Integrating diabetes self-management with the health goals of older adults: a qualitative exploration

Living with type 2 diabetes: A social cognitive perspective on adherence

OBJECTIVE

This mixed methods study examines the relationship between outcome expectations, self-efficacy, and self-care behaviors in individuals with type 2 diabetes (T2DM). It also explores the personal values motivating these behaviors through in-depth interviews.

METHODS

Adults with T2DM (n = 108, M age = 57 years, 58% female, 48% Black) completed questionnaires and participated in in-depth interviews using a laddering technique.

RESULTS

Ordinary least squares regression models were used to analyze the relationships between self-efficacy, outcome expectations, and four self-care behaviors (physical activity, dietary choices, blood glucose monitoring, and medication usage). The findings indicate that self-efficacy is significantly and positively associated with diet and physical activity. Both outcome expectations for blood glucose testing and self-efficacy are significantly and positively associated with self-reported monitoring. However, neither outcome expectation nor self-efficacy is associated with medication usage. The in-depth interviews revealed three common values related to self-care behaviors: maintaining health and longevity, agentic values of self-control, achievement, and self-esteem, and a sense of belonging.

CONCLUSIONS

This study sheds light on the complexity of diabetes self-management, offering insights into individuals' values, behavioral strategies, and the influence of control perceptions on this relationship, revealing both differences and commonalities in stated values.

PRACTICE IMPLICATIONS

By understanding how personal values drive diabetes self-care behaviors, practitioners can assist patients in establishing meaningful connections between their values and the challenges of living with diabetes.

Ascertainment of Minimal Clinically Important Differences in the Diabetes Distress Scale-17: A Secondary Analysis of a Randomized Clinical Trial

Importance

The Diabetes Distress Scale-17 (DDS-17) is a common measure of diabetes distress. Despite its popularity, there are no agreed-on minimal clinically important difference (MCID) values for the DDS-17.

Objective

To establish a distribution-based metric for MCID in the DDS-17 and its 4 subscale scores (interpersonal distress, physician distress, regimen distress, and emotional distress).

Design, Setting, and Participants

This secondary analysis of a randomized clinical trial used baseline and postintervention data from a hybrid (implementation-effectiveness) trial evaluating Empowering Patients in Chronic Care (EPICC) vs an enhanced form of usual care (EUC). Participants included adults with uncontrolled type 2 diabetes (glycated hemoglobin A1c [HbA1c] level >8.0%) who received primary care during the prior year in participating Department of Veterans Affairs clinics across Illinois, Indiana, and Texas. Data collection was completed in November 2018, and data analysis was completed in June 2023.

Interventions

Participants in EPICC attended 6 group sessions led by health care professionals based on collaborative goal-setting theory. EUC included diabetes education.

Main Outcomes and Measures

The main outcome was distribution-based MCID values for the total DDS-17 and 4 DDS-17 subscales, calculated using the standard error of measurement. Baseline to postintervention changes in DDS-17 and its 4 subscale scores were grouped into 3 categories: improved, no change, and worsened. Multilevel logistic and linear regression models examined associations between treatment group and MCID change categories and whether improvement in HbA1c varied in association with MCID category.

Results

A total of 248 individuals with complete DDS-17 data were included (mean [SD] age, 67.4 [8.3] years; 235 [94.76%] men), with 123 participants in the EPICC group and 125 participants in the EUC group. The MCID value for DDS-17 was 0.25 and MCID values for the 4 distress subscales were 0.38 for emotional and interpersonal distress and 0.39 for physician and regimen distress. Compared with EUC, more EPICC participants were in the MCID improvement category on DDS-17 (63 participants [51.22%] vs 40 participants [32.00%]; P = .003) and fewer EPICC participants were in the worsened category (20 participants [16.26%] vs 39 participants [31.20%]; P = .008). There was no direct association of DDS-17 MCID improvement (β = -0.25; 95% CI, -0.59 to 0.10; P = .17) or worsening (β = 0.18; 95% CI, -0.22 to 0.59; P = .38) with HbA1c levels among all participants.

Conclusions and Relevance

In this secondary analysis of data from a randomized clinical trial, an MCID improvement or worsening of more than 0.25 on the DDS-17 was quantitatively significant and patients in the EPICC group were more likely to experience improvement than those in the EUC group.

Trial Registration

ClinicalTrials.gov Identifier: NCT01876485.

Comparison of Collaborative Goal Setting With Enhanced Education for Managing Diabetes-Associated Distress and Hemoglobin A1c Levels: A Randomized Clinical Trial

IMPORTANCE

Type 2 diabetes is a prevalent and morbid condition. Poor engagement with self-management can contribute to diabetes-associated distress and hinder diabetes control.

OBJECTIVE

To evaluate the implementation and effectiveness of Empowering Patients in Chronic Care (EPICC), an evidence-based intervention to improve diabetes-associated distress and hemoglobin A1c (HbA1c) levels after the intervention and after 6-month maintenance.

DESIGN, SETTING, AND PARTICIPANTS

This hybrid (implementation-effectiveness) randomized clinical trial was performed in Veterans Affairs clinics across Illinois, Indiana, and Texas from July 1, 2015, to June 30, 2017. Participants included adults with uncontrolled type 2 diabetes (HbA1c level >8.0%) who received primary care during the prior year in participating clinics. Data collection was completed on November 30, 2018, and data analysis was completed on June 30, 2020. All analyses were based on intention to treat.

INTERVENTIONS

Participants in EPICC attended 6 group sessions based on a collaborative goal-setting theory led by health care professionals. Clinicians conducted individual motivational interviewing sessions after each group. Usual care was enhanced (EUC) with diabetes education.

MAIN OUTCOMES AND MEASURES

The primary outcome consisted of changes in HbA1c levels after the intervention and during maintenance. Secondary outcomes included the Diabetes Distress Scale (DDS), Morisky Medication Adherence Scale, and Lorig Self-efficacy Scale. Secondary implementation outcomes included reach, adoption, and implementation (number of sessions attended per patient).

