What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored Patient-Reported Outcome Measure for the Swedish National Diabetes Register

Monitoring what matters to people with diabetes: Do we underestimate the importance of behaviour, attitude, and well-being?

OBJECTIVE

Despite improvements in diabetes monitoring and treatment many patients do not achieve treatment goals. Person-centred approaches have been proposed. However, their practical implementation lags. One barrier is uncertainty about which person-reported outcomes (PROs) should be considered to add the most value. We sought to identify PROs that may be prioritised.

METHODS

We used data from a multi-stakeholder Delphi study aimed at developing a person-centred diabetes outcome set and analysed which PROs patients considered important for regular monitoring but healthcare providers less so. Linear regression analyses tested whether belonging to either stakeholder group would predict the importance attributed to an outcome.

RESULTS

We found disagreement between patients and healthcare providers on eleven PROs. Stakeholder group predicted perceived importance for ten: self-management behaviours (including performance, perceived importance, motivation, and capacity), sleep quality, diabetes symptoms, screening visit attendance, health status, lifestyle behaviours, and side effects.

CONCLUSION

Our findings suggest that, according to patients' preferences, self-management behaviours, health status and sleep are currently not adequately considered in diabetes management, compromising person-centred care.

PRACTICAL IMPLICATIONS

This study suggests that prioritising these PROs can facilitate the implementation of more person-centred diabetes monitoring which may support better-informed treatment decisions to achieve treatment goals.

Person-reported outcomes in registered randomised diabetes trials: A mapping review of constructs

AIM

Recently, efforts have been made to use and report person-reported outcomes (PROs) in randomised clinical trials (RCTs). Here, we aim to (1) assess the status of inclusion of PROs in registered RCTs over 5 years in people with type 1 or 2 diabetes, and (2) map the PRO measures (PROMs) onto predefined domains.

METHODS

The largest trial registries (Clinicatrials.gov, International Clinical Trial Platform and ISRCTN) were systematically searched for RCTs in people with type 1 and/or type 2 diabetes of all ages between 2018 and 2023. Coding of PROs comprised: (1) PRO measure(s) included yes or no; if yes: (2) PRO(s) as primary outcome yes or no; and (3) mapping PROMs onto predefined PRO domains and per type of intervention.

RESULTS

N = 1543 trials met our inclusion criteria, of which n = 673 (44%) included PROs, assessed by 545 different measures. Twenty per cent of drug trials (n = 112) and 71% of behavioural interventions (n = 405) included PROs. In 149 trials (9.6%), a PRO was the primary outcome. The psychological functioning domain was most often assessed across all trials (21.6%), specifically in behavioural (44.8%) and medical device interventions (29.7%). In drug trials, the physical functioning and functional health domain was most included (9%). Across all trials, the social and family functioning domain was least assessed (3%).

CONCLUSIONS

We noticed an increase in the inclusion of PROs in diabetes RCTs. However, PROs are rarely included as primary outcomes in the majority of studies, particularly in drug trials. The heterogeneity of PROMs used in RCTs underscores the need for standardisation of PROs.

Mixed methods study on the feasibility of implementing periodic continuous glucose monitoring among individuals with type 2 diabetes mellitus in a primary care setting

Background

Health care professionals (HCPs) play a central role in leveraging technologies to support individuals with diabetes. This mixed-method study was completed to determine the feasibility of implementing periodic continuous glucose monitoring (CGM) in a primary care setting.

Aim

This study aimed to evaluate and describe the experiences of using periodic CGM with data visualization tools in patients with type 2 diabetes to foster a person-centered approach in a primary care setting.

Methods

Fifty outpatients aged ≥18 years, diagnosed with type 2 diabetes, and with a disease duration of at least 2 years were included in this study. Data were collected from April 2021 to January 2022. Patients completed a single period of sensor measurements for 28 days and a diabetes questionnaire about feelings and experiences of health care. HbA1c was also measured. A focus group interview was conducted to evaluate and describe the HCPs experiences of using periodic CGM.

Results

Patients reported to HCPs that the CGM device was comfortable to wear and noted that LibreView was easy to use when scanning the sensor to obtain and visualize the glucose levels and trends. Data availability of CGM data was >70 %.Clinical observations revealed a mean reduction in HbA1c, mmol/mol from 60.06 [7.65 %] at baseline to 55.42 [7.20 %] after 4 weeks (p < 0.001). Two categories were identified: 1) Fostering dialogue on self-care and 2) Promoting understanding.

Conclusions

The HCPs and participants in this study had a positive experience or viewed the implementation of periodic CGM with data visualization tools as a positive experience and appeared to be feasible for implementation in a primary care setting.

Investigating Digital Patient-Reported Outcome Measures in Patient-Centered Diabetes Specialist Outpatient Care (DigiDiaS): Protocol for a Multimethod Prospective Observational Study

BACKGROUND

Living with type 1 diabetes is challenging, and to support self-management, repeated consultations in specialist outpatient care are often required. The emergence of new digital solutions has revolutionized how health care services can be patient centered, providing unprecedented opportunities for flexible, high-quality care. However, there is a lack of studies exploring how the use of digital patient-reported outcome measures (PROMs) for flexible specialist care affects diabetes self-management. To provide new knowledge on the relevance of using PROMs in standard care, we have designed a multimethod prospective study.

OBJECTIVE

The overall aim of this protocol is to describe our prospective multimethod observational study designed to investigate digital PROMs in a routine specialist outpatient setting for flexible patient-centered diabetes care (DigiDiaS).

METHODS

This protocol outlines the design of a multimethod prospective observational cohort study that includes data from electronic health records, self-reported questionnaires, clinical consultation field observations, and individual in-depth interviews with patients and diabetes health care personnel. All patients with type 1 diabetes at a designated outpatient clinic were invited to participate and use the digital PROM implemented in clinical care. Both users and nonusers of the digital PROM were eligible for the prospective study, allowing for a comparison of the two groups. Data were collected at baseline and after 12 months, including self-management as the primary outcome assessed using the Patient Activation Measure, along with the secondary outcomes of digital health literacy, quality of life, health economy, and clinical variables such as glycated hemoglobin.

RESULTS

The digital solution was implemented for routine clinical care in the department in November 2021, and data collection for the prospective study started in October 2022. As of September 6, 2023, 84.6% (186/220) of patients among those in the digital PROM and 15.5% (34/220) of patients among the nonusers have consented to participate. We expect the study to have enough participants by the autumn of 2023. With 1 year of follow-up, the results are expected by spring 2025.

