Patient factors and glycaemic control--associations and explanatory power

Glycemic control during TB treatment among Filipinos: The Starting Anti-Tuberculosis Treatment Cohort Study

Poor TB treatment outcomes are observed in patients with type 2 diabetes mellitus (DM) comorbidity and glycemic control throughout treatment may play a role. The objective of this study was to investigate glycemic control longitudinally among Filipino adults undergoing TB treatment using mixed-effects linear and logistic regression. Analyses were conducted in 188 DM-TB patients out of 901 enrolled in the Starting Anti-TB Treatment (St-ATT) cohort, with a median baseline glycosylated hemoglobin (HbA1c) of 8.2% (range 4.5-13.3%). Previous versus new DM diagnosis was associated with higher mean HbA1c (worse glycemic control) during treatment, with a smaller effect amongst those with central obesity (coefficient 0.80, 95% confidence interval [CI] 0.26, 1.57, P = 0.043) than amongst those without central obesity (coefficient 3.48, 95% CI 2.16, 4.80, P<0.001). In those with a new DM diagnosis, central obesity was associated with higher blood glucose (coefficient 1.62, 95% CI 0.72, 2.53, P = 0.009). Of 177 participants with ≥2 HbA1c results, 40% had uncontrolled glycemia (≥2 HbA1c results ≥8%). Of 165 participants with ≥3 HbA1c results, 29.9% had consistently-controlled glycemia, 15.3% had initially-uncontrolled glycemia, and 18.6% had consistently-uncontrolled glycemia. Previous versus new DM diagnosis and glucose-lowering medication use versus no use were associated with having uncontrolled versus controlled glycemia (adjusted odds ratio [aOR] 2.50 95%CI 1.61, 6.05, P = 0.042; aOR 4.78 95% CI 1.61,14.23, P<0.001) and more likely to have consistently-uncontrolled versus consistently-controlled glycemia (adjusted relative risk ratio [aRRR] 5.14 95% CI 1.37, 19.20, P = 0.015; aRRR 10.24 95% CI 0.07, 0.95, P = 0.003). Relapse cases of TB were less likely than new cases to have uncontrolled (aOR 0.20 95%CI 0.06, 0.63, P = 0.031) or consistently-uncontrolled (aRRR 0.25 95%CI 0.07, 0.95, P = 0.042) versus controlled glycemia. Those with long-term DM, suggested by previous diagnosis, glucose-lowering medication use and possibly central obesity, may require additional support to manage blood glucose during TB treatment.

Patient activation and medication adherence in adults

BACKGROUND

Patients' level of medication adherence provides conflicting results in its relationship to patient activation. Multiple factors may be contributing to these mixed results.

OBJECTIVES

The primary purpose was to assess the association of patient activation to medication adherence in adults with chronic health conditions and low health literacy (HL). Secondary objectives were to determine whether age, education, gender, and race were associated with activation.

METHODS

Participants completed self-report questionnaires regarding chronic disease self-management. Patient activation was measured using Hibbard's Patient Activation Measure (PAM). Self-report of medication adherence was determined using the Gonzalez-Lu adherence questionnaire. Block regressions first assessed the relation of demographic variables and education to adherence and then the added relation of patient activation in a second model.

RESULTS

The analyses included 301 participants (mean age 58 years; 53% female; mean chronic conditions of 6.6). Some of the most common chronic conditions included hypertension (60%), arthritis (51%), depression (49%), and hyperlipidemia (43%). The relation of older age to greater medication adherence was significant (P < 0.05) in both models. The addition of PAM was significantly related to better adherence (P < 0.001) and also increased the R squared value from 0.04 to 0.09. This change resulted in a moderate effect size (d = 0.50).

CONCLUSION

Evaluating patient activation at baseline may predict those more likely to be medication adherent in patients with low HL.

Relationship Between Patient Activation and Type 2 Diabetes Mellitus Self-management and Clinical Outcomes in Saudi Arabian Primary Care Setting

PURPOSE

Type 2 diabetes mellitus (T2DM) self-management is a comprehensive approach that individuals with T2DM employ to manage and control their condition. Patients' activation, "an individual's knowledge, skill, and confidence for managing their health and health care", has been used as a major driver of self-management. This study aimed to assess the relationship of patient activation with T2DM self-management and clinical outcomes.

DESIGN

A cross-sectional study.

SUBJECTS

Patients with type T2DM who age 18-years and older.

SETTING

The primary care centers in Saudi Arabia.

MEASURES

Patient activation measure (PAM) and the Summary of Diabetes Self-Care Activities (SDSCA).

ANALYSIS

Descriptive statistic, T-test, One-way ANOVA test, Chi-square test, and linear and logistic regressions were performed.

RESULTS

A total of 398 patients, mostly male (54.9%) with a mean age of 53.2 (±10.7) years old participated in the study. The participants' mean of Hemoglobin A1c (HbA1c) was 8.4% (±1.7%) and most of them (74.5%) had an uncontrolled HbA1c level (>7% %). The mean patient activation score was 55.9 (±13.5). 24.4% were at [PA1], 26.7% at [PA2], 37.4% at [PA3], and 11.5% at [PA4]. Patient activation level was positively associated with better glycemic control and self-management behaviors including diet, physical activity, blood glucose self-testing, foot care, and smoking (P < .05) but not with adherence to medication.

CONCLUSIONS

Our findings reveal a positive association between patient activation level and enhanced glycemic control and self-management behaviors and suggest that patient activation-informed self-management interventions are more likely to yield promising health outcomes.

Prevalence of medication adherence and glycemic control among patients with type 2 diabetes and influencing factors: A cross-sectional study

Background

This study aimed to assess medication adherence, glycemic control, and their influencing factors among outpatients at an Indonesian clinic with type 2 diabetes.

Methods

A cross-sectional study was conducted among patients with type 2 diabetes at a hospital-based clinic in Surabaya, Indonesia, from September to December 2018. A purposive sampling was used; patients aged 18 years and older, had diabetes and any comorbidity, received hypoglycemic agents, and provided written informed consent were included. The previously validated Brief Medication Questionnaire was used to measure medication adherence, while glycosylated hemoglobin (A1C) levels were used to evaluate glycemic control. Binary logistic regression was used to identify factors associated with medication adherence and glycemic control.

Results

Of 321 patients enrolled in the study, 268 (83.5%) patients were medication nonadherent. Patients who did not engage regularly in physical activity (aOR: 0.49, 95% CI: 0.26-0.93) was more likely to be medication adherent. Poor glycemic control (A1C: >7%) was observed in 106 (33.0%) of the patients. Patients who used a combination of oral hypoglycemic agents and insulin (aOR: 2.74, 95% CI: 1.09-6.86), did not take biguanide (aOR: 2.73, 95% CI: 1.16-6.43), reported hyperglycemia (aOR: 4.24, 95% CI: 1.53-11.81), and had comorbid diseases (aOR: 4.33, 95% CI: 1.08-17.34) increased the risk of having poor glycemic control. Patients who were more likely to achieve good glycemic control were male (aOR: 0.39, 95% CI: 0.20-0.74) and aged older (aOR: 0.95, 95% CI: 0.92-0.99).

Conclusions

The proportion of patients who were medication nonadherent was much higher than those with poor glycemic control. Whereas regular exercise was a predictor of nonadherence, age, sex, diabetes medication, not taking biguanide, acute complications, and comorbidity were predictors of poor glycemic control. Therefore, strategies are needed to improve medication adherence and glycemic control.

Glycated haemoglobin trajectories and one-year risk of potentially avoidable hospitalisations among adult type 2 diabetes patients seeking care at specialist outpatient clinics of a tertiary hospital: a cohort study

AIM

To evaluate the association between trajectories of glycated haemoglobin (HbA1c) and potentially avoidable hospitalisations (PAH).

