, in the psychometric validation, we included 146 participants, 58.2% female, the mean age was 56.8 and 31% had diabetes complications. The CFA indicated a good fit to the original three factor model (χ2 (132) = 162.738, p < 0.001; CFI = 0.990; TLI = 0.989; SRMR = 0.086 and RMSEA = 0.040. The BA dimension showed the lowest standardized factorial loads (λ) (ranging from 0.21 to 0.77), while λ ranged from 0.57 to 0.89 and from 0.46 to 0.73, for the PD and DE dimensions respectively. Cronbach’s alphas were 0.81, 0.63 and 0.74 and ICCs 0.70, 0.57 and 0.62 for PD, BA and DE, respectively. Regarding convergent validity, we observed weaker correlations than expected between DHP-18 dimensions and SF-12v2 dimensions (r > −0.40 in two of three hypotheses).

Conclusions

The original three factor model showed good fit to the data. Although reliability parameters were adequate for PD and DE dimensions, the BA presented lower internal consistency and future analysis should verify the applicability and cultural equivalence of some of the items of this dimension to Ecuador.

Integrating Patient Reported Outcome Measures (PROMs) into routine nurse-led primary care for patients with multimorbidity: a feasibility and acceptability study

BACKGROUND

The use of Patient Reported Outcome Measures (PROMS) in clinical practice has the potential to promote patient-centred care and improve patients' quality of life. Individualized PROMs may be particularly helpful in identifying, prioritizing and monitoring health problems of patients with multimorbidity. We aimed to develop an intervention centred around PROMs feedback as part of Primary Care annual reviews for patients with multimorbidity and evaluate its feasibility and acceptability.

METHODS

We developed a nurse-oriented intervention including (a) training of nurses on PROMs; (b) administration to patients with multimorbidity of individualized and standardized PROMS; and (c) feedback to both patients and nurses of PROMs scores and interpretation guidance. We then tailored the intervention to patients with two or more highly prevalent conditions (asthma, COPD, diabetes, heart failure, depression, and hip/knee osteoarthritis) and designed a non-controlled feasibility and acceptability evaluation in a convenience sample of primary care practices (5). PROMs were administered and scores fed back immediately ahead of scheduled annual reviews with nurses. Patients and nurses rated the acceptability of the intervention using with a brief survey including optional free comments. Thematic analysis of qualitative interviews with a sample of participating patients (10) and nurses (4) and of survey free comments was conducted for further in-depth evaluation of acceptability. Feasibility was estimated based on rates of participation and completion.

RESULTS

Out of 68 recruited patients (mean age 70; 47% female), 68 completed the PROMs (100%), received feedback (100%) and confirmed nurse awareness of their scores (100%). Most patients (83%) "agreed"/"strongly agreed" that the PROMs feedback had been useful, a view supported by nurses in 89% of reviews. Thematic analysis of rich qualitative data on PROMS administration, feedback and role in annual reviews indicated that both patients and nurses perceived the intervention as acceptable and promising, emphasizing its comprehensiveness and patient-centredness.

CONCLUSIONS

We have developed and tested an intervention focusing on routine PROM assessment of patients with multimorbidity in Primary Care. Preliminary findings support its feasibility and a high degree of acceptability from both patients and nurses. The next step is to conduct a full-scale trial for evaluating the effectiveness of the proposed intervention.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part-II, Strengthening the Health System: A Mixed-Methods Study Protocol

Diabetes is a major public health problem, increasingly affecting low- and middle-income countries. The project CEAD (Contextualizing Evidence for Action in Diabetes in low-resource settings) aims to evaluate the implementation of comprehensive diabetes care in two low-resource settings in Ecuador and to stimulate context-led health systems innovations to improve diabetes care and reduce inequity. The mixed-methods approach includes a 24-month retrospective study to assess the current level of implementation of comprehensive diabetes care and participants will be followed up prospectively for two years to assess changes in healthcare and clinical outcomes from the outset of the research. We will include individuals diagnosed with type-2 diabetes aged over 18 years, who are accessing diabetes care in health facilities in the study districts. Varied stakeholders (patients and family members, community members, healthcare workers and decision-makers) will interpret the underlying causes of the observed weaknesses and propose solutions to strengthen diabetes-related healthcare in focus group discussions (FG). A second set of FG will analyze perceived improvements in healthcare based on prospective cohort findings and consider the success/failure of any context-led innovations occurring throughout the research. Our study will demonstrate how evidence can be contextualized to stimulate local innovations and overcome weaknesses of diabetes-related healthcare in low resource settings.

Investigation of a Mobile Health Texting Tool for Embedding Patient-Reported Data Into Diabetes Management (i-Matter): Development and Usability Study

Background

Patient-reported outcomes (PROs) are increasingly being used in the management of type 2 diabetes (T2D) to integrate data from patients’ perspective into clinical care. To date, the majority of PRO tools have lacked patient and provider involvement in their development, thus failing to meet the unique needs of end users, and lack the technical infrastructure to be integrated into the clinic workflow.

Objective

This study aims to apply a systematic, user-centered design approach to develop i-Matter (investigating a mobile health [mHealth] texting tool for embedding patient-reported data into diabetes management), a theory-driven, mobile PRO system for patients with T2D and their primary care providers.

Methods

i-Matter combines text messaging with dynamic data visualizations that can be integrated into electronic health records (EHRs) and personalized patient reports. To build i-Matter, we conducted semistructured group and individual interviews with patients with T2D and providers, a design thinking workshop to refine initial ideas and design the prototype, and user testing sessions of prototypes using a rapid-cycle design (ie, design-test-modify-retest).

Results

Using an iterative user-centered process resulted in the identification of 6 PRO messages that were relevant to patients and providers: medication adherence, dietary behaviors, physical activity, sleep quality, quality of life, and healthy living goals. In user testing, patients recommended improvements to the wording and timing of the PRO text messages to increase clarity and response rates. Patients also recommended including motivational text messages to help sustain engagement with the program. The personalized report was regarded as a key tool for diabetes self-management by patients and providers because it aided in the identification of longitudinal patterns in the PRO data, which increased patient awareness of their need to adopt healthier behaviors. Patients recommended adding individualized tips to the journal on how they can improve their behaviors. Providers preferred having a separate tab built into the EHR that included the personalized report and highlighted key trends in patients’ PRO data over the past 3 months.

Conclusions

PRO tools that capture patients’ well-being and the behavioral aspects of T2D management are important to patients and providers. A clinical trial will test the efficacy of i-Matter in 282 patients with uncontrolled T2D.

Trial Registration

ClinicalTrials.gov NCT03652389; https://clinicaltrials.gov/ct2/show/NCT03652389

Measuring the Quality of Life in Diabetic Patients: A Scoping Review

BACKGROUND

Diabetes mellitus is a widely diffused chronic condition which impacts on several aspects of patients' lives. In the current clinical practice, the implementation in the clinical routine of monitoring systems of patients' outcomes has led to an increased generation and use of several measures for the assessment of patients' quality of life (QOL). Nevertheless, this construct appears to be particularly complex, and its operationalization is variable across different measures. The purpose of this paper is to offer an updated review of the diabetes-specific QOL measures present in scientific literature with a specific focus on the broad domains assessed.

METHODS

A scoping review was carried out with the purpose of identifying the existing measures in literature and describing their implicit representation of QOL in diabetes care. Five different databases (Scopus; Web of Science Core Collection; Medline; PsycInfo; and Cochrane Central Register of Controlled Trials) were searched with a string including validation studies of adult-only, diabetes-specific QOL measures. Each measure was then qualified according to its structure, a qualitative assessment of the broad domains of QOL it comprises, and finally an overview of the psychometric properties of its first validation.

RESULTS

30 scales were identified and assessed. Theme analysis shows that QOL is operationalized with multidimensional surveys comprising of both mental, physical, and social health components. Some scales also consider the impact of societal attitudes, public policies, and context on QOL.

CONCLUSION

Several self-report measures of QOL specifically developed for diabetic patients exist in scientific literature. The present scoping review reports scales structure, broad domains of QOL, and development purpose. This may help in understanding the concept of QOL in diabetic patients and may also serve the purpose of guiding the reader in the choice of the most appropriate instrument or in the development of a new one.

