Shared Decision-Making in Diabetes Care

Effectiveness of shared decision-making for glycaemic control among type 2 diabetes mellitus adult patients: A systematic review and meta-analysis

BACKGROUND

In diabetes care and management guidelines, shared decision-making (SDM) implementation is explicitly recommended to help patients and health care providers to make informed shared decisions that enable informed choices and the selection of treatments. Despite widespread calls for SDM to be embedded in health care, there is little evidence to support SDM in the management and care of diabetes. It is still not commonly utilized in routine care settings because its effects remain poorly understood. Hence, the current systematic review and meta-analysis aimed to evaluate the effectiveness of SDM for glycaemic control among type 2 diabetes adult patients.

METHODS

Literature sources were searched in MEDLINE, PubMed, Cochrane library and HINARI bibliographic databases and Google Scholar. When these records were searched and reviewed, the PICO criteria (P: population, I: intervention, C: comparator, and O: outcome) were applied. The extracted data was exported to RevMan software version 5.4 and STATA 17 for further analysis. The mean differences (MD) of glycated hemoglobin (HbA1c) were pooled using a random effect model (REM), and sub-group analysis were performed to evaluate the effect size differences across the duration of the follow-up period, modes of intervention, and baseline glycated hemoglobin level of patient groups. The sensitivity analysis was performed using a leave-one-out meta-analysis to quantify the impact of each study on the overall effect size in mean difference HbA1c%. Finally, the statistically significant MD of HbA1c% between the intervention groups engaged in SDM and control groups received usual care was declared at P ˂0.05, using a 95% confidence interval (CI).

RESULTS

In the database search, 425 records were retrieved, with only 17 RCT studies fulfilling the inclusion criteria and were included in the meta-analysis. A total of 5416 subjects were included, out of which 2782(51.4%) were included in trial arms receiving SDM and 2634(48.6%) were included in usual diabetes care. The Higgins (I2) test statistics were calculated to be 59.1%, P = 0.002, indicating statistically significant heterogeneity was observed among the included studies, and REM was used as a remedial to estimate the pooled MD of HbA1c% level between patients who participated in SDM and received usual care. As a result, the pooled MD showed that the SDM significantly lowered HbA1c by 0.14% compared to the usual care (95% CI = [-0.26, -0.02], P = 0.02). SDM significantly decreased the level of HbA1c by 0.14% (95% CI = -0.28, -0.01, P = 0.00) when shared decisions were made in person or face-to-face at the point of care, but there was no statistically significant reduction in HbA1c levels when patients were engaged in online SDM. In patients with poorly controlled glycaemic level (≥ 8%), SDM significantly reduced level of HbA1c by 0.13%, 95% CI = [-0.29, -0.03], P = 0.00. However, significant reduction in HbA1c was not observed in patients with ˂ 8%, HbA1c baseline level.

CONCLUSIONS

Overall, statistically significant reduction of glycated hemoglobin level was observed among T2DM adult patients who participated in shared decision-making compared to those patients who received diabetes usual care that could lead to improved long-term health outcomes, reducing the risk of diabetes-related complications. Therefore, we strongly suggest that health care providers and policy-makers should integrate SDM into diabetes health care and management, and further study should focus on the level of patients' empowerment, health literacy, and standardization of decision supporting tools to evaluate the effectiveness of SDM in diabetes patients.

Development of a Novel Mobile Health App to Empower Young People With Type 1 Diabetes to Exercise Safely: Co-Design Approach

BACKGROUND

Blood glucose management around exercise is challenging for youth with type 1 diabetes (T1D). Previous research has indicated interventions including decision-support aids to better support youth to effectively contextualize blood glucose results and take appropriate action to optimize glucose levels during and after exercise. Mobile health (mHealth) apps help deliver health behavior interventions to youth with T1D, given the use of technology for glucose monitoring, insulin dosing, and carbohydrate counting.

OBJECTIVE

We aimed to develop a novel prototype mHealth app to support exercise management among youth with T1D, detail the application of a co-design process and design thinking principles to inform app design and development, and identify app content and functionality that youth with T1D need to meet their physical activity goals.

METHODS

A co-design approach with a user-centered design thinking framework was used to develop a prototype mHealth app "acT1ve" during the 18-month design process (March 2018 to September 2019). To better understand and respond to the challenges among youth with diabetes when physically active, 10 focus groups were conducted with youth aged 13-25 years with T1D and parents of youth with T1D. Thereafter, we conducted participatory design workshops with youth to identify key app features that would support individual needs when physically active. These features were incorporated into a wireframe, which was critically reviewed by participants. A beta version of "acT1ve" was built in iOS and android operating systems, which underwent critical review by end users, clinicians, researchers, experts in exercise and T1D, and app designers.

RESULTS

Sixty youth with T1D, 14 parents, 6 researchers, and 10 clinicians were engaged in the development of "acT1ve." acT1ve included key features identified by youth, which would support their individual needs when physically active. It provided advice on carbohydrates and insulin during exercise, information on hypoglycemia treatment, pre- and postexercise advice, and an educational food guide regarding exercise management. "acT1ve" contained an exercise advisor algorithm comprising 240 pathways developed by experts in diabetes and exercise research. Based on participant input during exercise, acT1ve provided personalized insulin and carbohydrate advice for exercise lasting up to 60 minutes. It also contains other features including an activity log, which displays a complete record of the end users' activities and associated exercise advice provided by the app's algorithm for later reference, and regular reminder notifications for end users to check or monitor their glucose levels.

CONCLUSIONS

The co-design approach and the practical application of the user-centered design thinking framework were successfully applied in developing "acT1ve." The design thinking processes allowed youth with T1D to identify app features that would support them to be physically active, and particularly enabled the delivery of individualized advice. Furthermore, app development has been described in detail to help guide others embarking on a similar project.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619001414101; https://tinyurl.com/mu9jvn2d.

Empowering diabetes management: The impact of patient-provider collaboration on type 2 diabetes outcomes through autonomy support and shared decision-making

OBJECTIVES

Through the lens of self-determination theory, this quantitative study investigates how patient-provider collaboration through perceived shared decision-making (SDM) and autonomy support impact type 2 diabetes (T2D) outcomes.

METHODS

We sampled 474 individuals over 18 years old who self-identified as having T2D. Completed and valid responses were received from 378 participants from two separate groups in an online survey. Data was analyzed using the IBM Statistical Package for Social Sciences (SPSS), AMOS package, version 28, and Mplus, version 8.8.

RESULTS

Patient-provider collaboration through autonomy support improved treatment satisfaction (β = .16, ρ < .05) and self-management adherence (β = .43, ρ < .001). While collaboration through SDM improved treatment satisfaction (β = .25, ρ < .01), it worsened SM adherence (β = -.31, ρ < .001). The negative impact of SDM on self-management adherence was mitigated by our moderator, coping ability. However, coping ability minimally impacted treatment satisfaction and SM adherence when autonomous support was provided.

CONCLUSIONS

Autonomy support increases treatment satisfaction and self-management adherence. SDM enhances treatment satisfaction but may adversely affect self-management adherence. The study also suggests that coping ability can mitigate the negative effect of SDM on self-management adherence, although its influence is limited when autonomy support is provided by the provider.

PRACTICAL IMPLICATIONS

For providers, SDM and autonomy support permits shared power over treatment decisions while fostering independence over self-management tasks. Providers should evaluate patients' coping ability and adapt their approach to care based on the patient's coping capacity.