CONCLUSIONS

In conclusion, a multimethod prospective observational cohort study can offer valuable insights into the relevance, effectiveness, and acceptability of digital tools using PROMs in diabetes specialist care. Such knowledge is crucial for achieving broad and successful implementation and use of these tools in a large diabetes outpatient clinic.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52766.

Living with Type 1 Diabetes as Experienced by Adults with Prolonged Elevated HbA1c: A Qualitative Study

INTRODUCTION

High HbA1c levels in type 1 diabetes (T1D) are associated with increased risk of micro- and macrovascular complications and severe diabetes distress. A more comprehensive understanding of the adult perspective of living with T1D can improve the quality of care. We aimed to describe experiences of living with T1D as an adult with prolonged elevated HbA1c.

METHODS

Thirteen adults with T1D and HbA1c > 60 mmol/mol (7.6%) for at least 1 year were individually interviewed via a digital platform. The interviews were transcribed verbatim and analyzed using qualitative content analysis.

RESULTS

The analysis identified an overarching theme, "a lifelong follower", and generated two main categories describing study participants' experience: constraining and manageable. Constraining experiences were explained in obligated control, loss of control, environmental impact, and consequences of diabetes. Manageable experiences were described in everyday life, approach to diabetes, and support in life. Diabetes knowledge in health care and in the general public, and individualized care were important factors in feeling understood, safe, and supported.

CONCLUSIONS

The findings revealed the diverse experiences of adults with prolonged elevated HbA1c. Living with T1D, a lifelong non-chosen follower, could be perceived as constraining but manageable in different degrees. A person-centered care approach addressing both dimensions may be beneficial. Experiences of living with and managing diabetes are multifaceted and intertwined with life context and medical prerequisites.

Complementary elements of support after gastric-bypass surgery perceived by adults with previous type 2 diabetes: A qualitative study 2 years after bariatric surgery

Bariatric surgery is the most medically and cost-effective treatment for adults with obesity and type 2 diabetes mellitus (T2DM). Our findings suggest initial improvements in health-related quality of life that may decline as support from follow-up care ends. How patients experience long-term support is not well described. This study therefore aimed to investigate how adults with previous T2DM perceived different sources of support 2 years after bariatric surgery. In this qualitative study, individual interviews were conducted with 13 adults (10 women) 2 years after surgery. Using thematic analysis, one overarching theme (compiling complementary elements of support after gastric-bypass surgery), four themes and nine subthemes emerged. The results show that support was given and received from various sources, support needs varied over time depending on where the patient was in the process and that the sources of support were complementary. To conclude, our results show that support needs change in adults who have undergone bariatric surgery. Long-term professional and day-to-day support from family and other networks are essential and complementary elements of support. Healthcare staff should consider these findings, especially during the early follow-up period.

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.

A qualitative patient interview study to understand the experience of patients with nonalcoholic steatohepatitis

NASH is a potentially progressive form of NAFLD characterized by hepatocyte injury and liver inflammation which can cause fibrosis. Currently, there are limited data on the patient experience of NASH. Our aim was to use both literature review and patient interviews to understand the signs/symptoms and life impacts of NASH fibrosis stages F1-F4 that are important to patients, as well as begin to investigate the applicability of an instrument (ie, questionnaire) that may be used to capture patients' experiences. The literature review identified concepts (signs/symptoms and impacts) related to NASH fibrosis stages F1-F4 and the NASH-specific patient-reported outcome instrument (NASH-CHECK) for reporting patient experience of NASH. Interviews with 22 patients from Canada and the USA with NASH fibrosis stages F1-F4 revealed 27 signs/symptoms and 32 impacts that they felt were important, including fatigue, pain in the abdomen, worry, and frustration. Three concepts reported during patient interviews were not identified in the literature review. No concepts appeared to be exclusive to a specific fibrosis stage or presence/absence of obesity and no linear trends were identified between fibrosis stage or presence/absence of obesity and level of disturbance reported for concepts. The patient interviews supported the concepts included in the NASH-CHECK overall, demonstrating that it could be used to report the patient experience of NASH fibrosis stages F1-F4. Interviews with patients with NASH fibrosis stages F1-F4 revealed patients can self-report and elaborate on signs/symptoms and impacts related to the disease regardless of fibrosis stage. The NASH-CHECK was identified as a suitable instrument that could be used by patients with fibrosis stages F1-F4.

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 .

Factors associated with patient empowerment in Spanish adults with type 2 diabetes: A cross-sectional analysis

OBJECTIVE

The aim of the present study is to identify factors associated with patient empowerment in people living with type 2 diabetes mellitus (T2DM) in the Canary Islands (Spain).

METHODS

Secondary cross-sectional analysis was carried out of data obtained in the INDICA study: A 24-month cluster randomized-controlled trial evaluating the effectiveness of educational interventions supported by new technology decision tools for T2DM patients. Sociodemographic variables, clinical data (years since diagnosis, glycated haemoglobin level, creatine, triglycerides, waist hip index, body mass index and number of comorbidities), diabetes knowledge (DIATEK), affective outcomes (Beck Depression Inventory-II, the State subscale of the State-Trait Anxiety Inventory and The Diabetes Distress Scale) and diabetes-related quality of life (The Audit of Diabetes-Dependent Quality of life) were assessed as potential correlates of patient empowerment, assessed using the Diabetes Empowerment Scale-Short Form. Multilevel mixed linear regression models on patient empowerment were developed.

RESULTS

The analysis included the baseline data of 2334 patients. Results showed that age (B = -0.14; p < .001), diabetes knowledge (B = 0.61; p < .001) and state-anxiety (B = -0.09; p < .001) are significantly associated with patient empowerment. Sex, education level, living alone, employment status, country of birth, time since diagnosis, number of comorbidities, glycated haemoglobin level, depression and distress were not independently associated with patient empowerment in the multivariate analyses.

CONCLUSION

Younger age, lower state-anxiety and greater diabetes-specific knowledge are important correlates of patient empowerment. In line with the results of the INDICA study, interventions based on patient-centred care might be effective in improving patient empowerment in adults with T2DM. Understanding the factors associated with empowerment may help clinicians and policymakers to identify high-risk groups, prioritize resources and target evidence-based interventions to better support people with T2DM to be actively involved in their own care.

PATIENT OR PUBLIC CONTRIBUTION

Patients with T2DM were actively involved in the design of the INDICA study. Two patient associations were included as part of the research team and actively participated in designing the interventions and selecting outcome measures.