Health profile and medication adherence of diabetic patients in the Portuguese population

AIMS

To understand the psychological and behavioural impact of type 2 diabetes in the Portuguese Primary Care setting.

METHODS

Observational, cross-sectional study of a convenience sample of portuguese people diagnosed with type 2 diabetes mellitus. The Diabetes Health Profile (DHP-18) and the Four Item Morisky Medication Adherence Scale (MMAS-4) were applied, as well as socio-demographic and disease-related questions.

RESULTS

In a n=110 patient sample, lower education level showed a negative impact on the Psychological Distress dimension (p=0,013). In the Barriers to activity dimension, significant differences were found between different age groups (p=0,033) - a better health profile was observed in the 40-59 years group and also between gender (p=0,039) - greater impact in female subjects. Disinhibited Eating dimension wasn't associated with any of the studied variables. However, all the groups showed worse results in this domain. No associations were found between DHP and medication adherence. Worse medication adherence is more common when there is a prevailing notion of lack of control of diabetes.

DISCUSSION AND CONCLUSION

Using DHP, a larger negative impact related to type 2 diabetes mellitus is found in those with lower educational level, female and younger (20-39 years) or older (60-79 years) subjects. Broader information strategies aimed at improving the quality of life of diabetic patients is necessary, particularly those related to nutrition.

Psychometric testing of the Norwegian Diabetes Health Profile (DHP-18) in patients with type 1 diabetes

OBJECTIVE

The Diabetes Health Profile-18 (DHP-18) was developed to measure disease-specific health-related quality of life. It has been translated into Norwegian but remains invalidated. The purpose of this paper was to examine the psychometric properties of the Norwegian DHP-18.

RESEARCH DESIGN AND METHODS

Participants with type 1 diabetes were recruited from three outpatient clinics in Norway. Clinical and sociodemographic data were collected, and participants completed the DHP-18 and the Short-Form 36 (SF-36). Descriptive analysis, frequencies, t-tests and the chi-squared tests were used. Principal axis factoring (PAF) and confirmatory factor analysis (CFA) were used. Convergent validity was tested using Spearman's correlation between the DHP-18 and SF-36. Reliability was tested using Cronbach's alpha and intraclass correlation coefficient.

RESULTS

In total, 288 patients were included. No floor and ceiling effects were found. A forced PAF analysis revealed that three questions had an eigenvalue below 0.40. In the unforced PAF analysis, one question loaded below 0.40, while three questions loaded into a fourth factor. The correlation between the DHP-18 and SF-36 dimensions was low to moderate. Problematic internal consistency was observed for the disinhibited eating dimension in the forced PAF and in the suggested fourth dimension in the unforced PAF. CFA revealed poor fit. The test-retest reliability displayed good to excellent values, but responsiveness was limited.

CONCLUSIONS

Problematic issues were identified regarding factor structure, item loadings, internal consistency and responsiveness. Further evaluation of responsiveness is particularly recommended, and using a revised 14-item DHP version is suggested.

Health-Related Quality of Life Assessments with Once-Weekly Glucagon-Like Peptide-1 Receptor Agonists in Type 2 Diabetes Mellitus

Type 2 diabetes (T2DM) is associated with significant impairment in health-related quality of life (HRQoL). A patient-centered collaborative approach is recommended to optimize clinical outcomes, including HRQoL, in this patient population. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) provide effective glycemic control and have demonstrated beneficial effects on HRQoL and treatment satisfaction. Available once-weekly GLP-1 RAs may offer enhanced convenience compared with daily GLP-1 RAs and include exenatide extended-release (ER), dulaglutide, and semaglutide. This article reviews the impact of once-weekly GLP-1 RAs on HRQoL and treatment satisfaction in patients with T2DM. Compared with oral antihyperglycemic drugs, insulin, and daily GLP-1 RAs, once-weekly GLP-1 RAs offer benefits with regard to HRQoL and treatment satisfaction. These benefits appear to be largely mediated by relative drug effects on glycemic control, weight, and hypoglycemia. While there was not an overall class benefit of once-weekly GLP-1 RAs compared with daily GLP-1 RAs on HRQoL and treatment satisfaction, results suggested that once-weekly GLP-1 RAs may enhance certain elements of treatment satisfaction and increase willingness to continue treatment. In 2 studies comparing once-weekly GLP-1 RAs with each other, semaglutide produced significantly greater improvement in overall treatment satisfaction compared with exenatide ER but not dulaglutide. Once-weekly GLP-1 RAs represent an effective and convenient treatment option that may potentially increase treatment satisfaction and enhance adherence, contributing to improved health outcomes.

DISCLOSURES

This supplement was funded by Novo Nordisk. Billings reports personal fees from Dexcom, Novo Nordisk, and Sanofi. Handelsman reports research grants from Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Grifols, Janssen, Lexicon, Merck, Novo Nordisk, Regeneron, and Sanofi; speaker fees from Amarin, Amgen, AstraZeneca, Boehringer Ingelheim-Lilly, Janssen, Merck, Novo Nordisk, Regeneron, and Sanofi; and has served in advisory capacity to Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Eisai, Intarcia, Janssen, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron, and Sanofi. Heile reports speaker fees from and has served as advisor to Novo Nordisk. Schneider reports advisory board fees from Intarcia, Lilly, and Novo Nordisk. Wyne has nothing to disclose.

Estimating a Preference-Based Single Index Measuring the Quality-of-Life Impact of Self-Management for Diabetes

OBJECTIVE

Self-management is becoming increasingly important in diabetes but is neglected in conventional preference-based measures. The objective of this paper was to generate health state utility values for a novel classification system measuring the quality-of-life impact of self-management for diabetes, which can be used to generate quality-adjusted life years (QALYs).

METHODS

A large online survey was conducted using a discrete choice experiment (DCE), with duration as an additional attribute, on members of the UK general population ( n = 1,493) to elicit values for health (social limitations, mood, vitality, hypoglycaemia) and non-health (stress, hassle, control, support) aspects of self-management in diabetes. The data were modelled using a conditional fixed-effects logit model and utility estimates were anchored on the one to zero (full health to dead) scale.

RESULTS

The model produced significant and consistent coefficients, with one logical inconsistency and 3 insignificant coefficients for the milder levels of some attributes. The anchored utilities ranged from 1 for the best state to -0.029 for the worst state (meaning worse than dead) defined by the classification system.

CONCLUSION

The results presented here can potentially be used to generate utility values capturing the day to day impact of interventions in diabetes on both health and self-management. These utility values can potentially be used to generate QALYs for economic models of the cost-effectiveness of interventions in diabetes.

Comparison of Completion Rates for SF-36 Compared With SF-12 Quality of Life Surveys at a Tertiary Urban Wound Center

Patient-reported outcome measures derived from quality of life instruments are an important tool in monitoring disease progression and treatment response. Although a number of validated instruments are available, the Short Form-36 (SF-36) quality of life survey is the most widely used. It is imperative that the patients answer all the questions in this instrument for appropriate analysis and interpretation. It has been hypothesized that fewer questions (i.e., the Short Form-12 [SF-12]), will result in greater survey completion rates. The present study was a randomized prospective study comparing the completion rates for the SF-36 and SF-12 quality of life surveys. Patients presenting with a chronic wound were asked to complete the SF-36 or SF-12 survey. After an a priori power analysis was performed, the completion rates, patterns of skipped questions, and demographic information were analyzed using t tests for continuous variables or Fisher's exact test for categorical variables and both multivariate linear regression and logistic regression. A total of 59 subjects (30 completed the SF-12 and 29 completed the SF-36) participated in the present study. The SF-12 group had an 80% (24 of 30) completion rate compared with a 55% (16 of 29) completion rate for the SF-36 group (p < .05). However, the length of the survey did not affect the completion rate nor was a statistically detectable pattern of skipped questions found. College graduates were more likely to complete both surveys compared with high school graduates (p < .07). Although it is unclear why, our study results indicate that the SF-12 yields a higher total survey completion rate. However, completion appears independent of the shorter survey length.

