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Jones A, Vallis M, Pouwer F. If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes. Diabet Med 2015; 32:155-63. [PMID: 25354315 DOI: 10.1111/dme.12620] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2014] [Indexed: 12/29/2022]
Abstract
Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.
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Affiliation(s)
- A Jones
- Institute of Psychology, University of Southern Denmark, Odense, Denmark
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152
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Abstract
Patient satisfaction is an important component of dermatological care that reflects patients' perspectives on the care they receive. While physicians' expertise and judgment should always remain the foundation of providing appropriate and effective care, the patient experience can also be influenced by interpersonal relationships, expectations, and a sense of agency in the treatment patients receive. Dermatology providers can use practical techniques such as sitting rather than standing, reframing the concept of cure, and engaging patients in treatment decisions to improve the patient-provider experience and thereby optimize patient satisfaction.
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Affiliation(s)
- Eric Sorenson
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA,
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153
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Graphical presentation of confounding in directed acyclic graphs. Nephrol Dial Transplant 2014; 30:1418-23. [DOI: 10.1093/ndt/gfu325] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 09/11/2014] [Indexed: 11/12/2022] Open
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154
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Rash JA, Lavoie KL, Feldman RD, Campbell TS. Adherence to Antihypertensive Medications: Current Status and Future Directions. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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155
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Gupta S, Brenner AT, Ratanawongsa N, Inadomi JM. Patient trust in physician influences colorectal cancer screening in low-income patients. Am J Prev Med 2014; 47:417-23. [PMID: 25084682 PMCID: PMC4171139 DOI: 10.1016/j.amepre.2014.04.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 03/28/2014] [Accepted: 04/24/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) screening is effective but underutilized. Although physician recommendation is an important predictor of screening, considerable variation in CRC screening completion remains. PURPOSE To characterize the influence of patient trust in care providers on CRC screening behavior. METHODS Data were collected as part of a cluster-randomized CRC screening intervention trial performed in the San Francisco Community Health Network from March 2007 to January 2012 (analysis, Spring 2012). All study participants received a recommendation to complete CRC screening from their primary care provider (PCP). Included participants were aged 50-79 years, not current with screening, and completed the Wake Forest Trust Scale (WFTS) measuring trust in PCPs and doctors in general. Primary outcome was CRC screening completion (colonoscopy or fecal occult blood testing) within 12 months following enrollment. Multivariable association adjusted for race/ethnicity, language, and other sociodemographics was estimated using generalized estimating equations with logit link and binomial distribution. RESULTS WFTS response was 70.3% (701). Most participants (83%) were Latino, Asian, or black. Most had income <$30,000 (96%) and public health insurance (86%). Higher trust in PCP was associated with screening completion (OR=1.11, 95% CI=1.03, 1.17), but trust in doctors was not (OR=1.02, 95% CI=0.82, 1.28). Race, language, and other sociodemographic factors were not significant in multivariable analysis. CONCLUSIONS After controlling for traditional factors, trust in PCP remained the only significant driver of CRC screening completion in low-income patients. Interventions to promote CRC screening may be improved by including efforts to enhance patient trust in PCP.
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Affiliation(s)
- Shivani Gupta
- Emory University School of Medicine, Atlanta, Georgia
| | - Alison T Brenner
- Department of Health Services, University of Washington School of Public Health and Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Neda Ratanawongsa
- Division of General Internal Medicine and Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
| | - John M Inadomi
- Department of Health Services, University of Washington School of Public Health and Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington.