Implementing the Digital Diabetes Questionnaire as a Clinical Tool in Routine Diabetes Care: Focus Group Discussions With Patients and Health Care Professionals

BACKGROUND

The Diabetes Questionnaire is a digital patient-reported outcome and experience measure for adults living with diabetes. The Diabetes Questionnaire is intended for use in routine clinical visits in diabetes care and to enable patient perspectives to be integrated into the Swedish National Diabetes Register. The Diabetes Questionnaire was developed on the basis of patients' perspectives, and evidence for its measurement qualities has been demonstrated. Patients receive an invitation to complete the questionnaire before clinical visits, and the patient and health care professional (HCP) can discuss the findings, which are instantly displayed during the visit. Implementation processes for new tools in routine care need to be studied to understand the influence of contextual factors, the support needed, and how patients and HCPs experience clinical use.

OBJECTIVE

The aim of this study was to describe patients' and HCPs' experiences of initiating the use of the digital Diabetes Questionnaire as a clinical tool in routine diabetes care, supported by a structured implementation strategy involving initial education, local facilitators, and regular follow-ups.

METHODS

In this qualitative study, semistructured focus group discussions were conducted 12 months after the use of the Diabetes Questionnaire was initiated. Participants were diabetes specialist nurses and physicians (20 participants in 4 groups) at hospital-based outpatient clinics or primary health care clinics and adults with type 1 or type 2 diabetes (15 participants in 4 groups). The audiotaped transcripts were analyzed using inductive qualitative content analysis.

RESULTS

The results revealed 2 main categories that integrated patients' and HCPs' experiences, which together formed an overarching theme: While implementation demands new approaches, the Diabetes Questionnaire provides a broader perspective. The first main category (The Diabetes Questionnaire supports person-centered clinical visits) comprised comments expressing that the digital Diabetes Questionnaire can initiate and encourage reflection in preparation for clinical visits, bring important topics to light during clinical visits, and broaden the scope of discussion by providing additional information. The second main category (The process of initiating the implementation of the Diabetes Questionnaire) comprised comments that described differences in engagement among HCPs and their managers, challenges of establishing new routines, experiences of support during implementation, thoughts about the Diabetes Questionnaire, need to change local administrative routines, and opportunities and concerns for continued use.

CONCLUSIONS

The Diabetes Questionnaire can broaden the scope of health data in routine diabetes care. While implementation demands new approaches, patients and HCPs saw potential positive impacts of using the questionnaire at both the individual and group levels. Our results can inform further development of implementation strategies to support the clinical use of the questionnaire.

'Striving for freedom or remaining with what is well-known': a focus-group study of self-management among people with type 1 diabetes who have suboptimal glycaemic control despite continuous subcutaneous insulin infusion

INTRODUCTION

Continuous subcutaneous insulin infusion (CSII) treatment is beneficial for obtaining glycaemic control for many persons with type 1 diabetes mellitus (T1DM). Still, some individuals do not obtain improved HbA1C levels despite CSII treatment, and there is a lack of evidence regarding how psychosocial factors may influence glycaemic control. Thus, we aimed to explore the attitudes and experiences of self-management among people with T1DM and suboptimal glycaemic control despite CSII treatment.

RESEARCH DESIGN AND METHODS

A qualitative inductive design was applied, and four FGDs were performed with 37 adult men and women of various ages and duration of T1DM. All participants had suboptimal glycaemic control despite CSII treatment. Transcripts were analysed using qualitative manifest and latent content analysis.

RESULTS AND CONCLUSION

The themes Searching for freedom and flexibility and Preferring safety and the well-known illustrated the divergent psychosocial strategies adapted, which both resulted in suboptimal glycaemic control. The technical devices and their effects on glycaemic levels may be challenging to understand and adjust to fit people's lifestyles. The rapid advances of technology devices in diabetes care can potentially change peoples' lives, but is the educational support developing as fast? Multifaceted web-based education of high quality, including tailored support with a person-centred focus, is more important than ever before as the need for technical knowledge and understanding may put further disease burdens to patients with T1DM on CSII treatment.

Patient-Reported Experience and Outcome Measures in People Living with Diabetes: A Scoping Review of Instruments

BACKGROUND

Diabetes mellitus is a global public health concern, with over 463 million people living with this chronic disease. Pathology complexity, management difficulty, and limited participation in care has resulted in healthcare systems seeking new strategies to engage people living with diabetes. Patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) were developed to address the gap between the healthcare system expectation and patient preference.

OBJECTIVE

This study aimed to review the existing literature on PREMs and PROMs specific to type 1 and 2 diabetes, and report the dimensions report the dimensions they have measured.

METHODS

A scoping review was conducted from January 1985 to March 2020 of six databases, MEDLINE, EMBASE, PsycINFO, CINHAL, Scopus, and BiblioPro, to identify PREM and PROM instruments specific for type 1 and 2 diabetes.

RESULTS

Overall, 34 instruments were identified, 32 PROMs and two PREMs. The most common instrument included outcomes related to quality of life at 44% (n = 15), followed by satisfaction (whether with treatment, device, and healthy habits) at 26% (n = 9). Furthermore, instruments regarding personal well-being accounted for 15% (n = 5). For instruments that measure experiences of persons with diabetes, there were two scales of symptoms, and one related to the attitude patients have toward the disease.

CONCLUSIONS

Diabetes-specific validated instruments mainly focus on quality of life, education, and treatment, and sometimes overlap each other, in their subscales and assessment dimensions. Constructs such as cultural and religious beliefs, leisure, and work life may need more attention. There appears to be a gap in instruments to measure experiences of individuals who "live with diabetes" and seek to lead a "normal life."

Older People With Type 2 Diabetes-Individualising Management With a Specialised Community Team (OPTIMISE): Perspectives of Participants on Care

Despite the high prevalence of diabetes in older people, there is limited information on optimal methods to support their diabetes management, including how to incorporate technology. This article reports on the results of semi-structured interviews with 41 adult participants with type 2 diabetes (mean age 74 ± 7 years) on their perspectives of a new model of care (the Older People With Type 2 Diabetes-Individualising Management With a Specialised Community Team [OPTIMISE] program) for older people with type 2 diabetes. The OPTIMISE program involved telemedicine consultations, home visits by a credentialed diabetes educator, and intermittent flash glucose monitoring. Human connection and relationships were key to the positive perspectives expressed by participants in this program that used technology to enhance the care of older people in their homes.