Psychometric Properties of the Automated Insulin Delivery: Benefits and Burdens Scale for Adults with Type 1 Diabetes

Objective: To evaluate the psychometric properties of a patient-reported outcome measure, the Automated Insulin Delivery-Benefits and Burdens Scale (AID-BBS), which was designed to assess benefits and burdens of AID use in adults with type 1 diabetes (T1D). The measure was hypothesized to have validity, reliability, and clinical utility for predicting likelihood of continued use of an AID system. Research Design and Methods: A total of 217 adults with T1D (ages from 18 to 82 years) who were enrolled in an AID system research trial completed AID-BBS items at study midpoint (6 weeks) and at the end of the trial (13 weeks). Data were collected on pre-post glycemic outcomes. Participants completed other patient-reported psychosocial outcome measures (e.g., emotional well-being, diabetes distress, attitudes toward diabetes technology, diabetes treatment satisfaction) at Week 13. Likelihood of continued device use was assessed with three items at 13 weeks. Results: Exploratory factor analysis supported a one-factor structure for each subscale (15-item benefit and 9-item burden subscale) when evaluated separately. Convergent, discriminant, and predictive validity, internal consistency, and test-retest reliability were supported. Benefit and burden subscales at week 6 predicted usage intention above and beyond device impact on glycemic outcomes, also controlling for baseline glycemic outcomes. Conclusion: Findings support the AID-BBS as a psychometrically valid, reliable, and useful instrument for assessing burdens and benefits associated with AID system use in adults with T1D. The measure can be used to help health care providers set realistic expectations and proactively address modifiable burdens. Clinical Trial Registration Number: NCT04200313.

Diabetes distress and diabetes burnout explored in various areas of life in patients with type 1 diabetes: effect of short-term psychological intervention

INTRODUCTION

Diabetes distress (DD) and diabetes burnout (DB) are recognized psychological phenomena in patients with T1DM (type 1 diabetes mellitus). Still, there is an urgent need to create professional psychological intervention procedures to provide patients with adequate care.

AIM

The aim of the study was to assess the level of DD and DB in T1DM patients at baseline and after 5 of sessions psychological intervention in the group of participants who applied for help.

METHODS

34 T1DM patients who requested psychological support (22 females, 12 males) and 30 patients in a control group (14 females, 16 males) participated in the study. At baseline clinical test results between groups were compared. Next, in the studied group measurements were repeated after a set of five psychological face-to-face individual interventions which lasted 30-60 min each. They were support sessions with elements of cognitive-behavioral interventions done by clinical psychologists. Session 1: introduction, interview and collection of test results; session 2-4: work on the indicated by the patient and test results most problematic aspect of diabetes, session 5: a summary and plan for further treatment if needed. The control group results were obtained only at baseline. Research tools: DDS; PAID, Diabetes Burnout test by Polonsky.

RESULTS

At the baseline, significant differences were observed between the studied group and control group: in DB/DD levels: DB (3.9 ± 1.7 vs 2.4 ± 1.6; p < 0.001); DDS (3.2 ± 1.0 vs 2.7 ± 1.0; p = 0.064); PAID (62.3 ± 14.1vs 34.4 ± 21.0; p < 0.001). There were also group differences in HbA1c levels (8.7 ± 2.4 vs 7.3 ± 1.5; p = 0.028). After psychological interventions, there was a significant improvement in DB (3.9 ± 1.7vs 2.9 ± 1.2; p < 0.001; DDS (3.2 ± 1 vs 3.0 ± 0.7; p = 0.03); PAID (62.3 ± 14.1 vs 51.8 ± 12.5; p < 0.001).

CONCLUSIONS

DD and DB constitute a significant problem in the group of T1DM patients, but providing appropriate specialist care may help them accept diabetes and improve life satisfaction, as well as regain control over their diabetes management.

You may delay, but time will not. Beta cells lost are never found again: a case for timely initiation of basal insulin in type 2 diabetes

Since its first use just over a century ago, insulin treatment has evolved dramatically, such that the molecules are physiologic in nature, and treatment can now closely resemble the natural hormone response over 24 hours. Newer, longer-acting basal insulin analogs have provided insulin therapies with improved characteristics and, therefore, ease of use, and can readily be incorporated as part of routine treatment for type 2 diabetes (T2D), but evidence suggests that insulin remains underused in people with T2D. We review the barriers to initiation of basal insulin and the education needed to address these barriers, and we provide practical pointers, supported by evidence, for primary care physicians and advanced practice providers to facilitate timely initiation of basal insulin in the people with T2D who will benefit from such treatment.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

The Effect of Diabetes Management Shared Care Clinic on Glycated Hemoglobin A1c Compliance and Self-Management Abilities in Patients with Type 2 Diabetes Mellitus

Objective

We aim to evaluate the impact of diabetes management shared care clinic (DMSCC) on glycated hemoglobin A1c (HbA1c) compliance and self-management abilities in patients with type 2 diabetes mellitus (T2DM).

Methods

This study was a prospective cohort study of patients with T2DM participating in the DMSCC. At baseline and after management, the HbA1c levels were measured, the HbA1c compliance rate were calculated, and the Summary of Diabetes Self-Care Activities-6 (SDSCA-6), Diabetes Empowerment Scale-DAWN Short Form (DES-DSF), and Problem Areas in Diabetes Scale-Five-item Short Form (PAID-5) were completed. These pre- and post-management data were compared.

Results

A total of 124 eligible patients were enrolled. After the diabetes management of DMSCC, the average HbA1c decreased and the HbA1c compliance rate increased significantly (P < 0.01). SDSCA-6 showed significant improvement in physical activity, glycemic monitoring, smoking (P < 0.01), and taking medication (P < 0.05). DES-DSF suggested a greater willingness to try to effectively treat diabetes (P < 0.05). PAID-5 indicated significant improvement in diabetes-related emotional distress.

Conclusion

DMSCC can help patients with T2DM reduce HbA1c, increase HbA1c compliance, improve diabetes self-management behaviors, empowerment, and diabetes-related emotional distress and serve as an effective exploration and practice of diabetes self-management education and support.

Views of children with diabetes from underserved communities, and their families on diabetes, glycaemic control and healthcare provision: A qualitative evidence synthesis

AIMS

Children and young people with diabetes (CYPD) from socio-economically deprived and/or ethnic minority groups tend to have poorer glucose control and greater risk of diabetes-related complications. In this systematic review of qualitative evidence (qualitative evidence synthesis, QES), we aimed to explore the experiences and views of clinical encounters in diabetes care from the perspectives of CYPD and their family/carers from underserved communities and healthcare professionals in diabetes care.

METHODS

We searched 6 databases to March 2022 with extensive search terms, and used a thematic synthesis following methods of Thomas and Harden.

RESULTS

We identified 7 studies and described 11 descriptive themes based on primary and secondary constructs. From these, three "analytical themes" were developed. (1) "Alienation of CYPD" relates to their social identity and interaction with peers, family and health service practitioners in the context of diabetes self- and family/carer management and is impacted by communication in the clinical encounter. (2) "Empowerment of CYPD and family/carers" explores families' understanding of risks and consequences of diabetes and taking responsibility for self- and family/carer management in the context of their socio-cultural background. (3) "Integration of diabetes (into self and family)" focuses on the ability to integrate diabetes self-management into the daily lives of CYPD and family/carers beyond the clinical consultation.

CONCLUSIONS

The analytical themes are interdependent and provide a conceptual framework from which to explore and strengthen the therapeutic alliance in clinical encounters and to foster greater concordance with treatment plans. Communicating the biomedical aspects of managing diabetes in the clinical encounter is important, but should be balanced with addressing socio-emotional factors important to CYPD and family/carers.

