Self-management in patients with diabetes and chronic kidney disease is associated with incremental benefit in HRQOL

Health literacy and self-management among middle-aged and young hypertensive patients: a parallel mediation effect of illness perception and self-efficacy

Background

Hypertension is increasingly prevalent among young and middle-aged populations in rural China, accompanied by suboptimal self-management. Given that this population forms the backbone of the labor force, enhancing their self-management capabilities is crucial for improving overall population health. Studies indicate that individuals with good health literacy are more likely to effectively manage their health.

Methods

Grounded in the health literacy skills framework, a model was constructed in this study to examine the impact of health literacy on self-management among young and middle-aged hypertensive patients in rural China. Meanwhile, the mediating roles of illness perception and self-efficacy were also verified. Using a multi-stage stratified random sampling method, 338 patients were recruited to participate in the study. Structural equation modeling was utilized to establish the relationship model, and bootstrap tests were carried out to examine the mediating effects.

Results

The average self-management score was 70.45 ± 11.36. Health literacy exhibited a positive correlation with self-management (standardized β = 0.372, p < 0.001). The mediating effects through illness perception and self-efficacy were 0.040 and 0.236, constituting 6.68 and 39.31% of the total effect, respectively.

Conclusion

Illness perception and self-efficacy serve as parallel mediators amid the association between health literacy and self-management. Implementing psychological counseling and health education is imperative for augmenting self-management competence and cultivating an adaptive coping mentality.

Supporting Type 1 and Type 2 Diabetes Care in the Hemodialysis Unit: A Quality-improvement Initiative Throughout the COVID-19 Pandemic

OBJECTIVE

People living with diabetes mellitus (DM) and chronic kidney disease can have difficulty attending multiple appointments to receive DM care. We developed and studied the utility of a DM outreach program to offer in the hemodialysis (HD) unit.

METHODS

We conducted a quality improvement project in a satellite HD unit in London, Ontario, Canada, between August 1, 2019, and July 31, 2022. We assessed for baseline gaps in DM care among those with DM, performed root-cause analysis with key stakeholders to identify critical drivers of gaps, and conceptualized a certified diabetes educator-led outreach program to offer in the HD unit. We aimed to improve DM self-monitoring, hypo- and hyperglycemia, and DM-related screening. We used run and control charts to track outcome measures over time and modified our outreach program iteratively.

RESULTS

Fifty-eight persons with DM receiving HD participated in our program. Support spanned multiple waves of the COVID-19 pandemic. With 4 tests of change, we observed improvement in DM self-monitoring with a modest decline in self-reported hyperglycemia. There were no adverse consequences, and satisfaction with our program was high.

CONCLUSIONS

Although we did not meet all measures of success during the pandemic, outreach DM support in the HD unit appeared to improve self-monitoring and self-reported hyperglycemia. Similar programs could be modified and implemented in other centres.

What are the roles of eHealth literacy and empowerment in self-management in an eHealth care context? A cross-sectional study

AIMS

To examine the relationship among eHealth literacy, empowerment and self-management and the mediating effects of empowerment in diabetic kidney disease (DKD) patients in the eHealthcare context.

BACKGROUND

Self-management is an essential aspect of healthcare in delaying disease progression for DKD. In the eHealthcare era, health services providing self-management are transforming. The ability and confidence of patients to use eHealth services is a critical issue that impacts the effectiveness of self-management, but little is known about the role of eHealth literacy and empowerment in self-management.

DESIGN

A cross-sectional study guided by the STROBE.

METHODS

Overall, 127 Taiwanese patients were enrolled using convenience sampling. Data collection used structured questionnaires and chart reviews. Multiple regression was used to infer self-management predictors, and SPSS PROCESS macro and bootstrapping verified the mediating effects.

RESULTS

Empowerment and eHealth literacy both showed significant positive correlations with self-management. Empowerment was the main predictor of self-management and had a complete mediating effect between eHealth literacy and self-management.

CONCLUSION

Increasing patients' eHealth literacy can improve empowerment and prevent health inequality issues. Healthcare providers should consider improving patients' eHealth literacy to enhance their self-management.

RELEVANCE TO CLINICAL PRACTICE

Healthcare service systems need to create user-friendly eHealthcare environments, and healthcare professionals can provide multifaceted instructions that fit patients' eHealth literacy levels to enhance their motivation and confidence in disease care, thus cultivating positive self-management behaviours.

IMPACT

The popularity of eHealthcare services aimed at promoting self-management behaviours is increasing. However, the level of eHealth literacy is an essential factor that affects the effectiveness of self-management in the healthcare environment. In addition, empowerment is a major critical influence factor of self-management and a completely mediating variable between self-management and eHealth literacy. Consequently, healthcare providers should consider promoting patients' eHealth literacy to empower people using eHealthcare services for implementing self-management.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies in cross-sectional studies (STROBE) checklist was used to ensure comprehensive reporting.