Protocol for implementation of the 'AusPROM' recommendations for elective surgery patients: a mixed-methods cohort study

INTRODUCTION

Incorporating patient-reported outcome measures (PROMs) into usual care in hospitals can improve safety and quality. Gaps exist in electronic PROM (ePROM) implementation recommendations, including for elective surgery. The aims are to: (1) understand barriers and enablers to ePROM implementation in hospitals and develop Australian ePROM implementation recommendations (AusPROM); (2) test the feasibility and acceptability of the Quality of Recovery 15 item short-form (QoR-15) PROM for elective surgery patients applying the AusPROM and (3) establish if the QoR-15 PROM has concurrent validity with the EQ-5D-5L.

METHODS AND ANALYSIS

Phase I will identify staff barriers and facilitators for the implementation of the AusPROM recommendations using a Delphi technique. Phase II will determine QoR-15 acceptability for elective surgery patients across four pilot hospitals, using the AusPROM recommendations. For phase II, in addition to a consumer focus group, patients will complete brief acceptability surveys, incorporating the QoR-15, in the week prior to surgery, in the week following surgery and 4 weeks postsurgery. The primary endpoint will be 4 weeks postsurgery. Phase III will be the national implementation of the AusPROM (29 hospitals) and the concurrent validity of the QoR-15 and generic EQ-5D-5L. This protocol adopts the Guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trials Protocols guidelines.

ETHICS AND DISSEMINATION

The results will be disseminated via public forums, conferences and peer-reviewed journals. Ethics approval: La Trobe University (HEC20479).

TRIAL REGISTRATION NUMBER

ACTRN12621000298819 (Phase I and II) and ACTRN12621000969864 (Phase III).

The participatory development of a national core set of person-centred diabetes outcome constructs for use in routine diabetes care across healthcare sectors

BACKGROUND

This study sought to utilise participatory research methods to identify the perspectives of people with diabetes regarding which diabetes outcomes were most important to them. These findings were then used to support an expert working group representing multiple health sectors and healthcare disciplines and people with diabetes to establish a core set of patient-important outcome constructs for use in routine diabetes care.

METHODS

26 people with diabetes and family members were recruited through purposive sampling to participate in interviews, focus groups, voting and plenary activities in order to be part of identifying outcome constructs. Content and qualitative analysis methods were used with literature reviews to inform a national multi-stakeholder consensus process for a core set of person-centred diabetes outcome constructs to be used in routine diabetes care across health care settings.

RESULTS

21 people with diabetes and 5 family members representing type 1 and 2 diabetes and a range of age groups, treatment regimens and disease burden identified the following patient-reported outcome constructs as an important supplement to clinical indicators for outcome assessment in routine diabetes care: self-rated health, psychological well-being, diabetes related emotional distress and quality of life, symptom distress, treatment burden, blood sugar regulation and hypoglycemia burden, confidence in self-management and confidence in access to person-centred care and support. Consensus was reached by a national multi-stakeholder expert group to adopt measures of these constructs as a national core diabetes outcome set for use in routine value-based diabetes care.

CONCLUSIONS

We found that patient-reported outcome (PRO) constructs and clinical indicators are needed in core diabetes outcome sets to evaluate outcomes of diabetes care which reflect key needs and priorities of people with diabetes. The incorporation of patient-reported outcome constructs should be considered complementary to clinical indicators in multi-stakeholder value-based health care strategies. We found participatory research methods were useful in facilitating the identification of a core prioritised set of diabetes outcome constructs for routine value-based diabetes care. The use of our method for involving patients may be useful for similar efforts in other disease areas aimed at defining suitable outcomes of person-centred value-based care. Future research should focus on developing acceptable and psychometrically valid measurement instruments to evaluate these outcome constructs as part of routine diabetes care.

Perceived Benefits, Barriers, and Facilitators of a Digital Patient-Reported Outcomes Tool for Routine Diabetes Care: Protocol for a National, Multicenter, Mixed Methods Implementation Study

BACKGROUND

There is growing evidence that digital patient-reported outcome (PRO) questionnaires and PRO-based decision support tools may help improve the active engagement of people with diabetes in self-care, thereby improving the quality of care. However, many barriers still exist for the real-world effectiveness and implementation of such PRO tools in routine care. Furthermore, limited research has evaluated the acceptability, feasibility, and benefits of such tools across different health care settings.

OBJECTIVE

This study aims to evaluate the acceptability, feasibility, and perceived benefits of the Danish digital PRO diabetes tool in different health care settings in Denmark and to determine the factors affecting its implementation. Furthermore, the study evaluates the psychometric characteristics of the Danish PRO Diabetes Questionnaire and the validity of the scoring algorithms for dialogue support. The objective of this study is to guide the ongoing optimization of the PRO diabetes tool, its implementation, and the design of future randomized controlled effectiveness studies.

METHODS

We designed a multicenter, mixed methods, single-arm acceptability-feasibility implementation study protocol to contribute to the real-world pilot test of a new digital PRO diabetes tool in routine diabetes care. The use of the tool involves two main steps. First, the people with diabetes will complete a digital PRO Diabetes Questionnaire in the days before a routine diabetes visit. Second, the health care professional (HCP) will use a digital PRO tool to review the PRO results together with the people with diabetes during the visit. The PRO diabetes tool is designed to encourage and support people to take an active role for the people with diabetes in their own care and to expedite the delivery of person-centered, collaborative, and coordinated care.

RESULTS

A multicenter pilot study protocol and psychometrically designed digital data collection tools for evaluation were developed and deployed as part of a national evaluation of a new digital PRO diabetes intervention. A total of 598 people with diabetes and 34 HCPs completed the study protocol by April 1, 2021.

CONCLUSIONS

A large-scale, mixed methods, multicenter study for evaluating the use of the nationally developed PRO Diabetes Questionnaire in routine care across all health care sectors in Denmark by using the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model as a framework has been designed and is ongoing. This study is expected to provide new important and detailed information about the real-world acceptability, perceived relevance, and benefits of the PRO diabetes tool among a large heterogeneous population of people with diabetes in Denmark and HCPs in different care settings. The results will be used to further improve the PRO tool, design implementation facilitation support strategies, and design future controlled effectiveness studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28391.

Living with type 2 diabetes mellitus in the Kingdom of Tonga: a qualitative investigation of the barriers and enablers to lifestyle management

BACKGROUND

Despite the increasing prevalence of Type 2 Diabetes Mellitus (T2DM) in the Kingdom of Tonga, little is known of non-communicable disease experiences among adults living in this location. This investigation aimed to explore the barriers and enablers to healthy lifestyle in a group of men and women living with T2DM residing in this Pacific Island nation.

METHODS

This qualitative study consisted of three semi-structured focus groups (n = 16), conducted at the only Tongan Public Hospital located at Nuku'alofa, capital of Tonga (north coast of the island of Tongatapu). Discussions were audio-recorded, transcribed, cross-checked for consistency, and entered into a word processing document for analysis. Thematic analysis was employed to synthesise results.