RESULTS

A total of 280 participants with type 2 diabetes (mean [SD] age, 67.2 [8.4] years; 264 men [94.3]; 134 non-Hispanic White individuals [47.9%]) were equally randomized to EPICC or EUC. Participants receiving EPICC had significant postintervention improvements in HbA1c levels (F1, 252 = 9.12, Cohen d = 0.36 [95% CI, 0.12-0.59]; P = .003) and DDS (F1, 245 = 9.06, Cohen d = 0.37 [95% CI, 0.13-0.60]; P = .003) compared with EUC. During maintenance, differences between the EUC and EPICC groups remained significant for DDS score (F1, 245 = 8.94, Cohen d = 0.36 [95% CI, 0.12-0.59]; P = .003) but not for HbA1c levels (F1, 252 = 0.29, Cohen d = 0.06 [95% CI, -0.17 to 0.30]; P = .60). Improvements in DDS scores were modest. There were no differences between EPICC and EUC in improvements after intervention or maintenance for either adherence or self-efficacy. Among all 4002 eligible patients, 280 (7.0%) enrolled in the study (reach). Each clinic conducted all planned EPICC sessions and cohorts (100% adoption). The EPICC group participants attended a mean (SD) of 4.34 (1.98) sessions, with 54 (38.6%) receiving all 6 sessions.

CONCLUSIONS AND RELEVANCE

A patient-empowerment approach using longitudinal collaborative goal setting and motivational interviewing is feasible in primary care. Improvements in HbA1c levels after the intervention were not sustained after maintenance. Modest improvements in diabetes-associated distress after the intervention were sustained after maintenance. Innovations to expand reach (eg, telemedicine-enabled shared appointments) and sustainability are needed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01876485.

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.

Standardised approach to measuring goal-based outcomes among older disabled adults: results from a multisite pilot

BACKGROUND

Older adults with complex care needs face trade-offs in determining the right course of treatment. The Centers for Medicare and Medicaid Services identified 'Care is personalized and aligned with patient's goals' as a key meaningful measures category, yet existing quality measures typically assess disease-specific care and may not effectively evaluate what is most important to older adults and family members. Measures based on individualised goals and goal-based outcomes have been proposed as an alternative but are not routinely assessed or implemented.

OBJECTIVES

We tested two approaches to assessing goal-based outcomes that allow individuals to set goals based on their own priorities and measure progress-(1) goal attainment scaling and (2) existing, validated patient-reported outcome measures (PROM).

METHODS

A prospective cohort study of feasibility in seven sites (33 clinicians) of the two approaches with 229 individuals. We calculated performance on a measure of achievement of individually identified goals.

RESULTS

Both approaches were successfully implemented in a non-randomly selected population, and a goal-based outcome could be calculated for 189 (82%) of participants. Most individuals met their goal-based outcome (73%) with no statistical difference between the goal attainment scaling approach (74%) and the patient-reported outcomes approach (70%). Goals were heterogeneous ranging from participating in activities, health management, independence and physical health. Clinicians chose to use goal attainment scaling (n=184, 80%) more often than PROMs (n=49, 20%) and rated the goal attainment scaling approach as useful for providing patient care.

CONCLUSION

Goal-based outcomes have the potential to both improve the way healthcare is provided and fill a critical gap in value-based payment.

Patients' and clinicians' perspectives on relevant treatment outcomes in depression: qualitative study

BACKGROUND

Although symptomatic remission is considered the optimal outcome in depression, this is not always achieved. Furthermore, symptom indicators do not fully capture patients' and clinicians' perspectives on remission. Broader indicators of (partial) remission from depression should be considered.

AIMS

To investigate relevant outcomes of depression treatment in specialist care from patients' and clinicians' perspectives and to investigate whether these perspectives differ from each other.

METHOD

Three focus groups with 11 patients with depression and seven semi-structured interviews with clinicians were conducted exploring their perspectives on remission. All interviews were audio-recorded and transcribed verbatim. We analysed the transcripts thematically using the phenomenologist approach.

RESULTS

Independently, both patients and clinicians perceived the following outcomes relevant: restoring social functioning and interpersonal relations, regaining quality of life and achieving personal goals. All clinicians emphasised symptom reduction and satisfaction with treatment as relevant outcomes, whereas the former was not an obvious theme in patients. Unlike clinicians, patients made a clear distinction between treatment outcomes in first versus recurrent/chronic depression.

CONCLUSIONS

Classically defined study outcomes based on symptom resolution only partly reflect issues considered important by patients and clinicians in specialist depression treatment. Incorporating patients' and clinicians' perspectives in the development of measurable end-points makes them more suitable for use in trials and subsequent translation to clinical practice. Furthermore, evaluating patients' perspectives on treatment outcomes helps in the development of tailored interventions according to patients' needs.

Empowering patients in chronic care to improve diabetes distress and glycaemic control: Protocol for a hybrid implementation-effectiveness clinical trial

OBJECTIVES

To evaluate the effectiveness of a collaborative goal-setting intervention (Empowering Patients in Chronic Care [EPIC]) to improve glycaemic control and diabetesrelated distress, and implementation into routine care across multiple primary care clinics.

DESIGN

Randomized controlled trial comparing the effectiveness of the EPIC intervention with enhanced usual care (EUC) at five clinic sites located in the greater Chicago and Houston areas. We will measure differences in haemoglobin A1c (HbA1c) and diabetes distress scale scores among study arms at post-intervention and maintenance (6 months post-intervention). We will evaluate implementation of the intervention across sites using the RE-AIM framework. We will evaluate reach by comparing the per cent and characteristics of enrolled study participants among all potentially eligible participants in the given clinic population. Adoption is reflected by the characteristics of the involved providers and the number of intervention sessions conducted. Implementation of EPIC will be evaluated by number of sessions delivered, participants' evaluation of group sessions, and evaluation of quality of goal-setting.

PATIENTS

We randomized 280 participants with equal allocation to EPIC and enhanced usual care (EUC).

RESULTS

At baseline, the groups were similar with the exception that EUC participants were more likely to have prior diabetes education. At baseline, participants were predominately older men who have poorly controlled diabetes (mean HbA1c = 76 mmol/mol [9.1%]) and moderate levels of diabetes distress (mean DDS = 2.43).