PATIENT OR PUBLIC CONTRIBUTION

Patients were diagnosed with DKD in the study hospital. Physicians and case managers transferred patients to research assistants who screened them for the inclusion criteria and invited them to participate in this study if they met the requirements. After participants signed informed consent, the research nurse encouraged participants to respond to the research questionnaire face to face.

Functional limitation as a mediator of the relationship between multimorbidity on health-related quality of life in Australia: evidence from a national panel mediation analysis

Objective

The inverse relationships between chronic disease multimorbidity and health-related quality of life (HRQoL) have been well-documented in the literature. However, the mechanism underlying this relationship remains largely unknown. This is the first study to look into the potential role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL.

Methods

This study utilized three recent waves of nationally representative longitudinal Household, Income, and Labor Dynamics in Australia (HILDA) surveys from 2009 to 2017 (n = 6,814). A panel mediation analysis was performed to assess the role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL. The natural direct effect (NDE), indirect effect (NIE), marginal total effect (MTE), and percentage mediated were used to calculate the levels of the mediation effect.

Results

This study found that functional limitation is a significant mediator in the relationship between multimorbidity and HRQoL. In the logistic regression analysis, the negative impact of multimorbidity on HRQoL was reduced after functional limitation was included in the regression model. In the panel mediation analysis, our results suggested that functional limitation mediated ~27.2% (p < 0.05) of the link between multimorbidity and the composite SF-36 score for HRQoL. Functional limitation also mediated the relationship between the number of chronic conditions and HRQoL for each of the eight SF-36 dimensions, with a proportion mediated ranging from 18.4 to 28.8% (p < 0.05).

Conclusion

Functional status has a significant impact on HRQoL in multimorbid patients. Treatment should concentrate on interventions that improve patients' functioning and mitigate the negative effects of multimorbidity.

Chronic Kidney Disease Awareness Campaign and Mobile Health Education to Improve Knowledge, Quality of Life, and Motivation for a Healthy Lifestyle Among Patients With Chronic Kidney Disease in Bangladesh: Randomized Controlled Trial

BACKGROUND

Chronic kidney disease (CKD) is linked to major health consequences and a poor quality of life. Despite the fact that CKD is becoming more prevalent, public knowledge of the disease remains low.

OBJECTIVE

This study aimed to evaluate the outcome of a health education intervention designed to enhance knowledge, health-related quality of life (QOL), and motivation about healthy lifestyle among adults with CKD.

METHODS

This study was a parallel-group (1:1), randomized controlled trial in the Mirzapur subdistrict of Bangladesh that compared 2 groups of patients with CKD. Adults with CKD (stages 1-3) were enrolled in November 2020 and randomly assigned the intervention or control group. The intervention group received health education through a CKD awareness campaign and mobile health technologies and was observed for 6 months, whereas the control group received standard treatment. The primary outcome was the evaluation of improved scores on the CKD knowledge questionnaire, and the secondary outcomes were improved QOL and changes in the levels of blood pressure (BP), BMI, serum creatinine, fasting blood sugar (FBS), hemoglobin, cholesterol, high-density lipoprotein cholesterol, triglyceride, serum uric acid, blood urea nitrogen (BUN), and albumin-to-creatinine ratio.

RESULTS

The study enrolled 126 patients (control: n=63; intervention: n=63) and performed intention-to-treat analysis. The analyses included repeated measures ANOVA, and the results were observed to be significantly different from within groups (P<.001), between groups (P<.001), and the interaction of group × time factor (P<.001) for knowledge score. Diastolic BP and BMI showed significant differences arising from within groups (P<.001 and P=.01, respectively) and the interaction of group × time factor (P=.001 and P=.02, respectively); food salinity and hip circumferences showed significant differences arising from within groups (P=.001 and P=.03, respectively) and between groups (P=.001 and P=.02, respectively). Moreover, systolic BP and waist circumference showed significant differences from within groups (P<.001 and P=.003, respectively). However, no significant differences were found arising from within groups, between groups, and the interactions of group × time for QOL, urine salinity, and mid-upper arm circumference. Regarding the laboratory findings, from baseline to 6 months, the mean (SD) FBS decreased by 0.51 (3.77) mmol/L in the intervention group and 0.10 (1.44) mmol/L in the control group (P=.03); however, blood urea nitrogen increased by 3.64 (7.17) mg/dL in the intervention group and 1.68 (10.10) mg/dL in the control group (P=.01).

CONCLUSIONS

The health education strategy, which included a campaign and mobile health, showed promise for enhancing CKD knowledge among patients with CKD. This strategy may also aid patients with CKD in controlling their FBS and BP. The combined health education initiatives give evidence for scaling them up in Bangladesh and possibly other low- and middle-income countries, particularly in rural and peri-urban settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04094831; https://clinicaltrials.gov/ct2/show/NCT04094831.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/30191.

Experiences of midlife and older African American men living with type 2 diabetes

OBJECTIVE

Type 2 Diabetes Mellitus (T2DM) is a complicated disease that disproportionately affects African American men. Understanding the experiences of African American men living with T2DM is important for developing effective, culturally sensitive interventions. The purpose of this study was to describe how African American men view their T2DM and describe their perspectives on living with and self-managing T2DM.