RESULTS

Four main themes were identified: (1) Knowledge and Support; (2) Fear and Motivation; 3) Physical and Psychological Environment; and (4) Faith and Culture.

CONCLUSIONS

The qualitative findings from this study will assist the future development and information dissemination of culturally appropriate lifestyle-related for men and women living with T2DM in the Kingdom of Tonga. The need for collaboration between practitioners at the hospital, the church, family members, and local traditional healers is important if the lifestyle-related needs and wants of this group of people are to be met.

Needs and resources of people with type 2 diabetes in peri-urban Cochabamba, Bolivia: a people-centred perspective

BACKGROUND

The rising prevalence of type 2 diabetes results in a worldwide public healthcare crisis, especially in low- and middle-income countries (LMICs) with unprepared and overburdened health systems mainly focused on infectious diseases and maternal and child health. Studies regarding type 2 diabetes in LMICs describe specific interventions ignoring a comprehensive analysis of the local factors people see influential to their health. This study aims to meet this research gap by exploring what people with type 2 diabetes in Bolivia need to maintain or improve their health, how important they perceive those identified needs and to what extent these needs are met.

METHODS

From March until May 2019, 33 persons with type 2 diabetes from three periurban municipalities of the department of Cochabamba participated in this study. The concept mapping methodology by Trochim, a highly structured qualitative brainstorming method, was used to generate and structure a broad range of perspectives on what the participants considered instrumental for their health.

RESULTS

The brainstorming resulted in 156 original statements condensed into 72 conceptually different needs and resources, structured under nine conceptual clusters and four action domains. These domains illustrated with vital needs were: (1) self-management with use of plants and the possibility to measure sugar levels periodically; (2) healthcare providers with the need to trust and receive a uniform diagnosis and treatment plan; (3) health system with opportune access to care and (4) community with community participation in health and safety, including removal of stray dogs.

CONCLUSIONS

This study identifies mostly contextual factors like low literacy levels, linguistic problems in care, the need to articulate people's worldview including traditional use of natural remedies with the Bolivian health system and the lack of expertise on type 2 diabetes by primary health care providers. Understanding the needs and structuring them in different areas wherein action is required serves as a foundation for the planning and evaluation of an integrated people centred care program for people with type 2 diabetes. This participative method serves as a tool to implement the often theoretical concept of integrated people centred health care in health policy and program development.

Diabetes care provided by national standards can improve patients' self-management skills: A qualitative study of how people with type 2 diabetes perceive primary diabetes care

BACKGROUND

The increasing incidence of type 2 diabetes mellitus [T2DM] has resulted in extensive research into the characteristics of successful primary diabetes care. Even if self-management support and continuity are increasingly recognized as important, there is still a need for deeper understanding of how patients' experiences of continuity of care coincide with their needs for self-management and/or self-management support.

OBJECTIVE

To gain a deeper understanding of how people with T2DM perceive Swedish primary diabetes care and self-management support.

METHODS

This qualitative study used focus groups as the means for data collection. Participants were identified through a purposive sampling method differing in age, sex, diabetes duration and latest registered glycated haemoglobin level. Twenty-eight participants formed five focus groups. Qualitative content analysis was applied to interview transcripts.

RESULTS

The main theme emerging from the focus group data was that diabetes care provided by national standards improved self-management skills. Two themes that emerged from the analysis were (a) the importance of a clarification of structures and procedures in primary diabetes care and (b) health-care staff 'being there' and providing support enables trust and co-operation to enhance self-management.

CONCLUSIONS

Individual patients' self-management resources are strengthened if the importance of providing relational continuity, management continuity and informational continuity is considered. Patients also need assistance on 'how' self-management activities should be performed.

PATIENT CONTRIBUTION

Prior to the study, one pilot focus group was conducted with patients to obtain their perspectives on the content of the planned focus groups; thus, patients were involved in both planning and conduct of the study.

Feasibility of the Web-Based Intervention Designed to Educate and Improve Adherence Through Learning to Use Continuous Glucose Monitor (IDEAL CGM) Training and Follow-Up Support Intervention: Randomized Controlled Pilot Study

Background

Proper training and follow-up for patients new to continuous glucose monitor (CGM) use are required to maintain adherence and achieve diabetes-related outcomes. However, CGM training is hampered by the lack of evidence-based standards and poor reimbursement. We hypothesized that web-based CGM training and education would be effective and could be provided with minimal burden to the health care team.

Objective

The aim of this study was to perform a pilot feasibility study testing a theory-driven, web-based intervention designed to provide extended training and follow-up support to adolescents and young adults newly implementing CGM and to describe CGM adherence, glycemic control, and CGM-specific psychosocial measures before and after the intervention.

Methods

The “Intervention Designed to Educate and improve Adherence through Learning to use CGM (IDEAL CGM)” web-based training intervention was based on supporting literature and theoretical concepts adapted from the health belief model and social cognitive theory. Patients new to CGM, who were aged 15-24 years with type 1 diabetes for more than 6 months were recruited from within a public university’s endocrinology clinic. Participants were randomized to enhanced standard care or enhanced standard care plus the IDEAL CGM intervention using a 1:3 randomization scheme. Hemoglobin A_1c levels and psychosocial measures were assessed at baseline and 3 months after start of the intervention.

Results

Ten eligible subjects were approached for recruitment and 8 were randomized. Within the IDEAL CGM group, 4 of the 6 participants received exposure to the web-based training. Half of the participants completed at least 5 of the 7 modules; however, dosage of the intervention and level of engagement varied widely among the participants. This study provided proof of concept for use of a web-based intervention to deliver follow-up CGM training and support. However, revisions to the intervention are needed in order to improve engagement and determine feasibility.

Conclusions

This pilot study underscores the importance of continued research efforts to optimize the use of web-based intervention tools for their potential to improve adherence and glycemic control and the psychosocial impact of the use of diabetes technologies without adding significant burden to the health care team. Enhancements should be made to the intervention to increase engagement, maximize responsiveness, and ensure attainment of the skills necessary to achieve consistent use and improvements in glycemic control prior to the design of a larger well-powered clinical trial to establish feasibility.

Trial Registration

ClinicalTrials.gov NCT03367351, https://clinicaltrials.gov/ct2/show/NCT03367351.

Awareness regarding COVID-19 and problems being faced by young adults with type 1 diabetes mellitus amid nationwide lockdown in India: A qualitative interview study

AIMS

To assess the awareness about COVID-19 and the problems being faced by young adults with T1DM amid nationwide lockdown in India.