CONCLUSIONS

This hybrid effectiveness-implementation protocol is designed to accelerate the translation of a patient-centred diabetes care intervention from research to clinical practice.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Type 2 Diabetes Self-Management Barriers in Older Adults: An Integrative Review of the Qualitative Literature

Type 2 diabetes is a prevalent chronic health condition more frequently affecting adults ages 65 and older. Furthermore, these individuals tend to have more type 2 diabetes-associated complications, compared with younger individuals with diabetes, and face unique challenges throughout the self-management process. Despite many studies and reviews about diabetes self-management, few researchers focus specifically on older adults. Of particular importance is the need to understand self-management challenges through the patient's lens. Therefore, the purpose of the current review is to examine and summarize the qualitative literature concerning type 2 diabetes self-management barriers in older adults. Following critical appraisal of literature published from 2007-2018, 10 articles were reviewed and content analysis performed. Four themes emerged: Lack of Knowledge and Understanding, Self-Management Implementation Challenges, Culture and Language Barriers, and Health Care Providers as a Perceived Barrier. The state of the qualitative science, implications for nursing practice, and recommendations for future research are discussed. [Journal of Gerontological Nursing, 45(3), 43-54.].

A nursing metaparadigm perspective of diabetic foot ulcer care

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that impact on the patient, their social environment, overall health, and on nursing practice. Nursing scholars have integrated theories on practice to overcome these problems, but a lack of agreement in the available literature acts as a barrier to implementing these in practice. For that reason, using a nursing metaparadigm as a theoretical framework would assist nurses in managing care purposefully and proactively, thus possibly improving outcomes. There has been little discussion about the nursing metaparadigm in relation to DFU care. This article aims to identify why Fawcett's theory of the nursing metaparadigm is important as a fundamental part of DFU care. Understanding this will help to elucidate the phenomenon of DFUs. Moreover, identifying the elements of the DFU care framework is essential to improve reflective practice and intervention. This article discusses the concept of the nursing metaparadigm and its implications for practice in the care of patients with DFUs.

A narrative systematic review of factors affecting diabetes prevention in primary care settings

BACKGROUND

Type 2 diabetes is impacting millions of people globally; however, many future cases can be prevented through lifestyle changes and interventions. Primary care is an important setting for diabetes prevention, for at-risk populations, because it is a patient's primary point of contact with the health care system and professionals can provide lifestyle counselling and support, as well as monitoring health outcomes. These are all essential elements for diabetes prevention for at-risk adults.

AIM

To understand the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries.

METHODS

For this narrative systematic review, we combined qualitative and quantitative studies of diabetes prevention within a primary care setting for patients at-risk of developing the condition. We used an iterative approach for evidence collection, which included using several databases (MEDLINE, Embase, Pysch info, BNI, SSCI, CINAHL, ASSIA), where we combined diabetes terms with primary care terms. Narrative and thematic synthesis were utilised to identify the prominent themes emerging from the data.

RESULTS

A database of 6646 records was screened by the research team, and 18 papers were included. Three major themes were identified in this review. The first theme of context and setting of diabetes progression includes the risk and progression of diabetes, primary care as a setting, and where the responsibility for change is thought to lie. This review also found mixed views on the value of preventative services within primary care. The second theme focused on the various patient factors associated with diabetes prevention such as a patient's motivation to modify their current lifestyle, perceptions and knowledge (or lack thereof) of the impacts of diabetes, lack of follow-up in healthcare settings, and trust in healthcare professionals. The third theme was centred on professional factors impacting on diabetes prevention which included workload, time constraints, resources, self-efficacy and knowledge as well as professionals' perception of patient motivations towards change.

CONCLUSION

This review explored the factors influencing diabetes prevention in primary care, and identified the context of prevention, as well as patient and professional factors related to preventative services being offered in primary care. This systematic review complements previous reviews of real-world settings by exploring the significant factors in prevention, and the findings are relevant to academics, policymakers, patients and practitioners interested in understanding the factors associated with the delivery and uptake of diabetes prevention interventions.

[Peer training for patients with diabetes mellitus 2. A quantitative and qualitative evaluation in the Basque Country and Andalusia]

Objetivo

Evaluar la estrategia formativa entre iguales para pacientes con diabetes mellitus tipo 2 de los programas «Paciente Activo» (País Vasco) y «Escuela de Pacientes» (Andalucía).

Diseño

Diseño mixto cuantitativo/cualitativo de evaluación pre/post de los programas de formación llevado a cabo entre 2012 y 2014.

Emplazamiento

País Vasco y Andalucía.

Participantes

Un total de 409 pacientes y pacientes-formadores, participantes en la formación entre iguales. Muestreo intencional de 44 pacientes para el estudio cualitativo.

Método

Análisis estadístico bivariante y ganancias netas de las variables comunes de cuestionarios pre/post del País Vasco y Andalucía: salud autopercibida, actividades diarias, ejercicio físico, uso de servicios sanitarios y autocuidados. Análisis de contenido de 8 grupos focales con pacientes y pacientes-formadores, incluyendo: codificación, árbol de categorías y triangulación de resultados.

Resultados

La formación entre iguales incide positivamente en la realización de ejercicio físico, uso de recursos sanitarios y autoeficacia en los cuidados, con diferencias por género en algunas dimensiones. La formación se valora positivamente en cuanto que: favorece la relación de los/las pacientes con el personal sanitario, genera apoyo grupal y autoconfianza y facilita la gestión emocional. Las áreas de mejora identificadas son: acceso y continuidad de la formación, y aceptación y apoyo por parte del personal y las instituciones sanitarias.

Conclusiones

Los beneficios en salud y calidad de vida promovidos a través de la formación entre iguales requiere la colaboración de las instituciones y personal sanitario, que deben facilitar el acceso, la continuidad y la adecuación de los contenidos a las necesidades y expectativas de los/las pacientes.

"Everyone else gets ice cream here more often than I do--It burns me up"--Perspectives on Diabetes Care from Nursing Home Residents and their Doctors

BACKGROUND

To explore the perspectives of nursing home (NH) residents with diabetes and their doctors regarding the burdens of living with diabetes and diabetes treatments.

METHODS

Qualitative study of nursing home residents aged 65 and older with diabetes (n = 14) and nursing home physicians (n = 9) at a Department of Veterans Affairs nursing home (known as the Community Living Center). A semi-structured interview was used to elicit nursing home residents' and physicians' perspectives on the burden of diabetes and diabetes treatments. Transcripts were analyzed using constant comparative methods.