Impact of hypoglycemic episodes on health-related quality of life of type-2 diabetes mellitus patients: development and validation of a specific QoLHYPO© questionnaire

Background

Hypoglycemia is a limiting factor to achieving optimal glycemic control in patients with type-2 diabetes mellitus (T2DM), increasing risk of death and complications, reducing health-related quality of life (HRQoL) and work productivity and increasing healthcare costs.

The study’s primary objective was to develop and validate a specific questionnaire to assess the impact of hypoglycemia on the HRQoL of T2DM patients (QoLHYPO^© questionnaire).

Methods

A two-phase multicenter prospective, longitudinal, observational, epidemiologic study of consecutively enrolled patients, not involving any drug, was conducted: In phase 1 (questionnaire development), patients who had given their written informed consent, who were at least 30 years of age, had been diagnosed with T2DM at least 5 years prior, had an HbA1c test in the previous 3 months, and a hypoglycemic episode in the previous 6 months were included. To validate the questionnaire and assess reliability and responsiveness, phase 2 included two cohorts of patients. Patients in the reliability cohort would likely have stable clinical course during the 3 weeks following inclusion in the study and patients in the responsiveness cohort would likely experience changes in their clinical course in the 3 months after enrollment.

Results

Phase 1 included 168 patients: 10 attended semi-structured interviews, 18 for face validity, and 140 for the pilot test (Rasch analysis). Phase 2 included 227 patients: 142 in the reliability cohort and 85 in the responsiveness cohort.

Of the 37 items initially included in Phase 1, 11 (floor/ceiling effect analysis) and 13 (Rasch analysis) were discarded. The final version of the questionnaire consisted of 13 items.

Phase 2 results showed the questionnaire was unidimensional and able to accurately assess HRQoL. Intra-observer reproducibility (ICC = 0.920) and internal consistency (Cronbach’s alpha: visit 1 = 0.912; visit 2 = 0.901) were high, showing high reliability. Internal responsiveness was moderate (standardized effect size 0.5-0.8) and external responsiveness was lower (AUC > 0.5; not statistically significant). Minimal clinically important difference (MCID) was estimated to be 3.2 points.

Conclusions

The QoLHYPO^© questionnaire is a tool that can be used in routine clinical practice to assess the impact of hypoglycemia on the HRQoL of T2DM patients.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0875-1) contains supplementary material, which is available to authorized users.

Using a Discrete-Choice Experiment Involving Cost to Value a Classification System Measuring the Quality-of-Life Impact of Self-Management for Diabetes

OBJECTIVES

To describe the use of a novel approach in health valuation of a discrete-choice experiment (DCE) including a cost attribute to value a recently developed classification system for measuring the quality-of-life impact (both health and treatment experience) of self-management for diabetes.

METHODS

A large online survey was conducted using DCE with cost on UK respondents from the general population (n = 1497) and individuals with diabetes (n = 405). The data were modeled using a conditional logit model with robust standard errors. The marginal rate of substitution was used to generate willingness-to-pay (WTP) estimates for every state defined by the classification system. Robustness of results was assessed by including interaction effects for household income.

RESULTS

There were some logical inconsistencies and insignificant coefficients for the milder levels of some attributes. There were some differences in the rank ordering of different attributes for the general population and diabetic patients. The WTP to avoid the most severe state was £1118.53 per month for the general population and £2356.02 per month for the diabetic patient population. The results were largely robust.

CONCLUSIONS

Health and self-management can be valued in a single classification system using DCE with cost. The marginal rate of substitution for key attributes can be used to inform cost-benefit analysis of self-management interventions in diabetes using results from clinical studies in which this new classification system has been applied. The method shows promise, but found large WTP estimates exceeding the cost levels used in the survey.

Developing preference-based measures for diabetes: DHP-3D and DHP-5D

AIMS

The aim of this study was to develop two diabetes-specific preference-based measures [the Diabetes Health Profile-3 Dimension (DHP-3D) and the Diabetes Health Profile-5 Dimension (DHP-5D)] for use in the calculation of Quality Adjusted Life Years, a key outcome in economic evaluation. These measures were based on the non-preference-based instrument the Diabetes Health Profile.

METHODS

For DHP-3D, psychometric and Rasch analyses were used to develop a health state classification system based on the Diabetes Health Profile-18 (DHP-18). The DHP-5D added two dimensions to the DHP-3D to extend the range of impacts measured. Each classification system was valued by 150 general public respondents in the United Kingdom using Time Trade Off (TTO). Multivariate regression was used to estimate utility value sets. The matched dimensions across each measure were compared using z-score tests.

RESULTS

The DHP-3D included three dimensions defined as mood, eating and social limitations, and the DHP-5D added dimensions defined as hypoglycaemic attacks and vitality. For both, the random effects generalized least squares regression model produced consistent value sets, with the DHP-3D and DHP-5D ranging from 0.983 (best state) to 0.717 (worst state), and 0.979 to 0.618 respectively. The addition of the two extra dimensions leads to significant differences for the more severe levels of each matched dimension.

CONCLUSIONS

We have developed two diabetes-specific preference-based measures that, subject to psychometric assessment, can be used to provide condition-specific utility values to complement generic utilities from more widely validated measures such as the EuroQol-5 Dimension.

The Effect of Telehealth on Quality of Life and Psychological Outcomes Over a 12-Month Period in a Diabetes Cohort Within the Whole Systems Demonstrator Cluster Randomized Trial

BACKGROUND

Much is written about the promise of telehealth and there is great enthusiasm about its potential. However, many studies of telehealth do not meet orthodox quality standards and there are few studies examining quality of life in diabetes as an outcome.

OBJECTIVE

 To assess the impact of home-based telehealth (remote monitoring of physiological, symptom and self-care behavior data for long-term conditions) on generic and disease-specific health-related quality of life, anxiety, and depressive symptoms over 12 months in patients with diabetes. Remote monitoring provides the potential to improve quality of life, through the reassurance it provides patients.

METHODS

The study focused on participant-reported outcomes of patients with diabetes within the Whole Systems Demonstrator (WSD) Telehealth Questionnaire Study, nested within a pragmatic cluster-randomized trial of telehealth (the WSD Telehealth Trial), held across 3 regions of England. Telehealth was compared with usual-care, with general practice as the unit of randomization. Participant-reported outcome measures (Short-Form 12, EuroQual-5D, Diabetes Health Profile scales, Brief State-Trait Anxiety Inventory, and Centre for Epidemiological Studies Depression Scale) were collected at baseline, short-term (4 months) and long-term (12months) follow-ups. Intention-to-treat analyses testing treatment effectiveness, were conducted using multilevel models controlling for practice clustering and a range of covariates. Analyses assumed participants received their allocated treatment and were conducted for participants who completed the baseline plus at least one follow-up assessment (n=317).

RESULTS

 Primary analyses showed differences between telehealth and usual care were small and only reached significance for 1 scale (diabetes health profile-disinhibited eating, P=.006). The magnitude of differences between trial arms did not reach the trial-defined minimal clinically important difference of 0.3 standard deviations for most outcomes. Effect sizes (Hedge's g) ranged from 0.015 to 0.143 for Generic quality of life (QoL) measures and 0.018 to 0.394 for disease specific measures.

CONCLUSIONS

Second generation home-based telehealth as implemented in the WSD evaluation was not effective in the subsample of people with diabetes. Overall, telehealth did not improve or have a deleterious effect quality of life or psychological outcomes for patients with diabetes over a 12-month period.

Developing a questionnaire to determine the impact of self-management in diabetes: giving people with diabetes a voice

BACKGROUND

The prevalence of diabetes mellitus (DM) is increasing dramatically, placing considerable financial burden on the healthcare budget of each country. Patient self-management is crucial for the control of blood glucose, which largely determines the chances of developing diabetes-related complications. Self-management interventions vary widely, and a method is required for assessing the impact of self-management. This paper describes the development of a questionnaire intended for use to measure the impact of self-management in diabetes.