METHODS

A cross-sectional telephone-based qualitative interview study was conducted in young adults (aged 18-30 years) with T1DM amid lockdown. Following verbal consent, participants were asked 8 open-ended questions, 5 on awareness about COVID-19 and 3 catering to problems being faced concerning diet, physical activity and treatment amid lockdown. On average, 3 interviews were conducted per day with each lasting for 15-20 min. Interviews were recorded, transcribed and analyzed by qualitative content analysis.

RESULTS

Thirty-two participants were interviewed; after exclusion of two poorly recorded interviews, 30 were finally analyzed. Mean age of participants was 22.4 ± 4.0 years (M:F = 8:7). Only 30%, 40% and 53% of participants were aware of modes of transmission (respiratory droplets and fomites), cardinal symptoms (fever, cough and breathing difficulty) and means of prevention (staying indoors, social distancing and regular hand washing), respectively. Majority of participants were unaware of additional risks associated with COVID-19 in diabetes mellitus. Most participants could continue with their routine diet and prescribed treatment regime, however, 90% reported a reduction in physical activity and 72% experienced worsening of glycemic control amid lockdown.

CONCLUSIONS

Young adults with T1DM lack adequate awareness about COVID-19. Increasing awareness and imparting diabetes self-management education via digital/print media is needed.

New Diabetes Questionnaire to add patients' perspectives to diabetes care for adults with type 1 and type 2 diabetes: nationwide cross-sectional study of construct validity assessing associations with generic health-related quality of life and clinical variables

OBJECTIVES

To study evidence for construct validity, the aim was to describe the outcome from the recently developed Diabetes Questionnaire, assess the associations of that outcome with clinical variables and generic health-related quality of life, and study the sensitivity to differences between clinically relevant groups of glycaemic control in adults with type 1 and type 2 diabetes in a nation-wide setting.

DESIGN

Cross-sectional survey.

SETTING

Swedish diabetes care clinics connected to the National Diabetes Register (NDR).

PARTICIPANTS

Among 2479 adults with type 1 diabetes and 2469 with type 2 diabetes selected at random from the NDR, 1373 (55.4%) with type 1 and 1353 (54.8%) with type 2 diabetes chose to participate.

OUTCOME MEASURES

The Diabetes Questionnaire, the generic 36-item Short Form version 2 (SF-36v2) health survey and clinical variables.

RESULTS

Related to the prespecified assumptions, supporting evidence for construct validity for the Diabetes Questionnaire was found. Supporting divergent validity, the statistically significant correlations with the clinical variables were few and weak. In relation to the SF-36v2 and in support of convergent validity, the strongest correlations were seen in the Diabetes Questionnaire scales General Well-being and Mood and Energy. In those scales, machine learning analyses showed that about 40%-45% of the variance was explained by the SF-36v2 results and clinical variables. In multiple regression analyses among three groups with differing levels of glycated haemoglobin adjusted for demographics, other risk factors, and diabetes complications, the high-risk group had, in support of sensitivity to clinically relevant groups, statistically significant lower scores than the well-controlled group in most Diabetes Questionnaire scales.

CONCLUSIONS

This nation-wide study shows that the Diabetes Questionnaire captures some generic health-related quality-of-life dimensions, in addition to adding diabetes-specific information not covered by the SF-36v2 and clinical variables. The Diabetes Questionnaire is also sensitive to differences between clinically relevant groups of glycaemic control.

Experiences of self-management support in patients with diabetes and multimorbidity: a qualitative study in Norwegian general practice

Aim:

The purpose of this study was to explore how patients with diabetes and multimorbidity experience self-management support by general practitioners (GPs), nurses and medical secretaries in Norwegian general practice.

Background:

Self-management support is recognised as an important strategy to improve the autonomy and well-being of patients with long-term conditions. Collaborating healthcare professionals (cHCPs), such as nurses and medical secretaries, may have an important role in the provision of self-management support. No previous study has explored how patients with diabetes and multimorbidity experience self-management support provided by cHCPs in general practice in Norway.

Methods:

Semi-structured interviews with 11 patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) with one or more additional long-term condition were performed during February–May 2017.

Findings:

Patients experienced cHCPs as particularly attentive towards the psychological and emotional aspects of living with diabetes. Compared to GPs, whose appointments were experienced as stressful, patients found cHCPs more approachable and more likely to address patients’ questions and worries. In this sense, cHCPs complemented GP-led diabetes care. However, neither cHCPs nor GPs were perceived to involve patients’ in clinical decisions or goal setting during consultations.

A virtual clinic for the management of diabetes-type 1: study protocol for a randomised wait-list controlled clinical trial

BACKGROUND

Diabetes is a serious chronic disease. Medical treatment and good psychosocial support are needed to cope with acute and long-term effects of diabetes. Self-management is a large part of diabetes management, with healthcare providers playing a supportive role. Young adults with type 1 diabetes are of special interest as they tend to have higher mean glycosylated haemoglobin values than other patients with type 1 diabetes, and they often miss visits in traditional diabetes care. A well-designed virtual solution may improve a range of measures (e.g. glycaemic control and perceived health) and reduce hospitalisations.

METHOD

This randomised controlled trial with a control group using a wait list design will recruit 100 young adults from a hospital in Sweden. All participants will receive usual diabetes care besides the virtual clinic. The primary objective is to evaluate the effect of a virtual diabetes clinic on glycaemic control, treatment satisfaction and quality of life in young adults (aged 18-25 years) with type-1 diabetes. The secondary objective is to determine the effects of virtual care on the patient experience.

DISCUSSION

Virtual tools are becoming increasingly common in healthcare; however, it remains unclear if these tools improve diabetes self-management. The results of this study will build understanding of how healthcare providers can use a virtual clinic to improve diabetes self-management.

TRIAL REGISTRATION

Current controlled trials: ISRCTN, number: 73435627, registered 23 October 2019. https://doi.org/10.1186/ISRCTN73435627.

Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: A nationwide register-based cohort study

AIMS

To examine if personnel resources and organisational features in Swedish primary health-care centres (PHCCs) are associated to all-cause mortality (ACM) in people with type 2 diabetes mellitus (T2DM).

METHODS

A total of 187,570 people with T2DM registered in the Swedish National Diabetes Register (NDR) during 2013 were included in this nationwide cohort study. Individual NDR data were linked to data from a questionnaire addressing personnel resources and organisational features for 787 (68%) PHCCs as well as to individual data on socio-economic status and comorbidities. Furthermore, data on ACM were obtained and followed up until 30 January 2018. Hierarchical Cox regression analyses were applied.