RESULTS

The mean age of the nursing home residents was 74; Most (93%) were male and 50% self-identified themselves as white. The mean age of nursing home physicians was 39 and 55% were geriatricians. Dietary restrictions, loss of independence and fingersticks/insulin were noted to be the most burdensome aspects of diabetes. Nursing home residents with a more positive outlook were generally more engaged in their care, while nursing home residents with a more pessimistic outlook were less engaged, allowing their physicians to assume complete control of their care. While physicians noted the potential negative impact of dietary restrictions, nursing home residents' comments suggest that physicians underestimate the burden of dietary restrictions.

CONCLUSIONS

Veterans Affairs nursing home residents were substantially burdened by their diabetes treatments, especially dietary restrictions and fingerstick monitoring. Since there is little evidence that dietary restrictions improve outcomes, fewer dietary restrictions may be appropriate and lead to lower treatment burdens for nursing home residents with diabetes.

Type 2 diabetes patients' and providers' differing perspectives on medication nonadherence: a qualitative meta-synthesis

BACKGROUND

Poor adherence to medication regimens increases adverse outcomes for patients with Type 2 diabetes. Improving medication adherence is a growing priority for clinicians and health care systems. We examine the differences between patient and provider understandings of barriers to medication adherence for Type 2 diabetes patients.

METHODS

We searched systematically for empirical qualitative studies on the topic of barriers to medication adherence among Type 2 diabetes patients published between 2002-2013; 86 empirical qualitative studies qualified for inclusion. Following qualitative meta-synthesis methods, we coded and analyzed thematically the findings from studies, integrating and comparing findings across studies to yield a synthetic interpretation and new insights from this body of research.

RESULTS

We identify 7 categories of barriers: (1) emotional experiences as positive and negative motivators to adherence, (2) intentional non-compliance, (3) patient-provider relationship and communication, (4) information and knowledge, (5) medication administration, (6) social and cultural beliefs, and (7) financial issues. Patients and providers express different understandings of what patients require to improve adherence. Health beliefs, life context and lay understandings all inform patients' accounts. They describe barriers in terms of difficulties adapting medication regimens to their lifestyles and daily routines. In contrast, providers' understandings of patients poor medication adherence behaviors focus on patients' presumed needs for more information about the physiological and biomedical aspect of diabetes.

CONCLUSIONS

This study highlights key discrepancies between patients' and providers' understandings of barriers to medication adherence. These misunderstandings span the many cultural and care contexts represented by 86 qualitative studies. Counseling and interventions aimed at improving medication adherence among Type 2 diabetes might become more effective through better integration of the patient's perspective and values concerning adherence difficulties and solutions.

Self-Management and Self-Management Support Outcomes: A Systematic Review and Mixed Research Synthesis of Stakeholder Views

INTRODUCTION

Self-management has received growing attention as an effective approach for long-term condition management. Little is known about which outcomes of supported self-management are valued by patients, their families, health professionals and those who commission self-management services. This study systematically reviewed published empirical evidence in accordance with PRISMA guidelines to determine the outcomes of self-management valued by these key stakeholder groups, using three prominent exemplar conditions: colorectal cancer, diabetes and stroke.

AIM

To systematically review the literature to identify which generic outcomes of self-management have been targeted and are considered important using three exemplar conditions (colorectal cancer, diabetes and stroke), which collectively have a range of features that are likely to be representative of generic self-management issues.

METHODS

Systematic searching of nine electronic databases was conducted in addition to hand searches of review articles. Abstracts were identified against inclusion criteria and appraised independently by two reviewers, using a critical appraisal tool. Synthesis of findings was conducted using mixed research synthesis.

RESULTS

Over 20,536 abstracts were screened. 41 studies which met the review criteria were fully retrieved and appraised. The majority of evidence related to diabetes. Few studies directly focussed on stakeholders' views concerning desired self-management outcomes; the majority of evidence was derived from studies focusing upon the experience of self-management. The views of health care commissioners were absent from the literature. We identified that self-management outcomes embrace a range of indicators, from knowledge, skills, and bio-psychosocial markers of health through to positive social networks.

CONCLUSIONS

Patients', families', health professionals' and commissioners' views regarding which outcomes of self-management are important have not been clearly elicited. The extent to which bio-psychosocial indicators relate to successful self-management from the perspectives of all groups of stakeholders is unknown. Further investigation regarding which self-management outcomes are considered important by all stakeholders is necessary to guide the commissioning and design of future self-management services.

Health value & perceived control over health: behavioural constructs to support Type 2 diabetes self-management in clinical practice

AIMS AND OBJECTIVES

To explore health value and perceived control over health in relation to self-management behaviours in adults with Type 2 diabetes mellitus.

BACKGROUND

Helping people to modify health related behaviour in diabetes is complex due to a multitude of factors. Exploring the meaning of the constructs of Modified Social Learning Theory could be beneficial to identifying people at risk of poor diabetes self-management.

DESIGN

An exploratory qualitative study.

METHODS

Thirteen adults with insulin-treated Type 2 diabetes mellitus were purposively sampled. Data were collected through semi-structured interviews. An in-depth thematic analysis was carried out.

RESULTS

Health became a value priority on diagnosis of Type 2 diabetes mellitus. Participants described holding both terminal (relating to desired end states) and instrumental (a means to an end) health values pre-diagnosis but these became instrumental post-diagnosis to meet new lifestyle needs and maintain their quality of life. Descriptions of 'conflicts' in locus of control beliefs when managing Type 2 diabetes mellitus demonstrated influences on levels of self-efficacy and health value. Common themes that impacted on diabetes self-management included co-morbidities, medication management, blood glucose monitoring and reasoning for Type 2 diabetes mellitus.

CONCLUSIONS

Locus of control beliefs, levels of self-efficacy and health value were influenced by complications associated with Type 2 diabetes mellitus. The findings on Modified Social Learning Theory and instrumental health value as a moderator to health behaviour resulted in the development of a proposed framework with potential practical utility.