DESIGN

In-depth semi-structured qualitative interviews were conducted with 22 African American men aged 40-85 years diagnosed with T2DM. Interviews were transcribed and analyzed using NVivo 10 with thematic analysis.

RESULTS

Disbelief, shock, and denial were commonly experienced reactions at initial diagnosis. Many participants defined diabetes using words such as 'sugar' or 'glucose' and reported an awareness of health complications caused by diabetes, such as amputations and diabetic comas. Participants expressed various perspectives and attitudes towards having diabetes, including avoidance/apathy, fatalism, guilt and shame, fear and concern, and self-mastery. The majority of men described efforts to self-manage diabetes via glucose monitoring, changing dietary habits, and exercise. Many participants expressed concern over the financial burden associated with managing diabetes and reported that high costs can hinder a patient's ability to maintain active self-monitoring and deter patients from attending needed doctor's visits. Many participants expressed confidence in their healthcare providers, although a few expressed feelings of distrust and being uninformed. Participants tended to most appreciate physicians who spent time discussing their condition and who made an effort to engage in open patient-provider communication.

CONCLUSION

Living with diabetes can be emotionally, physically, and mentally challenging. Efforts to improve adoption and maintenance of self-management behaviors may benefit from sensitivity to the patient's attitude and perspectives towards diabetes self-management, assistance overcoming the financial burden of managing diabetes, and open patient-provider communication.

The Knowledge Assessment of Renal Transplantation (KART) 2.0: Development and Validation of CKD and Transplant Knowledge Scales

BACKGROUND AND OBJECTIVES

Many individuals with kidney disease, particularly those belonging to racial and ethnic minority groups and whose primary language is not English, lack knowledge related to kidney disease symptoms, physiologic functions of the kidney, and benefits and risks of kidney transplantation. Valid instruments to assess patients' knowledge of CKD and kidney transplantation are needed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using a sample of 977 patients with stages 3-5 CKD in the Kaiser Permanente health system, we developed the Knowledge Assessment of Renal Transplantation (KART) 2.0 instrument. We conducted cognitive interviews followed by item response theory (IRT) to reduce 48 candidate items. Construct validity was tested by examining differences in scores between patients who spent <1 and ≥1 hour receiving CKD and transplant education.

RESULTS

Cognitive interviews modified four items and omitted 11. IRT analyses resulted in two scales: the KART 2.0-Transplant Knowledge Scale (16 items; Cronbach's α=0.8) and the KART 2.0-CKD Knowledge Scale (nine items; Cronbach's α=0.79). Differential item functioning showed that the scales were unbiased to capture knowledge across self-identified race, primary language, CKD stage, and sex. Both scales distinguished patients who had spent <1 and ≥1 hour speaking with health professionals (effect size [ES]=0.33 [transplant], 0.54 [CKD]; P<0.001 for both), reading about kidney disease (ES=0.45 [transplant], 0.62 [CKD]; P<0.001), reading about kidney transplantation (ES=0.67 [transplant], 0.69 [CKD]; P<0.001), and reading about living donor kidney transplant (ES=0.76 [transplant], 0.62 [CKD]; P<0.001).

CONCLUSIONS

The KART 2.0 is a valid tool to assess patients' knowledge of CKD and kidney transplantation.

Validation of the revised Diabetes Self-Management Questionnaire (DSMQ-R) in the primary care setting

Background

Available tools measuring self-management in diabetes are often improperly validated or do not correlate with glucose metabolism. The Diabetes Self-Management Questionnaire (DSMQ-R) is a valid tool, that showed strong relationship with glucose metabolism in tertiary care among people with mostly type 1 diabetes.

Aim of the study

To validate the translated DSMQ-R questionnaire in a Hungarian sample of people with predominantly type 2 diabetes in primary care.

Methods

We enrolled 492 adults from 38 practices in this cross-sectional cohort study, who filled out the self-administered questionnaire, consisting of DSMQ-R and the Summary of Diabetes Self-Care Activities (SDSCA) questionnaires. Family doctors provided clinical data. The translation process was performed in six steps, reaching the expert committee appraisal. The validity of the questionnaire was evaluated by assessing reliability and construct validity.

Results

Cronbach’s alpha showed the questionnaire to reach good reliability (α = 0.845), although subscales had lower alphas. Contrary to the SDSCA questionnaire, the DSMQ-R sum scale differed significantly between persons on target vs not on target (median (interquartile range): 7.23 (6.17–8.44) vs 6.91 (5.91–8.02), and the DSMQ-R sum scale correlated significantly with BMI, HbA1c and SDSCA sum scale. In multivariate analysis higher DSMQ-R scores were significant predictor of achieving glycemic target goal.

Conclusion

The Hungarian translation of the DSMQ-R is a comprehensible tool to assess self-management of persons with diabetes. The questionnaire is valid and reliable in family practice, although its association with achievement of diabetes HbA1c target is weaker in primary than in tertiary care.