METHODS

An iterative development process was undertaken to identify the attributes of self-management using 5 steps. First, a literature review was undertaken to identify and understand themes relating to self-management of DM to inform a topic guide. Second, the topic guide was further refined following consultation with a Patient and Public Involvement group. Third, the topic guide was used to inform semi-structured interviews with patients with Type 1 DM (T1DM) and Type 2 DM (T2DM) to identify how self-management of DM affects individuals. Fourth, the research team considered potential attributes alongside health attributes from an existing measure (Diabetes Health Profile, DHP) to produce an instrument reflecting both health and self-management outcomes simultaneously. Finally, a draft instrument was tested in a focus group to determine the wording and acceptability.

RESULTS

Semi-structured interviews were carried out with 32 patients with T1DM and T2DM. Eight potential attributes were identified: fear/worry/anxiety, guilt, stress, stigma, hassle, control, freedom, and feeling supported. Four of these self-management attributes were selected with four health attributes (mood, worry about hypos (hypoglycaemic episodes), vitality and social limitations) to produce the Health and Self-Management in Diabetes (HASMIDv1) questionnaire.

CONCLUSIONS

HASMIDv1 is a short questionnaire that contains eight items each with four response levels to measure the impact of self-management in diabetes for both T1DM and T2DM. The measure was developed using a mixed-methods approach that involved semi-structured interviews with people with diabetes. The measure has high face validity. Ongoing research is being undertaken to assess the validity of this questionnaire for measuring the impact of self-management interventions in economic evaluation.

Placebo-controlled, randomized trial of the addition of once-weekly glucagon-like peptide-1 receptor agonist dulaglutide to titrated daily insulin glargine in patients with type 2 diabetes (AWARD-9)

AIM

To compare the addition of weekly dulaglutide vs the addition of placebo to titrated glargine in patients with type 2 diabetes (T2D) with sub-optimum glycated haemoglobin (HbA1c) concentration.

MATERIALS AND METHODS

Patients (N = 300) from this phase III, double-blind, parallel-arm, placebo-controlled study were randomized to weekly subcutaneous injections of dulaglutide 1.5 mg or placebo with titrated daily glargine (mean ± standard deviation baseline dose: 39 ± 22 U), with or without metformin (≥1500 mg/d). The primary endpoint was superiority of dulaglutide/glargine to placebo/glargine with regard to change from baseline in HbA1c level at 28 weeks.

RESULTS

Least squares (LS) mean ± standard error (s.e.) HbA1c changes from baseline were -1.44 ± 0.09% (-15.74 ± 0.98 mmol/mol) with dulaglutide/glargine and -0.67 ± 0.09% (-7.32 ± 0.98 mmol/mol) with placebo/glargine at 28 weeks (LS mean difference [95% confidence interval] -0.77% [-0.97, -0.56]; P < .001). Body weight decreased with dulaglutide/glargine and increased with placebo/glargine (LS mean difference: -2.41 ± 0.39 kg; P < .001). Increases from baseline in mean glargine dose were significantly smaller with dulaglutide/glargine vs placebo/glargine (13 ± 2 U [0.1 ± 0.02 U/kg] vs 26 ± 2 U [0.3 ± 0.02 U/kg], respectively; P < .001; LS mean ± s.e. final dose: dulaglutide/glargine, 51 ± 2 U; placebo/glargine, 65 ± 2 U). The hypoglycaemia rate (≤3.9 mmol/L threshold) was 7.69 ± 15.15 and 8.56 ± 16.13 events/patient/year, respectively (P = .488). One episode of severe hypoglycaemia occurred in the dulaglutide/glargine group. Common gastrointestinal adverse events with dulaglutide were nausea (12.0%), diarrhoea (11.3%) and vomiting (6.0%).

CONCLUSIONS

Weekly dulaglutide 1.5 mg added to basal insulin is an efficacious and well tolerated treatment option for patients with T2D.

The validity and reliability of the English version of the diabetes distress scale for type 2 diabetes patients in Malaysia

BACKGROUND

Several disease specific instruments have been developed to identify and assess diabetes distress. In Malaysia, the Problem Areas in Diabetes Scale has been validated in Malay, but it does not have specific domains to assess the different areas of diabetes-related distress. Hence, we decided to use the Diabetes Distress Scale instead. To date, only the Malay version of the Diabetes Distress Scale has been validated in Malaysia. However, English is widely spoken by Malaysians, and is an important second language in Malaysia. Therefore, our aim was to determine the validity and reliability of the English version of the Diabetes Distress Scale among patients with type 2 diabetes in Malaysia.

METHODS

The Diabetes Distress Scale was administered to 114 patients with type 2 diabetes, who could understand English, at baseline and 4 weeks later, at a primary care clinic in Malaysia. To assess for convergent validity, the Depression Anxiety Stress Scale was administered at baseline. Discriminative validity was assessed by analysing the total diabetes distress scores of participants with poor (HbA1c > 7.0%) and good glycaemic control (HbA1c ≤ 7.0%).

RESULTS

The majority of our participants were male 65(57.0%), with a median duration of diabetes of 9.5 years. Exploratory factor analysis showed that the Diabetes Distress Scale had 4 subscales, as per the original Diabetes Distress Scale. The overall Cronbach's α was 0.920 (range = 0.784-0.859 for each subscale). The intraclass correlation ranged from 0.436 to 0.643 for test-retest. The Diabetes Distress Scale subscales were significantly correlated with the different subscales of the Depression Anxiety Stress Scale (spearman's rho range = 0.427-0.509, p < 0.001). Patients with poor glycaemic control had significantly higher diabetes distress score (1.88) compared to those with good glycaemic control (1.50) (p < 0.001).

CONCLUSIONS

The English version of the Diabetes Distress Scale was found to be a valid and reliable instrument to evaluate diabetes distress among patients with type 2 diabetes in Malaysia. It can be used in clinical practice to offer a useful indicator of the effect of diabetes-induced distress during clinic visits, especially for patients with poor glycemic control. This would ensure that these patients are provided the care that is required.

Switching from Biphasic Human Insulin to Premix Insulin Analogs: A Review of the Evidence Regarding Quality of Life and Adherence to Medication in Type 2 Diabetes Mellitus

Diabetes is a growing public health concern. Effective use of therapies for this chronic disease is necessary to improve long-term prognosis, but treatment adherence can be difficult to promote in clinical practice, and insulin, in particular, can impact both positively and negatively on patients' quality of life (QoL). Currently, guidelines advocate for QoL as a treatment goal in its own right, with treatment decisions based on patient concerns regarding injection frequency and adverse events, as well as glycemic control. Successful insulin management ideally requires a regimen to replicate normal endogenous insulin release, and this was a key driver in the development of insulin analogs. These analogs have also been associated with lower hypoglycemia risk, lower levels of postprandial glucose excursions, better adherence, improved QoL, and higher patient satisfaction with treatment. Premixed insulin is prescribed for many patients with type 2 diabetes mellitus (T2D), as it combines both prandial and basal treatment, reducing the number of injections. Evidence suggests that premixed insulin analogs have advantages over conventional premixed human insulin for T2D treatment, but the objective of this review was to assess the evidence that switching from a biphasic human insulin to a biphasic insulin analog regimen improves patient QoL.

FUNDING

Novo Nordisk.

Self management interventions for type 2 diabetes in adult people with severe mental illness

BACKGROUND

People with severe mental illness are twice as likely to develop type 2 diabetes as those without severe mental illness. Treatment guidelines for type 2 diabetes recommend that structured education should be integrated into routine care and should be offered to all. However, for people with severe mental illness, physical health may be a low priority, and motivation to change may be limited. These additional challenges mean that the findings reported in previous systematic reviews of diabetes self management interventions may not be generalised to those with severe mental illness, and that tailored approaches to effective diabetes education may be required for this population.

OBJECTIVES

To assess the effects of diabetes self management interventions specifically tailored for people with type 2 diabetes and severe mental illness.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform (ICTRP) Search Portal, ClinicalTrials.gov and grey literature. The date of the last search of all databases was 07 March 2016.

SELECTION CRITERIA

Randomised controlled trials of diabetes self management interventions for people with type 2 diabetes and severe mental illness.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and full-text articles, extracted data and conducted the risk of bias assessment. We used a taxonomy of behaviour change techniques and the framework for behaviour change theory to describe the theoretical basis of the interventions and active ingredients. We used the GRADE method (Grades of Recommendation, Assessment, Development and Evaluation Working Group) to assess trials for overall quality of evidence.