METHODS

We performed a cohort study in a tertiary hospital in Singapore among adult type 2 diabetes patients with ≥3HbA1c tests over two years. Then, we followed up for one year after the last HbA1c reading. Glycaemic control was analysed by (1)HbA1c trajectories through group-based trajectory modelling, and (2)mean HbA1c. PAH was defined using the Agency of Healthcare Research and Quality criteria, categorising as overall, acute, chronic, diabetes-composites.

RESULTS

A total of 14923 patients (mean age:62.9±12.8 years;55.2% men)were included. Four HbA1c trajectories were observed; low-stable(n=9854,66.0%), moderate-stable(n=3125,20.9%), high-decrease(n=1017,6.8%) and high-persistent(n=927,6.2%). Compared to the low-stable trajectory, one-year risk ratio(RR) and 95%CI, respectively for moderate-stable, high-decrease and high-persistent trajectories were as follows:(1)overall PAH:1.15(1.00-1.31),1.53(1.31-1.80),1.96(1.58-2.43);(2)diabetes PAH:1.30(1.04-1.64),1.98(1.55-2.53),2.24(1.59-3.15);(3)acute PAH:1.14(0.90-1.44),1.29(0.95-1.77),1.75(1.17-2.62); and (4)chronic PAH:1.21(1.02-1.43),1.62(1.34-1.97),2.14(1.67-2.75). Mean HbA1c was significantly associated with overall and chronic-composites of PAH whilst evidence of a non-linear relationship with diabetes-composite of PAH was noted.

CONCLUSION

Patients with high-decrease trajectory had a risk lower than those with persistently-high HbA1c, highlighting that a greater risk of hospitalisation conferred by poor glycaemic control is potentially reversible. Determining HbA1c trajectories could help to identify the high-risk individuals for targeted and intensive management to improve care and reduce hospitalisations.

Factors associated with diabetes-related distress among Asian patients with poorly controlled type-2 diabetes mellitus: a cross-sectional study in primary care

BACKGROUND

Diabetes-related distress (DRD) is a negative emotional state related to the burden of living with diabetes mellitus. It has been associated with poor self-care and glycaemic control. This cross-sectional study aimed to examine the factors associated with DRD among urban Asian patients with poorly controlled type-2 diabetes mellitus (T2DM) in primary care in Singapore. The factors included demographics, diabetes history, medical co-morbidities, mood disorders and social history.

METHODS

Patients with T2DM and HbA1c of 8% or more were recruited from 2 public primary care centres in Singapore. They were administered a questionnaire survey to identify DRD based on the Problem Area In Diabetes (PAID) scale. Their anxiety and depression were screened using GAD-7 and PHQ-9, and quality of life (QOL) measured using the EQ-5D-5L. Their clinical data, including HbA1c, comorbidities and medications, were extracted from the electronic medical records.

RESULTS

Among the 356 subjects, the prevalence of DRD was 17.4%. DRD was significantly associated with younger age (AOR (95% CI) = 0.93 (0.89-0.97), p = 0.001), ex-smoker status (AOR (95% CI) = 22.30 (2.43-204.71), p = 0.006) and history of kidney disease (AOR (95% CI) = 3.41 (1.39-8.35), p = 0.007). Those who screened positive for depression (AOR (95% CI) = 4.98 (1.19-20.86), p = 0.028) were almost five times more likely to have DRD. Quality of life was lower among those with DRD (EQ5D index score AOR (95% CI) = 0.11 (0.01-0.97), p = 0.047), who also tended to feel that diabetes pharmacotherapy interfered with their normal life (AOR (95% CI) = 2.89 (1.38-6.08), p = 0.005).

CONCLUSION

About 1 in 6 patients with poorly controlled T2DM had DRD. Younger age, ex-smoker status, history of kidney disease, and those with depressive symptoms were most at risk.

Preoperative patient activation predicts minimum clinically important difference for PROMIS pain and physical function in patients undergoing elective spine surgery

BACKGROUND CONTEXT

Patient activation is a patient's willingness to take independent actions to manage their own health care.

PURPOSE

The goal of this study is to determine whether preoperative patient activation measure (PAM) predicts minimum clinically important difference (MCID) for Patient-Reported Outcomes Measurement Information System (PROMIS) pain, physical function, depression, and anxiety for patients undergoing elective spine surgery.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

A single-institution, academic database of patients undergoing elective spine surgery.

OUTCOME MEASURE

MCID at 1-year follow-up for PROMIS pain, physical function, depression and anxiety.

METHODS

We retrospectively reviewed a single-institution, academic database of patients undergoing elective spine surgery. Preoperative patient activation was evaluated using the PAM-13 survey, which was used to stratify patients into four activation stages. Primary outcome variable was achieving MCID at 1-year follow-up for PROMIS pain and physical function. Multivariable logistic regression analysis was used to determine impact of patient activation on PROMIS pain and the physical function.

RESULTS

Of the 430 patients, 220 (51%) were female with a mean age of 58.2±16.8. Preoperatively, 34 (8%) were in activation stage 1, 45 (10%) in stage 2, 98 (23%) in stage 3, and 253 (59%) in stage 4. At 1-year follow up, 248 (58%) achieved MCID for PROMIS physical function, 256 (60%) achieved MCID for PROMIS pain, 151 (35.28%) achieved MCID for PROMIS depression, and 197 (46%) achieved MCID for PROMIS anxiety. For PROMIS physical function, when compared to patients at stage 1 activation, patients at stage 2 (aOR:3.49, 95% CI:1.27, 9.59), stage 3 (aOR:3.54, 95% CI:1.40, 8.98) and stage 4 (aOR:7.88, 95% CI:3.29, 18.9) were more likely to achieve MCID. For PROMIS pain, when compared against patients at stage 1, patients at stage 3 (aOR:2.82, 95% CI:1.18, 6.76) and stage 4 (aOR:5.44, 95% CI:2.41, 12.3) were more likely to achieve MCID. For PROMIS depression, when compared against patients at stage 1, patients at stage 4 were more likely to achieve MCID (Adjusted Odds Ratio (aOR):2.59, 95% CI:1.08-6.19). For PROMIS anxiety, when compared against patients at stage 1, stage 3 (Adjusted Odds Ratio (aOR):3.21, 95% CI:1.20-8.57), and stage 4 (aOR:5.56, 95% CI:2.20-14.01) were more likely to achieve MCID.

CONCLUSION

Patients at higher stages of activation were more likely to achieve MCID for PROMIS pain, physical function, depression, and anxiety at 1-year follow-up. Routine preoperative assessment of patient activation may help identify patients at risk of poor outcomes.

Health Extension for Diabetes: Impact of a Community-Based Diabetes Self-Management Support Program on Older Adults' Activation

OBJECTIVE

The goals of this study were to determine whether completion of a community-based diabetes self-management support (DSMS) program delivered through a university Cooperative Extension network increased Patient Activation Measure (PAM) scores and to examine predictors of improvement in PAM score in individuals participating in the DSMS.

METHODS

The Health Extension for Diabetes (HED) is a 4-month program delivered via a paraprofessional extension agent in partnership with an established diabetes self-management education and support program. The study population included 148 adults (median age 69 years; interquartile range 60-74 years) with diabetes recruited from local community organizations. Data for the analysis were collected before and after participation in the intervention as part of a longitudinal study, using the PAM and Self-Efficacy for Diabetes instruments. Descriptive statistics were gathered, and hypothesis tests and simple and multivariable regression analyses were conducted.

RESULTS

The mean PAM score increased by 6.58 points, with a 5-point change considered clinically significant. From pre- to post-intervention, PAM scores significantly decreased for 23 participants, decreased for 6, did not change for 14, increased for 21, and significantly increased for 84. Higher pre-intervention PAM scores, younger age, greater educational attainment, and higher baseline self-efficacy scores were associated with increased post-intervention PAM scores when not controlling for potential covariates. Age was no longer associated with higher PAM scores after controlling for covariates.

CONCLUSION

Community-based DSMS interventions can be effective in generating positive change in individuals' activation. HED provides a feasible and accessible DSMS option that addresses key diabetes self-management components while effectively improving individuals' activation. It is recommended that people living with diabetes attend a DSMS program such as HED to increase their ability to effectively self-manage various components of their chronic condition.