Socioeconomic aspects of incretin-based therapy

Incretin-based therapies, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs), have demonstrated cardiovascular benefits in people with type 2 diabetes. However, socioeconomic disparities in their uptake may constrain the collective advantages offered by these medications to the broader population. In this review we examine the socioeconomic disparities in the utilisation of incretin-based therapies and discuss strategies to address these inequalities. Based on real-world evidence, the uptake of GLP-1 RAs is reduced in people who live in socioeconomically disadvantaged areas, have low income and education level, or belong to racial/ethnic minorities, even though these individuals have a greater burden of type 2 diabetes and cardiovascular disease. Contributing factors include suboptimal health insurance coverage, limited accessibility to incretin-based therapies, financial constraints, low health literacy and physician-patient barriers such as provider bias. Advocating for a reduction in the price of GLP-1 RAs is a pivotal initial step to enhance their affordability among lower socioeconomic groups and improve their value-for-money from a societal perspective. By implementing cost-effective strategies, healthcare systems can amplify the societal benefits of incretin-based therapies, alongside measures that include maximising treatment benefits in specific subpopulations while minimising harms in vulnerable individuals, increasing accessibility, enhancing health literacy and overcoming physician-patient barriers. A collaborative approach between governments, pharmaceutical companies, healthcare providers and people with diabetes is necessary for the effective implementation of these strategies to enhance the overall societal benefits of incretin-based therapies.

A global research priority agenda to advance public health responses to fatty liver disease

BACKGROUND & AIMS

An estimated 38% of adults worldwide have non-alcoholic fatty liver disease (NAFLD). From individual impacts to widespread public health and economic consequences, the implications of this disease are profound. This study aimed to develop an aligned, prioritised fatty liver disease research agenda for the global health community.

METHODS

Nine co-chairs drafted initial research priorities, subsequently reviewed by 40 core authors and debated during a three-day in-person meeting. Following a Delphi methodology, over two rounds, a large panel (R1 n = 344, R2 n = 288) reviewed the priorities, via Qualtrics XM, indicating agreement using a four-point Likert-scale and providing written feedback. The core group revised the draft priorities between rounds. In R2, panellists also ranked the priorities within six domains: epidemiology, models of care, treatment and care, education and awareness, patient and community perspectives, and leadership and public health policy.

RESULTS

The consensus-built fatty liver disease research agenda encompasses 28 priorities. The mean percentage of 'agree' responses increased from 78.3 in R1 to 81.1 in R2. Five priorities received unanimous combined agreement ('agree' + 'somewhat agree'); the remaining 23 priorities had >90% combined agreement. While all but one of the priorities exhibited at least a super-majority of agreement (>66.7% 'agree'), 13 priorities had <80% 'agree', with greater reliance on 'somewhat agree' to achieve >90% combined agreement.

CONCLUSIONS

Adopting this multidisciplinary consensus-built research priorities agenda can deliver a step-change in addressing fatty liver disease, mitigating against its individual and societal harms and proactively altering its natural history through prevention, identification, treatment, and care. This agenda should catalyse the global health community's efforts to advance and accelerate responses to this widespread and fast-growing public health threat.

IMPACT AND IMPLICATIONS

An estimated 38% of adults and 13% of children and adolescents worldwide have fatty liver disease, making it the most prevalent liver disease in history. Despite substantial scientific progress in the past three decades, the burden continues to grow, with an urgent need to advance understanding of how to prevent, manage, and treat the disease. Through a global consensus process, a multidisciplinary group agreed on 28 research priorities covering a broad range of themes, from disease burden, treatment, and health system responses to awareness and policy. The findings have relevance for clinical and non-clinical researchers as well as funders working on fatty liver disease and non-communicable diseases more broadly, setting out a prioritised, ranked research agenda for turning the tide on this fast-growing public health threat.

Topic Modeling Analysis of Diabetes-Related Health Information during the Coronavirus Disease Pandemic

This study aimed to provide diabetes-related health information by analyzing queries posted in the diabetes-related online community required during the COVID-19 pandemic. A total of 9156 queries from the diabetes-related online community, dated between 1 December 2019 and 3 May 2022, were used in the study. The collected data were preprocessed for bidirectional encoder representation from transformer topic modeling analysis. Topics were extracted using the class-based term frequency-inverse document frequency for nouns and verbs. From the extracted verbs, words with common definitions were subject to substitution and unification processes, which enabled the identification of multifrequent verb categories by noun topics. The following nine noun topics were extracted, in this order: dietary management, drug management, gestational and childhood diabetes, management of diabetic complications, use and cost of medical treatment, blood glucose management, exercise treatment, COVID-19 vaccine and complications, and diabetes in older adults. The top three verb categories by noun topics were permission, method, and possibility. This study provided baseline data that can be used by clinical nurses to deliver diabetes-related education and management based on information sought by patients.

Problem-based shared decision-making in diabetes care: a secondary analysis of video-recorded encounters

OBJECTIVES

To describe the range of collaborative approaches to shared decision-making (SDM) observed in clinical encounters of patients with diabetes and their clinicians.

DESIGN

A secondary analysis of videorecordings obtained in a randomised trial comparing usual diabetes primary care with or without using a within-encounter conversation SDM tool.

SETTING

Using the purposeful SDM framework, we classified the forms of SDM observed in a random sample of 100 video-recorded clinical encounters of patients with type 2 diabetes in primary care.

MAIN OUTCOME MEASURES

We assessed the correlation between the extent to which each form of SDM was used and patient involvement (OPTION12-scale).

RESULTS

We observed at least one instance of SDM in 86 of 100 encounters. In 31 (36%) of these 86 encounters, we found only one form of SDM, in 25 (29%) two forms, and in 30 (35%), we found ≥3 forms of SDM. In these encounters, 196 instances of SDM were identified, with weighing alternatives (n=64 of 196, 33%), negotiating conflicting desires (n=59, 30%) and problemsolving (n=70, 36%) being similarly prevalent and developing existential insight accounting for only 1% (n=3) of instances. Only the form of SDM focused on weighing alternatives was correlated with a higher OPTION12-score. More forms of SDM were used when medications were changed (2.4 SDM forms (SD 1.48) vs 1.8 (SD 1.46); p=0.050).

CONCLUSIONS

After considering forms of SDM beyond weighing alternatives, SDM was present in most encounters. Clinicians and patients often used different forms of SDM within the same encounter. Recognising a range of SDM forms that clinicians and patients use to respond to problematic situations, as demonstrated in this study, opens new lines of research, education and practice that may advance patient-centred, evidence-based care.

Practical Guidance for Healthcare Providers on Collaborating with People with Type 2 Diabetes: Advancing Treatment and Initiating Injectable Therapy

Type 2 diabetes (T2D) progresses over time, and to achieve and maintain adequate glucose control, many people eventually require injectable therapies such as insulin. However, there can be significant barriers to the initiation of these medications, both from people living with T2D and from healthcare practitioners (HCPs). Misconceptions and misinformation relating to the potential risks and benefits of injectable therapies are common and can contribute to negative perceptions regarding their use. Additionally, HCPs are often unaware of the emotional burden associated with T2D. In particular, diabetes distress is a key contributory factor that needs to be addressed to alleviate fears before diabetes education can be successful. The onus is often on the HCP to initiate effective, individualized communication with each patient and make that person feel an active and equal participant in the management of their T2D. Shared decision-making has been demonstrated to improve understanding of the pathophysiology and treatment options, to increase risk awareness, adherence, and persistence, and to improve self-management behaviors (e.g., exercise, self-care) and patient satisfaction. While therapeutic inertia can result from both patient and HCP, HCPs need to bear the responsibility for escalating therapy when necessary. A proactive approach by the HCP, combined with shared decision-making and a patient-centric approach, are important for optimal T2D management; therefore, an open and effective relationship between the HCP and the person living with T2D is essential. This article is written by a person with T2D, a nurse practitioner/Certified Diabetes Care and Education Specialist, and a clinical endocrinologist, with the goal of providing a holistic view of the management experience, exploring patient needs and expectations, recognizing and avoiding HCP and patient barriers, and providing practical advice to HCPs to empower patients who would benefit from injectable therapy.Infographic and video abstract available for this article.