RESULTS

After a median follow-up of 4.2 years, 27,136 (14.5%) participants had died. An association was found between number of whole-time-equivalent (WTE) general practitioner's (GP's) devoted to diabetes care/500 people with T2DM and lower risk of early death (hazard ratio 0.919 [95% confidence interval 0.895-0.945] per additional WTE GP; p = 0.002). No other personnel resources or organisational features were significantly associated with ACM.

CONCLUSIONS

This nationwide register-based cohort study suggests that the number of WTE GPs devoted to diabetes care have an impact on the risk of early death in people with T2DM.

Investigation of a Mobile Health Texting Tool for Embedding Patient-Reported Data Into Diabetes Management (i-Matter): Development and Usability Study

Background

Patient-reported outcomes (PROs) are increasingly being used in the management of type 2 diabetes (T2D) to integrate data from patients’ perspective into clinical care. To date, the majority of PRO tools have lacked patient and provider involvement in their development, thus failing to meet the unique needs of end users, and lack the technical infrastructure to be integrated into the clinic workflow.

Objective

This study aims to apply a systematic, user-centered design approach to develop i-Matter (investigating a mobile health [mHealth] texting tool for embedding patient-reported data into diabetes management), a theory-driven, mobile PRO system for patients with T2D and their primary care providers.

Methods

i-Matter combines text messaging with dynamic data visualizations that can be integrated into electronic health records (EHRs) and personalized patient reports. To build i-Matter, we conducted semistructured group and individual interviews with patients with T2D and providers, a design thinking workshop to refine initial ideas and design the prototype, and user testing sessions of prototypes using a rapid-cycle design (ie, design-test-modify-retest).

Results

Using an iterative user-centered process resulted in the identification of 6 PRO messages that were relevant to patients and providers: medication adherence, dietary behaviors, physical activity, sleep quality, quality of life, and healthy living goals. In user testing, patients recommended improvements to the wording and timing of the PRO text messages to increase clarity and response rates. Patients also recommended including motivational text messages to help sustain engagement with the program. The personalized report was regarded as a key tool for diabetes self-management by patients and providers because it aided in the identification of longitudinal patterns in the PRO data, which increased patient awareness of their need to adopt healthier behaviors. Patients recommended adding individualized tips to the journal on how they can improve their behaviors. Providers preferred having a separate tab built into the EHR that included the personalized report and highlighted key trends in patients’ PRO data over the past 3 months.

Conclusions

PRO tools that capture patients’ well-being and the behavioral aspects of T2D management are important to patients and providers. A clinical trial will test the efficacy of i-Matter in 282 patients with uncontrolled T2D.

Trial Registration

ClinicalTrials.gov NCT03652389; https://clinicaltrials.gov/ct2/show/NCT03652389

Patients' and Health Care Professionals' Perceptions of the Potential of Using the Digital Diabetes Questionnaire to Prepare for Diabetes Care Meetings: Qualitative Focus Group Interview Study

Background

In effective diabetes management, it is important that providers and health care systems prioritize the delivery of patient-centered care and that they are respectful of and responsive to individual patient preferences and barriers.

Objective

The objective of the study was to conduct focus group interviews to capture patients’ and health care professionals’ perceptions and attitudes regarding digital technology and to explore how the digital Diabetes Questionnaire can be used to support patient participation in diabetes care, as a basis for an implementation study.

Methods

A qualitative study was conducted with six focus group discussions with diabetes specialist nurses and medical doctors (n=29) and four focus group discussions with individuals with diabetes (n=23). A semistructured focus group interview guide was developed, including probing questions. The data were transcribed verbatim, and qualitative content analysis was performed using an inductive approach.

Results

Two main categories were revealed by the qualitative analysis: perceptions of digital technology and the digital questionnaire in diabetes management and care and perceptions of participation in diabetes care. An overarching theme that emerged from the focus group interviews was patients’ and professionals’ involvement in diabetes care using digital tools.

Conclusions

The analysis identified important factors to consider when introducing the digital Diabetes Questionnaire in clinical use. Both professionals and patients need support and training in the practical implementation of the digital questionnaire, as well as the opportunity to provide feedback on the questionnaire answers.

Explaining variance in health literacy among people with type 2 diabetes: the association between health literacy and health behaviour and empowerment

Background

To reflect the health literacy (HL) skills needed for managing type 2 diabetes (T2DM) in everyday life, HL in people with T2DM should be measured from a broader perspective than basic skills, such as proficiency in reading and writing. The HLS-Q12, based on the European Health Literacy Survey Questionnaire (HLS-EU-Q47), assesses four cognitive domains across three health domains. International studies on people with T2DM show inconsistent results regarding the association between HL and general health and the association between HL and glycaemic control. Moreover, knowledge is needed related to the link between HL and empowerment for those with T2DM. The aims of this study were to examine the association between i) HL and general health and diabetes outcomes, ii) HL and health behaviours and iii) HL and empowerment in people with T2DM.

Methods

During March and April 2015, 388 adults with T2DM responded to a paper-and-pencil self-administered questionnaire. A sequential multiple regression analysis was applied to explore the association between HL, as measured by the HLS-Q12, and health conditions, HbA1c, health behaviours and empowerment.

Results

For people with T2DM, higher levels of HL were associated with higher levels of education, better overall health conditions and higher self-perceived empowerment. No empirical evidence strengthening either the link between HL and glycaemic control or the link between HL and health behaviours was found.

Conclusions

The independent variables education level, overall health condition and empowerment explained about one-third of the total observed variance in HL.

Quality of life in chronic conditions using patient-reported measures and biomarkers: a DEA analysis in type 1 diabetes

BACKGROUND

A chronic disease impacts a patient's daily life, with the burden of symptoms and managing the condition, and concerns of progression and disease complications. Such aspects are captured by Patient-Reported Outcomes Measures (PROM), assessments of e.g. wellbeing. Patient-Reported Experience Measures (PREM) assess patients' experiences of healthcare and address patient preferences. Biomarkers are useful for monitoring disease activity and treatment effect and determining risks of progression and complications, and they provide information on current and future health. Individuals may differ in which among these aspects they consider important. We aimed to develop a measure of quality of life using biomarkers, PROM and PREM, that would provide an unambiguous ranking of individuals, without presuming any specific set of importance weights. We anticipated it would be useful for studying needs and room for improvement, estimating the effects of interventions and comparing alternatives, and for developing healthcare with a broad focus on the individual. We wished to examine if efficiency analysis could be used for this purpose, in an application to individuals with type 1 diabetes.