The association between patient activation and healthcare resources utilization: a systematic review and meta-analysis

OBJECTIVES

To measure the association between patient activation and hospitalization or emergency department (ED) visits among adults with chronic diseases.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of English articles was performed using the following databases: PubMed, Cochrane Library, Web of Science, PsycINFO, and Embase. Articles were searched from 2005 until July 2021. Observational studies that measured the association between patient activation, measured by the Patient Activation Measure (PAM), and hospitalization or ED visits among adults with chronic or multichronic diseases were included. Pairs of reviewers independently screened the studies and extracted data for qualitative and quantitative synthesis. The methodological quality was assessed using the Quality in Prognostic Studies (QUIPS) tool.

RESULTS

A total of nine observational studies (153,121 participants) were included in the qualitative synthesis, whereas six were pooled in the quantitative synthesis (151,359 participants). High levels of patient activation were significantly associated with a reduced risk for both hospitalizations (RR [95% CI] = 0.69 [0.61; 0.77], I² = 78%) and ED visits (RR [95% CI] = 0.76 [0.70; 0.84], I² = 72%).

CONCLUSIONS

Our findings suggest the existence of an inverse association between patient activation and healthcare resources utilization. Further observational studies are needed to fully comprehend the magnitude of this association.

Association between patient activation, self-management behaviours and clinical outcomes in adults with diabetes or related metabolic disorders: a systematic review and meta-analysis protocol

INTRODUCTION

Diabetes and related metabolic disorders such as obesity and cardiovascular diseases (CVD) are a growing global issue. Equipping individuals with the necessary 'knowledge, skills and confidence to self-manage their health' (ie, patient activation (PAct)) may lead to improvements in health outcomes. It is unclear whether existing evidence allows us to assume a causal relationship. We aim to synthesise and critically appraise evidence on the relationship between PAct and self-management behaviours and clinical outcomes of people living with diabetes and related metabolic disorders.

METHODS AND ANALYSIS

The protocol is based on guidance on Preferred Reporting Items for Systematic Review and Meta-analysis Protocols. We will search Medline, Embase, CENTRAL, PsycInfo, Web of Science and CINAHL using search terms related to PAct, diabetes, pre-diabetes, obesity and CVD. Any quantitative study design is eligible provided studies assess the association between PAct and clinical outcomes and/or self-management behaviours of diabetes and related metabolic disorders. Outcomes include behavioural (eg, diet) and clinical (eg, blood pressure) outcomes. Two reviewers will independently screen titles/abstracts and full texts and assess risk of bias using the revised Cochrane risk-of-bias tool for randomised trials or the Risk of Bias Assessment Tool for Nonrandomised Studies (RoBANS).One reviewer will extract data, with independent checking by a second reviewer. We will critically assess the level of evidence available for assuming a causal association between PAct and outcomes. Data permitting, we will use the Hunter-Schmidt random-effects method to meta-analyse correlations across studies.

ETHICS AND DISSEMINATION

Ethical approval is not required. The review will be disseminated in the form of a peer-reviewed journal article, at conferences and other presentations. The findings of the review will be of interest to clinical commissioning groups, policymakers and intervention deliverers/developers.

PROSPERO REGISTRATION NUMBER

CRD42021230727.

Patient activation and treatment decision-making in the context of cancer: examining the contribution of informal caregivers' involvement

PURPOSE

The present work investigated the relationship between patient activation, treatment decision-making, and adherence to the prescribed treatment regimen. Given the role of informal caregivers in patient-reported outcomes, it was additionally assessed whether caregiver involvement acted as a moderator of this relationship.

METHODS

Survey data collected from 504 cancer survivors were utilized. Structural equation modeling (SEM) controlling for covariates was used to examine the relationship between patient activation measure (PAM), caregiver involvement, and the identified outcomes. Moderator analysis was conducted using multiple group SEM.

RESULTS

Patient activation was significantly associated with treatment planning being reflective of survivors' goals and values (p < 0.001); adherence to treatment (p = 0.011); and satisfaction (p < 0.001). Caregiver's involvement significantly moderated the association between activation and adherence to treatment.

CONCLUSIONS

Patient activation was positively associated with all three selected outcomes. However, for cancer survivors reporting low rates of caregiver's involvement, patient activation was not associated with treatment adherence. Research is needed to test and deliver self-management interventions inclusive of informal caregivers.

IMPLICATIONS FOR CANCER SURVIVORS

Findings supported the need not only to monitor and sustain patient activation across the cancer continuum, but also to assume a dyadic perspective when designing self-management interventions in cancer survivorship.

Engagement With a Health Information Technology-Augmented Self-Management Support Program in a Population With Limited English Proficiency: Observational Study

Background

Limited English proficiency (LEP) is an important driver of health disparities. Many successful patient-level interventions to prevent chronic disease progression and complications have used automated telephone self-management support, which relies on patient activation and communication to achieve improved health outcomes. It is not clear whether these interventions are similarly applicable to patients with LEP compared to patients with English proficiency.

Objective

The objectives of this study were as follows: (1) To examine the impact of LEP on patient engagement (primary outcome) with a 12-month language-concordant self-management program that included automated telephone self-management support, designed for patients with chronic kidney disease (CKD). (2) To assess the impact of LEP on change in systolic blood pressure (SBP) and albuminuria (secondary outcomes) resulting from the self-management program.

Methods

This was a secondary analysis of the Kidney Awareness Registry and Education (KARE) pilot trial (NCT01530958) which was funded by the National Institutes of Health in August 2011, approved by the University of California Institutional Review Board in October 2011 (No. 11-07399), and executed between 2013 and 2015. Multivariable logistic and linear models were used to examine various facets of patient engagement with the CKD self-management support program by LEP status. Patient engagement was defined by patient’s use of educational materials, completion of a health coaching action plan, and degree of participation with automated telephone self-management support. Changes in SBP and albuminuria at 12 months by LEP status were determined using multivariable linear mixed models.

Results

Of 137 study participants, 53 (38.7%) reported LEP, of which 45 (85%) were Spanish speaking and 8 (15%) Cantonese speaking. While patients with LEP and English proficiency similarly used the program’s educational materials (85% [17/20] vs 88% [30/34], P=.69) and completed an action plan (81% [22/27] vs 74% [35/47], P=.49), those with LEP engaged more with the automated telephone self-management support component. Average call completion was 66% among patients with LEP compared with 57% among those with English proficiency; patients with LEP requested more health coach telephone calls (P=.08) and had a significantly longer average automated call duration (3.3 [SD 1.4] min vs 2.2 [1.1 min], P<.001), indicating higher patient engagement. Patients with LEP randomized to self-management support had a larger, though nonstatistically significant (P=.74), change in SBP (–4.5 mmHg; 95% CI –9.4 to 0.3) and albuminuria (–72.4 mg/dL; 95% CI –208.9 to 64.1) compared with patients with English proficiency randomized to self-management support (–2.1 mmHg; 95% CI –8.6 to 4.3 and –11.1 mg/dL; 95% CI –166.9 to 144.7).

Conclusions

Patients with LEP with CKD were equally or more engaged with a language-concordant, culturally appropriate telehealth intervention compared with their English-speaking counterparts. Augmented telehealth may be useful in mitigating communication barriers among patients with LEP.

Trial Registration

ClinicalTrials.gov NCT01530958; https://clinicaltrials.gov/ct2/show/NCT01530958

<p>Decreasing Avoidable Vision Loss: Identifying Antecedents of Adherence</p>

Adherence to medication treatment protocols and active participation by individuals in their medical care are important for all patients, but especially for those with chronic conditions such as vision loss. Adherence is crucial for decreasing avoidable vision loss. Failure to take medications as prescribed and keep scheduled appointments reduces treatment effectiveness, increases complications and results in poorer outcomes. Reasons for nonadherence vary by diagnosis and include not understanding the importance of adherence, low health literacy, lack of adequate self-efficacy, low level of activation and behavioral issues including depression. Patients may lack information about their condition and its prognosis, available treatment alternatives, and other essential information such as how to monitor their eye condition, what to do if vision deteriorates and how to get needed community-based help. Each of these factors impedes patients’ ability to engage with their physician and participate in their own care. The ability of individuals with vision loss to actively and effectively manage their health care, ie, activation, has been understudied. When patients are involved with their own care, their care experience, and most importantly, their outcomes, are improved. Identifying antecedents of adherence may help provide disease- and patient-specific pathways to reduce avoidable vision loss.