Sociodemographic and behavioural risk factors associated with low awareness of diabetes mellitus medication in Indonesia: Findings from the Indonesian Family Life Survey (IFLS-5)

Introduction

Low awareness of the necessity of taking medication is common among patients with diabetes mellitus (DM) due to their lack of understanding of the disease. Therefore, it is essential to determine the underlying risks influencing low awareness to design effective intervention strategies. This study aims to evaluate the association of sociodemographic and behavioural factors with low awareness to take medication among patients with DM in Indonesia.

Method

Retrospective data were obtained from the Indonesian Family Life Survey (IFLS-5), a national cross-sectional population-based survey among respondents with DM aged ≥15 years. DM status was confirmed by HbA1c testing, while sociodemographic and other health-related information was obtained from self-reported data. Gender, age, educational level, marital status, economic status, comorbidity, religiosity, residence and health insurance status were considered sociodemographic, whereas blood glucose monitoring status, sleeping problems, depression status, having a general medical check-up, satisfaction with healthcare needs and happiness status were considered behavioural risk factors. Awareness of DM medication was determined by self-reported responses to the question asked by the surveyor. Logistic regression analysis was used to evaluate the association between sociodemographic and behavioural factors and low awareness of DM medication. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

Result

Most of the 706 respondents were female (58.8%) and aged 55-65 years (28.8%). Most of them showed low awareness of diabetes medication (87.7%). Irregular blood glucose monitoring (OR: 23.61, 95% CI 11.46-48.65; p < 0.001), without any comorbidity (OR: 2.03, 95% CI 1.05-3.90; p = 0.034), never had any general medical check-up (OR: 2.52, 95% CI 1.12-5.36; p = 0.016), 26-35 years of age (OR: 4.96, 95% CI 1.06-23.19; p = 0.042), 36-45 years of age (OR: 5.04, 95% CI 1.17-21.69; p = 0.030) and having no health insurance coverage (OR: 2.08, 95% CI 1.12-3.87; p = 0.021) were significantly associated with low awareness of diabetes medication.

Conclusion

Healthcare professionals should regularly evaluate blood glucose level, perform routine medical check-ups, prioritise patient satisfaction by providing appropriate care, involve patients in decision-making by determining their needs and then tailor an intervention to meet the need for, and improve their awareness of, DM medication.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

An insight into patients’ perspectives on barriers affecting participation in shared decision making among patients with diabetes mellitus in Malawi

Background

Patient participation in decision making is a basic tenet for a patient centred care experience and, has potential to improve care experiences and responsiveness in chronic diseases such as Diabetes Mellitus (DM). However, documented experiences show that patient participation in decisions making is wanting. As Malawi strives to institutionalise patient centred care delivery, it is important to examine patients’ experiences and perceptions to identify barriers affecting their participation in shared decision making because this may provide evidence supporting strategies in implementation of the institutionalisation.

Aim

The study sought to describe perspectives about barriers to participation in shared decision making among patients with DM in Malawi.

Methods

This was an exploratory qualitative study. We targeted patients attending DM clinics in four public health facilities in southern Malawi from September to December 2019. We used In-Depth Interviews and Focus Group Discussions. Data was managed using Nvivo version 11 software and analysed using Content Analysis.

Results

The study highlights the values, perceptions and benefits of shared decision making. Furthermore, patients’ narratives expose the struggles and vulnerabilities in their attempts to engage their providers towards shared decision making.

Conclusion

Interactional power imbalances, insufficient dialogue and patients’ own restrictive attitudes towards engagement with their providers thwarts SDM in clinical encounters. To make SDM a reality, transforming medical education that emphasizes on the value of good patient-provider relationship and providers’ attitudes to regard patients as active partners may be a good starting point. Additionally, strategies that empower and change patients’ perceptions about SDM require investment.

Adherence to antidiabetic treatment in primary health care in individuals with type 2 diabetes. A survey including socio-demographic, patient related and clinical factors

BACKGROUND

Adherence to medications is a critical element in diabetes management.

OBJECTIVE

To investigate patient-related factors associated with adherence to antidiabetic treatment in patients with type 2 diabetes in primary health-care units.

METHODS

A cross-sectional study among patients receiving diabetes care in 18 primary care units in Mexico City was conducted. Data were collected from medical records and medical interviews. Adherence to antidiabetic therapy and patient-related factors associated with adherence were evaluated through a self-administered questionnaire. Socio-demographic, clinical, behavioral (self-care activities including a healthy diet, exercise or physical activity, self-monitoring of blood glucose testing, and foot care), and patients-adherence-related factors (health-care provider-patient communication; daily and social activities, and support network; alternative treatment beliefs; comorbidity, diabetes symptoms, and treatment; side effects and treatment access) were compared between the adherent and non-adherent group.

RESULTS

Of 319 outpatients, 48.3% were adherent to their antidiabetic therapy. In the adjusted analysis, patient-related factors associated to adherence were exercise and physical activity self-care behavior (OR=1.26; 95%CI 1.09-1.46), treatment interference with daily activities (OR=0.27; 95%CI 0.14-0.52), not satisfied with resolution of questions by the physician (OR=0.42; 95%CI 0.19-0.94), independently to increased cardiovascular risk and insulin treatment.

CONCLUSION

A low proportion of outpatients with T2D with regular primary care were adherent to diabetes treatment and this was associated with patient-related factors like answering patients' treatment-related questions by the physician. This information may be useful to identify patients at risk for low adherence, and to guide the design of quality-of-care strategies, like diabetes education programs to address suboptimal adherence in patients, and health-care professional communication skills training, particularly in primary care health systems.

Comparing Patient Perspectives on Diabetes Management to the Deficit-Based Literature in an Ethnic Minority Population: A Mixed-Methods Study

Marginalized racial/ethnic minorities have disproportionately high rates of type 2 diabetes prevalence, complications and mortality. Researchers and policymakers have typically addressed these disparities using a deficit-based discourse focused on individual/cultural deficiencies or failure. A mixed-methods study was used to compare the deficit discourse to the perspectives of adults with diabetes in the Arab minority in Israel, using data from 10 focus groups (5 men's, 5 women's) and 296 quantitative in-person surveys. Both qualitative and quantitative data were triangulated. In addition, multivariable regression models tested associations between diabetes management perspectives and participant characteristics. Contrary to the deficit-based characterizations of patients as fatalistic and unknowledgeable, participants viewed diabetes as a chronic disease with serious complications. They expressed more support for patient responsibility in diabetes management than for passive fatalism, and were less fatalistic as educational level and adequacy of diabetes self-care training increased. The impact of social/environmental barriers and changing cultural norms on lifestyle behaviors was highlighted. Over 95% used prescription medications for diabetes management, although 35% reported economic barriers. The deficit discourse is not well-aligned with Arab patients' evolving perceptions and needs, and has deflected attention from the socioeconomic/structural determinants of health, and the healthcare system's responsibility to provide effective, culturally-relevant diabetes services.

An Intuitive Risk Communication Tool to Enhance Patient-Provider Partnership in Diabetes Consultation

INTRODUCTION

This technology report introduces an innovative risk communication tool developed to support providers in communicating diabetes-related risks more intuitively to people with type 2 diabetes mellitus (T2DM).

METHODS

The development process involved three main steps: (1) selecting the content and format of the risk message; (2) developing a digital interface; and (3) assessing the usability and usefulness of the tool with clinicians through validated questionnaires.