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156
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Gudzune KA, Bennett WL, Cooper LA, Bleich SN. Patients who feel judged about their weight have lower trust in their primary care providers. PATIENT EDUCATION AND COUNSELING 2014; 97:128-31. [PMID: 25049164 PMCID: PMC4162829 DOI: 10.1016/j.pec.2014.06.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 05/28/2014] [Accepted: 06/28/2014] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate whether overweight and obese patients have less trust in their primary care providers (PCPs) if they feel judged about their weight by these PCPs. METHODS We conducted a national internet-based survey of 600 adults engaged in primary care with a BMI ≥ 25 kg/m(2) in 2012. Our dependent variable was high patient trust in their PCP (score ≥ 8/10). Our independent variable was "feeling judged about my weight by my PCP" dichotomized as "often/sometimes" versus "never." We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights. RESULTS Overall, 21% felt that their PCP judged them about their weight. Respondents who perceived judgment were significantly less likely to report high trust in their PCP [OR 0.55, 95% CI 0.31-0.98]. CONCLUSION While only a fifth of overweight and obese patients perceived weight-related judgment from their PCPs, these patients were significantly less likely to report high trust in these providers. Given patients' decreased trust in providers who convey weight-related judgment, our results raise concerns about potential effects on the doctor-patient relationship and patient outcomes. PRACTICE IMPLICATIONS Addressing provider stigma toward patients with obesity could help build trust in these patient-provider relationships and improve quality of care.
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Affiliation(s)
- Kimberly A Gudzune
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Wendy L Bennett
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sara N Bleich
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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157
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Development of protocol for the management of cervical cancer symptoms in resource-constrained developing countries. Support Care Cancer 2014; 23:581-600. [PMID: 25223351 DOI: 10.1007/s00520-014-2427-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022]
Abstract
Cervical cancer is the commonest malignancy of women in economically emerging countries. Patients have distressing symptoms from presentation through follow-up or end of life. Cervical cancer imposes significant burden on health care system due to distressing symptoms and associated loss of quality-adjusted life years (QALY). Multitude of drugs and surgical measures in various combinations can relieve these distressing symptoms and various clinical conditions. The protocols and guidelines for alleviation or relief of symptoms by general pharmacological and surgical measures form an important policy subject in planning cervical cancer management program. These protocol and guidelines are based on the mechanism of action of drugs, extrapolation from management of similar symptoms, and clinical situations arising out of other non-cancerous conditions and experience of health care professionals. Therefore, rigorous evaluation of effectiveness of supportive health care services in developing countries is the need of hour. However, evaluation of such protocol and guidelines are not feasible in emerging economies due to resource constraint. Industrialized affluent nations are also not able to implement and further support care guidelines despite its recognition as an integral part of multidisciplinary management of cancer. Aforementioned factors have created blind spot zone of management purview of cervical cancer. Hence, we attempt to develop protocol for management of adverse events of cervical cancer. Symptoms' and medical conditions' management guidelines evolved on the basis of empirical clinical practice in community and premier oncology centers in resource-constrained developing countries has been presented in this short report. This report should not be an end in itself but has to attract attention of policy-makers, academicians, researchers, and practitioners toward advancing supportive care needs of cancer patients in low- and middle-income countries (LMIC).
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158
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Bauer AM, Thielke SM, Katon W, Unützer J, Areán P. Aligning health information technologies with effective service delivery models to improve chronic disease care. Prev Med 2014; 66:167-72. [PMID: 24963895 PMCID: PMC4137765 DOI: 10.1016/j.ypmed.2014.06.017] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/14/2014] [Accepted: 06/11/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care, have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care. METHOD A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other. RESULTS Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings. CONCLUSION HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States.
| | - Stephen M Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Wayne Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Patricia Areán
- Department of Psychiatry, University of California, San Francisco, United States
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159
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Bauer AM, Parker MM, Schillinger D, Katon W, Adler N, Adams AS, Moffet HH, Karter AJ. Associations between antidepressant adherence and shared decision-making, patient-provider trust, and communication among adults with diabetes: diabetes study of Northern California (DISTANCE). J Gen Intern Med 2014; 29:1139-47. [PMID: 24706097 PMCID: PMC4099457 DOI: 10.1007/s11606-014-2845-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence. OBJECTIVE To determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence. DESIGN Observational new prescription cohort study. SETTING Kaiser Permanente Northern California. PATIENTS One thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010. MEASUREMENTS Exposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription). RESULTS After adjusting for potential confounders, patients' perceived lack of shared decision-making was significantly associated with primary non-adherence (RR = 2.42, p < 0.05), early non-persistence (RR = 1.34, p < 0.01) and NPMG (estimated 5% greater gap in medication supply, p < 0.01). Less trust in provider was significantly associated with early non-persistence (RRs 1.22-1.25, ps < 0.05) and NPMG (estimated NPMG differences 5-8%, ps < 0.01). LIMITATIONS All patients were insured and had consistent access to and quality of care. CONCLUSIONS Patients' perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence. Further research should explore whether interventions for healthcare providers and systems that foster shared decision-making and trust might also improve medication adherence.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195-6560, USA,
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160
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Anhang Price R, Elliott MN, Zaslavsky AM, Hays RD, Lehrman WG, Rybowski L, Edgman-Levitan S, Cleary PD. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev 2014; 71:522-54. [PMID: 25027409 DOI: 10.1177/1077558714541480] [Citation(s) in RCA: 505] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patient care experience surveys evaluate the degree to which care is patient-centered. This article reviews the literature on the association between patient experiences and other measures of health care quality. Research indicates that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilization. Patient experience measures that are collected using psychometrically sound instruments, employing recommended sample sizes and adjustment procedures, and implemented according to standard protocols are intrinsically meaningful and are appropriate complements for clinical process and outcome measures in public reporting and pay-for-performance programs.
