Psychometric properties of the Chinese version of the Problem Areas in Diabetes scale (SG-PAID-C) among high-risk polypharmacy patients with uncontrolled type 2 diabetes in Singapore

Validity of the short-form five-item Problem Area in Diabetes questionnaire as a depression screening tool in type 2 diabetes mellitus patients

AIMS/INTRODUCTION

Depression is prevalent in diabetes patients and associated with poor outcomes, but is currently underdiagnosed, with no firm consensus on screening methods. We evaluated the validity of the short-form five-item Problem Areas in Diabetes (PAID-5) questionnaire as a screening tool for depression, comparing it with the Beck Depression Inventory-II (BDI-II) and nine-item Patient Health Questionnaire (PHQ-9).

MATERIALS AND METHODS

A total of 208 English-speaking adults with type 2 diabetes, recruited from outpatient clinics, completed the BDI-II, PHQ-9 and PAID-5 questionnaires in English. Cronbach's α was used for internal reliability. Convergent validity was examined with BDI-II and PHQ-9. Receiver operating characteristics analyses were used to identify optimal PAID-5 cut-offs for the diagnosis of depression.

RESULTS

All three screening tools were highly reliable, with BDI-II, PHQ-9 and PAID-5 having a Cronbach's α of 0.910, 0.870 and 0.940, respectively. There was a good correlation between BDI-II and PHQ-9, with a correlation co-efficient (r) of 0.73; and a moderate correlation between PAID-5 and PHQ-9, and PAID-5 and BDI-II, with r of 0.55 and 0.55 respectively (P values <0.01). An optimal PAID-5 cut-off ≥9 corresponded to both a BDI-II cut-off >14 (sensitivity 72%, specificity 784%, area under the curve 0.809) and a PHQ-9 cut-off >10 (sensitivity 84%, specificity 74%, area under the curve 0.806). Using a PAID-5 cut-off ≥9, the prevalence of depressive symptoms was 36.1%.

CONCLUSIONS

Depressive symptoms are prevalent in people with type 2 diabetes, with the degree of distress significantly related to the severity of depressive symptoms. PAID-5 is a valid and reliable screening tool, and a score ≥9 could prompt further confirmation for depression.

Patient-reported outcomes for people with diabetes: what and how to measure? A narrative review

Patient-reported outcomes (PROs) are valuable for shared decision making and research. Patient-reported outcome measures (PROMs) are questionnaires used to measure PROs, such as health-related quality of life (HRQL). Although core outcome sets for trials and clinical practice have been developed separately, they, as well as other initiatives, recommend different PROs and PROMs. In research and clinical practice, different PROMs are used (some generic, some disease-specific), which measure many different things. This is a threat to the validity of research and clinical findings in the field of diabetes. In this narrative review, we aim to provide recommendations for the selection of relevant PROs and psychometrically sound PROMs for people with diabetes for use in clinical practice and research. Based on a general conceptual framework of PROs, we suggest that relevant PROs to measure in people with diabetes are: disease-specific symptoms (e.g. worries about hypoglycaemia and diabetes distress), general symptoms (e.g. fatigue and depression), functional status, general health perceptions and overall quality of life. Generic PROMs such as the 36-Item Short Form Health Survey (SF-36), WHO Disability Assessment Schedule (WHODAS 2.0), or Patient-Reported Outcomes Measurement Information System (PROMIS) measures could be considered to measure commonly relevant PROs, supplemented with disease-specific PROMs where needed. However, none of the existing diabetes-specific PROM scales has been sufficiently validated, although the Diabetes Symptom Self-Care Inventory (DSSCI) for measuring diabetes-specific symptoms and the Diabetes Distress Scale (DDS) and Problem Areas in Diabetes (PAID) for measuring distress showed sufficient content validity. Standardisation and use of relevant PROs and psychometrically sound PROMs can help inform people with diabetes about the expected course of disease and treatment, for shared decision making, to monitor outcomes and to improve healthcare. We recommend further validation studies of diabetes-specific PROMs that have sufficient content validity for measuring disease-specific symptoms and consider generic item banks developed based on item response theory for measuring commonly relevant PROs.

Severe distress & denial among Asian patients with Type 2 Diabetes Mellitus in the primary care: A prospective, multicentre study

AIMS

To determine the point-prevalence and distribution of diabetes distress among primary care Asians with Type 2 Diabetes Mellitus (T2DM) and evaluate its association with cardiovascular risk.

