Patient-reported assessments in diabetes care: clinical and research applications

The participatory development of a national core set of person-centred diabetes outcome constructs for use in routine diabetes care across healthcare sectors

BACKGROUND

This study sought to utilise participatory research methods to identify the perspectives of people with diabetes regarding which diabetes outcomes were most important to them. These findings were then used to support an expert working group representing multiple health sectors and healthcare disciplines and people with diabetes to establish a core set of patient-important outcome constructs for use in routine diabetes care.

METHODS

26 people with diabetes and family members were recruited through purposive sampling to participate in interviews, focus groups, voting and plenary activities in order to be part of identifying outcome constructs. Content and qualitative analysis methods were used with literature reviews to inform a national multi-stakeholder consensus process for a core set of person-centred diabetes outcome constructs to be used in routine diabetes care across health care settings.

RESULTS

21 people with diabetes and 5 family members representing type 1 and 2 diabetes and a range of age groups, treatment regimens and disease burden identified the following patient-reported outcome constructs as an important supplement to clinical indicators for outcome assessment in routine diabetes care: self-rated health, psychological well-being, diabetes related emotional distress and quality of life, symptom distress, treatment burden, blood sugar regulation and hypoglycemia burden, confidence in self-management and confidence in access to person-centred care and support. Consensus was reached by a national multi-stakeholder expert group to adopt measures of these constructs as a national core diabetes outcome set for use in routine value-based diabetes care.

CONCLUSIONS

We found that patient-reported outcome (PRO) constructs and clinical indicators are needed in core diabetes outcome sets to evaluate outcomes of diabetes care which reflect key needs and priorities of people with diabetes. The incorporation of patient-reported outcome constructs should be considered complementary to clinical indicators in multi-stakeholder value-based health care strategies. We found participatory research methods were useful in facilitating the identification of a core prioritised set of diabetes outcome constructs for routine value-based diabetes care. The use of our method for involving patients may be useful for similar efforts in other disease areas aimed at defining suitable outcomes of person-centred value-based care. Future research should focus on developing acceptable and psychometrically valid measurement instruments to evaluate these outcome constructs as part of routine diabetes care.

Tackling clinical inertia: Use of coproduction to improve patient engagement

Clinical inertia is common in all chronic diseases, including diabetes. Despite the advent of newer agents for the management of hyperglycemia, hypertension, and dyslipidemia, the number of people with diabetes hitting all three targets remains small. The causes of clinical inertia are multifactorial, with contributory elements from people with diabetes, physicians, and the system within which they work. Every health care provider should have the best interest of their patients at heart; most people with diabetes want to maintain their health for as long as possible, and the maintenance of good health is not only the purpose of the system, but also the most cost-effective strategy. It is the thesis of this article that a potential reversible contributor to clinical inertia is the communication among these individual elements, which can be called "coproduction." The coproduction model of open communication encourages discourse, allowing the person with diabetes to understand their diagnosis and therefore better engage in treatment options. Improving engagement allows the healthcare team, including the physician and the person with diabetes, to establish shared goals that are important to all team members and to agree to acceptable side effects or risks of interventions in order to achieve these goals. Everyone needs to acknowledge that non-adherence exists and can be an issue, thereby allowing reasons to be explored. Only once the person with diabetes is allowed to take full ownership of their disease and actively participate in decision making can they take control of their disease, thereby improving outcomes.

Development of an instrument for patient-reported outcomes in Thai patients with type 2 diabetes mellitus (PRO-DM-Thai)

Background

Effectiveness of self-care and treatment of diabetes mellitus depends upon patient awareness of their own health and disease outcomes. Physician decisions are improved by insight into patient perspectives.

Objective

To develop an instrument for patient-reported outcomes in Thai patients with type 2 diabetes mellitus (PRO-DM-Thai).

Methods

The study consisted of: (1) content development using a literature review and in-depth interviews of providers and patients, and validity testing using a content validity index (CVI); (2) construct validity and reliability testing by confirmatory factor and Cronbach’s α analyses of data from a cross-sectional descriptive survey of 500 participants from May to June, 2011; and, (3) criterion-related validity from a cross-sectional analytical survey of 200 participants from September to November, 2011.