Physical Activity, Blood Pressure Control, and Health-Related Quality of Life Among Hypertensive Individuals: A Cross-Sectional Study in Jiangsu Province, China

Hypertension has become one of the most serious chronic diseases that threaten public health. Regulating self-management is considered a priority and in which physical activity plays a vital role. Based on the Fifth National Health Service Survey (NHSS, 2013), a total of 6079 patients with hypertension were investigated by stratified cluster random sampling. This study explored the relationships between blood pressure control and physical activity, and health-related quality of life (HRQoL). Tobit regression and generalized linear regression analysis were used to explore the relationships among participants' socioeconomic characteristics, health behaviors, and HRQoL. The results showed that 4712 respondents (77.51%) had no problems in any aspect, but the proportion of respondents with problems increased significantly with age (P for trend <.001). Blood pressure control was significantly correlated with the health utility value (P < .001). Patients who participated in physical activity and maintained normal daily blood pressure also showed higher health utility value. Physical activity was significantly related to blood pressure control and HRQoL. Therefore, regular physical activity is recommended for hypertensive residents to improve HRQoL.

Interprofessional Medication Adherence Program for Patients With Diabetic Kidney Disease: Protocol for a Randomized Controlled and Qualitative Study (PANDIA-IRIS)

Background

Despite effective treatments, more than 30% of patients with diabetes will present with diabetic kidney disease (DKD) at some point. Patients with DKD are among the most complex as their care is multifactorial and involves different groups of health care providers. Suboptimal adherence to polypharmacy is frequent and contributes to poor outcomes. As self-management is one of the keys to clinical success, structured medication adherence programs are crucial. The PANDIA-IRIS (patients diabétiques et insuffisants rénaux: un programme interdisciplinaire de soutien à l’adhésion thérapeutique) study is based on a routine medication adherence program led by pharmacists.

Objective

The aim of this study is to define the impact of the duration of this medication adherence program on long-term adherence and clinical outcomes in patients with DKD.

Methods

This monocentric adherence program consists of short, repeated motivational interviews focused on patients’ medication behaviors combined with the use of electronic monitors containing patients’ medications. When patients open the electronic monitor cap to take their medication, the date and hour at each opening are registered. In total, 73 patients are randomized as 1:1 in 2 parallel groups; the adherence program will last 6 months in the first group versus 12 months in the second group. After the intervention phases, patients continue using their electronic monitors for a total of 24 months but without receiving feedback. Electronic monitors and pill counts are used to assess medication adherence. Persistence and implementation will be described using Kaplan-Meier curves and generalized estimating equation multimodeling, respectively. Longitudinal adherence will be presented as the product of persistence and implementation and modelized by generalized estimating equation multimodeling. The evolution of the ADVANCE (Action in Diabetes and Vascular disease: Preterax and Diamicron Modified-Release Controlled Evaluation) and UKPDS (United Kingdom Prospective Diabetes Study) clinical scores based on medication adherence will be analyzed with generalized estimating equation multimodeling. Patients’ satisfaction with this study will be assessed through qualitative interviews, which will be transcribed verbatim, coded, and analyzed for the main themes.

Results

This study was approved by the local ethics committee (Vaud, Switzerland) in November 2015. Since then, 2 amendments to the protocol have been approved in June 2017 and October 2019. Patients’ recruitment began in April 2016 and ended in October 2020. This study was introduced to all consecutive eligible patients (n=275). Among them, 73 accepted to participate (26.5%) and 202 (73.5%) refused. Data collection is ongoing and data analysis is planned for 2022.

Conclusions

The PANDIA-IRIS study will provide crucial information about the impact of the medication adherence program on the adherence and clinical outcomes of patients with DKD. Monitoring medication adherence during the postintervention phase is innovative and will shed light on the duration of the intervention on medication adherence.

Trial Registration

Clinicaltrials.gov NCT04190251_PANDIA IRIS; https://clinicaltrials.gov/ct2/show/NCT04190251

International Registered Report Identifier (IRRID)

DERR1-10.2196/25966

Inter-relationship of risk factors and pathways associated with chronic kidney disease in patients with type 2 diabetes mellitus: a structural equation modelling analysis

OBJECTIVES

Diabetes mellitus is the most common cause of chronic kidney disease (CKD); however, the inter-relationships and pathogenetic mechanisms among risk factors are still largely unknown. Structural equation modelling (SEM) was applied to test a hypothesis of causal pathways related to CKD in patients with type 2 diabetes mellitus (T2DM).

STUDY DESIGN

This is a prospective observational study.

METHODS

A total of 3395 patients with T2DM were enrolled in this study. A hypothesised SEM was applied to assess associations among demographic data, diabetic self-management behaviours, diabetes control, lifestyle, psycho-social, chronic inflammation factors, anthropometric and metabolic variables simultaneously and the risk of CKD.