MAIN RESULTS

We included one randomised controlled trial involving 64 participants with schizophrenia or schizoaffective disorder. The average age of participants was 54 years; participants had been living with type 2 diabetes for on average nine years, and with their psychiatric diagnosis since they were on average 28 years of age. Investigators evaluated the 24-week Diabetes Awareness and Rehabilitation Training (DART) programme in comparison with usual care plus information (UCI). Follow-up after trial completion was six months. Risk of bias was mostly unclear but was high for selective reporting. Trial authors did not report on diabetes-related complications, all-cause mortality, adverse events, health-related quality of life nor socioeconomic effects. Twelve months of data on self care behaviours as measured by total energy expenditure showed a mean of 2148 kcal for DART and 1496 kcal for UCI (52 participants; very low-quality evidence), indicating no substantial improvement. The intervention did not have a substantial effect on glycosylated haemoglobin A1c (HbA1c) at 6 or 12 months of follow-up (12-month HbA1c data 7.9% for DART vs 6.9% for UCI; 52 participants; very low-quality evidence). Researchers noted small improvements in body mass index immediately after the intervention was provided and at six months, along with improved weight post intervention. Diabetes knowledge and self efficacy improved immediately following receipt of the intervention, and knowledge also at six months. The intervention did not improve blood pressure.

AUTHORS' CONCLUSIONS

Evidence is insufficient to show whether type 2 diabetes self management interventions for people with severe mental illness are effective in improving outcomes. Researchers must conduct additional trials to establish efficacy, and to identify the active ingredients in these interventions and the people most likely to benefit from them.

Development and validation of the short version of the diabetes obstacles questionnaire (DOQ-30) in six European countries

BACKGROUND

Patients with type 2 diabetes reveal different obstacles in living with the disease. The EGPRN initiated a qualitative research EUROBSTACLE to create a broadly conceptualized diabetes-related quality of life (DR-QoL) instrument. It led to the development of the diabetes obstacle questionnaire (DOQ), a five-point Likert-scaled measure, consisting of 78 items in eight scales.

OBJECTIVES

To develop and validate a short, easy-to-use version of the DOQ.

METHODS

A cross-sectional study with the DOQ was carried out. Participants answered the DOQ and GPs added some clinical data from their medical records. Data of 853 patients from Belgium, France, Estonia, Serbia, Slovenia, and Turkey were included in the analysis. The selection of items for the short version of the DOQ was achieved with exploratory factor analysis (EFA). Construct validity was proved with EFA and Pearson correlations between the DOQ and the new DOQ-30. Internal reliability was established with Cronbach's alpha.

RESULTS

DOQ-30 resulted in 30 items in nine subscales. It explained 49.8% of items' variance. It shows a considerable good internal reliability and construct validity.

CONCLUSION

The DOQ-30 is a five-point Likert-scaled broadly conceptualized measure of DR-QoL. It addresses a variety of obstacles, such as social, psychological, cognitive and behavioural. The DOQ-30 is ready for implementation in general practice and research in Europe as a valuable instrument to assess DR-QoL.

Clinical outcomes and resource use after 24 months of insulin therapy in Turkish patients with type 2 diabetes: subgroup analysis of the TREAT study

PURPOSE

This study evaluated levels of metabolic control, resource use and quality of life in Turkish patients with type 2 diabetes initiated on insulin in routine care.

PATIENTS AND METHODS

The prospective, observational TREAT study evaluated patients from five different countries who were initiated on insulin and followed for 24 months. In this paper, we present the results of a cohort analysis specific to Turkish patients from the study.

RESULTS

A total of 211 patients in the Turkish multicenter cohort [male patients 50.2%, age 56.5 year±8.9 SD, body mass index (BMI) 30.6 kg/m2±5.4 SD, diabetes duration 9.7 year±5.9 SD] initiated insulin at baseline. Oral antidiabetic drugs had been used by 93.4% of patients prior to insulin initiation, and 65.9% had used more than one regimen. Pre-existing metformin therapy was continued by 68.7% of patients after insulin initiation. In the three most common insulin regimens, glycosylated haemoglobin (HbA1C) declined over 24 months from 10.27% to 7.82% (long/intermediate acting), from 10.82% to 7.52% (premixed) and from 10.42% to 7.67% (basal-bolus). Less than 25% achieved a glycaemic goal of HbA1C≤7.0% and changes in insulin dose or regimen rarely occurred. Premixed insulin regimens were associated with greatest weight gain. Hypoglycaemic episodes were reported by more patients at 3, 6 and 12 months than at baseline or at 18 or 24 months. Healthcare use increased over baseline levels in the first 6 months, but was closer to baseline levels at subsequent assessments. Patient recorded health profiles improved after initiating insulin, particularly quality of life scores related to psychological distress and pain/discomfort. Morisky scores predictive of medication adherence and treatment persistence also improved.

CONCLUSIONS

In Turkish patients with type 2 diabetes, metabolic control remained suboptimal after initiating insulin as part of routine care even after 24 months of insulin treatment. Apparent shortcomings in routine care in most patients included a high baseline HbA1C because of delayed insulin initiation and an unwillingness to individualise insulin regimens.

Biphasic vs basal bolus insulin regimen in Type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

AIM

We aim to evaluate the effects of biphasic insulin compared with a basal bolus insulin regimen on glycaemic control, total daily insulin requirements, risk of hypoglycaemia, weight and quality of life in patients with diabetes mellitus.

METHODS

MEDLINE, EMBASE, PubMed and Scopus databases were searched for studies up to November 2013. Interventions that lasted for more than four weeks and were reported in English were considered for the review. Meta-analysis was performed on eligible studies.

RESULTS

Fifteen randomized controlled trial studies, involving 4384 patients, were included. Greater HbA1c reductions were seen with basal-bolus compared with biphasic insulin regimens, between-treatment weighted mean difference (WMD) for baseline-to-endpoint changes in HbA1c was -0.2% (95% CI: -0.36 to -0.03) [-2.2 (-3.9, -0.3) mmol/mol]. In non-insulin naïve (n = 8) patients with Type 2 diabetes, HbA1c reduction was greater in the basal bolus group; WMD = -0.22% (95% CI: -0.42 to -0.02) [-2.4 (-4.6, -0.2) mmol/mol], but in insulin naïve patients (n = 5), HbA1c was equivalent between the two regimens; WMD (-0.15% (95% CI: -0.52 to 0.22) [-1.6 (-5.7, 2.4) mmol/mol]. Total daily insulin requirements and weight were increased with both regimens, whereas hypoglycaemia rates were comparable between the two regimens. Greater HbA1c reduction was observed in the basal bolus group compared with the biphasic regimen at the expense of higher daily insulin requirements and weight gain, but with no greater risk of hypoglycaemia.

CONCLUSIONS

Biphasic and basal bolus regimens were equally effective in reducing HbA1c in insulin naïve patients with Type 2 diabetes and both regimens are equally effective for initiating insulin in Type 2 diabetes.

Review of patient-reported outcome instruments measuring health-related quality of life and satisfaction in patients with type 2 diabetes treated with oral therapy

OBJECTIVE

Treatments and their mode of administration may represent a burden for patients and can therefore impact their health-related quality of life (HRQL) or treatment/health satisfaction. Patients with type 2 diabetes mellitus (T2DM) can be treated with oral hypoglycemic agents (OHAs), injectable medications (such as insulin), or a combination of agents. This review aimed to identify patient-reported outcome (PRO) instruments measuring HRQL and/or satisfaction that could differentiate between oral medications based on medication related attributes such as efficacy, tolerability, weight loss, dosing frequency and pill burden.

RESEARCH DESIGN AND METHODS

Medline, Embase, PsycINFO, Cochrane Library and the Patient-Reported Outcome and Quality of Life Questionnaires (PROQOLID) biomedical databases were searched to identify instruments and document their development methodology, content and psychometric properties (i.e. validity, reliability), responsiveness and ability to detect changes between treatments.