RELEVANCE TO CLINICAL PRACTICE

This research demonstrates the relevance of exploring the constructs of Modified Social Learning Theory (MSLT) in relation to diabetes self-management behaviours in Type 2 diabetes mellitus. The proposed Type 2 diabetes mellitus Self-management Behaviour Support framework incorporates Modified Social Learning Theory and instrumental health value as the theoretical basis for development and could provide clinical nurses and doctors with a tool that will allow for in-depth assessment and planning of Type 2 diabetes mellitus patients' self-management behaviours.

Life-long battle: Perceptions of type 2 diabetes in Thailand

BACKGROUND

The number of people in Thailand who have Type 2 diabetes has increased dramatically making it one of the country's major health problems. The rising prevalence of diabetes in Thailand is associated with dietary changes, reduced physical activity and health education. Although there is much research about health education programmes, the most effective methods for promoting sustainability and adherence to self-management among diabetics remains unclear.

OBJECTIVES

To examine the perceptions of participants in Thailand regarding Type 2 diabetes and to utilize the findings to formulate a model for patient education.

METHODS

A grounded theory approach was selected and semi-structured face to face interviews and focus group were used to gather data from 33 adults with Type 2 diabetes.

RESULTS

Five explanatory categories emerged from the data: causing lifelong stress and worry, finding their own ways, after a while, still cannot and wanting a normal life.

CONCLUSION

A new approach to patient education about Type 2 diabetes in Thailand is needed to give patients a better understanding, provide recommendations that they can apply to their daily lives, and include information about alternative medication. The Buddhist way of thinking and effective strategies enhancing self-efficacy should be applied to patient education to promote sustainability and adherence to self-management.

Listening to Older Adults' Values and Preferences for Type 2 Diabetes Care: A Qualitative Study

Individuals' values and preferences have a considerable impact on their motivation and, therefore, their willingness to follow treatment recommendations. This qualitative study aimed to describe older adults' values and preferences for type 2 diabetes care. Older adults valued an effective physician-patient treatment relationship and quality of life in their diabetes care. They preferred physicians who knew them as a person and were honest about their diabetes treatment and progression of the illness. When developing treatment plans, providers should assess the effect that treatment will likely have on older adults' health, while explicitly acknowledging their values and preferences for care as a prelude to better patient-centered care and potentially shared decision-making.

Strategies for enhancing information, motivation, and skills for self-management behavior changes: a qualitative study of diabetes care for older adults in Korea

PURPOSE

To describe strategies for enhancing information, motivation, and skills related to changes in diabetes self-management behavior among community-dwelling older adults in Korea.

PATIENTS AND METHODS

A total of five focus group interviews (three separate focus groups) were conducted with 12 older adults with type 2 diabetes and five diabetes educators. Qualitative content analysis was used.

RESULTS

"One's own willingness and ability" emerged as a fundamental belief about the strategies for diabetes self-management. Six major themes under three categories were identified. Under the information category, the recurrent themes were: 1) repeatedly offering detailed knowledge regarding self-management, 2) providing information about current health status, and 3) identifying experiential knowledge of blood glucose control. The recurrent themes in the motivation category were: 1) ensuring a positive attitude regarding self-management, and 2) encouragement or feedback from significant others. Furthermore, in the skills category, we found that the following theme emerged: hands-on skills training with numerical standards.

CONCLUSION

This study identified six tailored strategies for enhancing information, motivation, and skills for diabetes self-management behavior changes. These strategies can be used in the development of a culturally sensitive diabetes self-management program for older adults.

Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions

With the aging of the population and continuing advances in health care, patients seen in the primary care setting are increasingly complex. At the same time, the number of screening and chronic condition management tasks primary care providers are expected to cover during brief primary care office visits has continued to grow. These converging trends mean that there is often not enough time during each visit to address all of the patient's concerns and needs, a significant barrier to effectively providing patient-centered care. For complex patients, prioritization of which issues to address during a given visit must precede discrete decisions about disease-specific treatment preferences and goals. Negotiating this process of setting priorities represents a major challenge for patient-centered primary care, as patient and provider priorities may not always be aligned. In this review, we present a synthesis of recent research on how patients and providers negotiate the visit process and describe a conceptual model to guide innovative approaches to more effective primary care visits for complex patients based on defining visit priorities. The goal of this model is to inform interventions that maximize the value of available time during the primary care encounter by facilitating communication between a prepared patient who has had time before the visit to identify his/her priorities and an informed provider who is aware of the patient's care priorities at the beginning of the visit. We conclude with a discussion of key questions that should guide future research and intervention development in this area.

Evaluation of a new durable insulin pen with memory function among people with diabetes and healthcare professionals

OBJECTIVES

The aim of the study was to evaluate durable insulin pens among people with diabetes (PwD) and healthcare professionals (HCPs), by comparing two durable insulin pens with memory function: NovoPen® 5 (NP5) and HumaPen® Memoir™ (HPM), and two durable insulin pens without memory function: HumaPen Luxura® (HPL) and ClikSTAR® (CS).

RESEARCH DESIGN AND METHODS

This cross-over, multicentre usability test was conducted in China, Germany and the UK. Participants evaluated all four pens in randomised order by performing handling and usability tasks related to everyday use during a face-to-face interview. Tasks, pens and preferences were rated by completing a questionnaire comprising of rating and open-ended questions.

RESULTS

NP5 was preferred by 51% of participants compared with HPM (22%, p < 0.01), HPL (12%, p < 0.01) and CS (15%, p < 0.01). Participants preferred the design of NP5 (in particular, appearance, length and robustness). Memory function for the two pens was rated equally by participants, but 54% of PwD rated NP5 as 'very easy' to learn to use versus 22% for HPM and significantly more HCPs found it 'very easy' to teach patients to use NP5 versus HPM (6-point rating scale; difference in mean score, p < 0.01). Substantially, more PwD would be confident in using NP5 (64%) compared with HPM (43%), HPL (49%) and CS (45%) (6-point rating scale; difference in mean score, p < 0.01).

CONCLUSIONS

NP5 was preferred by > 50% of PwD and HCPs. NP5 was more highly rated for design, memory function and ease of learning/teaching compared with HPM. Most PwD would be confident in using NP5 for administering daily insulin injections.