Results

PRO-DM-Thai passed all of the validity tests. The instrument comprises seven dimensions and 44 items, including physical function, symptoms, psychological well-being, self-care management, social well-being, global judgments of health, and satisfaction with care and flexibility of treatment. The CVI at the item-level (I-CVI) were between 0.83 to 1.00 and the scale-level average agreement (S-CVI/Ave) was 0.98. All dimension models had overall fit with empirical data, while the hypothesized model demonstrated a good fit (χ2 = 5.23; (df = 6), P > 0.05, AGFI = 0.986, RMSEA = 0.000). Cronbach’s α for the total scale was 0.91 and for the subscales was 0.72-0.90. The total scores effectively discriminated groups of patients with different levels of disease control.

Conclusion

PRO-DM-Thai showed satisfactory levels of validity and reliability when applied to Thai diabetic patients.

Patients with type 2 diabetes at risk for major depressive disorder over time

PURPOSE

We wanted to identify risk factors associated with the development of major depressive disorder (MDD) among patients with type 2 diabetes over time.

METHODS

In a noninterventional study, 338 adult patients with type 2 diabetes and no MDD diagnosis at baseline were assessed 3 times during 18 months (9-month intervals) to ascertain predictors of MDD. We tested a model incorporating personal, behavioral, biologic, and psychosocial variables to identify predictors of MDD. Exploratory analyses tested whether current negative affect mediated the relationship between predictors and subsequent MDD. We also conducted a stratified analysis of moderate vs high negative affect to explore whether level of baseline negative affect mediated the relationship between specific predictors and MDD.

RESULTS

Prior MDD and negative affect predicted future development of MDD. In subpopulations stratified by moderate negative affect, negative life events, an elevated body mass index (BMI), prior MDD, and poor control of glycated hemoglobin (hemoglobin A(1c)) each predicted MDD. In subpopulations stratified by elevated negative affect, negative life events and poor control of hemoglobin A(1c) predicted MDD. Current negative affect partially mediated the relationship between prior MDD and subsequent MDD, as well as the relationship between negative life events and subsequent MDD.

CONCLUSIONS

Although negative affect at baseline was the primary predictor of subsequent MDD, when stratified by negative affect, negative life events, BMI, and poor control of hemoglobin A(1c) also predicted MDD. Thus, life stresses and patients' disease-related concerns are important when understanding what predicts subsequent MDD. Addressing depressive symptoms and broader life context issues expands the scope of a potential intervention to reduce the risk of developing MDD in persons with type 2 diabetes.

Are current psychometric tools suitable for measuring outcomes of diabetes education?

AIMS

To critically appraise the suitability, validity, reliability, feasibility and sensitivity to change of available psychometric tools for measuring the education outcomes identified in the (Australian) National Consensus on Outcomes and Indicators for Diabetes Patient Education.

METHODS

Potentially suitable psychometric measurement tools were identified through a two-step process. Step 1: a structured semi-systematic literature review and consultation with experts; step 2: development of inclusion criteria and a formal, purpose-designed, systematically derived Appraisal Checklist-from the literature and with expert psychometric advice-to critically appraise the identified tools for relevance, validity, reliability, responsiveness to change, burden, feasibility and acceptability.

RESULTS

Searching medline, PubMed, PsycINFO and cinhal yielded 37 diabetes-specific and generic measurement tools. Eleven of these did not address the research questions, leaving 26 tools. Of these, 11 assessed indicators of psychological adjustment; seven assessed various domains of self-determination; five measured self-management behaviours, for example, foot care, blood glucose testing and lifestyle domains; and three measured diabetes knowledge und understanding, respectively. When the Appraisal Checklist was applied, only three tools met all criteria, namely the Problem Areas in Diabetes (PAID) scale, the Summary of Diabetes Self-Care Activities (SDSCA) scale and the Appraisal of Diabetes Scale (ADS). However, a number of other suitable tools [i.e. the Diabetes Integration Scale (ATT19), the Diabetes Health Profile (DHP-1/18), the Self-Care Inventory-Revised (SCI-R), the Diabetes Management Self Efficacy Scale Australian/English version (DMSES-A/E), the Diabetes Empowerment Scale-Short Form (DES-SF)] met all except one criteria, that is, either no formal test-retest or no responsiveness to change data.

CONCLUSIONS

Although numerous tools were identified, few met rigorous psychometric appraisal criteria. Issues of suitability, adequate psychometric testing for the intended purpose, burden and feasibility need to be considered before adopting tools for measuring diabetes education outcomes.