RESULTS

The tool calculates personalized risk information based on a validated simulation model (United Kingdom Prospective Diabetes Study Outcomes Model 2) and delivers it using more intuitive risk formats, such as "effective heart age" to convey cardiovascular risks. Clinicians reported high scores for the usability and usefulness of the tool, making its adoption in routine care promising.

CONCLUSIONS

Despite increased use of risk calculators in clinical care, this is the first time that such a tool has been developed in the diabetes area. Further studies are needed to confirm the benefits of using this tool on behavioral and health outcomes in T2DM populations.

Initiating second-line antidiabetic medication among older adults with type 2 diabetes on Metformin

Background

Antidiabetic medications (ADM), especially sulfonylureas (SFU) and basal insulin (BI), are associated with increased risk of hypoglycemia, which is especially concerning among older adults in poor health. The objective of this study was to investigate prescribing patterns of ADM in older adults according to their health status.

Methods

This case control study analyzed administrative claims between 2013 and 2017 from a large national payer. The study population was derived from a nationwide database of 84,720 U.S. adults aged ≥65, who were enrolled in Medicare Advantage health insurance plans. Participants had type 2 diabetes on metformin monotherapy, and started a second-line ADM during the study period. The exposure was a binary variable for health status, with poor health defined by end-stage medical conditions, dementia, or residence in a long-term nursing facility. The outcome was a variable identifying which second-line ADM class was started, categorized as SFU, BI, or other (i.e. all other ADM classes combined).

Results

Over half of participants (54%) received SFU as initial second-line ADM, 14% received BI, and 32% received another ADM. In multivariable models, the odds of filling SFU or BI was higher for participants in poor health than those in good or intermediate health [OR 1.13 (95% CI 1.05-1.21) and OR 2.34 (95% CI 2.14-2.55), respectively]. SFU and BI were also more commonly filled by older adults with poor glycemic control.

Conclusions

Despite clinical consensus to use caution prescribing SFU and BI among older adults in poor health, these medications remain frequently used in this particularly vulnerable population.

Key Factors Relevant for Healthcare Decisions of Patients with Type 1 and Type 2 Diabetes in Secondary Care According to Healthcare Professionals

PURPOSE

Understanding which factors are important for healthcare decisions of patients with diabetes in clinical practice is important to personalise diabetes care strategies and tailor care plans to the individual. The main drivers for these healthcare decisions remain unclear. This study assessed which key factors are relevant for healthcare decisions during clinical consultations for patients with type 1 diabetes (T1DM) and type 2 diabetes (T2DM), according to healthcare professionals.

MATERIALS AND METHODS

Annual diabetes reviews were performed as part of a trial assessing the impact of a consultation model facilitating person-centred diabetes care in six hospital outpatient clinics. After each consultation, we asked healthcare professionals to choose a maximum of three out of 20 factors that were most relevant for healthcare decisions about treatment goals and the professional support needed during the upcoming year. Factors were characterised as either person or disease-related. Percentages reflect the number of annual diabetes reviews in which the key factor was reported.

RESULTS

Seventeen physicians and eight diabetes specialist nurses reported the key factors relevant for healthcare decisions in 285 annual diabetes reviews (T1DM n = 119, T2DM n = 166). Healthcare professionals most often reported quality of life (31.9%), motivation (27.0%) and diabetes self-management (25.6%), and to a lesser extent glycaemic control (24.2%), to be important for decisions about treatment goals. For decisions about the professional support needed during the upcoming year patient's preferences (33.7%), diabetes self-management (33.3%), quality of life (27.0%) and motivation (25.6%) were most often considered relevant by healthcare professionals.

CONCLUSION

According to healthcare professionals, person-related factors such as quality of life, diabetes self-management and motivation are predominantly relevant for healthcare decisions about treatment goals and the professional support needed during the upcoming year.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Equity in Medical Care for People Living With Diabetes

Disparities and inequities exist for individuals with diabetes in marginalized communities of color, especially among people with low socioeconomic status. Although these barriers are apparent, only a few care models have been designed for and examined in racially and ethnically diverse individuals. This article reviews models that have been developed and examined in a variety of different populations and focuses on how to implement elements from these programs in clinical practice. Health equity-promoting ideas and approaches that can be applied throughout the life span (children to seniors) are also included. As diabetes health care providers, researchers, educators, policymakers, and advocates, we must now combine our efforts and focus on historically excluded populations to bridge the gap to essential diabetes care.

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial

Background

MyDiabetesPlan is a web-based, interactive patient decision aid that facilitates patient-centred, diabetes-specific, goal-setting and shared decision-making (SDM) with interprofessional health care teams.

Objective

Assess the feasibility of (1) conducting a cluster randomized controlled trial (RCT) and (2) integrating MyDiabetesPlan into interprofessional primary care clinics.

Methods

We conducted a cluster RCT in 10 interprofessional primary care clinics with patients living with diabetes and at least two other comorbidities; half of the clinics were assigned to MyDiabetesPlan and half were assigned to usual care. To assess recruitment, retention, and resource use, we used RCT conduct logs and financial account summaries. To assess intervention fidelity, we used RCT conduct logs and website usage logs. To identify barriers and facilitators to integration of MyDiabetesPlan into clinical care across the IP team, we used audiotapes of clinical encounters in the intervention groups.

Results

One thousand five hundred and ninety-seven potentially eligible patients were identified through searches of electronic medical records, of which 1113 patients met the eligibility criteria upon detailed chart review. A total of 425 patients were randomly selected; of these, 213 were able to participate and were allocated (intervention: n = 102; control: n = 111), for a recruitment rate of 50.1%. One hundred and fifty-one patients completed the study, for a retention rate of 70.9%. A total of 5745 personnel-hours and $6104 CAD were attributed to recruitment and retention activities. A total of 179 appointments occurred (out of 204 expected appointments—two per participant over the 12-month study period; 87.7%). Forty (36%), 25 (23%), and 32 (29%) patients completed MyDiabetesPlan at least twice, once, and zero times, respectively. Mean time for completion of MyDiabetesPlan by the clinician and the patient during initial appointments was 37 min. From the clinical encounter transcripts, we identified diverse strategies used by clinicians and patients to integrate MyDiabetesPlan into the appointment, characterized by rapport building and individualization. Barriers to use included clinician-related, patient-related, and technical factors.

Conclusion

An interprofessional approach to SDM using a decision aid was feasible. Lower than expected numbers of diabetes-specific appointments and use of MyDiabetesPlan were observed. Addressing facilitators and barriers identified in this study will promote more seamless integration into clinical care.

Trial registration Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: February 11, 2015. Protocol version: Version 1; February 26, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01673-w.

Identifying and Reducing Disparities in Young Adults With Diabetes

This article outlines how social and health care determinants can affect young adults with diabetes. The authors provide a detailed description of each determinant's influence on diabetes self-management and offer solutions to help mitigate these harmful effects.

Patient-important outcomes to inform shared decision making and goal setting for diabetes treatment

OBJECTIVE

Despite well-established treatment guidelines, diabetes is difficult to manage for many individuals. The importance of using shared decision making to optimize diabetes treatment is recognized, yet what matters most to individuals with diabetes is not well established. Our goal was to identify patients' goals and priorities for diabetes management.

METHODS

We engaged 141 participants through interviews and group concept mapping to identify patient-important outcomes (PIOs) for diabetes care. We generated a master list of PIOs by aggregating interview data coded to "goals" and ideas brainstormed during concept mapping, and then a patient advisory board sorted the PIOs into higher-level domains.

RESULTS

We identified 41 PIOs sorted into 7 broad domains: optimize daily self-care, optimize long term health, learn about diabetes, achieve measurable goals, manage medications, manage diet and best utilize medical / professional services.

CONCLUSIONS

Most (4/7) of PIO domains focused on personal and life goals, not medically-oriented goals. Use of these PIOs and domains may facilitate more effective SDM discussions for patients with diabetes.