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Affiliation(s)
| | | | | | - Ron D Hays
- UCLA Department of Medicine, Los Angeles, CA, USA
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161
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Barton JL, Trupin L, Tonner C, Imboden J, Katz P, Schillinger D, Yelin EH. English language proficiency, health literacy, and trust in physician are associated with shared decision making in rheumatoid arthritis. J Rheumatol 2014; 41:1290-7. [PMID: 24931952 PMCID: PMC4286372 DOI: 10.3899/jrheum.131350] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Treat-to-target guidelines promote shared decision making (SDM) in rheumatoid arthritis (RA). Also, because of high cost and potential toxicity of therapies, SDM is central to patient safety. Our objective was to examine patterns of perceived communication around decision making in 2 cohorts of adults with RA. METHODS Data were derived from patients enrolled in 1 of 2 longitudinal, observational cohorts [University of California, San Francisco (UCSF) RA Cohort and RA Panel Cohort]. Subjects completed a telephone interview in their preferred language that included a measure of patient-provider communication, including items about decision making. Measures of trust in physician, education, and language proficiency were also asked. Logistic regression was performed to identify correlates of suboptimal SDM communication. Analyses were performed on each sample separately. RESULTS Of 509 patients across 2 cohorts, 30% and 32% reported suboptimal SDM communication. Low trust in physician was independently associated with suboptimal SDM communication in both cohorts. Older age and limited English proficiency were independently associated with suboptimal SDM in the UCSF RA Cohort, as was limited health literacy in the RA Panel Cohort. CONCLUSION This study of over 500 adults with RA from 2 demographically distinct cohorts found that nearly one-third of subjects report suboptimal SDM communication with their clinicians, regardless of cohort. Lower trust in physician was independently associated with suboptimal SDM communication in both cohorts, as was limited English language proficiency and older age in the UCSF RA Cohort and limited health literacy in the RA Panel Cohort. These findings underscore the need to examine the influence of SDM on health outcomes in RA.
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Affiliation(s)
| | | | | | | | | | - Dean Schillinger
- University of California, San Francisco
- UCSF Center for Vulnerable Populations, San Francisco General Hospital
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162
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Gopalan A, Tahirovic E, Moss H, Troxel AB, Zhu J, Loewenstein G, Volpp KG. Translating the hemoglobin A1C with more easily understood feedback: a randomized controlled trial. J Gen Intern Med 2014; 29:996-1003. [PMID: 24567202 PMCID: PMC4061357 DOI: 10.1007/s11606-014-2810-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 10/17/2013] [Accepted: 02/04/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Previous work has indicated that for patients with diabetes, there is value in understanding glycemic control. Despite these findings, patient understanding of the hemoglobin A1C value (A1C) is notably poor. In this study, we test the effect of two alternative communication formats of the A1C on improving glycemic control among patients with poorly controlled diabetes. METHODS 177 patients with poorly controlled diabetes were randomized to one of three study arms that varied in the information they received: (1) a "diabetes report card" containing individualized information about glycemic control for each participant with letter grades ranging from A to F; (2) a "report card" containing a face whose emotion reflected current glycemic control; or (3) a "report card" with glycemic control expressed with the A1C value (standard arm). The primary study outcome was change in A1C at 6 months. Secondary outcomes included changes in participant perceptions of their glycemic control. RESULTS The average A1C for enrolled participants was 9.9 % (S.D. 1.7) and did not differ significantly among study arms. We noted no significant differences in change in A1C at 6 months between the standard and experimental arms. Using multiple imputation to account for missing A1C values, the changes in A1C for the letter grade, face, and standard arms were -0.55 % (-1.15, 0.05), -0.89 % (-1.49, -0.29), and -0.74 % (-1.51, 0.029), respectively (p = 0.67 for control vs. grade, p = 0.76 for control vs. face). DISCUSSION Feedback to patients with poorly controlled diabetes in the form of letter grades and faces did not differentially impact glycemic control at 6 months or participant perceptions of current control. These efforts to improve communication and patient understanding of disease management targets need further refinement to significantly impact diabetes outcomes. CLINICAL TRIAL ID NCT01143870.