RESULTS

Nineteen instruments were retained based on their potential to differentiate between OHAs. Ten instruments assessed HRQL, amongst which the Audit of Diabetes Dependent Quality of Life, Diabetes 39, Diabetes Health Profile and Impact of Weight on Quality of Life displayed good psychometric properties in T2DM populations and comprehensive HRQL content. Nine instruments assessed satisfaction. Both the Oral Hypoglycemic Agent Questionnaire (OHAQ) and Diabetes Medication Satisfaction (DiabMedSat) Questionnaire have highly relevant content regarding drug attributes. The OHAQ is specific to oral treatment and the DiabMedSat includes HRQL items. The Diabetes Treatment Satisfaction Questionnaire is a standard instrument that is extensively used and provides conclusive results in studies of patients with T2DM.

CONCLUSIONS

Very few of the existing PRO instruments are specific to OHAs. Despite satisfaction instruments being recommended to differentiate between OHAs in studies of T2DM based on medication attributes, we find that none of the existing instruments appear to be useful in detecting differences between treatments, therefore limiting their use in clinical and observational research.

Effectiveness of continuous glucose monitoring in dialysis patients with diabetes: the DIALYDIAB pilot study

AIMS

The DIALYDIAB trial addresses the contribution of iterative sequences of continuous glucose monitoring (CGM) on glucose control in dialysis patients with diabetes.

MATERIALS AND METHODS

In this before-after monocentric 12-week pilot study, dialysis patients with diabetes were monitored with self-monitoring blood glucose (SMBG) 3 times per day during a 6-week period followed by a 5-day CGM recording at 2-week interval during another 6-week period. SMBG and CGM profiles were remotely analyzed by a single diabetes expert who gave therapeutic counseling to dialysis physicians.

RESULTS

Fifteen patients who entered the study had a male/female ratio 8/7, age 60.9±14.8 years, BMI 29.9±7.8, diabetes duration 19.2±8.5 years and dialysis duration 6.5±6.9 years. Treatments were diet alone (20%) or diet plus insulin (80%). Mean CGM glucose level was 8.3±2.5 mmol/l at baseline (T0), 8.2±1.6 mmol/l at the end of the SMBG period (T1) (ns) and 7.7±1.6 mmol/l at the end of the CGM period (T2) (p<0.05 vs. T0). Glucose AUC>10 mmol/l was 0.9±1.4 mmol/l/day at T0 and decreased to 0.4±0.5 at T2 (p<0.05)) without change in glucose AUC<3.3 mmol/l. Treatment adaptation was higher during the CGM period (1.4±1.0 and 2.1±0.9 treatment change at T1 and T2, respectively; p<0.05).

CONCLUSIONS

In patients with diabetes on chronic dialysis, iterative CGM monitoring was associated with more frequent treatment changes and finally, better glucose control, without increased risk of hypoglycemia.

A mobile telehealth intervention for adults with insulin-requiring diabetes: early results of a mixed-methods randomized controlled trial

Background

The role of technology in health care delivery has grown rapidly in the last decade. The potential of mobile telehealth (MTH) to support patient self-management is a key area of research. Providing patients with technological tools that allow for the recording and transmission of health parameters to health care professionals (HCPs) may promote behavior changes that result in improved health outcomes. Although for some conditions the evidence of the effectiveness of MTH is clear, to date the findings on the effects of MTH on diabetes management remain inconsistent.

Objective

This study aims to evaluate an MTH intervention among insulin-requiring adults with diabetes to establish whether supplementing standard care with MTH results in improved health outcomes—glycated hemoglobin (HbA1c), blood pressure (BP), health-related quality of life (HRQoL), diabetes self-management behaviors, diabetes health care utilization, and diabetes self-efficacy and illness beliefs. An additional objective was to explore the acceptability of MTH and patients’ perceptions of, and experience, using it.

Methods

A mixed-method design consisting of a 9-month, two-arm, parallel randomized controlled trial (RCT) was used in combination with exit qualitative interviews. Quantitative data was collected at baseline, 3 months, and 9 months. Additional intervention fidelity data, such as participants’ MTH transmissions and contacts with the MTH nurse during the study, were also recorded.

Results

Data collection for both the quantitative and qualitative components of this study has ended and data analysis is ongoing. A total of 86 participants were enrolled into the study. Out of 86 participants, 45 (52%) were randomized to the intervention group and 36 (42%) to the control group. Preliminary data on MTH training sessions and MTH usage by intervention participants are presented in this paper. We expect to publish complete study results in 2015.

Conclusions

The range of data collected in this study will allow for a comprehensive evaluation of processes and outcomes. The early results presented suggest that MTH usage decreases over time and that MTH participants would benefit from attending more than one training session.

Trial Registration

ClinicalTrials.gov NCT00922376; http://clinicaltrials.gov/ct2/show/NCT00922376 (Archived by WebCite at http://www.webcitation.org/6Vu4nhLI6).

Establishing the thematic framework for a diabetes-specific health-related quality of life item bank for use in an english-speaking asian population

Aims

To establish a thematic framework for a Diabetes Mellitus (DM)-specific health-related quality of life (HRQoL) item bank by identifying important HRQoL themes and content gaps in existing DM-specific HRQoL measures and determining whether Patient-Reported Outcomes Measurement Information System (PROMIS) item banks are useful as a starting point.

Methodology

English-speaking Type 2 DM patients were recruited from an outpatient specialist clinic in Singapore. Thematic analysis was performed through open coding and axial coding. Items from four existing DM-specific measures and PROMIS Version 1.0 and 2.0 item banks were compared with identified themes and sub-themes.

Results

42 patients participated (25 men and 17 women; 28 Chinese, 4 Malay, 8 Indians, 2 other ethnicities). Median age was 53.70 years (IQR45.82–56.97) and the median disease duration was 11.13 (SD9.77) years. 10 subthemes (neutral emotions, coping emotions, empowered to help others, support from family, spend more time with family, relationships, financial burden on family, improved relationship, social support and religion/spirituality) were not covered by existing DM-specific measures. PROMIS covered 5 of 6 themes, 15 of 30 subthemes and 19 of 35 codes identified. Emotional distress (frustration, fear and anxiety) was most frequently mentioned (200 times).

Conclusions

We had developed a thematic framework for assessing DM-specific HRQoL in a multi-ethnic Asian population, identified new items that needed to be written and confirmed that PROMIS was a useful starting point. We hope that better understanding and measurement of HRQoL of Asian DM patients will translate to better quality of care for them.

Change in health status in long-term conditions over a one year period: a cohort survey using patient-reported outcome measures

Background

Enhancing quality of life for people with long-term conditions by monitoring patient-reported outcome measure scores is a key domain of health care policy. This study investigated the responsiveness of patient-reported outcome measures for long-term conditions.

Methods

A cohort survey was conducted in 33 primary care practices and 4485 patients (1334 asthma, 567 chronic obstructive pulmonary disease, 1121 diabetes, 525 epilepsy, 520 heart failure and 418 stroke) were sent a baseline survey containing a generic (EQ-5D) and a disease-specific measure. Baseline respondents were sent a follow-up after 1 year. Differences in scores for each long-term condition were assessed by paired t-tests. The relationship between scores and self-reported ‘change in health’ was assessed by analysis of variance.

Results

The baseline achieved a 38.4% response rate and the follow-up 71.5%. The only significant difference for the EQ-5D was found for the Visual Analogue Scale in heart failure between baseline and follow-up, and for change in health. Significant differences between baseline and follow-up scores were found on the disease-specific measures for 1 asthma dimension and 1 stroke dimension. No significant differences were found for other conditions. Significant differences between self-reported change in health and the disease-specific measures were found for 4 asthma dimensions and 2 stroke dimensions.

Conclusions

Few significant differences were found between the baseline and follow up or between ‘change in health’ and PROMs scores. This could be explained by the time frame of one year being too short for change to occur or by the PROMs not being responsive enough to change in a primary care sample. The latter is unlikely as the PROMs were in part chosen for their responsiveness to change. The baseline response rates may mean that the sample is not representative, and stable patients may have been more likely to participate. If PROMs are to be used routinely to monitor outcomes in LTCs, further research is needed to maximize response rates, to ensure that the PROMs used are reliable, valid and sensitive enough to detect change and that the time frame for data collection is appropriate.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-014-0123-2) contains supplementary material, which is available to authorized users.