PRACTICE IMPLICATIONS

Use of PIOs from this work can enable the empowerment of patients to voice their priorities during SDM conversations, thus facilitating development of truly individualized diabetes treatment plans.

"I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes

Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.

Patient Markers of Successful Diabetes Management

PURPOSE

For individuals with diabetes, diabetes health status may not align with A1C targets. Patients may use nonclinical targets when assessing their diabetes management success. Identifying these targets is important in developing patient-centered management plans. The purpose of this study was to identify patient markers of successful diabetes management among patients in an urban academic health system.

METHODS

A secondary analysis of semistructured interviews was completed with 89 adults with type 1 or type 2 diabetes. Participants had a recent diabetes-related emergency department (ED) visits or hospitalization or were primary care patients with an A1C >7.5%. Interviews were conducted to saturation. Demographic data were collected via self-report and electronic medical records. Interviews were analyzed using conventional content analysis. This analysis focused on patient perceptions of successful management coded to "measuring management success."

RESULTS

Although most participants cited A1C or blood glucose as a marker of successful diabetes management, they had varied understanding of these metrics. Most used a combination of targets from the following categories: 1) A1C, blood glucose, and numbers; 2) engagement in medical care; 3) taking medication and medication types; 4) symptoms; 5) diet, exercise, and weight; and 6) stress management and social support.

CONCLUSION

Individuals not meeting glycemic goals and/or with recent diabetes-related ED visits or hospitalizations had varied understanding of A1C and blood glucose targets. They use multiple additional markers of successful management and had a desire for management discussions that incorporate these markers. These measures should be incorporated into their care plans along with clinical targets.

Experience and knowledge of Lyme disease: A scoping review of patient-provider communication

There has been limited research on patient-provider communication dynamics regarding Lyme disease (LD) diagnosis and treatment. Evidence suggests communication in the clinical encounter improves when both patient and healthcare provider (HCP) have concordant orientations (or beliefs) on discussed topics, resulting in higher patient satisfaction and care outcomes. The purpose of this scoping review was to characterize and summarize current research findings on patient and provider knowledge and experiences regarding LD - two factors that may influence the orientation of both patients and providers toward LD in the clinical setting. None of the articles included in the review specifically addressed patient-provider interaction and relationships as the main objective. However, the existing literature indicates notable HCP uncertainty regarding LD diagnosis, treatment, and applied practice patterns. Current research also describes limited knowledge of LD among patient populations and a high prevalence of negative perceptions of care received in mainstream healthcare settings among individuals with persistent symptoms. We identified a critical gap in research that seeks to understand the dynamic of patients and HCPs communicating on the topic of LD in the clinical setting. Future research may identify opportunities where the patient-provider communication dynamic can be improved.

Identifying research gaps: A review of virtual patient education and self-management

BACKGROUND

Avatars in Virtual Reality (VR) can not only represent humans, but also embody intelligent software agents that communicate with humans, thus enabling a new paradigm of human-machine interaction.

OBJECTIVE

The research agenda proposed in this paper by an interdisciplinary team is motivated by the premise that a conversation with a smart agent avatar in VR means more than giving a face and body to a chatbot. Using the concrete communication task of patient education, this research agenda is rather intended to explore which patterns and practices must be constructed visually, verbally, para- and nonverbally between humans and embodied machines in a counselling context so that humans can integrate counselling by an embodied VR smart agent into their thinking and acting in one way or another.

METHODS

The scientific literature in different bibliographical databases was reviewed. A qualitative narrative approach was applied for analysis.

RESULTS

A research agenda is proposed which investigates how recurring consultations of patients with healthcare professionals are currently conducted and how they could be conducted with an embodied smart agent in immersive VR.

CONCLUSIONS

Interdisciplinary teams consisting of linguists, computer scientists, visual designers and health care professionals are required which need to go beyond a technology-centric solution design approach. Linguists' insights from discourse analysis drive the explorative experiments to identify test and discover what capabilities and attributes the smart agent in VR must have, in order to communicate effectively with a human being.

Making Diabetes Care Fit—Are We Making Progress?

The care of patients with diabetes requires plans of care that make intellectual, practical, and emotional sense to patients. For these plans to fit well, patients and clinicians must work together to develop a common understanding of the patient’s problematic human situation and co-create a plan of care that responds well to it. This process, which starts at the point of care, needs to continue at the point of life. There, patients work to fit the demands of their care plan along with the demands placed by their lives and loves. Thought in this way, diabetes care goes beyond the control of metabolic parameters and the achievement of glycemic control targets. Instead, it is a highly individualized endeavor that must arrive at a care plan that reflects the biology and biography of the patient, the best available research evidence, and the priorities and values of the patient and her community. It must also be feasible within the life of the patient, minimally disrupting those aspects of the patient life that are treasured and justify the pursuit of care in the first place. Patient-centered methods such as shared decision making and minimally disruptive medicine have joined technological advances, patient empowerment, self-management support, and expert patient communities to advance the fit of diabetes care both at the point of care and at the point of life.

Automated vs. Human Health Coaching: Exploring Participant and Practitioner Experiences

Health coaching can be an effective intervention to support self-management of chronic conditions like diabetes, but there are not enough coaching practitioners to reach the growing population in need of support. Conversational technology, like chatbots, presents an opportunity to extend health coaching support to broader and more diverse populations. However, some have suggested that the human element is essential to health coaching and cannot be replicated with technology. In this research, we examine automated health coaching using a theory-grounded, wizard-of-oz chatbot, in comparison with text-based virtual coaching from human practitioners who start with the same protocol as the chatbot but have the freedom to embellish and adjust as needed. We found that even a scripted chatbot can create a coach-like experience for participants. While human coaches displayed advantages expressing empathy and using probing questions to tailor their support, they also encountered tremendous barriers and frustrations adapting to text-based virtual coaching. The chatbot coach had advantages in being persistent, as well as more consistently giving choices and options to foster client autonomy. We discuss implications for the design of virtual health coaching interventions.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Person-centered diabetes care and patient activation in people with type 2 diabetes

INTRODUCTION

The American Diabetes Association and the European Association for the Study of Diabetes advocate a person-centered approach to enhance patient engagement in self-care activities. To that purpose, people with diabetes need adequate diabetes knowledge, motivation, skills and confidence. These prerequisites are captured by the concept 'patient activation'. The Dutch Diabetes Federation implemented a person-centered consultation model for the annual diabetes review. To assess its relationship with patient activation, we measured the change in patient activation, and in person and disease-related factors in people with type 2 diabetes after their second person-centered annual review.

RESEARCH DESIGN AND METHODS

Observational study in 47 primary care practices and six outpatient hospital clinics.

FOLLOW-UP

1 year. From 2.617 people with diabetes and capable of completing questionnaires (no additional exclusion criteria) 1.487 (56.8%) participated, 1366 with type 2 diabetes.

MAIN OUTCOME

patient activation (13-item Patient Activation Measure, score 0-100). Before the first and after the second review, participants completed questionnaires. Medical data were retrieved from electronic records. We performed a repeated measure analysis using a linear mixed model in 1299 participants, who completed the first set of questionnaires.

RESULTS

In 1299 participants (41.6% female, mean age 66 years, median diabetes duration 10 years, median glycated hemoglobin (HbA1c) 6.8%/51 mmol/mol), the mean baseline activation level was 58.9 (SD 11.7). Independent of actual diabetes care, activation levels increased 1.53 units (95% CI 0.67 to 2.39, p=0.001). Several diabetes perceptions improved significantly; diabetes distress level decreased significantly. Body mass index (-0.22, 95% CI -0.33 to -0.10, p<0.001) and low-density lipoprotein cholesterol (-2.71 mg/dL, 95% CI -4.64 to -0.77, p=0.004) decreased, HbA1c increased 0.08% (95% CI 0.03 to 0.12) (p=0.001).