METHODS

This was a prospective, multicentre study conducted in two outpatient clinics. Patients aged ≥ 21 years with uncontrolled T2DM (HbA1c > 7.0 % [53 mmol/mol]) and polypharmacy were stratified based on their Framingham Risk Score (FRS-high ≥ 10 %, low < 10 %) and matched in accordance to their baseline HbA1c. Cardiovascular risk was estimated using FRS while diabetes distress was measured using Problem Areas in Diabetes (PAID) scale (denial 0-10, severe distress ≥ 40).

RESULTS

Of 1940 patients approached, 210 were recruited. A final 132 (62.9 %) participants were eligible for analysis. Median PAID score was 17.5 (IQR 6.25-41.56), with an even distribution in each distress category. There was no significant difference in PAID scores between the high and low FRS groups (20.00vs13.75, p = 0.446). Additionally, PAID score distribution within each group was similar (McNemar-Bowker test, p = 0.477). However, a high prevalence of severe distress (31.4 %) and denial (33.8 %) was detected. Among those in denial, 58.7 % had accompanying intermediate-high 10-year cardiovascular risk.

CONCLUSION

In our sample of Asian primary care patients, a high prevalence of severe diabetes distress and denial was detected although no clear association between cardiovascular risk and diabetes distress was found. Future studies should assess the longitudinal changes and impact of other risk factors in diabetes distress. (Abstract: 199 words).

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.

Patient-reported outcome measures for assessing health-related quality of life in people with type 2 diabetes: A systematic review

Patient-Reported Outcome Measures (PROMs) are important tools to assess outcomes relevant to patients, with Health-Related Quality Of Life (HRQOL) as an important construct to be measured. Many different HRQOL PROMs are used in the type 2 diabetes field, however a complete overview of these PROMs is currently lacking. We therefore aimed to systematically describe and classify the content of all PROMs that have specifically been developed or validated to measure (aspects of) HRQOL in people with type 2 diabetes. A literature search was performed in PubMed and EMBASE until 31 December 2021. Studies on the development or validation of a PROM measuring HRQOL, or aspects of HRQOL, in people with type 2 diabetes were included. Title and abstract and full-text screening were conducted by two independent researchers and data extraction was performed independently by one of the researchers. Data were extracted on language in which the PROM was developed, target population, construct(s) being measured, names of (sub)scales and number of items per (sub)scale. In addition, all PROMs and subscales were classified according to specific aspects of HRQOL based on the Wilson & Cleary model (symptom status, functional status, general health perceptions) to aid researchers in PROM selection. In total 220 studies were identified that developed or validated PROMs that measure (aspects of) HRQOL in people with type 2 diabetes. Of the 116 unique HRQOL PROMs, 91 (of the subscales) measured symptom status, 60 measured functional status and 26 measured general health perceptions. In addition, 16 of the PROMs (subscales) measured global quality of life. 61 of the 116 PROMs (subscales) also include characteristics of the individual (e.g. aspects of personality, coping) or environment (e.g. social or financial support) and patient-reported experience measures (PREMs, e.g. measure of a patient's perception of their personal experience of the healthcare they have received, e.g. treatment satisfaction), which are not part of the HRQOL construct. Only 9 of the 116 PROMs measure all aspects of HRQOL based on the Wilson & Cleary model. Finally, 8 of the 116 PROMs stating to measure HRQOL, measured no HRQOL construct. In conclusion, a large number of PROMs are available for people with type 2 diabetes, which intend to measure (aspects of) HRQOL. These PROMs measure a large variety of (sub)constructs, which are not all HRQOL constructs, with a small amount of PROMs not measuring HRQOL at all. There is a need for consensus on which aspects of HRQOL should be measured in people with type 2 diabetes and which PROMs to use in research and daily practice. PROSPERO: CRD42017071012. COMET database: http://www.comet-initiative.org/studies/details/956 .

Measurement Properties of Patient-Reported Outcome Measures for Diabetes: Systematic Review

BACKGROUND

The management of diabetes is complex. There is growing recognition of the use of patient-reported outcome measures (PROMs) as a standardized method of obtaining an outlook on patients' functional status and well-being. However, no systematic reviews have summarized the studies that investigate the measurement properties of diabetes PROMs.

OBJECTIVE

Our aims were to conduct a systematic review of studies investigating the measurement properties of diabetes PROMs by evaluating the methodological quality and overall level of evidence of these PROMs and to categorize them based on the outcome measures assessed.