Effects of Point-Of-Care Testing in General Practice for Type 2 Diabetes Patients on Ambulatory Visits and Hospitalizations

Point-of-care testing (POCT) of HbA1c means instant test results and more coherent counseling that is expected to improve diabetes management and affect ambulatory visits and hospitalizations. From late 2008, POCT has been implemented and adopted by a segment of the general practices in the capital region of Denmark. The aim of this study is to assess whether the introduction of POCT of HbA1c in general practice (GP) has affected patient outcomes for T2 diabetes patients in terms of hospital activity. We apply difference-in-differences models at the GP clinic level to assess the casual effects of POCT on the following hospital outcomes: (1) admissions for diabetes, (2) admissions for ambulatory care sensitive diabetes conditions (ACSCs), (3) ambulatory visits for diabetes. The use of POCT is remunerated by a fee, and registration of this fee is used to measure the GP’s use of POCT. The control group includes clinics from the same region that did not use POCT. The sensitivity of our results is assessed by an event study approach and a range of robustness tests. The panel data set includes 553 GP clinics and approximately 30,000 diabetes patients from the capital region of Denmark, observed in the years 2004–2012. We find that voluntary adoption of POCT of HbA1c in GP has no effect on hospital admissions and diabetes-related hospital ambulatory visits. Event study analysis and different treatment definitions confirm the robustness of these results. If implementation of POCT of HbA1c improves other parts of diabetes management as indicated in the literature, it seems worthwhile to implement POCT of HbA1c in the capital region of Denmark. However, doubts around the quality of POCT of HbA1c testing and a desire to capture data at central labs may prevent implementation of more value based HbA1c testing.

Preoperative patient activation is predictive of improvements in patient-reported outcomes following minimally invasive lumbar decompression

PURPOSE

To determine whether there is an association between preoperative 10-Item Patient Activation Measure (PAM-10) scores and clinical outcomes following MIS LD.

METHODS

Patients undergoing a primary MIS LD were retrospectively reviewed and stratified according to their preoperative PAM-10 scores: "low PAM," "moderate PAM," and "high PAM." Preoperative PAM score cohorts were tested for improvements in Oswestry Disability Index (ODI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) back and leg pain using multivariate linear regression.

RESULTS

Eighty-nine patients were included: 29 had a low PAM score, 32 had a moderate PAM score, and 28 had a high PAM score. Cohorts experienced similar preoperative VAS back pain, VAS leg pain, ODI, and SF-12 PCS. Patients with low PAM scores experienced a trend of higher pain scores throughout 6 months with VAS back pain being significant at 3 months and VAS leg pain being significant at 6-week and 3-month follow-up. Patients with lower PAM scores experienced a worse improvement in ODI at 6-week, 3-month, and 6-month timepoints. Lastly, patients with lower PAM scores demonstrated less improvement in SF-12 PCS at 3-month and 6-month follow-up.

CONCLUSIONS

Lower preoperative PAM scores were associated with worse improvement in clinical outcomes following MIS LD. Patients with lower PAM scores had diminished improvement in long-term patient-reported outcomes including ODI, SF-12, and VAS back and leg pain. Our investigation suggests that preoperative PAM assessments may be an effective tool to predict postoperative outcomes following MIS LD.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study

Background

Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information.

Objective

The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting.

Methods

A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes.

Results

The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA_1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA_1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA_1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12).

Conclusions

Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group.

Trial Registration

ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.6993

Activation in individuals with vision loss

Vision loss and blindness are significant causes of disability. Patient activation has been previously unstudied in individuals with vision loss. Among our 146 participants, visual acuities for 38.3 percent were better than 20/70, 43.2 percent had acuities between 20/70 and 20/400, and 12.3 percent had acuities of <20/400. Participants with lower Patient Activation Measure scores missed more clinic visits (p = 0.017); those participants with caregivers also had lower PAM scores (p = 0.002). Targeting interventions to address patient activation in patients with vision loss may increase patient involvement in their care, increase treatment protocol adherence, and improve outcomes.

Increasing patient activation through diabetes self-management education: Outcomes of DESMOND in regional Western Australia

OBJECTIVE

To evaluate the effects of the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) program on patient activation in adults living with type 2 diabetes (T2D).

METHODS

233 individuals attended a DESMOND program in 26 locations across regional Western Australia. Individuals completed the Patient Activation Measure (PAM) prior to and immediately after DESMOND participation.

RESULTS

Patient Activation significantly increased by 9.7 points from pre to post DESMOND intervention (p < 0.001, z = -7.94). Of all participants who exhibited an increase in patient activation, 87% (n = 142) experienced a clinically significant (>5 point) increase. Post-DESMOND participation, an 86% reduction (from 6% -0.9%) in the proportion of participants scoring in the lowest PAM level (Level 1) was observed (p < 0.01).

CONCLUSION

DESMOND, a structured diabetes self-management education (DSME) program aimed at strengthening the role of people living with type 2 diabetes in self-managing their healthcare, significantly increased patient activation in a real-world setting.

PRACTICE IMPLICATIONS

In line with international diabetes guidelines it is recommended that people living with T2D, particularly those with lower levels of activation, attend an evidence based DSME such as DESMOND to increase their capacity to effectively self-manage their condition.

Changes in diabetes distress among people with type 2 diabetes during a risk screening programme for diabetic kidney disease - Longitudinal observations of the PRIORITY study

AIMS

To investigate levels and changes in diabetes distress over the course of the PRIORITY (Proteomic prediction and Renin angiotensin aldosterone system Inhibition prevention Of early diabetic nephRopathy In people with TYpe 2 diabetes and normoalbuminuria) randomised controlled trial of screening for diabetic kidney disease (DKD) risk among people with type 2 diabetes (T2D) at a specialist diabetes clinic in Denmark.

METHODS

Of 436 trial participants with T2D, 216 were invited to complete the 17-item diabetes distress scale at the time of screening (T1, n = 180), immediately after receiving the screening results at 6-8 weeks (T2, n = 169), and at 12 months follow up (T3, n = 107). Linear mixed models were used to explore changes in diabetes distress.

RESULTS

No significant changes in diabetes distress were observed between the time of screening, receiving results, and at 12 months. Changes in diabetes distress were not influenced by diabetes empowerment, sense of coherence, or perceived support for diabetes self-management.

CONCLUSIONS

In contrast to previous studies demonstrating that screening programmes can have negative psychological consequences, our findings indicate that participating in this screening programme for DKD does not influence emotional burden or physician-related distress among people with T2D.

Impact of a community-based approach to patient engagement in rural, low-income adults with type 2 diabetes

OBJECTIVE

This secondary analysis examined the relationships between Patient Activation Measure (PAM) scores, use of health services, and HgA1C.

DESIGN

A feasibility study was conducted for a community-based intervention for high-risk adults with uncontrolled diabetes. Data were collected at baseline and monthly, including PAM and modified Diabetes Self-Management Assessment Report Tool.

INTERVENTION

Participants (n = 58) were randomized to a 3-month nurse (RN) telephone management or community health worker (CHW) in-home intervention, focusing on medication adherence, timely follow-up, diabetes self-management coaching, and linkage to resources.