CONCLUSIONS

Person-centered diabetes care was associated with a slightly higher patient activation level, improved diabetes perception and small improvements in clinical outcomes. Person-centered care may enhance patient engagement, but one should not expect substantial improvement in patient outcomes in the short term.

Patient decisional needs when considering treatment intensification for type 2 diabetes: A qualitative study in China

AIMS

This study explored decisional needs of patients with type 2 diabetes in China when considering treatment intensification to achieve good glycemic control, from both the patient's and practitioners' perspectives.

METHODS

Interviews were conducted with 35 patients, and individual interviews and focus groups with 28 practitioners in Beijing, China. Topic guides based on the Ottawa Decisional Support Framework were modified for the Chinese context. Two interviewers independently extracted and coded transcripts of their notes into-overarching themes. Content analysis was performed to analyze participants' responses.

RESULTS

Patients (34/35) reported having tried different medications and some (15/35) visited multiple hospitals and consulted different doctors. Patients' knowledge of medications was suboptimal (26/35), and most patients were not aware of their glucose levels (23/35). Although most were receptive to add-on medications, both patients and practitioners reported a range of uncertainty about the decision, and patients wanted more reliable information. Patients (15/35) and practitioners (19/28) recognized the importance of a trusting relationship when adding medications. Both reported similar values and preferences, but these were rarely discussed when adding medications. Although most patients (32/35) reported that they were capable of making a decision on adding medications, few practitioners (6/28) perceived their patients were capable.

CONCLUSIONS

Findings suggest a need for reliable information, more discussion about values and preferences and decision support to help engage patients and practitioners in a shared decision-making process. Decision support tools may facilitate the process for patients with type 2 diabetes in China considering add-on medications.

How mHealth can facilitate collaboration in diabetes care: qualitative analysis of co-design workshops

Background

Individuals with diabetes are using mobile health (mHealth) to track their self-management. However, individuals can understand even more about their diabetes by sharing these patient-gathered data (PGD) with health professionals. We conducted experience-based co-design (EBCD) workshops, with the aim of gathering end-users’ needs and expectations for a PGD-sharing system.

Methods

N = 15 participants provided feedback about their experiences and needs in diabetes care and expectations for sharing PGD. The first workshop (2017) included patients with Type 2 Diabetes (T2D) (n = 4) and general practitioners (GPs) (n = 3). The second workshop (2018) included patients with Type 1 Diabetes (T1D) (n = 5), diabetes specialists (n = 2) and a nurse. The workshops involved two sessions: separate morning sessions for patients and healthcare providers (HCPs), and afternoon session for all participants. Discussion guides included questions about end-users’ perceptions of mHealth and expectations for a data-sharing system. Activities included brainstorming and designing paper-prototypes. Workshops were audio recorded, transcribed and translated from Norwegian to English. An abductive approach to thematic analysis was taken.

Results

Emergent themes were mHealth technologies’ impacts on end-users, and functionalities of a data-sharing system. Within these themes, similarities and differences between those with T1D and T2D, and between HCPs, were revealed. Patients and providers agreed that HCPs could use PGD to provide more concrete self-management recommendations. Participants’ paper-prototypes revealed which data types should be gathered and displayed during consultations, and how this could facilitate shared-decision making.

Conclusion

The diverse and differentiated results suggests the need for flexible and tailorable systems that allow patients and providers to review summaries, with the option to explore details, and identify an individual’s challenges, together. Participants’ feedback revealed that both patients and HCPs acknowledge that for mHealth integration to be successful, not only must the technology be validated but feasible changes throughout the healthcare education and practice must be addressed. Only then can both sides be adequately prepared for mHealth data-sharing in diabetes consultations. Subsequently, the design and performance of the joint workshop sessions demonstrated that involving both participant groups together led to efficient and concrete discussions about realistic solutions and limitations of sharing mHealth data in consultations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05955-3.

Exercise capacity is associated with hospital readmission among patients with diabetes

INTRODUCTION

Patients with diabetes are at greater risk of hospital readmission than patients without diabetes. There is a need to identify more modifiable risk factors for readmission as potential targets for intervention. Cardiorespiratory fitness is a predictor of morbidity and mortality. The purpose of this study was to examine whether there is an association between exercise capacity based on the maximal workload achieved during treadmill stress testing and readmission among patients with diabetes.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included adult patients with diabetes discharged from an academic medical center between July 1, 2012 and December 31, 2018 who had a stress test documented before the index discharge. Univariate analysis and multinomial multivariable logistic regressions were used to evaluate associations with readmission within 30 days, 6 months, and 1 year of discharge. Exercise capacity was measured as metabolic equivalents (METs).

RESULTS

A total of 580 patients with 1598 hospitalizations were analyzed. Mean METs of readmitted patients were significantly lower than for non-readmitted patients (5.7 (2.6) vs 6.7 (2.6), p<0.001). After adjustment for confounders, a low METs level (<5) was associated with higher odds of readmission within 30 days (OR 5.46 (2.22-13.45), p<0.001), 6 months (OR 2.78 (1.36-5.65), p=0.005), and 1 year (OR 2.16 (1.12-4.16), p=0.022) compared with medium (5-7) and high (>7) METs level. During the 6.5-year study period, patients with low METs had a mean of 3.2±3.6 hospitalizations, while those with high METs had 2.5±2.4 hospitalizations (p=0.007).

CONCLUSIONS

Lower exercise capacity is associated with a higher risk of readmission within 30 days, 6 months, and 1 year, as well as a greater incidence of hospitalization, in patients with diabetes. Future studies are needed to explore whether exercise reduces readmission risk in this population.

Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review

BACKGROUND

Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool.

RESULTS

Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias.

CONCLUSIONS

DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.

Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment

OBJECTIVE

Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making.

METHODS

A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models.

RESULTS

Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics.

CONCLUSION

Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.

"I Had Nobody to Represent Me": How Perceptions of Diabetes Health-Care Providers' Age, Gender and Ethnicity Impact Shared Decision-Making in Adults With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to investigate how patients' perceptions of their diabetes health-care providers' (HCP) age, gender and ethnicity impact shared decision-making using the Theory of Planned Behaviour.

METHODS

Adult participants receiving diabetes care at community sites, primary care or specialty clinics participated in semistructured, one-on-one interviews conducted from November 2018 to January 2019. Responses were transcribed and qualitatively analyzed for emergent themes using statistical software (NVivo version 9).

RESULTS

We conducted 28 interviews with participants 34 to 81 years of age. The following themes were identified: 1) participants' gestalt of their diabetes HCP was strongly gender dependent 2) there was a hidden preference for Caucasian HCPs, 3) age evoked a less defensive response with regard to shared decision-making and 4) degree of trust in self and in their diabetes HCP directed participants' readiness to be part of the shared decision-making.

CONCLUSIONS

Participants' narrative experiences strongly suggest that they view their diabetes HCPs through a gendered and racialized lens.

Receipt of recommended complications and comorbidities screening in youth and young adults with type 1 diabetes: Associations with metabolic status and satisfaction with care

OBJECTIVES

This study sought to: (a) assess the prevalence of diabetes complications and comorbidities screening as recommended by the American Diabetes Association (ADA) for youth and young adults (YYAs) with type 1 diabetes (T1D), (b) examine the association of previously measured metabolic status related to diabetes complications with receipt of recommended clinical screening, and (c) examine the association of satisfaction with diabetes care with receipt of recommended clinical screening.