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Affiliation(s)
- Anjali Gopalan
- The Philadelphia VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA,
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163
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Spatz ES, Sheth SD, Gosch KL, Desai MM, Spertus JA, Krumholz HM, Ross JS. Usual source of care and outcomes following acute myocardial infarction. J Gen Intern Med 2014; 29:862-9. [PMID: 24553957 PMCID: PMC4026492 DOI: 10.1007/s11606-014-2794-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 10/01/2013] [Accepted: 01/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The quality of the relationship between a patient and their usual source of care may impact outcomes, especially after an acute clinical event requiring regular follow-up. OBJECTIVE To examine the association between the presence and strength of a usual source of care with mortality and readmission after hospitalization for acute myocardial infarction (AMI). DESIGN Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, 19-center study. PATIENTS AMI patients discharged between January 2003 and June 2004. MAIN MEASURES The strength of the usual source of care was categorized as none, weak, or strong based upon the duration and familiarity of the relationship. Main outcome measures were readmissions and mortality at 6 months and 12 months post-AMI, examined in multivariable analysis adjusting for socio-demographic characteristics, access and barriers to care, financial status, baseline risk factors, and AMI severity. KEY RESULTS Among 2,454 AMI patients, 441 (18.0 %) reported no usual source of care, whereas 247 (10.0 %) and 1,766 (72.0 %) reported weak and strong usual sources of care, respectively. When compared with a strong usual source of care, adults with no usual source of care had higher 6-month mortality rates [adjusted hazard ratio (aHR) = 3.15, 95 % CI, 1.79-5.52; p < 0.001] and 12-month mortality rates (aHR = 1.92, 95 % CI, 1.19-3.12; p = 0.01); adults with a weak usual source of care trended toward higher mortality at 6 months (aHR = 1.95, 95 % CI, 0.98-3.88; p = 0.06), but not 12 months (p = 0.23). We found no association between the usual source of care and readmissions. CONCLUSIONS Adults with no or weak usual sources of care have an increased risk for mortality following AMI, but not for readmission.
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Affiliation(s)
- Erica S Spatz
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA,
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164
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Marzec LN, Maddox TM. Medication adherence in patients with diabetes and dyslipidemia: associated factors and strategies for improvement. Curr Cardiol Rep 2014; 15:418. [PMID: 24057772 DOI: 10.1007/s11886-013-0418-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Dyslipidemia and diabetes mellitus are commonly coincident, and together contribute to the development of atherosclerotic disease. Medication therapy is the mainstay of treatment for dyslipidemia. Optimal medication therapy for dyslipidemia in patients with diabetes reduces cardiovascular events but necessitates patients take multiple medications. As a result, sub-optimal adherence to medication therapy is common. Factors contributing to medication non-adherence in patients taking multiple medications are complex and can be grouped into patient-, social and economic-, medication therapy-, and health provider and health system-related factors. Strategies aimed at improving medication adherence may target the patient, health care providers, or health systems. Recent data suggest medication non-adherence contributes to racial health disparities. In addition, health literacy, cost-related medication non-adherence, and patient beliefs regarding medication therapy have all been recently described as factors affecting medication adherence. Data from within the last year support an important role for regular contact between patients and health care providers to effectively address these factors. Cost-related barriers to medication adherence have recently been addressed through examination of health system approaches to decreasing cost-related non-adherence.