RESULTS

Demographic data (including education, marital status and mini-mental state examination score) (-0.075), white blood cell count (0.084), high blood pressure (0.144), World Health Organisation (WHO) 5 well-being index (-0.082), diabetes control (0.099), triglyceride (0.091) and uric acid (0.282) levels had direct effects on the risk of CKD. The final model could explain 26% of the variability in baseline CKD status. In addition, the same direct and specific indirect factors at baseline CKD status analysis contributed to the risk of CKD at the 12-month follow-up. The final model could explain 31% of the variability in the risk of CKD at the 12-month follow-up.

CONCLUSIONS

This study investigates associations between factors obtained from real-world daily practice and CKD status simultaneously and delineates the potential pathways and inter-relationships of the risk factors that contribute to the development of CKD in patients with T2DM.

Providing diabetes education to patients with chronic kidney disease: A survey of diabetes educators in Ontario, Canada

BACKGROUND

Patients with diabetes and chronic kidney disease (CKD) have complex diabetes care needs. Diabetes educators can play an important role in their clinical care.

AIM

To understand diabetes educators' experience providing diabetes support to patients with CKD and elicit their view on the additional care needs of this population.

METHODS

We conducted a quantitative online survey of diabetes educators between May 2019 and May 2020. We surveyed English-speaking educators actively practicing in Ontario, Canada for at least 1 year. We recruited them through provincial Diabetes Education Programs and Diabetes Education Section Chairs of Diabetes Canada.

RESULTS

We made email contact with 219/233 (94%) Diabetes Education Programs and 11/12 (92%) provincial Diabetes Canada Section Chairs. 122 unique diabetes educators submitted complete surveys (survey participation rate ∼79%). Most worked in community education programs (91%). Almost half were registered nurses (48%), and 39% had practiced for more than 15 years. Respondents noted difficulty helping patients balance complex medical conditions (19%), faced socioeconomic barriers (17%), and struggled to provide dietary advice (16%). One-third were uncertain of how to support those receiving dialysis. Eighty-five percent felt they needed more training and education to care for this high-risk group. When asked about the care needs of patients with CKD, almost all (90%) felt that patients needed more diabetes support in general. Improvement in care coordination was most commonly suggested (38%).

CONCLUSIONS

In this study of the diabetes educators' experience treating patients with diabetes and CKD, respondents noted numerous challenges. There may be opportunities to better support both diabetes care professionals, and patients who live with multiple medical comorbidities.

Health-related quality of life in patients with chronic kidney disease

Introduction: In the last three decades, health systems have continued to pay increasing attention to the quality of life (QOL) due to definitional changes in the concept of health and disease. The health-related quality of life (HRQOL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of CKD. Areas covered: We attempt to thoroughly explore how CKD affects HRQOL domains with a quick primer on HRQOL assessment instruments in patients with CKD. Also, we pointed out the factors affecting HRQOL in patients with CKD as well as the clinical application of HRQOL in CKD management. Expert opinion: The general population enjoys higher HRQOL than patients with CKD in all domains. Similarly, pre-dialysis and kidney-transplant patients have better HRQOL than dialysis population. There are many factors which negatively impact HRQOL in CKD which include for example depression, anxiety, and cognitive impairment for the social domain, inactivity, and frailty for the physical domain as well as lack of social support and extroversion in the social domain. Additionally, social disparities and CKD-related factors would influence HRQOL. Of note, there is no global standard HRQOL assessment tool. Finally, HRQOL should be included in future CKD management guidelines.

Health related quality of life and healthcare utilization among adults with diabetes and kidney and eye complications in the United States

BACKGROUND

One-third of adults with diabetes in the United States have chronic kidney disease (CKD), and 19% of them have eye complications (ECs). However, little is known about the Health-related Quality of Life (HRQoL) of adults with both of these diabetes-related complications. Therefore, the purpose of this study is to examine differences in the HRQoL, mental health, and healthcare utilization of adults with diabetes who have CKD, ECs, both or neither.

METHODS

A cross-sectional study design was implemented using data from multiple panels (2009-2015) of the Medical Expenditure Panel Survey. HRQoL was measured using the SF-12 Physical and Mental Component Summary (PCS & MCS) scores. The HRQoL, mental health, and healthcare utilization of four mutually exclusive groups: 1) diabetes with both CKD and ECs; 2) diabetes with CKD only; 3) diabetes with ECs only, and 4) diabetes with neither CKD nor ECs were compared. In all analyses, adults with neither CKD nor ECs were the reference group.

RESULTS

There were 8415 adults with diabetes who met the inclusion criteria. Approximately, 75% of the study sample had neither CKD nor ECs, 13.3% had ECs only, 5.7% had CKD only, and 5.5% had both CKD and ECs. In the adjusted analyses, adults with both CKD and/or ECs complications exhibited significantly lower HRQoL compared to those with neither CKD nor ECs. Mental illness and psychological distress were higher among adults with both CKD and ECs compared to those with neither CKD nor ECs. Furthermore, adults with CKD and/or ECs had higher polypharmacy, inpatient and emergency services use compared to those with neither CKD nor ECs.