RESULTS

Sample was mostly female (73%), African-American (90%), low income (75%), high school education or less (80%), and mean age of 59 years. A positive association between PAM score and self-reported diabetes care recommendations was found (r = .356, p = .014) and significant correlation between baseline PAM score and HgA1C levels (r = -.306, p = .029). A paired samples t test showed statistically significant increases in PAM scores in the CHW intervention group (mean increase +8.5, CI [+2.49 to +14.65]); baseline (M = 60.31, SD = 13.3) to end of study ([M = 68.89, SD = 16.39], t(22) = 2.924, p = .008 [two-tailed]).

CONCLUSION

A community-based approach to diabetes management demonstrated a positive effect on patient activation. Although disparities in health care access among rural, low-income populations exist, community-based interventions show potential for improving patient engagement in diabetes management and recommended health services.

The Effect of Depression on Poor Glycemic Control in Adults with Type 2 Diabetes: The Mediating Roles of Self-Efficacy and Self-Management Behaviors

<b><i>Background:</i></b> High levels of depression and poor self-efficacy and self-management are associated with worse glycemic control, but the linkage and pathway between these variables are poorly understood. We conducted this study to investigate the hypothesis that self-efficacy and self-management mediate the influence of depression on poor glycemic control. <b><i>Methods:</i></b> We studied a purposive sample of 142 adults with type 2 diabetes attending a public clinic in Ilam, Iran. Hierarchical linear regression analysis and structural equation modeling were used to explore the relationships among the variables of interest. <b><i>Result:</i></b> Depression directly and negatively affects self-efficacy and indirectly affects self-management behaviors, which in turn have direct effects on hemoglobin A1c (HbA1c). Self-efficacy mediates the relationship between depression and self-management behaviors. Self-efficacy and self-management behaviors partially mediate the effect of depression on HbA1c. These results confirmed that the data fit the hypothesized model very well. <b><i>Conclusion:</i></b> Careful monitoring of glycemic control might be important in those individuals who exhibit clinical signs of depression. Effective treatment programs should probably pay close attention to not only screening and treatment of depression but also skills training to enhance patient self-efficacy and self-management of diabetes to improve HbA1c.

The Effects of Mindfulness-Based Interventions on Diabetes-Related Distress, Quality of Life, and Metabolic Control Among Persons with Diabetes: A Meta-Analytic Review

Mindfulness-based interventions (MBIs) have improved psychological outcomes for multiple chronic health conditions, including diabetes. A meta-analytic review of the literature was conducted on all located studies (n = 14) investigating MBIs that targeted diabetes-related distress (DRD) and diabetes-related outcomes among people with Type 1 and Type 2 diabetes. PsychInfo, PubMed, Medline, and Web of Science were searched for MBIs that were designed to improve DRD and other secondary outcomes, including quality of life and measures of metabolic control. A meta-analysis of these outcomes uncovered small-to-moderate effect sizes for intervention studies measuring pretreatment to posttreatment changes in DRD and metabolic control among treatment group participants. However, the pretreatment to follow-up comparisons for DRD and metabolic control were small and unreliable. For control groups, all pre-treatment to post-treatment and pre-treatment to follow-up comparisons were unreliable for all outcomes. A moderate effect size for treatment-control comparisons was found for intervention studies measuring quality of life outcomes at posttreatment, but not at follow-up comparisons. All other effect sizes for treatment-control comparisons were unreliable. Limitations and implications for MBIs among individuals with diabetes are discussed.

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.

Patient activation in individuals with type 2 diabetes mellitus: associated factors and the role of insulin

AIM

This study explored the relationship between insulin use and patient activation (a person's internal readiness and capabilities to undertake health-promoting actions) in individuals with type 2 diabetes mellitus and aimed to identify demographic, clinical and psychosocial factors involved in patient activation.

METHODS

In this cross-sectional study, baseline data from a Dutch nationwide study were analyzed. Patient activation was assessed with the Patient Activation Measure 13. A linear mixed model was used to take clustering into account.

RESULTS

In total, 1,189 persons were included (310 of whom were on insulin), enrolled via 47 general practices and six hospitals. Their mean Patient Activation Measure 13 score was 59±12. We found no association between insulin therapy and patient activation. In the multivariable analysis, individuals with a better health status, very good or very poor social support (vs good social support), individuals who felt they had greater control over their illness and those with a better subjective understanding of their illness showed higher patient activation. Individuals with a lower educational level and those who expected their illness to continue showed a lower activation level.

CONCLUSION

Patient activation does not differ between individuals with type 2 diabetes mellitus on insulin therapy and those on other therapies.

The Design and Testing of the Psychometric Properties of the Person Engagement Index Instrument to Measure a Person's Capacity to Engage in Health Care

BACKGROUND AND PURPOSE

Patient engagement has been considered a powerful tool to improve health outcomes. A composite instrument to measure the factors that impact a person's capacity to engage in his or her health care was an identified gap in the literature. This study developed and tested the psychometric properties of the Person Engagement Index (PEI) instrument.

METHODS

The instrument was tested among 338 medical-surgical inpatients at four health care systems (five facilities), with psychometric evaluation for validity, reliability, and exploratory factor analysis.

RESULTS

Exploratory factor analysis revealed a four-factor solution that accounted for 63.9% of the total variance. Internal consistency results were Cronbach's α = .896 for the overall scale and each subscale: Engagement in Health Care = .885, Technology Use in Health Care = .854, Proactive Approach to Health Care = .728, and Psychosocial Support = .880.

CONCLUSIONS

The results of the PEI study indicate that it is a valid and reliable instrument among the adult medical-surgical population. Further testing of the instrument is recommended among other populations and across the care continuum.

Patient activation among people living with HIV: a cross-sectional comparative analysis with people living with diabetes mellitus

Standardized self-management supports are an integral part of care delivery for many chronic conditions. We used the validated Patient Activation Measure (PAM®) to assess level of engagement for self-management from a sample of 165 people living with HIV (PLWH) and 163 people with diabetes. We conducted multivariable logistic regression to assess associations between demographics and PAM® scores. PLWH had high levels of activation that were no different from those of people with diabetes (mean score = 67.2, SD = 14.2 versus 65.0, SD = 14.9, p = 0.183). After adjusting for patient characteristics, only being on disability compared to being employed or a student was associated with being less activated (AOR = 0.276, 95%CI = 0.103-0.742). Our findings highlight the potential for the implementation of existing standardized chronic disease self-management programs to enhance the care delivery for PLWH, with people on disability as potential target populations.

Glycemic control among primary care patients with type 2 diabetes mellitus in the Gaza Strip, Palestine

AIM

In this study, we aimed to assess the level of good glycemic control, to determine association between adherence to antidiabetic medications and glycosylated hemoglobin (HbA1c) and to examine factors influencing good glycemic control.

MATERIALS AND METHODS

A cross-sectional design was employed among 369 patients with type 2 diabetes mellitus (T2DM) from four Ministry of Health health centers in 2016. A sample of 3 ml blood was taken to measure the HbA1c, and patients were asked to fill out a pretested questionnaire. Univariate and multivariate logistic regressions, to identify independent factors associated with good glycemic control, were conducted using SPSS software version 22 (IBM Corp, Armonk, NY, USA).

RESULTS

Mean [±standard deviation (SD)] of HbA1c was 8.97 (2.02) and one fifth of patients had good glycemic control (HbA1c ⩽ 7%). Factors associated with good glycemic control were: older age [odds ratio (OR) = 0.96, 95% confidence interval (CI): 0.933-0.988), high medication adherence (OR: 2.757, 95% CI: 1.308-4.693), and better health literacy (OR= 2.124, 95% CI: 1.917-4.921). Duration of diabetes mellitus (DM > 7 years) was inversely related to good glycemic control (OR = 2.255, 95% CI: 1.189-4.276).

CONCLUSION

Our study showed that glycemic control was suboptimal, and factors associated with that were: older age, high medication adherence, and better health literacy. Knowledge of these factors could be an entry toward helping patients and targeting interventions to improve glycemic control and prevent diabetes-related complications.