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Affiliation(s)
- Lucas N Marzec
- VA Eastern Colorado Health Care System, Cardiology Section, 111B, 1055 Clermont Street, Denver, CO, 80220, USA
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165
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2014:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Farley H, Enguidanos ER, Coletti CM, Honigman L, Mazzeo A, Pinson TB, Reed K, Wiler JL. Patient satisfaction surveys and quality of care: an information paper. Ann Emerg Med 2014; 64:351-7. [PMID: 24656761 DOI: 10.1016/j.annemergmed.2014.02.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/31/2014] [Accepted: 02/21/2014] [Indexed: 11/17/2022]
Abstract
With passage of the Patient Protection and Affordable Care Act of 2010, payment incentives were created to improve the "value" of health care delivery. Because physicians and physician practices aim to deliver care that is both clinically effective and patient centered, it is important to understand the association between the patient experience and quality health outcomes. Surveys have become a tool with which to quantify the consumer experience. In addition, results of these surveys are playing an increasingly important role in determining hospital payment. Given that the patient experience is being used as a surrogate marker for quality and value of health care delivery, we will review the patient experience-related pay-for-performance programs and effect on emergency medicine, discuss the literature describing the association between quality and the patient-reported experience, and discuss future opportunities for emergency medicine.
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Affiliation(s)
- Heather Farley
- Department of Emergency Medicine, Christiana Care Health System, Newark, DE.
| | - Enrique R Enguidanos
- Department of Emergency Medicine, Providence Regional Medical Center, Everett, WA
| | | | - Leah Honigman
- Department of Emergency Medicine, the George Washington University Hospital, Washington, DC
| | - Anthony Mazzeo
- Department of Emergency Medicine, Mercy Fitzgerald Hospital, Darby, PA
| | - Thomas B Pinson
- Department of Emergency Medicine, Mayes County Medical Center, Pryor, OK
| | - Kevin Reed
- Department of Emergency Medicine, MedStar Harbor Hospital, Baltimore, MD
| | - Jennifer L Wiler
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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167
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Grindrod KA, Li M, Gates A. Evaluating user perceptions of mobile medication management applications with older adults: a usability study. JMIR Mhealth Uhealth 2014; 2:e11. [PMID: 25099993 PMCID: PMC4114457 DOI: 10.2196/mhealth.3048] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/30/2014] [Accepted: 02/17/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Medication nonadherence has a significant impact on the health and wellbeing of individuals with chronic disease. Several mobile medication management applications are available to help users track, remember, and read about their medication therapy. OBJECTIVE The objective of this study was to explore the usability and usefulness of existing medication management applications for older adults. METHODS We recruited 35 participants aged 50 and over to participate in a 2-hour usability session. The average age ranged from 52-78 years (mean 67 years) and 71% (25/35) of participants were female. Each participant was provided with an iPad loaded with four medication management applications: MyMedRec, DrugHub, Pillboxie, and PocketPharmacist. These applications were evaluated using the 10 item System Usability Scale (SUS) and visual analog scale. An investigator-moderated 30-minute discussion followed, and was recorded. We used a grounded theory (GT) approach to analyze qualitative data. RESULTS When assessing mobile medication management applications, participants struggled to think of a need for the applications in their own lives. Many were satisfied with their current management system and proposed future use only if cognition and health declined. Most participants felt capable of using the applications after a period of time and training, but were frustrated by their initial experiences with the applications. The early experiences of participants highlighted the benefits of linear navigation and clear wording (eg, "undo" vs "cancel") when designing for older users. While there was no order effect, participants attributed their poor performance to the order in which they tried the applications. They also described being a part of a technology generation that did not encounter the computer until adulthood. Of the four applications, PocketPharmacist was found to be the least usable with a score of 42/100 (P<.0001) though it offered a drug interaction feature that was among the favorite features of participants. The usability scores for MyMedRec (56/100), DrugHub (57/100), and Pillboxie (52/100) were not significantly different and participants preferred MyMedRec and DrugHub for their simple, linear interfaces. CONCLUSIONS With training, adults aged 50 and over can be capable and interested in using mHealth applications for their medication management. However, in order to adopt such technology, they must find a need that their current medication management system cannot fill. Interface diversity and multimodal reminder methods should be considered to increase usability for older adults. Lastly, regulation or the involvement of older adults in development may help to alleviate generation bias and mistrust for applications.