CONCLUSIONS

The results indicate that the presence of both CKD and/or ECs was negatively associated with poor HRQoL, poor mental health, higher psychological distress and healthcare utilization in adults with diabetes. The findings emphasize the need for routine assessment and treatment for diabetes-related CKD and/or ECs complications to improve the quality of care for individuals with diabetes.

The impact of chronic kidney disease on developed countries from a health economics perspective: A systematic scoping review

Chronic kidney disease (CKD) affects over 10% of the global population and poses significant challenges for societies and health care systems worldwide. To illustrate these challenges and inform cost-effectiveness analyses, we undertook a comprehensive systematic scoping review that explored costs, health-related quality of life (HRQoL) and life expectancy (LE) amongst individuals with CKD. Costs were examined from a health system and societal perspective, and HRQoL was assessed from a societal and patient perspective. Papers published in English from 2015 onward found through a systematic search strategy formed the basis of the review. All costs were adjusted for inflation and expressed in US$ after correcting for purchasing power parity. From the health system perspective, progression from CKD stages 1-2 to CKD stages 3a-3b was associated with a 1.1-1.7 fold increase in per patient mean annual health care cost. The progression from CKD stage 3 to CKD stages 4-5 was associated with a 1.3-4.2 fold increase in costs, with the highest costs associated with end-stage renal disease at $20,110 to $100,593 per patient. Mean EuroQol-5D index scores ranged from 0.80 to 0.86 for CKD stages 1-3, and decreased to 0.73-0.79 for CKD stages 4-5. For treatment with renal replacement therapy, transplant recipients incurred lower costs and demonstrated higher HRQoL scores with longer LE compared to dialysis patients. The study has provided a comprehensive updated overview of the burden associated with different CKD stages and renal replacement therapy modalities across developed countries. These data will be useful for the assessment of new renal services/therapies in terms of cost-effectiveness.

Predictors for self-management in older adults with type 2 diabetic nephropathy

AIM AND OBJECTIVES

To investigate factors related to self-management and predictors of self-management in older adult patients with type 2 diabetic nephropathy.

BACKGROUND

Diabetic patients suffer many comorbidities during their lifetime, and the process of self-management is complex. Self-management and an integrated care experience are extremely important for older adults with diabetic nephropathy.

DESIGN

A cross-sectional correlation design was adopted.

METHODS

A total of 123 older patients were enrolled in the study from June 2016 to November 2017. Data collection involved a demographic questionnaire, the Patients' Experience of Integrated Care Questionnaire and the Partners in Health Scale to measure the integrated care experience and self-management. Data analysis included descriptive statistics, independent t tests, Pearson product-moment correlation and multiple linear regression. The methods are consistent with the STROBE criteria (Data S1).

RESULTS

The results showed that the majority of the sample was female (56.9%). The average age was 77 years old. Stepwise regression analysis showed that re-admission during the past year (p < .001), physical function (p < .001) and integrated care experience (p < .001) are predictors of self-management in older adult patients with type 2 diabetic nephropathy and explained 42.8% of the variation in self-management behaviour.

CONCLUSION

The results can be used to enhance the awareness of clinicians of the importance of an integrated care experience and self-management among older patients with type 2 diabetic nephropathy. Clinicians also should pay attention to physical function and the integrated care experience to promote self-management.

RELEVANCE TO CLINICAL PRACTICE

Studies on the integrated care experience and self-management of diabetic neuropathy in older adults are limited in Taiwan. The results of this study provide valuable information to support the importance of integrated care among this specific population.

Health-related quality of life and readmission of patients with cardiovascular disease in South Korea

AIMS

The purpose of this study was to investigate the health-related quality of life (HRQOL) of patients with cardiovascular disease and its relationship to hospital readmission.

METHODS

The cross-sectional study used data from 1037 adults aged ⩾19 years diagnosed with myocardial infarction or angina pectoris. Raw data were obtained from the fourth to sixth Korea National Health and Nutrition Examination Survey (2007-2014).

RESULTS

Readmission was found to be associated with age, living status, education level, unemployment, individual income level, stroke, osteoarthritis, diabetes, depression, low stress level, walking days per week, and activity limitations due to cardiovascular disease.

CONCLUSION

In summary, readmission was related to HRQOL among patients with myocardial infarction. Interventions that consider efforts to reduce readmission through improved diagnosis and development of systematic management of cardiovascular disease symptoms are required.

A need-based approach to self-management education for adults with co-morbid diabetes and chronic kidney disease

BACKGROUND

Self-management education needs have not been assessed in patients with complex co-morbid conditions such as diabetes and chronic kidney disease (CKD). The objectives of this study were to 1) determine the self-management education needs for patients with co-morbid diabetes and CKD and 2) co-develop an educational resource meeting the self-management education needs of patients with co-morbid diabetes and CKD.