Evaluation of preference for a novel durable insulin pen with memory function among patients with diabetes and health care professionals

BACKGROUND

Improving adherence to insulin treatment for better glycemic control remains a challenge in the management of diabetes. New technological aids are required to help support adherence. This study evaluated preference for the NovoPen(®) 5 (NP5), a durable insulin pen with memory function, compared with the HumaPen Luxura(®) (HPL) among patients with diabetes and health care professionals.

METHODS

This crossover, multicenter usability study included insulin pen-experienced patients with diabetes and health care professionals treating patients with diabetes in Canada, China, and Germany. Participants evaluated NP5 and HPL in a randomized order by performing handling tasks in a usability test related to everyday use during a face-to-face interview. Tasks, pens, and preferences were assessed by completing a questionnaire comprised of rating and open-ended questions relating to confidence in everyday diabetes management.

RESULTS

Overall, 300 patients with diabetes and 150 health care professionals participated in the study. Significantly more participants preferred NP5 (81%) to HPL (18%) (P < 0.001). Also, 82% of patients with diabetes had more confidence in NP5 for managing their daily injections versus 11% with HPL (P < 0.001), and 7% had no preference. Memory function was most helpful in giving patients with diabetes confidence about when they last injected (63%), how much insulin they last injected (62%) and improving diabetes management (55%). Participants gave higher ratings to NP5 than to HPL on all parameters relating to performing an injection (ease of handling, satisfaction when using the pen, convenience of using the pen day-to-day, quality of the pen, and the extent to which the pen meets their needs; P < 0.05 for all comparisons).

CONCLUSION

NP5 was preferred to HPL by most participants. Significantly more patients with diabetes had more confidence for managing daily insulin injections when using NP5, the pen with a memory function.

The effect of a patient-oriented treatment decision aid for risk factor management in patients with diabetes (PORTDA-diab): study protocol for a randomised controlled trial

Background

To improve risk factor management in diabetes, we need to support effective interactions between patients and healthcare providers. Our aim is to develop and evaluate a treatment decision aid that offers personalised information on treatment options and outcomes, and is intended to empower patients in taking a proactive role in their disease management. Important features are: (1) involving patients in setting goals together with their provider; (2) encourage them to prioritise on treatments that maximise relevant outcomes; and (3) integration of the decision aid in the practice setting and workflow. As secondary aim, we want to evaluate the impact of different presentation formats, and learn more from the experiences of the healthcare providers and patients with the decision aid.

Methods and design

We will conduct a randomised trial comparing four formats of the decision aid in a 2×2 factorial design with a control group. Patients with type 2 diabetes managed in 18 to 20 primary care practices in The Netherlands will be recruited. Excluded are patients with a recent myocardial infarction, stroke, heart failure, angina pectoris, terminal illness, cognitive deficits, >65 years at diagnosis, or not able to read Dutch. The decision aid is offered to the patients immediately before their quarterly practice consultation. The same decision information will be available to the healthcare provider for use during consultation. In addition, the providers receive a set of treatment cards, which they can use to discuss the benefits and risks of different options. Patients in the control group will receive care as usual. We will measure the effect of the intervention on patient empowerment, satisfaction with care, beliefs about medication, negative emotions, health status, prescribed medication, and predicted cardiovascular risk. Data will be collected with questionnaires and automated extraction from medical records in 6 months before and after the intervention.

Discussion

This decision aid is innovative in supporting patients and their healthcare providers to make shared decisions about multiple treatments, using the patient’s data from electronic medical records. The results can contribute to the further development and implementation of electronic decision support tools for the management of chronic diseases.

Trial registration

Dutch Trial register NTR1942.

Transitioning from active treatment: colorectal cancer survivors' health promotion goals

OBJECTIVE

The purpose of this study is to describe the post-treatment goals of colorectal cancer (CRC) survivors. We sought to determine whether goals were a salient concept during the period immediately following treatment, and whether a goal-setting intervention might be feasible and acceptable to these patients.

METHOD

Semi-structured qualitative interviews were administered to a convenience sample of 41 CRC patients who were 0-24 months post-treatment. Topics discussed included expectations and goals for future health, cancer prevention awareness, health-promoting behavior-change goals, and post-treatment cancer issues. Content analysis was used to explore emergent themes.

RESULTS

Overall, participants' health-related goals were: being healthy, getting back to normal, and not having a cancer recurrence. Most of the CRC survivors reported being proactive with their health by maintaining healthy behaviors or making healthy behavior changes, or had goals to change their behavior. All respondents had plans to maintain follow-up care and regular screening appointments. Some patients were managing treatment side effects or non-cancer issues that limited their functional abilities. Many respondents were satisfied with the care they received, and felt it was now their responsibility to do their part in taking care of themselves.

SIGNIFICANCE OF RESULTS

CRC survivors talk about goals, and many of them are either making or have an interest in making health behavior changes. Self-management support could be an appropriate strategy to assist patients with achieving their health goals post-treatment. Patients may need help addressing lingering treatment side effects or non-cancer issues. Healthcare providers should consider assessing patients' goals to help patients resolve post-treatment issues and promote healthy behaviors.

Behavioral health coaching for rural-living older adults with diabetes and depression: an open pilot of the HOPE Study

Background

Patients with diabetes are at increased risk for depression, compounding the burden of disease. When comorbid with diabetes, depression leads to poorer health outcomes and often complicates diabetes self-management. Unfortunately, treatment options for these complex patients are limited and comprehensive services are rarely available for patients in rural settings.

Methods

A small open trial was conducted to test the acceptability, feasibility and preliminary outcomes of a telephone-delivered coaching intervention for rural-dwelling older adults with uncontrolled diabetes and comorbid, clinically significant depressive symptoms. A total of eight older adults were enrolled in Healthy Outcomes through Patient Empowerment (HOPE), a 10-session (12-week), telephone-based coaching intervention. Primary study constructs included measures of diabetes control (Hemoglobin [Hb] A1c), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and diabetes-related distress (Problem Areas in Diabetes Scale [PAID]). Assessments were conducted at baseline, post-intervention, and 6-month follow-up. Acceptability and feasibility were evaluated using patient surveys, focused exit interviews, and session attendance data.