METHODS

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the Embase, PubMed, and PsychINFO databases. The PROMs were evaluated with the COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) guidelines.

RESULTS

A total of 363 articles evaluating the measurement properties of PROMs for diabetes in the adult population were identified, of which 238 unique PROMs from 248 studies reported in 209 articles were validated in the type 2 diabetes population. PROMs with at least a moderate level of evidence for ≥5 of 9 measurement properties include the Chinese version of the Personal Diabetes Questionnaire (C-PDQ), Diabetes Self-Management Instrument Short Form (DSMI-20), and Insulin Treatment Appraisal Scale in Hong Kong primary care patients (C-ITAS-HK), of which the C-PDQ has a "sufficient (+)" rating for >4 measurement properties. A total of 43 PROMs meet the COSMIN guidelines for recommendation for use.

CONCLUSIONS

This study identified and synthesized evidence for the measurement properties of 238 unique PROMs for patients with type 2 diabetes and categorized the PROMs according to their outcome measures. These findings may assist clinicians and researchers in selecting appropriate high-quality PROMs for clinical practice and research.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020180978; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020180978.

PAID-PL-The Polish Version of the Problem Areas in Diabetes Scale: Perfect Reliability and a One-Factor Structure

PURPOSE

The aim of this study was to assess the structure and validate the Polish version of the Problem Areas in Diabetes (PAID) scale, as the current translations of the original English version significantly vary in their psychometric properties.

PATIENTS AND METHODS

Two hundred and sixteen consecutive Polish outpatients were invited to participate in this international cross-sectional study on depression in diabetes. The research was based on the demographic and clinical characteristics of the study population, including the level of glycated hemoglobin (HbA_1c) and scores obtained in the Polish versions of the following questionnaires: PAID, World Health Organization-Five Well-Being Index (WHO-5), Patient Health Questionnaire 9 (PHQ-9). The psychiatric diagnosis was conducted with the use of Mini-International Neuropsychiatric Interview (M.I.N.I.).

RESULTS

Exploratory factor analyses yielded a 1-factor structure that included all 20 items. The internal consistency of the Polish version of PAID was high (Cronbach α = 0.97). There were significant positive correlation between PAID and PHQ-9 and a negative correlation between PAID and WHO-5. We also observed a negative association between PAID scores and age and a positive correlation between PAID and HbA_1c levels. Patients with depression reported significantly higher PAID scores as compared with those without depressive symptoms.

CONCLUSION

The Polish version of PAID has a one-factor structure and is a reliable, valid outcome measure for Polish outpatients with type 2 diabetes and it may constitute a useful instrument for screening for psychologic issues in diabetic patients during their appointments at the diabetes clinic.

Investigation on the association between diabetes distress and productivity among patients with uncontrolled type 2 diabetes mellitus in the primary healthcare institutions

AIMS

To investigate associations between diabetes distress and productivity, and to identify the potential risk factors that could affect these particular associations.

METHODS

This cross-sectional study was conducted in three outpatient healthcare institutions. Patients aged ≥21 years with uncontrolled T2DM and polypharmacy were included. The Problem Areas in Diabetes (PAID) measuring diabetes distress and Work Productivity and Activity Impairment General Health (WPAI-GH) measuring productivity were administered by trained interviewers.

RESULTS

A total of 259 patients were analysed. Point prevalence of clinically severe diabetes distress, work productivity loss and life productivity loss were 7.7%, 45.0% and 35.1% respectively. Diabetes distress was positively associated with work productivity loss (p = 0.001) and life productivity loss (p < 0.001). Multiple linear regression analysis demonstrated that diabetes distress (p = 0.003), the total number of chronic medications (p = 0.012), insulin therapy (p = 0.027) and the presence of chronic kidney disease (p = 0.038) were significantly associated with work impairment. Diabetes distress (p = 0.001) and the presences of osteoarthritis (p = 0.039) were significantly associated with activity impairment.

CONCLUSION

Healthcare professionals should screen patients for diabetes distress to prevent productivity losses, especially in patients with polypharmacy and/or on insulin and with coexisting osteoarthritis or chronic kidney disease.

When qualitative data contradict quantitative data: diabetes distress in the Chinese-Canadian community

AIMS

To use both quantitative and qualitative approaches to characterize the diabetes distress profile of Chinese-Canadians with Type 2 diabetes and to better understand their experience of living with diabetes.