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Affiliation(s)
- Kelly Anne Grindrod
- School of Pharmacy, Faculty of Science, University of Waterloo, Waterloo, ON, Canada.
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168
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Bynum W. Why physicians need to be more than automated medical kiosks. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:212-214. [PMID: 24362391 DOI: 10.1097/acm.0000000000000092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The last 20 years have seen an unprecedented technological revolution, including the development of the personal computer. The new technologies that have emerged during this age of innovation have allowed human beings to connect widely with one another through electronic media and have made life more efficient and streamlined. Likewise, this technological renaissance has helped to define medicine as one of the most innovative professions by providing physicians with diagnostics and interventions that are more accurate, efficacious, and safe, to the benefit of physicians and the public. However, in both life and the practice of medicine, these new technologies have had the unintended consequence of reducing the value of direct human connection and threaten to isolate individuals in spite of advancing society. In this commentary, the author argues that human beings need to make a more concerted effort to connect with each other through both enhanced communication technologies and direct human contact. Likewise, leaders in medicine need to embrace and promote technological advancement while at the same time working to maintain the human connection that physicians have with their patients and teaching learners to do the same. Doing so will prevent physicians from becoming automated medical kiosks that offer sound, innovative medical advice but that lack the personality, compassion, and emotion that will lead to better health.
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Affiliation(s)
- William Bynum
- Dr. Bynum is attending faculty, National Capital Consortium Family Medicine Residency, Fort Belvoir Community Hospital, Fort Belvoir, Virginia. At the time this commentary was written, he was a third-year resident
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Marcum ZA, Driessen J, Thorpe CT, Gellad WF, Donohue JM. Effect of multiple pharmacy use on medication adherence and drug-drug interactions in older adults with Medicare Part D. J Am Geriatr Soc 2014; 62:244-52. [PMID: 24521363 PMCID: PMC4115075 DOI: 10.1111/jgs.12645] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the association between multiple pharmacy use and medication adherence and potential drug-drug interactions (DDIs) in older adults. DESIGN Cross-sectional propensity score-weighted analysis. SETTING 2009 claims data. PARTICIPANTS A nationally representative sample of 926,956 Medicare Part D beneficiaries aged 65 and older continuously enrolled in fee-for-service Medicare and Part D that year who filled one or more prescriptions at a community retail or mail order pharmacy. MEASUREMENTS Multiple pharmacy use was defined as concurrent (overlapping time periods) or sequential use (non-overlapping time periods) of ≥ 2 pharmacies in the year. Medication adherence was calculated using a proportion of days covered of 0.80 or greater for eight therapeutic categories (beta-blockers, renin angiotensin system antagonists, calcium channel blockers, statins, sulfonylureas, biguanides (metformin), thiazolidinediones, and dipeptidyl peptidase-IV inhibitors). Potential DDIs arising from use of certain drugs across a broad set of classes were defined as the concurrent filling of two interacting drugs. RESULTS Overall, 38.1% of the sample used multiple pharmacies. Those using multiple pharmacies (concurrently or sequentially) consistently had higher adjusted odds of nonadherence (ranging from 1.10 to 1.31, P < .001) across all chronic medication classes assessed after controlling for sociodemographic, health status, and access to care factors than single pharmacy users. The adjusted predicted probability of exposure to a DDI was also slightly higher for those using multiple pharmacies concurrently (3.6%) than for single pharmacy users (3.2%, adjusted odds ratio (AOR) = 1.11, 95% confidence interval (CI) = 1.08-1.15) but lower in individuals using multiple pharmacies sequentially (2.8%, AOR = 0.85, 95% CI = 0.81-0.91). CONCLUSIONS Filling prescriptions at multiple pharmacies was associated with lower medication adherence across multiple chronic medications and a small but statistically significant greater likelihood of DDIs in concurrent pharmacy users.