Results

Clinically significant improvements were realized post-intervention and at 6-month follow-up for outcomes related to diabetes and depression. Effect sizes using Cohen's d were determined post-intervention and at 6-month follow-up, respectively, for HbA1c (d=0.36; d=0.28), PHQ-9 (d=1.48; d=1.67, and PAID (d=1.50; d=1.06) scores. Among study participants, HbA1c improved from baseline by a mean (M) of 1.13 (SD=1.70) post-intervention and M=0.84 (SD=1.62) at 6 months. Depression scores, measured by the PHQ-9, improved from baseline by M=5.14 (SD=2.27) post-intervention and M=7.03 (SD=4.43) at 6-month follow-up. PAID scores also improved by M=17.68 (SD=10.7) post-intervention and M=20.42 (SD=20.66) from baseline to 6-month follow-up. Case examples are provided for additional context and to more fully articulate salient intervention concepts.

Conclusion

Although preliminary, data from this small open trial suggest that HOPE holds the potential to improve both physical (diabetes) and emotional (diabetes distress, depression) health outcomes and that changes can be maintained over a 6-month time period. As envisioned by the authors, HOPE may function as an extension of traditional primary care for rural-dwelling older adults with multiple comorbidities. A future randomized clinical trial will test HOPE’s broader effectiveness with rural-dwelling older adults.

Trial registration

NCT01274715

Knowing the ABCs: a comparative effectiveness study of two methods of diabetes education

OBJECTIVE

To test an active-learning, empowerment approach to teaching patients about the "diabetes ABCs" (hemoglobin A(1)C, systolic blood pressure, and low density lipoprotein cholesterol).

METHODS

84 (97%) diabetic patients who participated in a randomized effectiveness trial of two clinic-based group educational methods and completed a post-intervention assessment. The empowerment arm participated in a group session that incorporated two educational innovations (a conceptual metaphor to foster understanding, and team-based learning methods to foster active learning). The traditional diabetes education arm received a didactic group session focused on self-management and educational materials about the diabetes ABCs. Participants in both arms received individual review of their current ABC values.

RESULTS

A questionnaire evaluated knowledge, understanding, and recall of the diabetes ABCs was administered three months after enrollment in the study. At three months, participants in the empowerment group demonstrated greater understanding of the diabetes ABCs (P<0.0001), greater knowledge of their own values (P<0.0001), and greater knowledge of guideline-derived target goals for the ABCs compared with participants in the traditional arm (P<0.0001).

CONCLUSION

An active-learning, empowerment-based approach applied to diabetes education can lead to greater understanding and knowledge retention.

PRACTICE IMPLICATIONS

An empowerment approach to education can facilitate informed, activated patients and increase performance of self-management behaviors.

The provision of diabetes-monitoring exams to older Latinos

OBJECTIVES

To explore factors associated with the provision of diabetes-monitoring practices among older Latinos with type 2 diabetes.

METHOD

Data from 547 Latinos (≥ 55 years) were analyzed from the 2007 California Health Interview Survey. Multivariate logistic regression modeled the relationship between health status and sociodemographic factors and the receipt of semiannual HbA1c tests, annual foot exams, and annual retinal exams.

RESULTS

The majority of older Latino diabetics received foot exams (87%) and retinal exams (77%), but the provision of semiannual HbA1c tests (30%) was low. Higher English-language proficiency and health insurance coverage were associated with the provision of HbA1c tests and foot exams, but not retinal exams. Insulin therapy was positively associated with semiannual HbA1c testing, but negatively associated with foot exams.

DISCUSSION

There are considerable missed opportunities in the provision of diabetes monitoring for older Latinos, particularly those with limited English proficiency, less comprehensive insurance, and noninsulin therapy.

Cardiovascular disease in the elderly

The aging of the population worldwide will result in increasing numbers of elderly patients, among whom heart disease is the leading cause of death. Changes in cardiovascular physiology with normal aging and prevalent comorbidities result in differences in the effects of common cardiac problems as well as the response to their treatments. Patient-centered goals of care such as maintenance of independence and reduction of symptoms may be preferred over increased longevity. New less-invasive treatments are likely to improve outcomes in elderly patients who previously have been considered at prohibitive risk for traditional procedures. Clinical trials enrolling elderly patients are limited and recommendations for management from younger patients frequently lack evidence-based support in patients aged >75 years.

Effects of depression and antidepressant use on goal setting and barrier identification among patients with type 2 diabetes

PURPOSE

The purpose of this study was to examine the effects of depression and antidepressant use on goal setting and barrier identification in patients with type 2 diabetes.

METHODS

In a large diabetes education network, 778 patients with type 2 diabetes were enrolled in the American Association of Diabetes Educators (AADE) Outcomes System as part of their routine diabetes education between 2005 and 2008. Self-reported depression, 7 self-identified behavior change goals, and 13 barriers to diabetes self-care were collected from the Diabetes Self-Management Assessment Report Tool (D-SMART(®)); antidepressant use was documented from the Diabetes Educator Tool (D-ET(®)). Multiple linear regression was used to evaluate the effects of depression or antidepressant use on the number of goals or the number of barriers while controlling for relevant covariates.

RESULTS

Among 778 patients (507 nondepressed, 181 depressed with antidepressant use, 90 depressed without antidepressant use), median age was 58, 60.9% were female, and 85.9% were Caucasian. Patients with and without depression had a similar number of self-identified behavior change goals, whereas patients with depression had 1 additional barrier to diabetes self-care compared with those without depression. In the depressed subgroup, antidepressant use had no association with the number of goals that the subjects set or the number of barriers they identified.

CONCLUSIONS

Among patients with type 2 diabetes, depression was associated with a slightly greater number of barriers, which may support the importance of depression screening and depression treatment in patients with diabetes.

Having a diagnosis of diabetes is not associated with general diabetes knowledge in rural Hispanics

PURPOSE

The prevalence of diabetes among Hispanics in Washington State is 30% greater than it is for non-Hispanic whites. Hispanics also have higher rates of diabetes-related complications and mortality due to the disease. Although interventions have been developed for the Hispanic community, studies in rural settings are limited. To address this we conducted a study to identify factors associated with general diabetes knowledge in a rural Hispanic population.

METHODS

This study was conducted as part of a larger project in partnership with a local community hospital in Washington State's Lower Yakima Valley. Diabetes knowledge was assessed as part of a screening survey using 5 statements selected from the Diabetes Knowledge Questionnaire. Men and women (N = 1,297) between the ages of 18 and 92 attending community-oriented events took part in the survey. Gender, education, age, birthplace, diabetic status, and family history of diabetes were tested as predictors of diabetes knowledge.