METHODS

Patients with co-morbid diabetes and CKD attending a co-designed, patient-centred outpatient diabetes and kidney clinic at a tertiary metropolitan hospital were recruited for semi-structured interviews. Maximal variation sampling was used, ensuring adequate representation of different gender, age, diabetes duration and stage of CKD. Data were thematically analysed using grounded theory.

RESULTS

Forty-two patients participated. Most were male (67%) and the mean age was 64.8 (11.1) years. The majority of patients preferred an educational resource in the form of a Digital Versatile Disc (DVD) and they thought that current education could be improved. In particular patients wanted further education on 1) management of diabetes and kidney disease (including nutrition and lifestyle, and prevention of the progression of kidney disease) and 2) complications of comorbid diabetes and kidney disease.

CONCLUSION

Patients with co-morbid diabetes and kidney disease have education gaps on the management of, and complications of diabetes and kidney disease. Interventions aimed at improving patient education need to be delivered through education resources co-developed by patients and health staff. A targeted education resource in the form of a DVD, addressing these needs, may potentially close these gaps.

Patient-reported barriers and outcomes associated with poor glycaemic and blood pressure control in co-morbid diabetes and chronic kidney disease

AIMS

In patients with comorbid diabetes and chronic kidney disease, the extent to which patient-reported barriers to health-care and patient reported outcomes influence the quality of health care is not well established. This study explored the association between patient-reported barriers to health-care, patient activation, quality of life and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets.

METHODS

This cross-sectional study recruited adults with diabetes and CKD (eGFR 20 to <60 ml/min/1.73m²) across four hospitals. We combined clinical data with results from a questionnaire comprising measures of patient-identified barriers to care, the Patient Activation Measure (PAM), 12-Item Short Form Survey (SF-12), and the Summary of Diabetes Self-Care Activity (SDSCA).

RESULTS

199 patients, mean age 68.7 (SD 9.6), 70.4% male and 90.0% with type 2 diabetes were studied. Poor glycaemic control was associated with increased odds of patient reported "poor family support" (OR 4.90; 95% CI 1.80 to 13.32, p < 0.002). Poor BP control was associated with increased odds of patient reported, "not having a good primary care physician" (OR 6.01; 2.42 to 14.95, p < 0.001). The number of barriers was not associated with increased odds of poor control (all p > 0.05).

CONCLUSIONS

Specific patient-reported barriers, lack of patient perceived family and primary care physician support, are associated with increased odds of poor glycaemic and blood pressure control respectively. Interventions addressing these barriers may improve treatment target attainment.

HRQOL in Diverse Ethnic Groups with Diabetes: Findings from the 2014 BRFSS

OBJECTIVE

The study's objective is to examine differences in mental and physical health-related quality of life (HRQOL) in non-Hispanic White, non-Hispanic Black, and Hispanic adults with diabetes.

DESIGN

A secondary analysis of 2014 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted. A total of 26 states participated in the 2014 BRFSS core and optional diabetes models (n = 17,923). HRQOL was measured by the number of mentally and physically unhealthy days during the past month, respectively. A series of regression models were developed to assess differences in HRQOL without and with inclusion of demographic (age, marital status, income, gender, and education) and diabetes-related (depression, sleep time, insulin use, complications, age of diabetes diagnosis, BMI, smoking, and exercise) factors.

RESULTS

In the fully adjusted models (inclusion of demographic and diabetes-related factors), non-Hispanic Whites had more mentally (β = 0.88, p = 0.03) and physically (β = 1.35, p = 0.01) unhealthy days per month compared to Hispanics. Non-Hispanic Blacks (β = 1.42, p < 0.01) also had more mentally unhealthy days per month in relation to Hispanics when adjusting for demographic and diabetes-related factors. Depression emerged as a potent predictor of mentally (β = 8.60; p < 0.0001) and physically (β = 4.43; p < 0.0001) unhealthy days in the multivariate models.

CONCLUSION

Non-Hispanic Black and White adults with diabetes may be more vulnerable to poor HRQOL compared to their Hispanic counterparts. Increased, widened application of diabetes interventions targeting depression appears warranted to improve HRQOL outcomes.

The association between patient activation and self-care practices: A cross-sectional study of an Australian population with comorbid diabetes and chronic kidney disease

Objective

This study aimed to examine the association between performance of self‐care activities and patient or disease factors as well as patient activation levels in patients with diabetes and chronic kidney disease (CKD) in Australia.

Methods

A cross‐sectional study was conducted among adults with diabetes and CKD (eGFR <60 mL/min/1.73m²) who were recruited from renal and diabetes clinics of four tertiary hospitals in Australia. Demographic and clinical data were collected, as well as responses to the Patient Activation Measure (PAM) and the Summary of Diabetes Self‐Care Activities (SDSCA) scale. Regression analyses were performed to determine the relationship between activation and performance of self‐care activities.