The construct validity and responsiveness of the EQ-5D, SF-6D and Diabetes Health Profile-18 in type 2 diabetes

BACKGROUND

Interest in the measurement of health related quality of life and psychosocial functioning from the patient's perspective in diabetes mellitus has grown in recent years. The aim of this study is to investigate the psychometric performance of and agreement between the generic EQ-5D and SF-6D and diabetes specific DHP-18 in Type 2 diabetes. This will support the future use of the measures by providing further evidence regarding their psychometric properties and the conceptual overlap between the instruments. The results will inform whether the measures can be used with confidence alongside each other to provide a more holistic profile of people with Type 2 diabetes.

METHODS

A large longitudinal dataset (n = 1,184) of people with Type 2 diabetes was used for the analysis. Convergent validity was tested by examining correlations between the measures. Known group validity was tested across a range of clinical and diabetes severity indicators using ANOVA and effect size statistics. Agreement was examined using Bland-Altman plots. Responsiveness was tested by examining floor and ceiling effects and standardised response means.

RESULTS

Correlations between the measures indicates that there is overlap in the constructs assessed (with correlations between 0.1 and 0.7 reported), but there is some level of divergence between the generic and condition specific instruments. Known group validity was generally good but was not consistent across all indicators included (with effect sizes from 0 to 0.74 reported). The EQ-5D and SF-6D displayed a high level of agreement, but there was some disagreement between the generic measures and the DHP-18 dimensions across the severity range. Responsiveness was higher in those who self-reported change in health (SRMs between 0.06 and 0.25).

CONCLUSIONS

The psychometric assessment of the relationship between the EQ-5D, SF-6D and DHP-18 shows that all have a level of validity for use in Type 2 diabetes. This suggests that the measures can be used alongside each other to provide a more holistic assessment of with the quality of life impacts of Type 2 diabetes.

Patient-reported outcomes among patients using exenatide twice daily or insulin in clinical practice in six European countries: the CHOICE prospective observational study

BACKGROUND

Improvements in the clinical condition of patients with type 2 diabetes are often accompanied by improvements in health-related quality of life and other patient-reported outcomes (PROs), but data assessing injectable treatment initiation from the patient's perspective in routine clinical practice are lacking. We examined PROs in patients initiating injectable treatment in the CHOICE (CHanges to treatment and Outcomes in patients with type 2 diabetes initiating InjeCtablE therapy) study.

METHODS

CHOICE was a 24-month, prospective observational study conducted in six European countries. Patients initiated exenatide twice daily (BID) or insulin based on a physician's clinical judgement. Clinical and PRO data were collected at baseline (injectable therapy initiation) and after approximately 3, 6, 12, 18 and 24 months. The two treatment cohorts had different baseline characteristics; therefore, no statistical comparisons of endpoints between main cohorts were conducted.

RESULTS

There were 2388 patients eligible for analysis (exenatide BID cohort, n = 1114; insulin cohort, n = 1274). Mean positive changes in Impact of Weight on Quality of Life-Lite (IWQOL-Lite) total score and EuroQoL5-Dimension (EQ-5D) index and visual analogue scale (VAS) scores were observed in both cohorts with most changes observed during the first 6 months after injectable therapy initiation. Patients who experienced weight loss (≥ 1 kg) at 24 months appeared to have higher mean improvements in IWQOL-Lite total score than did patients with weight gain or no weight change. Patients who met the composite clinical endpoint of glycated haemoglobin (HbA1c) <7.0%, no weight gain (≤ 1 kg) and no hypoglycaemia generally experienced higher mean improvements in EQ-5D index and VAS scores (compared with patients who did not meet this endpoint) and Diabetes Health Profile-18 scores (versus the main cohorts). High levels of missing data were observed for all PRO measures in both cohorts compared with those for clinical outcomes.

CONCLUSIONS

These data from a clinical practice study support those from clinical trials, suggesting that PROs are not adversely affected, and may be improved, by injectable therapy initiation. PRO data may aid appropriate treatment selection for individual patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00635492.

Systematic review of the psychometric properties and theoretical grounding of instruments evaluating self-care in people with type 2 diabetes mellitus

AIM

To determine the psychometric properties and theoretical grounding of instruments that evaluate self-care behaviour or barriers in people with type 2 diabetes.

BACKGROUND

There are many instruments designed to evaluate self-care behaviour or barriers in this population, but knowledge about their psychometric validation processes is lacking.

DESIGN

Systematic review.

DATA SOURCES

We conducted a search for psychometric or validation studies published between January 1990-December 2012. We carried out searches in Pubmed, CINAHL, PsycINFO, ProQuolid, BibliPRO and Google SCHOLAR to identify instruments that evaluated self-care behaviours or barriers to diabetes self-care.

REVIEW METHODS

We conducted a systematic review with the following inclusion criteria: Psychometric or clinimetric validation studies that included patients with type 2 diabetes (exclusively or partially) and which analysed self-care behaviour or barriers to self-care and proxies like self-efficacy or empowerment, from a multidimensional approach. Language: Spanish or English. Two authors independently assessed the quality of the studies and extracted data using Terwee's proposed criteria: psychometrics properties, dimensionality, theoretical ground and population used for validation through each included instrument.

RESULTS

Sixteen instruments achieved the inclusion criteria for the review. We detected important methodological flaws in many of the selected instruments. Only the Self-management Profile for Type 2 Diabetes and Problem Areas in Diabetes Scale met half of Terwee's quality criteria.

CONCLUSION

There are no instruments for identifying self-care behaviours or barriers elaborated with a strong validation process. Further research should be carried out to provide patients, clinicians and researchers with valid and reliable instruments that are methodologically solid and theoretically grounded.

Clinical outcomes and costs for patients with type 2 diabetes mellitus initiating insulin therapy in Greece: two-year experience from the INSTIGATE study

AIMS

To evaluate the quality of metabolic control, clinical outcomes, resource costs, and quality of life among patients with type 2 diabetes mellitus (T2DM), who initiated insulin for the first time as part of routine clinical practice.

METHODS

The INSTIGATE study is a prospective, multicentric, observational study of patients initiating insulin treatment. This sub-cohort analysis focuses on Hellenic outcomes.

RESULTS

At baseline, 263 Greek patients were enrolled just before initiating insulin for the first time. At the 6-month visit, 237 patients (90.1%) remained and consented to an additional 18-month observation period. In these 237 extension patients, over the 24-month post-initiation period, HbA1c (mean(SD)) decreased from 9.7%(1.6%) to 7.1%(0.9%) and body weight and BMI increased (+3(6)kg and +1.1(2.2)kg/m(2), respectively). At each post-baseline visit approximately one in five patients reported ≥1 episodes of hypoglycaemia in the preceding 3-6 months. Median total costs fluctuated from 438€ at baseline to 538€ up to 6 months and 451€ at 24 months; mean costs were 496(383)€, 573(276)€ and 485(247)€, respectively.

CONCLUSIONS

In this cohort, insulin treatment seems to be effective with little long-term impact on cost. Findings should be interpreted in the context of an observational study.

Patients with Type 2 Diabetes Initiating Exenatide Twice Daily or Insulin in Clinical Practice: CHOICE Study

INTRODUCTION

Changes to Treatment and Outcomes in Patients with Type 2 Diabetes Initiating Injectable Therapy (CHOICE) is a European prospective, observational cohort study assessing time to, and factors associated with, a significant change in therapy after type 2 diabetes patients initiate their first injectable glucose-lowering therapy, and these patients' clinical outcomes over 24 months. The authors report baseline data and factors associated with the injectable treatment regimen.

METHODS

Demographic, clinical, and healthcare resource-use data were collected at initiation of injectable therapy and analyzed using univariate tests between cohorts and multivariate logistic regression analysis for treatment.