FINDINGS

Overall, general knowledge was high with 71%-84% of participants responding correctly to 4 of 5 statements, while only 17% of participants responded correctly to a fifth statement. Although no variable was associated with all statements, family history, gender, and education were most frequently associated with knowledge. Diabetic status, age, and birthplace were less often or not associated with the knowledge statements.

CONCLUSION

Contrary to expectations, having a diagnosis of diabetes was not among the factors most frequently associated with diabetes knowledge. Future research should investigate the roles of family history, gender, and diabetic status as conduits of diabetes education among rural Hispanics.

Life values and self-regulation behaviours among adults with type 2 diabetes

AIM

The aim of this study was to identify life values in adults with type 2 diabetes and to describe their experiences of how these values may influence self-regulation behaviours.

BACKGROUND

Daily self-regulation behaviours have been described as challenging, because the individuals try to find a balance between them and life values. However, little is known about how life values may influence the motivation for necessary self-regulation behaviours.

DESIGN AND METHODS

A descriptive/explorative qualitative design that included focus groups was used to collect data. The sample consisted of 19 adults with type 2 diabetes. Data were analysed using qualitative content analysis.

RESULTS

The findings revealed six themes: maintaining health and longevity, a feeling of bodily well-being, preserving a positive body image, self-determination, maintaining the ability to work and belonging. The results reflect the fact that many life values have a major influence on self-regulation behaviours.

CONCLUSIONS

The findings indicate that several of the life values can conflict with self-regulation behaviours, which in turn may influence the motivation for self-regulation of type 2 diabetes. Some of these values could be considered to be related to self-worth, which is regarded as an important motivational component for engaging in a task. Moreover, this study highlights the fact that goals related to self-regulation behaviours were formulated in more general than in specific terms.

RELEVANCE TO CLINICAL PRACTICE

This study may help health professionals to understand how adults' life values influence their motivation for adequate self-regulation. The findings indicate that the existing support structures should make an effort to learn about people's life values and take them into account when giving advice about self-regulation behaviours. Moreover, people with type 2 diabetes should be supported by health professionals to set more specific self-regulation goals that are consistent with their life values.

Patient perceptions of treatment and illness when prescribed multiple medicines for co-morbid type 2 diabetes

Illness and treatment perceptions are vital for people self-managing co-morbid conditions with associated cardiovascular disease, such as type 2 diabetes (T2D). However, perceptions of a co-morbid condition and the use of multiple medicines have yet to be researched. This study investigated the illness and treatment perceptions of people with co-morbid T2D. The Brief Illness Perception Questionnaire (repeated for T2D, hypertension, and hyperlipidemia) and the Beliefs about Medicines Questionnaire Specific Concerns Scales (repeated for Oral hypoglycemic agents, anti-hypertensive medicines, and statins) were sent to 480 people managing co-morbid T2D. Data on the number of medicines prescribed were collected from medical records. Significantly different perceptions were found across the illnesses. The strongest effect was for personal control; the greatest control reported for T2D. Illness perceptions of T2D differed significantly from perceptions about hyperlipidemia. Furthermore, illness perceptions of T2D also differed from perceptions of hypertension with the exception of perceptions of illness severity. Hypertension and hyperlipidemia shared similar perceptions about comprehensibility, concerns, personal control, and timeline. Significant differences were found for beliefs about treatment necessity, but no difference was found for treatment concerns. When the number of medicines was taken as a between-subjects factor, only intentional non-adherence, treatment necessity beliefs, and perceptions of illness timeline were accounted for. Co-morbid illness and treatment perceptions are complex, often vary between illnesses, and can be influenced by the number of medicines prescribed. Further research should investigate relationships between co-morbid illness and treatment perception structures and self-management practices.

Using qualitative methods to inform the trade-off between content validity and consistency in utility assessment: the example of type 2 diabetes and Alzheimer's disease

BACKGROUND

Key stakeholders regard generic utility instruments as suitable tools to inform health technology assessment decision-making regarding allocation of resources across competing interventions. These instruments require a 'descriptor', a 'valuation' and a 'perspective' of the economic evaluation. There are various approaches that can be taken for each of these, offering a potential lack of consistency between instruments (a basic requirement for comparisons across diseases). The 'reference method' has been proposed as a way to address the limitations of the Quality-Adjusted Life Year (QALY). However, the degree to which generic measures can assess patients' specific experiences with their disease would remain unresolved. This has been neglected in the discussions on methods development and its impact on the QALY values obtained and resulting cost per QALY estimate underestimated. This study explored the content of utility instruments relevant to type 2 diabetes and Alzheimer's disease (AD) as examples, and the role of qualitative research in informing the trade-off between content coverage and consistency.

METHOD

A literature review was performed to identify qualitative and quantitative studies regarding patients' experiences with type 2 diabetes or AD, and associated treatments. Conceptual models for each indication were developed. Generic- and disease-specific instruments were mapped to the conceptual models.

RESULTS

Findings showed that published descriptions of relevant concepts important to patients with type 2 diabetes or AD are available for consideration in deciding on the most comprehensive approach to utility assessment. While the 15-dimensional health related quality of life measure (15D) seemed the most comprehensive measure for both diseases, the Health Utilities Index 3 (HUI 3) seemed to have the least coverage for type 2 diabetes and the EuroQol-5 Dimensions (EQ-5D) for AD. Furthermore, some of the utility instruments contained items that could not be mapped onto either of the proposed conceptual models.

CONCLUSIONS

Content of the utility measure has a significant impact on the treatment effects that can be observed. This varies from one disease to the next and as such contributes to lack of consistency in observable utility effects and incremental utility scores. This observation appears to have been omitted from the method development considerations such as reference methods. As a result, we recommend that patients' perspectives obtained via qualitative methods are taken into consideration in the ongoing methods development in health state descriptions for generic utility instruments. Also, as a more immediate contribution to improving decision making, we propose that a content map of the chosen utility measure with patient-reported domains be provided as standard reporting in utility measurement in order to improve the transparency of the trade-offs in relation to patient relevance and consistency.