Results

A total of 317 patients (70% men) with a mean age of 66.9 (SD=11.0) years participated. The mean (SD) PAM and composite SDSCA scores were 57.6 (15.5) % (range 0‐100) and 37.3 (11.2) (range 0‐70), respectively. Younger age, being male, advanced stages of CKD and shorter duration of diabetes were associated with lower scores in one or more self‐care components. Patient activation was positively associated with the composite SDSCA score, and in particular the domains of general diet and blood sugar checking (P<.05), but not specific diet, exercising and foot checking.

Conclusion

In people with diabetes and CKD, a high level of patient activation was positively associated with a higher overall level of self‐care. Our results identify subgroups of people who may benefit from tailored interventions to further improve their health outcomes. Further prospective studies are warranted to confirm present findings.

The effect of health literacy and self-management efficacy on the health-related quality of life of hypertensive patients in a western rural area of China: a cross-sectional study

Background

Hypertension is a common and frequently occurring chronic disease of the cardiovascular system. Besides the pathological factors, the occurrence and exacerbation of hypertension are also associated with many factors of lifestyle and behaviors. Thus hypertensive patients’ Health-related quality of life (HRQL) is not only influenced by the disease itself but also by many subjective factors such as health literacy and self-management efficacy, especially in the deeper part of southwestern China and thus is less developed compared to the other places. The purpose of this study was to examine the association between the HRQL of hypertensive patients and health literacy and self-management efficacy as well as how they affect the HRQL, so as to provide a theoretical reference for improving the HRQL of patients with hypertension in less developed areas.

Methods

This was a cross-sectional study of baseline data from a clustered randomized controlled trial. The study design had passed a cross-national peer review and accepted grants by the China Medical Board. It was also registered in the Chinese Clinical Trial Registry (ChiCTR-OOR-14005563).

A standardized questionnaire adapted from a previous validated WHO questionnaire was used for the survey which included detailed questions about patient’s socio-demographic characteristics and self-reported information.

Patients’ HRQL was measured by the Mandarin version of the 36-item Short Form. We used the validated Mandarin version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale to assess patients’ self-management efficacy. The validated three-item Brief Health Literacy Screening (BHLS) was used to measure the patients’ health literacy.

A structural equation model was constructed, and p ≤ 0.05 was taken as significant.

Results

Demographic characteristics, health literacy and self-management efficacy have all significant effects on HRQL. Age, education level, self-management efficacy and health literacy were significantly related to the HRQL. The constructed model had a good fit for the data according to the model fit indices. Based on the model, health literacy (r = 0.604, p = 0.029) and Self-management efficacy (r = 0.714, p = 0.018) have a significant impact on HRQL. Demographic characteristics were inversely related to HRQL (r = −0.419, p = 0.007), but have a significant impact on health literacy (r = 0.675, p = 0.029) and self-management efficacy (r = 0.379, p = 0.029). At the same time, self-management efficacy was positively correlated to health literacy (r = 0.413, p < 0.01).

Conclusions

Age, education level, self-management efficacy and health literacy were all related to the HRQL of patient with hypertension, which means that patients who are more elderly and have lower education level, low self-management efficacy and poor health literacy get worse HRQL. This may imply the necessary to introduce routine assessment of health literacy and self-management efficacy into assessment procedures for hypertensive patients’ health management. Such assessment can help professionals to identify the population at greatest risk for poor health outcomes and low well-being in the future. In clinical practice, effective interventions such as direct guidance and education to raise the self-management efficacy and enhance health literacy might improve the HRQL of patients with hypertension.

Trial registration

Retrospectively registered Chinese Clinical Trial Registry (ChiCTR-OOR-14005563).

Name of registry: Effects of the integrated delivery system and payment system of community-based intervention on rural patients of chronic diseases in Qianjiang District, China

Date of registration: Retrospectively registered 23 November 2014.

Date of enrolment of the first participant to the trial: 5 July 2012

Wearable sensors: can they benefit patients with chronic kidney disease?

INTRODUCTION

This article ponders upon wearable medical measurement devices in relation to Chronic Kidney Disease (CKD) and its' associated comorbidities - and whether these might benefit CKD-patients. We aimed to map the intersection(s) of nephrology and wearable sensor technology to help technologists understand medical aspects, and clinicians to understand technological possibilities that are available (or soon will become so). Areas covered: A structured literature search on main comorbidities and complications CKD patients suffer from, was used to steer mini-reviews on wearable sensor technologies clustered around 3 themes being: Cardiovascular-related, diabetes-related and physical fitness/frailty. This review excludes wearable dialysis - although also strongly enabled by miniaturization - because that highly important theme deserves separate in-depth reviewing. Expert commentary: Continuous progress in integrated electronics miniaturization enormously lowered price, size, weight and energy consumption of electronic sensors, processing power, memory and wireless connectivity. These combined factors boost opportunities for wearable medical sensors. Such devices can be regarded as enablers for: Remote monitoring, influencing human behaviour (exercise, dietary), enhanced home care, remote consults, patient education and peer networks. However, to make wearable medical devices succeed, the challenge to fit them into health care structures will be dominant over the challenge to realize the bare technologies themselves.