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Affiliation(s)
- Zachary A. Marcum
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh,PA
| | - Julia Driessen
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Carolyn T. Thorpe
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
- VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Walid F. Gellad
- VA Pittsburgh Healthcare System, Pittsburgh, PA
- Department of General Internal Medicine, School of Medicine, University of Pittsburgh and RAND, Pittsburgh, PA
| | - Julie M. Donohue
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Lithovius R, Harjutsalo V, Forsblom C, Saraheimo M, Groop PH. Antihypertensive treatment and resistant hypertension in patients with type 1 diabetes by stages of diabetic nephropathy. Diabetes Care 2014; 37:709-17. [PMID: 24170765 DOI: 10.2337/dc13-2023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess blood pressure (BP) control, antihypertensive treatment, and prevalence of resistant hypertension (RH) in patients with type 1 diabetes stratified by stage of diabetic nephropathy. RESEARCH DESIGN AND METHODS This cross-sectional study included a nationally representative cohort of patients with type 1 diabetes (N = 3,678) from the Finnish Diabetic Nephropathy Study (FinnDiane). The data were linked to the Drug Prescription Register to obtain purchases of antihypertensive drugs 6 months prior to the baseline visit. The treatment targets were based on the American Diabetes Association guidelines. RH was defined as failure to reach BP target despite the use of three or more antihypertensive drugs of different classes (one of which was a diuretic). RESULTS In patients with normal albumin excretion rate, 14.1% were on antihypertensive treatment and 74.6% of them had uncontrolled BP despite treatment. The corresponding figures were 60.5 and 71.2% for the microalbuminuric patients, 90.3 and 80.0% for the macroalbuminuric patients, 88.6 and 88.1% for dialysis, and 91.2 and 90.4% for kidney-transplanted patients. The prevalence of RH was 1.2% in the normoalbuminuric, 4.7% in the microalbuminuric, 28.1% in the macroalbuminuric, 36.6% in the dialysis, and 26.3% in the kidney transplant groups. Age (odds ratio 1.04 [95% CI 1.02-1.05]), estimated glomerular filtration rate (0.97 [0.96-0.97]), waist-to-hip ratio (1.44 [1.15-1.80]), triglycerides (1.19 [1.01-1.40]), microalbuminuria (2.58 [1.43-4.67]), and macroalbuminuria (5.61 [3.20-9.84]) were independently associated with RH. CONCLUSIONS The prevalence of uncontrolled hypertension and RH increases with advanced diabetic nephropathy. These data suggest that there is an urgent need for improvement of antihypertensive treatment.
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Vigersky RA, Fitzner K, Levinson J. Barriers and potential solutions to providing optimal guideline-driven care to patients with diabetes in the U.S. Diabetes Care 2013; 36:3843-9. [PMID: 24159181 PMCID: PMC3816882 DOI: 10.2337/dc13-0680] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/16/2013] [Indexed: 02/03/2023]
Abstract
The cost of diabetes, driven primarily by the cost of preventable diabetes complications, will continue to increase with the epidemic rise in its prevalence in the U.S. The Diabetes Working Group (DWG), a consortium of professional organizations and individuals, was created to examine the barriers to better diabetes care and to recommend mitigating solutions. We consolidated three sets of guidelines promulgated by national professional organizations into 29 standards of optimal care and empanelled independent groups of diabetes care professionals to estimate the minimum and maximum time needed to achieve those standards of care for each of six clinical vignettes representing typical patients seen by diabetes care providers. We used a standards-of-care economic model to compare provider costs with reimbursement and calculated "reimbursement gaps." The reimbursement gap was calculated using the maximum and minimum provider cost estimate (reflecting the baseline- and best-case provider time estimates from the panels). The cost of guideline-driven care greatly exceeded reimbursement in almost all vignettes, resulting in estimated provider "losses" of 470,000-750,000 USD/year depending on the case mix. Such "losses" dissuade providers of diabetes care from using best practices as recommended by national diabetes organizations. The DWG recommendations include enhancements in care management, workforce supply, and payment reform.