Evaluating the Psychometric Properties of the Arabic Version of the Diabetes Distress Scale

The current study evaluated the psychometric properties of the Arabic version of the Diabetes Distress Scale (DDS-A) among Arab patients with diabetes mellitus (DM) using a descriptive cross-sectional design. Participants' DDS-A total scores significantly correlated with depressive symptoms (r = 0.288, p = 0.000) as well as two subscales, emotional burden (r = 0.276, p = 0.000) and regimen distress (r = 0.265, p = 0.000). Participants' DDS-A scores had significant negative correlations with income, DM self-management, and knowledge (r = -0.184, p = 0.008; r = -0.310, p = 0.000; r = -0.174, p = 0.003, respectively) and a positive correlation with HbA1c level (r = 0.153, p = 0.018). Factor analysis revealed a four-factor solution that retained all items and explained a variance of 65.59%. Cronbach's alpha was 0.822 for the total scale and 0.778 to 0.881 for the subscales, indicating a high internal consistency. The DDS-A was found to be a psychometrically sound measure to evaluate DM-related distress among Arab patients. [Journal of Psychosocial Nursing and Mental Health Services, 55(9), 43-51.].

The effect of guided self-determination on self-management in persons with type 1 diabetes mellitus and HbA1c ≥64 mmol/mol: a group-based randomised controlled trial

OBJECTIVES

To determine whether the impact of guided self-determination (GSD) applied in group training (GSD-GT) in people with chronically elevated HbA_1c and type 1 diabetes mellitus (DM) was superior to 'care as usual' in improving HbA_1c and psychological functioning.

SETTING

An outpatient clinic at a university hospital in Western Norway.

PARTICIPANTS

A total of 178 adults (all Caucasian) aged 18-55 (mean age 36.7±10.7, 62% women) with type 1 DM for at least 1 year and HbA_1c ≥64 mmol/mol (8.0%) were randomly assigned to participate in either GSD-GT or a control group (CG). Exclusion criteria were severe comorbidity, major psychiatric disorder, cognitive deficiency/language barriers and pregnancy.

INTERVENTION

Intervention group met seven times for 2 hours over 14 weeks to promote patient autonomy and intrinsic motivation using reflection sheets and advanced professional communication in accordance with the GSD methodology.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was HbA_1c and secondary outcomes (all outcomes 9 months post intervention) were self-monitored blood glucose frequency, self-reported diabetes competence, autonomy support by healthcare providers (Health Care Climate Questionnaire), autonomous versus controlled diabetes motivation (Treatment Self-Regulation Questionnaire), diabetes distress (Problem Areas In Diabetes Scale (PAID) and Diabetes Distress Scale (DDS)), self-esteem (Rosenberg Self-Esteem Scale) and psychological well-being (World Health Organization five-item Well-Being Index scale).

RESULTS

Among participants allocated to the GSD-GT (=90) 48 completed the study, whereas 83 completed in the CG (n=88). With 95% CIs GSD-GT did not have effect on HbA_1c (B -0.18, CI (-0.48, 0.12), p=0.234). GSD-GT improved autonomy-motivated behaviour (B 0.51, CI (0.25, 0.77), p<0.001), diabetes distress (PAID, B -6.96, CI (-11.40, -2.52), p=0.002), total DDS (B -5.15, CI (-9.34, -0.96), p=0.016), DDS emotional burden (B -7.19, CI (-13.20, -1.19), p=0.019) and self-esteem (B 1.43, CI (0.34, 2.52), p=0.011).

CONCLUSIONS

Results from this behavioural intervention must be interpreted cautiously because of recruitment and attrition problems. Medical outcomes did not improve. Psychological outcomes improved, especially reduced diabetes distress.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov NCT 01317459.

Does patient activation level affect the cancer patient journey?

OBJECTIVES

We assess how patient activation is associated with behaviors and experiences of people with cancer, including: understanding risks; making treatment decisions; communicating with providers; coping with symptoms; and adhering to regimens.

METHODS

The study utilizes survey data from six surveys each including 500 cancer survivors. Multivariate analyses are presented.

RESULTS

Higher activated patients are more than 9 times more likely to feel their treatment plans reflect their values, 4.5 times more likely to cope with side effects, and almost 3.3 times more likely to initiate a healthier diet after their diagnosis, than are less activated patients. Less activated patients are less likely understand their diagnosis, to follow treatment regimens, and to be satisfied with their care.

CONCLUSIONS

The findings show that all along the care continuum, patient activation is associated with differences in experiences.

PRACTICE IMPLICATIONS

The findings point to the value of assessing patients' activation levels at the beginning of their cancer experience.

Diabetes Distress, Depression and Glycemic Control in a Canadian-Based Specialty Care Setting

OBJECTIVES

The objectives of this study were to determine rates of diabetes distress and depression in patients with type 2 diabetes in a tertiary care setting, to examine the relationship among glycemic control, diabetes distress and depression, and to identify predictors of diabetes distress and depression on the basis of demographic and clinical characteristics.

METHODS

We recruited 148 adults with type 2 diabetes who were presenting to a specialty diabetes clinic in Vancouver, British Columbia, Canada. Participants completed a questionnaire measuring diabetes distress, depressive symptoms and demographic backgrounds. The Diabetes Distress Scale was used to assess overall distress as well as 4 distinct distress dimensions, including emotional burden, physician-related, regimen-related and interpersonal distress. The Personal Health Questionnaire-9 was used to assess depressive symptoms. Glycated hemoglobin (A1C) data were also collected.

RESULTS

The prevalence of diabetes distress and depression was 39% and 12% in our population, respectively. A1C levels emerged as a significant predictor of emotional burden (p=0.03) and regimen-related distress (p=0.01); higher A1C levels were associated with increased distress regarding emotional functioning and regimen adherence. A1C levels (p=0.02) and education levels (p=0.03) emerged as predictors of physician-related distress, with higher A1C levels associated with decreased distress regarding confidence in physicians.

CONCLUSIONS

Our findings reveal that the rate of diabetes distress for patients in a tertiary care setting is high. Furthermore, diabetes distress, particularly emotion- and self-care-related distress, plays a significant role in glycemic control, whereas depression does not. Routine screening for diabetes distress as part of an initial specialty clinic evaluation should be explored.

Enhancing mHealth Technology in the Patient-Centered Medical Home Environment to Activate Patients With Type 2 Diabetes: A Multisite Feasibility Study Protocol

BACKGROUND

The potential of mHealth technologies in the care of patients with diabetes and other chronic conditions has captured the attention of clinicians and researchers. Efforts to date have incorporated a variety of tools and techniques, including Web-based portals, short message service (SMS) text messaging, remote collection of biometric data, electronic coaching, electronic-based health education, secure email communication between visits, and electronic collection of lifestyle and quality-of-life surveys. Each of these tools, used alone or in combination, have demonstrated varying degrees of effectiveness. Some of the more promising results have been demonstrated using regular collection of biometric devices, SMS text messaging, secure email communication with clinical teams, and regular reporting of quality-of-life variables. In this study, we seek to incorporate several of the most promising mHealth capabilities in a patient-centered medical home (PCMH) workflow.

OBJECTIVE

We aim to address underlying technology needs and gaps related to the use of mHealth technology and the activation of patients living with type 2 diabetes. Stated differently, we enable supporting technologies while seeking to influence patient activation and self-care activities.

METHODS

This is a multisite phased study, conducted within the US Military Health System, that includes a user-centered design phase and a PCMH-based feasibility trial. In phase 1, we will assess both patient and provider preferences regarding the enhancement of the enabling technology capabilities for type 2 diabetes chronic care management. Phase 2 research will be a single-blinded 12-month feasibility study that incorporates randomization principles. Phase 2 research will seek to improve patient activation and self-care activities through the use of the Mobile Health Care Environment with tailored behavioral messaging. The primary outcome measure is the Patient Activation Measure scores. Secondary outcome measures are Summary of Diabetes Self-care Activities Measure scores, clinical measures, comorbid conditions, health services resource consumption, and technology system usage statistics.

RESULTS

We have completed phase 1 data collection. Formal analysis of phase 1 data has not been completed. We have obtained institutional review board approval and began phase 1 research in late fall 2016.