METHODS

We recruited 40 Chinese-Canadian adults with Type 2 diabetes who completed a Mandarin- or Cantonese-language diabetes education programme in Richmond, British Columbia. Using a mixed-methods sequential explanatory research design, participants first completed a 15-item Chinese version of the Diabetes Distress Scale, which included three subscales: emotional burden, regimen-related distress, and physician distress. The self-report survey was followed by a semi-structured interview that addressed the following diabetes-related topics: perspectives towards the healthcare team, emotional health, diabetes-related concerns and stressors, diabetes diagnosis experience, and sources of social support and diabetes education.

RESULTS

The mean (sd) scores for total distress 1.5 (0.5), emotional burden 1.7 (0.7), regimen-related distress 1.4 (0.5), and physician distress 1.4 (0.9), fell within the 'low distress' range (< 2.0). Qualitative analysis of semi-structured interviews showed that some participants were dissatisfied with diabetes care providers and experienced emotional challenges, particularly early in their diagnosis. Other themes that emerged included eating distress, fear of complications, language barriers, and medication concerns.

CONCLUSIONS

Not only did the qualitative findings from semi-structured interviews capture aspects of diabetes distress that were not included in the quantitative survey, it also uncovered inconsistencies between the two datasets. To more accurately understand the diabetes distress experience of any ethnic community, both quantitative and qualitative approaches contribute unique value.

Risk factors and quality of life of patients with high diabetes-related distress in primary care: a cross-sectional, multicenter study

PURPOSE

This study aimed to examine risk factors and quality of life of patients with high diabetes-related distress (DRD) in primary care.

METHODS

A cross-sectional, multicenter study was conducted in four primary healthcare institutions. Patients aged ≥ 21 years with T2DM were included; patients who were pregnant or unable to communicate independently were excluded from this study. The problem area in diabetes (PAID) measuring DRD, European quality of life-5 dimensions (EQ-5D), and audit of diabetes-dependent quality of life (ADDQoL) measuring quality of life were administered by trained research assistants.

RESULTS

A total of 525 patients were eligible for this study. The mean PAID score was 26.90 ± 20.23, with 27.8% of patients reporting having high DRD (PAID score ≥ 40). Patients who were younger than 50 years (OR 4.577, 95% CI 1.977-10.600) and patients with HbA1c greater than 9% (OR 1.720, 95% CI 1.064-2.779) were at higher risk of having high DRD (p < 0.05). Patients with high DRD have a lower EQ-5D index value (B = - 0.141) and ADDQoL AWI (B = - 1.276) than patients with little/no DRD (p < 0.001).

CONCLUSION

High DRD was more common among younger patients and patients with poorer glycemic control. High DRD was associated with poorer quality of life and early screening and management of DRD is recommended.

Psychometric properties of the Chinese version of the Problem Areas in Diabetes scale (SG-PAID-C) among high-risk polypharmacy patients with uncontrolled type 2 diabetes in Singapore

Aims/Introduction

Undetected diabetes distress is a cause of concern. However, the lack of a validated questionnaire is a barrier to screening for diabetes distress. The aim of the present study was to examine the validity and reliability of the Chinese version of the Problem Areas in Diabetes scale (SG‐PAID‐C), and its association with sociodemographic and clinical parameters in patients with type 2 diabetes.

Materials and Methods

This cross‐sectional study was carried out in four outpatient healthcare institutions in Singapore. Chinese‐speaking patients with uncontrolled type 2 diabetes, polypharmacy, and multiple comorbidities were administered the SG‐PAID‐C and European Quality of Life‐5 Dimensions questionnaires as quality of life measures. The factorial construct, convergent validity and internal consistency of SG‐PAID‐C were evaluated.

Results

The exploratory factor analysis resulted in a three‐factor structure of SG‐PAID‐C with subscales on emotional‐ and management‐related problem (11 items), ability to cope with diabetes problem (3 items) and support‐related problem (2 items). The findings also showed good model fit in the confirmatory factor analysis, and provided support for the construct and convergent validity of SG‐PAID‐C. Overall, the internal consistency of SG‐PAID‐C was good (Cronbach's alpha = 0.900). Sex and duration of diabetes were positively associated with the 16‐item SG‐PAID‐C, whereas age and type of antidiabetic agents were inversely associated with the 16‐item SG‐PAID‐C.

Conclusions

The 16‐item SG‐PAID‐C is a valid and reliable instrument for use among patients with uncontrolled type 2 diabetes in Singapore. Future studies on its clinical utility should be carried out.