RESULTS

Overall, 1,177 patients initiated exenatide twice daily (b.i.d.) and 1,315 initiated insulin. Most patients were recruited by secondary-care physicians. Univariate analyses revealed statistically significant differences between the characteristics of patients who initiated exenatide b.i.d. and patients who initiated insulin. On multivariate analysis, higher body mass index [BMI; 5 kg/m(2) higher: odds ratio (OR) 2.10, 95% confidence intervals (CI) 1.84-2.40], lower glycated hemoglobin (HbA(1c); 1% higher: OR 0.77, 95% CI 0.69-0.86), and lower age (5 years older: OR 0.82, 95% CI 0.76-0.88) were the variables most strongly associated with increased probability of receiving exenatide b.i.d. (P < 0.0001). Patients initiating exenatide b.i.d. had a mean BMI of 35.3 ± 6.5 kg/m(2), HbA(1c) of 8.4 ± 1.4%, and age of 58 ± 10 years, compared with 29.7 ± 5.4 kg/m(2), 9.2 ± 1.9%, and 64 ± 11 years, respectively, in patients initiating insulin (P < 0.0001). Other characteristics significantly associated with exenatide b.i.d. initiation were "disinhibited eating" (Diabetes Health Profile-18), lower random blood glucose, less blood glucose self-monitoring, lower low-density lipoprotein cholesterol, and receipt of diet/exercise advice.

CONCLUSIONS

Patients who initiated exenatide b.i.d. were on average younger and more obese with lower HbA(1c) than those initiating insulin.

Development and preliminary testing of a brief screening measure of healthy lifestyle for diabetes patients

OBJECTIVES

Improving diabetes control is a critical issue world-wide, because mortality rates and costs are increasing dramatically. Maintaining a healthy lifestyle is positively associated with diabetes control. However, the availability of practical screening tools suitable for determining and modifying healthy or unhealthy lifestyle choices is limited. The main aim of this study was to determine the appropriateness of the type 2 diabetes and health promotion scale (T2DHPS) for use in patients with type 2 diabetes.

METHODS

This study examined the Cronbach's alpha, content validity, construct and concurrent validity of the Chinese language version of the T2DHPS for assessing lifestyle and disease control among patients with type 2 diabetes. The dimensions of the T2DHPS were generated from the Chinese version of adult health promotion and interviews with experts, and were corroborated by the literature. A total of 323 patients previously diagnosed with type 2 diabetes were recruited. A cross-sectional, descriptive design questionnaire was developed and tested at diabetes outpatient departments in three teaching hospitals between August 2010 and June 2011. Construct validity was established using factor analysis. The total and subscale scores of the T2DHPS were correlated with biomarkers of diabetes control for concurrent validity.

RESULTS

Kaiser-Meyer-Olkin (KMO) and Bartlett's sphericity tests showed that the sample met the criteria required for factor analysis. A 28-item Likert-type scale of the T2DHPS was established, and explained 56.7% of the total variance. The simplified version of the T2DHPS was made up of six dimensions of behavior: physical activity, risk reduction, stress-management, enjoy life, health responsibility and a healthy diet. The reliability coefficient for the total scale was 0.89, and alpha coefficients for the subscales ranged from 0.63 to 0.86. Concurrent validity indicated that the T2DHPS is significantly positively associated with diabetes control.

CONCLUSIONS

T2DHPS was shown to be a reliable and valid tool for assessing patients with type 2 diabetes, and can possibly predict diabetic control. This scale appears to be a useful screening tool for type 2 diabetic people in primary health care settings, to promote health status through modification of an unhealthy lifestyle.

Resource utilisation and clinical data before and after switching between short-acting human insulin and rapid-acting insulin analogues in patients with type 2 diabetes: the SWING study

AIM

SWING was a prospective, observational study conducted in nine European countries primarily to assess direct treatment costs when switching from short-acting human insulins to rapid-acting insulin analogues (H-A) or vice versa (A-H) in patients with type 2 diabetes.

METHODS

Data were collected at a baseline visit (time of switch) and at approximately 3, 6 and 12 months post-switch.

RESULTS

In total, 2389 patients switched from H-A (n=2203) or A-H (n=186); another 603 were enrolled but ineligible. Mean (SD) direct diabetes-related costs (pro-rated to account for variable visit schedules) were €548.7 (865.8) 6 months prior to switch, €625.6 (1474.9) at 0-6 months and €568.6 (590.7) 6-12 months following switch for H-A, and €544.5 (421.0), €481.0 (301.5) and €461.6 (335.0) for A-H, respectively. Mean (SD) HbA(1c) decreased over 12 months by 1.08 (1.53)% units H-A and 1.17 (1.45)% units A-H. A small decline in hypoglycaemia occurred over time, but there were no clinically meaningful changes in mean PROs.

CONCLUSIONS

There were small changes in mean direct diabetes-related costs (following adjustment for time interval) in patients switching in either direction. Improvements in mean HbA(1c) and incidence of hypoglycaemia cannot necessarily be attributed to therapeutic switch.

A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial

Background

It is expected that increased demands on services will result from expanding numbers of older people with long-term conditions and social care needs. There is significant interest in the potential for technology to reduce utilisation of health services in these patient populations, including telecare (the remote, automatic and passive monitoring of changes in an individual's condition or lifestyle) and telehealth (the remote exchange of data between a patient and health care professional). The potential of telehealth and telecare technology to improve care and reduce costs is limited by a lack of rigorous evidence of actual impact.

Methods/Design

We are conducting a large scale, multi-site study of the implementation, impact and acceptability of these new technologies. A major part of the evaluation is a cluster-randomised controlled trial of telehealth and telecare versus usual care in patients with long-term conditions or social care needs. The trial involves a number of outcomes, including health care utilisation and quality of life. We describe the broad evaluation and the methods of the cluster randomised trial

Discussion

If telehealth and telecare technology proves effective, it will provide additional options for health services worldwide to deliver care for populations with high levels of need.

Trial Registration

Current Controlled Trials ISRCTN43002091

Patient-reported outcome measures: an overview

With the increasing prominence of the patients' involvement in the care they receive, the assessment of outcomes based on the patient's perspective using patient-reported outcome measures (PROMs), are increasingly accompanying the traditional clinical ways of measuring health and the effects of treatment on the patient. This article provides an overview as to what PROMs are and the different health constructs they are purported to measure. Differences between generic and disease-specific, multidimensional and index scored PROMs are also described. Factors relating to the choice of a PROM are discussed with a particular focus on the importance of developing a measurement strategy and endpoint model to ensure the appropriate PROM is selected to measure the desired outcome. Examples of the application of PROMs are given together with some of the methodological approaches to interpreting PROM data. Finally, issues on maximizing the benefits of using PROMs are briefly discussed.

Factors associated with psychological and behavioral functioning in people with type 2 diabetes living in France

BACKGROUND

To identify demographic and clinical factors associated with psychological and behavioral functioning (PBF) in people with type 2 diabetes living in France.

METHODS

In March 2002, approximately 10,000 adults, who had been reimbursed for at least one hypoglycemic treatment or insulin dose during the last quarter of 2001, received a questionnaire about their health status and PBF (3,646 responders). For this analysis, the 3,090 persons with type 2 diabetes, aged 18-85 years old were selected.PBF was measured with the adapted version of the Diabetes Health Profile for people with type 2 diabetes. This permitted the calculation of three functional scores - psychological distress (PD), barriers to activity (BA), and disinhibited eating (DE) - from 0 (worst) to 100 (best).

RESULTS

Major negative associations were observed with PBF for microvascular complications (a difference of 6.7 in the BA score between persons with and without microvascular complications) and severe hypoglycemia (difference of 7.9 in the BA score), insulin treatment (-8.5 & -9.5 in the PD & BA scores respectively, as compared to treatment with oral hypoglycemic agents), non-adherence to treatment (-12.3 in the DE score for persons forgetting their weekly treatment), increasing weight (-8.5 & -9.7 in the PD & DE scores respectively, as compared to stable weight), at least one psychiatrist visit in 2001 (-8.9 in the DE score), and universal medical insurance coverage (-7.9 in the PD score) (due to low income).

CONCLUSION

Prevention and management of microvascular complications or adherence to treatment (modifiable factors) could be essential to preserving or improving PBF among people with type 2 diabetes. A specific approach to type 2 diabetes management may be required in groups with a low socioeconomic profile (particularly people with universal medical insurance coverage), or other non modifiable factors.