CONCLUSIONS

The study hypotheses suggest that patients can, and will, improve their activation in chronic care management. Improved activation should translate into improved diabetes self-care. Expected benefits of this research to the scientific community and health care services include improved understanding of how to leverage mHealth technology to activate patients living with type 2 diabetes in self-management behaviors. The research will shed light on implementation strategies in integrating mHealth into the clinical workflow of the PCMH setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02949037. https://clinicaltrials.gov/ct2/show/NCT02949037. (Archived by WebCite at http://www.webcitation.org/6oRyDzqei).

Outcomes of infants born near term

Most research on outcomes of preterm birth has centred on babies born at <32 weeks gestation and at highest risk of mortality and serious morbidity. Recent years have seen a dramatic increase in studies focusing on late preterm infants (34-36 weeks gestation). Early epidemiological studies demonstrated increased risks of mortality and adverse neonatal outcomes in this group, prompting further investigations. These increased risks have been confirmed and more recent studies have also included babies born at 37-38 weeks, now defined as 'early-term' births. It now seems that it is inappropriate to consider term and preterm as a dichotomy; gestational age rather represents a continuum in which risk and severity of adverse outcomes increase with decreasing gestational age, but where measurable effects can be detected even very close to full term. In this review, we summarise current evidence for the outcomes of infants born at late preterm and early-term gestations.

Measuring patient activation: The utility of the Patient Activation Measure within a UK context-Results from four exemplar studies and potential future applications

OBJECTIVE

Patient activation can be measured using the Patient Activation Measure (PAM) developed by Hibbard et al., however, little is known about the uses of the PAM in research and in practice. This study aims to explore its differing utility in four UK exemplar sites.

METHODS

Data from four exemplars in a range of health settings with people living with long-term conditions (i.e. stroke or COPD) were evaluated. PAM scores were described and explored in relation to clinical and sociodemographic variables and outcome measures.

RESULTS

PAM scores illustrated that most with COPD or stroke reported PAM levels of 3 or 4, indicating that they are engaging, but may need help to sustain their scores. The exemplars illustrate the utility of, and potential issues involved in, using PAM as a process/outcome measure to predict activation and the effectiveness of interventions, and as a tool to inform tailoring of targeted interventions.

CONCLUSIONS

The PAM tool has been shown to be useful as an outcome measure, a screening tool to tailor education, or a quality indicator for delivery of care.

PRACTICE IMPLICATIONS

However good demographic and patient history are needed to substantiate PAM scores. Further work is needed to monitor PAM prospectively.

Associations between patient characteristics, social relations, diabetes management, quality of life, glycaemic control and emotional burden in type 1 diabetes

AIM

The objective was to investigate associations between emotional burden and a number of individual variables: patient characteristics, social relations, diabetes management in everyday life, generic quality of life and glycaemic control, including determining to what extend these variables explain the differences in emotional burden in a large Danish population of people with type 1 diabetes.

METHODS

We analysed a cross-sectional survey of 2419 Danish adults with type-1 diabetes mellitus and data from an electronic patient record. Data were analysed using hierarchical regression of factors of interest with emotional burden of diabetes as the dependent variable.

RESULTS

High emotional burden of diabetes was associated with being female, younger age, other chronic illness, low diabetes-specific support, low generic quality of life, low diabetes empowerment and high Hba1c. Low diabetes empowerment, low generic quality of life and low diabetes-specific support were associated with the largest difference in emotional burden level.

CONCLUSIONS

A variety of psychosocial and behavioural factors such as low social support, low generic quality of life and difficulties in managing diabetes are associated with high emotional burden in type-1 diabetes. These findings may call for an expansion of the effort to decrease the emotional burden of diabetes for those who are heavily burdened. Future research should explore the causality of the explored associations as well as potential subgroup differences in order to guide the development of appropriate interventions.

Association between depression and glycemic control among type 2 diabetes patients in Lima, Peru

INTRODUCTION

There is limited and controversial information regarding the potential impact of depression on glycemic control. This study aims to evaluate the association between depression and poor glycemic control. In addition, the prevalence of depression and rates of poor glycemic control were determined.

METHODS

Cross-sectional study performed in the endocrinology unit of two hospitals of ESSALUD in Peru. The outcome of interest was poor glycemic control, evaluated by glycated hemoglobin (HbA1c: <7% versus ≥7%), whereas the exposure of interest was depression defined as 15 or more points in the Patient Health Questionnaire-9 tool. The association of interest was evaluated using Poisson regression models with robust standard errors reporting prevalence ratios (PR) and 95% confidence intervals (95% CI) adjusting for potential confounders.

RESULTS

A total of 277 participants, 184 (66.4%) males, mean age 59.0 (SD: 4.8), and 7.1 (SD: 6.8) years of disease were analyzed. Only 31 participants (11.2%; 95% CI: 7.5%-14.9%) had moderately severe or severe depression, whereas 70 (25.3%; 95% CI 20.3%-30.8%) had good glycemic control. Depression increased the probability of having poor glycemic control (PR=1.32; 95% CI 1.15-1.51) after adjusting for several potential confounders.

CONCLUSIONS

There is an association between depression and poor glycemic control among type 2 diabetes patients. Our results suggest that early detection of depression might be important to facilitate appropriate glycemic control and avoid further metabolic complications.

Longitudinal relationship between diabetes-specific emotional distress and follow-up HbA1c in adults with Type 1 diabetes mellitus

AIM

To examine whether diabetes-specific emotional distress was related to follow-up glycaemic control in adults with Type 1 diabetes mellitus.

METHODS

Adults with Type 1 diabetes mellitus completed the Diabetes Distress Scale and reported sociodemographic information when attending a clinical consultation at a university endocrinology unit. Blood samples to determine baseline HbA1c were taken during consultations. All respondents' HbA1c measurements registered from January 2009 to December 2011 were collected from medical records. The relationship between baseline diabetes-specific emotional distress and HbA1c was examined with linear mixed-effects models in 175 patients with complete data.

RESULTS

After controlling for confounders, baseline diabetes-specific emotional distress and glycaemic control were significantly associated (fixed-effect coefficient 0.40, P < 0.001) and the regimen-related distress subscale had the strongest association with glycaemic control (fixed-effect coefficient 0.47, P < 0.001). The two-item measure of diabetes-specific distress had a weaker but still significant association with glycaemic control (fixed-effect coefficient 0.31, P < 0.001). None of these relationships was significant after adjusting for the baseline HbA1c .

CONCLUSIONS

People with elevated baseline diabetes-specific emotional distress are at risk of prolonged suboptimum glycaemic control; therefore, elevated diabetes-specific emotional distress, especially regimen-related distress, might be an important marker for prolonged suboptimum glycaemic control, and might indicate a need for special attention regarding patient self-management.

Determinants of medication adherence among adults with type 2 diabetes mellitus in three Malaysian public health clinics: a cross-sectional study

Medication adherence (MA) in adults with type 2 diabetes mellitus (T2D) is associated with improved disease control (glycated hemoglobin, blood pressure, and lipid profile), lower rates of death and diabetes-related complications, increased quality of life, and decreased health care resource utilization. However, there is a paucity of data on the effect of diabetes-related distress, depression, and health-related quality of life on MA. This study examined factors associated with MA in adults with T2D at the primary care level. This was a cross-sectional study conducted in three Malaysian public health clinics, where adults with T2D were recruited consecutively in 2013. We used the 8-item Morisky Medication Adherence Scale (MMAS-8) to assess MA as the main dependent variable. In addition to sociodemographic data, we included diabetes-related distress, depressive symptoms, and health-related quality of life as independent variables. Independent association between the MMAS-8 score and its determinants was done using generalized linear models with a gamma distribution and log link function. The participant response rate was 93.1% (700/752). The majority were female (52.8%), Malay (52.9%), and married (79.1%). About 43% of patients were classified as showing low MA (MMAS-8 score <6). Higher income (adjusted odds ratio 0.90) and depressive symptoms (adjusted odds ratio 0.99) were significant independent determinants of medication non-adherence in young adults with T2D. Low MA in adults with T2D is a prevalent problem. Thus, primary health care providers in public health clinics should focus on MA counselling for adult T2D patients who are younger, have a higher income, and symptoms of depression.