METHODS

The study included 2172 SEARCH for Diabetes in Youth participants with T1D (>10 years old, diabetes duration >5 years). Mean participant age was 17.7 ± 4.3 years with a diabetes duration of 8.1 ± 1.9 years. Linear and multinomial regression models were used to evaluate associations.

RESULTS

Sixty percent of participants reported having three or more hemoglobin A1c (HbA1c) measurements in the past year. In terms of diabetes complications screening, 93% reported having blood pressure measured, 81% having an eye examination, 71% having lipid levels checked, 64% having a foot exam, and 63% completing albuminuria screening in accordance with ADA recommendations. Youth known to have worse glycemic control in the past had higher odds of not meeting HbA1c screening criteria (OR 1.11, 95% CI = 1.05, 1.17); however, after adjusting for race/ethnicity, this was no longer statistically significant. Greater satisfaction with diabetes care was associated with increased odds of meeting screening criteria for most of the ADA-recommended measures.

CONCLUSIONS

Efforts should be made to improve diabetes complications screening efforts for YYAs with T1D, particularly for those at higher risk for diabetes complications.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Patient Perceptions of Diabetes Guideline Frameworks for Individualizing Glycemic Targets

IMPORTANCE

Diabetes guidelines recommend considering specific factors, such as diabetes duration and life expectancy, to individualize treatment in older adults. These individualized glycemic targets inform decisions on whether to intensify or deintensify medication treatment plans. How older adults with diabetes perceive these factors used to individualize glycemic targets is unknown.

OBJECTIVES

To examine how older adults perceive factors used in diabetes guidelines for individualizing glycemic targets.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional national survey was conducted from December 13, 2018, to January 3, 2019, of a nationally representative, probability-based online survey panel (KnowledgePanel). A total of 1364 KnowledgePanel members who were 65 years or older and had type 2 diabetes were invited to participate in the survey; 836 (61.3%) responded, and 818 (60.0%) completed the survey.

MAIN OUTCOMES AND MEASURES

The study randomized participants to 2 vignettes: one about adding and the other about removing diabetes medications from treatment plans. Participants rated the importance of 7 factors (diabetes duration, established diabetes complications, other health conditions, life expectancy, risk of adverse effects, cost, and treatment effort) in these treatment decisions using binary (yes/no) responses and the best-worst scaling method to quantify the factors' relative importance. All participants then answered questions on how different levels of each factor were associated with aggressiveness of diabetes treatment.

RESULTS

The sample included 818 participants (mean [SD] age, 74.0 [6.8] years; 469 [53.7%] male; and 668 [67.7%] white). A total of 410 participants answered questions about adding medicine, whereas 408 participants answered questions about stopping medicine. Of the 7 factors to consider for adding a diabetes medication to the treatment plan, the number who deemed each factor important ranged from 197 (45.6%) to 263 (62.8%). In contrast, these same factors were considered important by only 29 (8.4%) to 146 (37.7%) of participants when deciding to stop use of a diabetes medication. In both decisions, participants perceived the risk of adverse effects as the most important factor (relative importance was 22.8 for adding a medicine and 25.0 for stopping a medicine on a ratio scale in which, for each decision, the relative importance of the 7 factors adds up to 100, with 0 indicating complete indifference and 100 complete priority). In contrast to current guideline recommendations, most participants believed that patients with longer disease duration (498 [60.1%]), more established complications (632 [75.6%]), and greater number of other health conditions (545 [67.5%]) should receive more aggressive diabetes treatment.

CONCLUSIONS AND RELEVANCE

Many older adults do not place high importance on factors recommended by guidelines to individualize diabetes treatment, especially when deciding to stop use of diabetes medications. Moreover, when considering treatment aggressiveness, many older adults weighted several factors in the opposite direction than suggested by the guidelines. Individualizing diabetes care in older adults will require effective communication regarding the benefits and consequences of making changes to treatment plans.

Benefits and harms of intensive glycemic control in patients with type 2 diabetes

Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients' goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.

Beyond pros and cons - developing a patient decision aid to cultivate dialog to build relationships: insights from a qualitative study and decision aid development

BACKGROUND

An individualized approach using shared decision-making (SDM) and goal setting is a person-centred strategy that may facilitate prioritization of treatment options. SDM has not been adopted extensively in clinical practice. An interprofessional approach to SDM with tools to facilitate patient participation may overcome barriers to SDM use. The aim was to explore decision-making experiences of health professionals and people with diabetes (PwD), then develop an intervention to facilitate interprofessional shared decision-making (IP-SDM) and goal-setting.

METHODS

This was a multi-phased study. 1) Feasibility: Using a descriptive qualitative study, individual interviews with primary care physicians, nurses, dietitians, pharmacists, and PwD were conducted. The interviews explored their experiences with SDM and priority-setting, including facilitators and barriers, relevance of a decision aid for priority-setting, and integration of SDM and a decision aid into practice. 2) Development: An evidence-based SDM toolkit was developed, consisting of an online decision aid, MyDiabetesPlan, and implementation tools. MyDiabetesPlan was reviewed by content experts for accuracy and comprehensiveness. Usability assessment was done with 3) heuristic evaluation and 4) user testing, followed by 5) refinement.

RESULTS

Seven PwD and 10 clinicians participated in the interviews. From interviews with PwD, we identified that: (1) approaches to decision-making were diverse and dynamic; (2) a trusting relationship with the clinician and dialog were critical precursors to SDM; and, (3) goal-setting was a dynamic process. From clinicians, we found: (1) complementary (holistic and disease specific) approaches to the complex patient were used; (2) patient-provider agendas for goal-setting were often conflicting; (3) a flexible approach to decision-making was needed; and, (4) conflict could be resolved through SDM. Following usability assessment, we redesigned MyDiabetesPlan to consist of data collection and recommendation stages. Findings were used to finalize a multi-component toolkit and implementation strategy, consisting of MyDiabetesPlan, instructional card and videos, and orientation meetings with participating patients and clinicians.

CONCLUSIONS

A decision aid can provide information, facilitate clinician-patient dialog and strengthen the therapeutic relationship. Implementation of the decision aid can fit into a model of team care that respects and exemplifies professional identity, and can facilitate intra-team communication.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.

Exploring patient perspectives of prediabetes and diabetes severity: a qualitative study

Objective: This qualitative study sought to identify and describe patients' variant perceptions of disease severity after receiving a type 2 diabetes (T2DM) or prediabetes (preDM) diagnosis. Design: Researchers interviewed 29 patients from two US medical centers to ascertain perceptions of severity. We used the constant comparative method from a grounded theory approach to identify themes from patients' perspectives that inform their disease severity. This approach was used to help translate research to practice and ultimately identify intervention strategies informed by authentic experiences of preDM and T2DM patients. Results: Perceptions of disease severity fell into two groups: high and low severity. Patients diagnosed with T2DM and preDM emerged in both groups and were comparative in terms of sample size, gender, and ethnic diversity. Several factors contributed to patients' beliefs, including what they were told about the disease, observations from experiences within their own social network, and information from formal diabetes classes and their own research. The two perspectives diverged when patients described how their belief was informed by three thematic properties or personal factors: (i) fears; (ii) clinician communication; and (iii) social comparisons. Conclusions: Beliefs about severity are influenced by patients' fears, interactions with clinicians, and experiences within their social networks. These findings show that when interacting with patients with T2DM or preDM, clinicians should elicit patient perceptions of disease severity so they may then tailor the discussion to address these perceptions and help patients grasp the severity of these conditions.

Prediabetes: A wake-up call

Prediabetes continues to be a national and worldwide health concern, affecting 84 million adults in the US. Early identification and intervention have been successful in delaying and/or preventing the progression to type 2 diabetes mellitus (T2DM). To curb the increasing prevalence of T2DM, recognizing the importance of identifying and managing prediabetes is paramount.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.