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Abstract
Approximately 50% of patients with cardiovascular disease and/or its major risk factors have poor adherence to their prescribed medications. Finding novel methods to help patients improve their adherence to existing evidence-based cardiovascular drug therapies has enormous potential to improve health outcomes while potentially reducing health care costs. The goal of this report is to provide a review of the current understanding of adherence to cardiovascular medications from the point of view of prescribing clinicians and cardiovascular researchers. Key topics addressed include: (1) definitions of medication adherence; (2) prevalence and impact of non-adherence; (3) methods for assessing medication adherence; 4) reasons for poor adherence; and 5) approaches to improving adherence to cardiovascular medications. For each of these topics, the report seeks to identify important gaps in knowledge and opportunities for advancing the field of cardiovascular adherence research.
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Jansà M, Vidal M, Giménez M, Conget I, Galindo M, Roca D, Colungo C, Esmatjes E, Salamero M. Psychometric analysis of the Spanish and Catalan versions of the Diabetes Self-Care inventory-revised version questionnaire. Patient Prefer Adherence 2013; 7:997-1005. [PMID: 24124352 PMCID: PMC3794847 DOI: 10.2147/ppa.s50271] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The purpose of this study was to validate the Spanish and Catalan versions of the Diabetes Self-Care Inventory-Revised Version (SCI-R) questionnaire to assess the degree of adherence to self-care among adults with diabetes. METHODS We validated the Spanish and Catalan translation from, and back translation to, English and cultural adaptation of the SCI-R in type 1 diabetes patients on multiple insulin doses or continuous subcutaneous insulin infusion and in type 2 diabetes patients on oral agents and/or insulin. Internal reliability, structural validity, and external validity (correlation with glycated hemoglobin) were evaluated. Responsiveness to change was assessed in patients 1 year after onset of type 1 diabetes and following a structured education program. RESULTS The SCI-R presented good internal reliability Cronbach's α: 0.75, test-retest reliability (r = 0.82) and structural validity (r > 0.40). The external validity was also good; the SCI-R correlated with HbA1c in patients with type 1 diabetes on multiple insulin doses (r = -0.50) or continuous subcutaneous insulin infusion (r = -0.66) and in patients with type 2 diabetes on multiple insulin doses (r = -0.62). However, it was not satisfactory in patients on oral agents (r = -0.20) and/or bedtime insulin (r = -0.35). Responsiveness to change was analyzed in 54 patients (age 27.3±7.4 years, 26% men, HbA1c 6.8% ±1.1%); the SCI-R score was 72.3% ±13.7% and correlated negatively with glycated hemoglobin (r = -0.42) and 3 scales of the Diabetes Quality of Life questionnaire (lower score indicating better perception): Impact (r = -0.37), Social Worry (r = -0.36) and Diabetes Worry (r = -0.38), all at P < 0.05. CONCLUSION The Spanish and Catalan versions of the SCI-R questionnaire show good psychometric properties and both could be considered as useful tools for evaluating self-care behavior in patients with type 1 or type 2 diabetes. However, there are still some subgroups of patients with type 2 diabetes in which the validity of this questionnaire needs further evaluation.
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Affiliation(s)
- Margarida Jansà
- Diabetes Unit, Endocrinology and nutrition, Hospital Clinic, Barcelona, Spain
- Correspondence: Margarida Jansà, Diabetes Unit, Endocrinology and nutrition, Institut Clinic de Malalties Digestives i Metabòliques Hospital Clinic, 170 Villarroel St, 08036 Barcelona, Spain, Tel +34 93 227 9846, Fax +34 93 451 6638, Email
| | - Mercè Vidal
- Diabetes Unit, Endocrinology and nutrition, Hospital Clinic, Barcelona, Spain
| | - Marga Giménez
- Diabetes Unit, Endocrinology and nutrition, Hospital Clinic, Barcelona, Spain
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and nutrition, Hospital Clinic, Barcelona, Spain
| | - Mercedes Galindo
- Endocrinology and nutrition Department, Hospital Clinico, Madrid, Spain
| | - Daria Roca
- Diabetes Unit, Endocrinology and nutrition, Hospital Clinic, Barcelona, Spain
| | | | - Enric Esmatjes
- Diabetes Unit, Endocrinology and nutrition, Hospital Clinic, Barcelona, Spain
| | - Manel Salamero
- Psychology Department, Hospital Clinic, Barcelona, Spain
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