A1C Testing and its Sociodemographic Predictors: Implications for Diabetes Self-management Programs

Background:

One of the Healthy People (2020) goals related to the glycated hemoglobin (HbA1C) test is to increase the percentage of adults (aged 18 years and older) with diabetes who have had an HbA1C test at least twice in the past 12 months from 64.6% percent in 2008 to 71.1% by 2020. However, Texas has historically trailed behind several other states in achieving this goal. Targeted interventions for demographic subgroups of population could be a strategy to increase testing. However, little is known about the sociodemographic predictors of A1C test.

Method:

Texas Behavioral Risk Factor Surveillance System (BRFSS) data (2011 and 2012) were used to identify sociodemographic predictors of having had at least one A1C test in the past 12 months among diabetic patients. The sociodemographic predictors examined included age, sex, race/ethnicity, marital status, educational attainment, insurance status, whether or not the respondents had a primary care physician, and age when diabetes was diagnosed. A logistic model was developed to predict the membership.

Results:

Multivariate logistic regression indicated that insurance status and educational attainment are predictors of adherence to an annual A1C test. Those with insurance were nearly 3 times more likely than those without insurance to report adherence to annual A1C test (odds ratio [OR] = 2.82, 95% confidence interval [CI], 1.47-5.42, P = .002), when controlled for all other sociodemographic variables. Likewise, those with more than college-level education were also nearly 3 times more likely than those with less than high school level education to report adherence (OR = 2.74, 95% CI, 1.27-5.89, P = .010).

Conclusion:

Population-based diabetes management programs should consider educational attainment level and insurance status of individuals when developing interventions to increase the rate of adherence to A1C testing recommendation among diabetic patients. Targeting interventions toward individuals with less than high school education and ensuring that diabetic individuals have some form of health insurance coverage may be helpful.

The association between the measurement of adherence to anti-diabetes medicine and the HbA1c

BACKGROUND

Adherence to medicines is important in subjects with diabetes, as nonadherence is associated with an increased risk of morbidity and mortality. However, it is not clear whether there is an association between adherence to medicines and glycaemic control, as not all studies have shown this. One of the reasons for this discrepancy may be that, although there is a standard measure of glycaemic control i.e. HbA1c, there is no standard measure of adherence to medicines. Adherence to medicines can be measured either qualitatively by Morisky or non-Morisky methods or quantitatively using the medicines possession ratio (MPR).

AIMS OF THE REVIEW

The aims of this literature review are (1) to determine whether there is an association between adherence to anti-diabetes medicines and glycaemic control, and (2) whether any such association is dependent on how adherence is measured. Methods A literature search of Medline, CINAHL and the Internet (Google) was undertaken with search terms; 'diabetes' with 'adherence' (or compliance, concordance, persistence, continuation) with 'HbA1c' (or glycaemic control).

RESULTS

Twenty-three studies were included; 10 qualitative and 12 quantitative studies, and one study using both methods. For the qualitative methods measurements of adherence to anti-diabetes medicines (non-Morisky and Morisky), eight out of ten studies show an association with HbA1c. Nine of ten studies using the quantitative MPR, and two studies using MPR for insulin only, have also shown an association between adherence to anti-diabetes medicines and HbA1c. However, the one study that used both Morisky and MPR did not show an association. Three of the four studies that did not show a relationship, did not use a range of HbA1c values in their regression analysis. The other study that did not show a relationship was specifically in a low income population.

CONCLUSIONS

Most studies show an association between adherence to anti-diabetes medicines and HbA1c levels, and this seems to be independent of method used to measure adherence. However, to show an association it is necessary to have a range of HbA1c values. Also, the association is not always apparent in low income populations.

What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs

Patient engagement is an increasingly important component of strategies to reform health care. In this article we review the available evidence of the contribution that patient activation-the skills and confidence that equip patients to become actively engaged in their health care-makes to health outcomes, costs, and patient experience. There is a growing body of evidence showing that patients who are more activated have better health outcomes and care experiences, but there is limited evidence to date about the impact on costs. Emerging evidence indicates that interventions that tailor support to the individual's level of activation, and that build skills and confidence, are effective in increasing patient activation. Furthermore, patients who start at the lowest activation levels tend to increase the most. We conclude that policies and interventions aimed at strengthening patients' role in managing their health care can contribute to improved outcomes and that patient activation can-and should-be measured as an intermediate outcome of care that is linked to improved outcomes.

The role of patient activation in improving blood pressure outcomes in Black patients receiving home care

Variations in patients' self-management knowledge, skills, and confidence as measured by the Patient Activation Measure (PAM) have been linked to variations in health behavior and outcomes. In a randomized trial, we tested two blood pressure (BP) control interventions, one grounded in activation principles. Study participants were Black home care patients (N = 587) with uncontrolled hypertension. This article examines intervention impacts on 12-month PAM score change, other predictors of PAM change, and associations between PAM change and BP outcomes. In multivariate models, the interventions did not significantly affect PAM change. Baseline characteristics associated with increased PAM were lower PAM score, higher income, higher health literacy, younger age, lower systolic BP, diabetes, and fewer medications. PAM increase was associated with a modest reduction in diastolic BP but not with improved systolic BP or BP control. Although studies suggest that increasing activation may lead to improved patient outcomes, this study did not find it to be so.

Questionnaire survey on the continuity of home oxygen therapy after a disaster with power outages

BACKGROUND

After the Great East Japan Earthquake, oxygen-dependent patients in areas experiencing power outages could not continue home oxygen therapy (HOT) without oxygen cylinders. The purpose of this study was to examine use of oxygen cylinders in areas experiencing power outages and the effects of HOT interruption on patients' health.

METHODS

Questionnaires were mailed to 1106 oxygen-dependent patients and HOT-prescribing physicians in Akita, near the disaster-stricken area. We investigated patients' actions when unable to use an oxygen concentrator and classified the patients based on oxygen cylinder use. Patients who experienced an interruption of or reduction in oxygen flow rate by their own judgment were assigned to the "interruption" and "reduction" groups, respectively; those who maintained their usual flow rate were assigned to the "continuation" group. Differences were tested using analysis of variance and the χ2 tests.

RESULTS

In total, 599 patients responded to the questionnaire. Oxygen cylinders were supplied to 574 patients (95.8%) before their oxygen cylinders were depleted. Comparison of the continuation (n=356), reduction (n=64), and interruption (n=154) groups showed significant differences in family structure (p=0.004), underlying disease (p=0.014), oxygen flow rate (p<0.001), situation regarding use (p<0.001), knowledge of HOT (p<0.001), and anxiety about oxygen supply (p<0.001). There were no differences in changes in physical condition.

CONCLUSIONS

Most patients could receive oxygen cylinders after the disaster. Some patients discontinued their usual oxygen therapy, but their overall health status was not affected.

Exploring patient activation in the clinic: measurement from three perspectives

OBJECTIVE

To further conceptualize and operationalize patient activation (PA), using measures from patient, physician, and researcher perspectives.

DATA SOURCE/STUDY SETTING

Multimethod observation in 2010 within a family medicine clinic.

STUDY DESIGN

Part of an intervention with 130 patients with type 2 diabetes, this observational study further looked at PA in 19 physician-patient dyads. Data Collection. Observations occurred in a teaching hospital, which served as recruiting and study site.

PRINCIPAL FINDINGS

PA correlated with knowledge, self-efficacy, promotion orientation, and exercise intent. Patient-reported PA did not correlate with researcher-observed or physician-reported PA behavior. Researcher-observed PA correlated with physician-observation items.

CONCLUSIONS

Results provide evidence for measuring different perspectives in studies of PA. When patients report they are activated in self-management, behavior does not indicate they are active in clinical communication, a critical component of collaborative decision making.