RESULTS

We used PROM and PREM data linked to registry data on risk factors, in a large sample selected from the National Diabetes Registry in Sweden. Efficiency analysis appears useful for evaluating the situation of individuals with type 1 diabetes. Quality of life was estimated as efficiency, which differed by age. The contribution of different components to quality of life was heterogeneous, and differed by gender, age and duration of diabetes. Observed quality of life shortfall was mainly due to inefficiency, and to some extent due to the level of available inputs.

CONCLUSIONS

The efficiency analysis approach can use patient-reported outcomes measures, patient-reported experience measures and comorbidity risk factors to estimate quality of life with a broad focus on the individual, in individuals with type 1 diabetes. The approach enables ranking and comparisons using all these aspects in parallel, and allows each individual to express their own view of which aspects are important to them. The approach can be used for policy regarding interventions on inefficiency as well as healthcare resource allocation, although currently limited to type 1 diabetes.

Empowering Diabetes Self-Management Through Technology and Nurse Health Coaching

Purpose

This research explores the impact of mobile health (mHealth) technology and nurse health coaching on views of diabetes self-management (DSM) for persons living with diabetes.

Methods

Three focus groups (N = 24) were conducted with individuals living with type 2 diabetes who participated in a nurse health coaching and mHealth technology intervention study. Qualitative thematic analysis was used to identify overarching themes in each group.

Results

Major themes identified following intervention participation included enhanced perspectives about living with diabetes, increased awareness of how health behaviors influence DSM, improved support, and increased ownership of DSM.

Conclusions

The themes identified suggest that the mHealth technology and health coaching intervention together may have had an empowering effect on participants’ DSM. These results suggest that providing nurse health coaching with mHealth technology may help individuals ameliorate some of the challenges of living with and managing diabetes.

Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study

PURPOSE OF REVIEW

In recent years, the recommendation for and use of patient-reported outcome measures (PROMs) in routine diabetes care has significantly increased. We review recent evidence and highlight key opportunities and challenges related to the active clinical use of PROMs to support person-centered diabetes care and focus areas for future research in the area.

RECENT FINDINGS

Recent pragmatic studies support that integration of multi-dimensional PROMs for diabetes in clinical care as part of a care improvement strategy can be acceptable for and valued by people with diabetes (PWD) and healthcare professionals (HCPs) and may improve multiple aspects of quality of care, including screening, medical care monitoring and decision support, individualization of self-management support and goal-setting, and broader benefits related to active patient participation and person-centred diabetes care. We identify multiple intervention, individual, and care setting characteristics, which influence acceptability, feasibility, implementation, and effectiveness of PROMs in routine care. Recent clinical PROM studies highlight the value of mixed methods research and systematic involvement of PWD, clinicians, and other stakeholders in the design and implementation of questionnaires for patient input in routine diabetes care. We identified a new significant trend towards participatory development of multi-dimensional PROMs with the aim of IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes. While results from large-scale randomized controlled studies are still limited, a growing number of pragmatic implementation studies support that user-centric PROM interventions have the potential to facilitate significant improvements in care for PWD.

Health-related quality of life and glycaemic control among adults with type 1 and type 2 diabetes - a nationwide cross-sectional study

Background

Health-related quality of life and glycaemic control are some of the central outcomes in clinical diabetes care and research. The purpose of this study was to describe the health-related quality of life and assess its association with glycaemic control in adults with type 1 and type 2 diabetes in a nationwide setting.

Methods

In this cross-sectional survey, people with type 1 (n = 2479) and type 2 diabetes (n = 2469) were selected at random without replacement from the Swedish National Diabetes Register. Eligibility criteria were being aged 18–80 years with at least one registered test of glycated haemoglobin (HbA_1c) the last 12 months. The generic 36-item Short Form version 2 (SF-36v2) was answered by 1373 (55.4%) people with type 1 diabetes and 1353 (54.8%) with type 2 diabetes.

Results

Correlation analyses showed weak correlations between scores on the SF-36v2 and glycaemic control for both diabetes types. After the participants were divided into three groups based on their levels of HbA_1c, multivariate regression analyses adjusted for demographics, other risk factors and diabetes complications showed that among participants with type 1 diabetes, the high-risk group (≥70 mmol/mol/8.6%) had statistically significantly lower means in five out of eight domains of the SF-36v2 and the mental component summary measure, as compared with the well-controlled group (< 52 mmol/mol/6.9%). Among the participants with type 2 diabetes, the high-risk group had the lowest statistically significantly means in seven domains and both summary measures.

Conclusions

Among people with type 1 and type 2 diabetes, adults with high-risk HbA_1c levels have lower levels of health-related quality of life in most but not all domains of the SF-36v2. This finding was not explained by demographics, other risk factors, or diabetes complications. The weak individual-level correlations between HRQOL scores and levels of glycaemic control argues for the need to not focus exclusively on either HbA_1c levels or HRQOL scores but rather on both because both are important parts of a complex, life-long, challenging condition.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1212-z) contains supplementary material, which is available to authorized users.

Towards a better understanding of postprandial hyperglycemic episodes in people with diabetes: impact on daily functioning

OBJECTIVE

Acute postprandial hyperglycemia (aPPHG) is often symptomatic and can be associated with behavioral changes such as impaired working memory and attention. However, there is little evidence of the impact of aPPHG on the daily lives of patients. The aim of this study was to explore the frequency and severity of aPPHG episodes and their impact on daily functioning in people with insulin-treated diabetes.

METHODS

Adults (n = 1200) with insulin-treated diabetes mellitus type 1 (T1DM) or 2 (T2DM), most of whom experienced aPPHG, were recruited to complete an online cross-sectional survey in the USA and UK. The survey captured self-reported severity and frequency of aPPHG episodes and included a newly developed questionnaire (aPPHG-Q) assessing the impact of aPPHG episodes on patients' daily lives. Data was analyzed separately according to diabetes type and country. Regression analyses were used to assess the relationship between severity or frequency and scores on the aPPHG-Q.

RESULTS

Between 70% and 86% of USA, and 87% and 88% of UK participants reported experiencing aPPHG episodes. Increasing frequency and severity of aPPHG episodes were associated with worse scores on the aPPHG-Q in patients with both T1DM and T2DM in both countries (p < .014) on all subscale scores (excluding the worry and concerns scores for T1DM in the UK), although the magnitude of the association was smaller for aPPHG frequency.

CONCLUSIONS

Increased severity and frequency of aPPHG episodes in patients with insulin-treated diabetes is associated with greater burden and experience of symptoms, and can negatively impact daily functioning.

Patient-reported outcome and experience measures for diabetes: development of scale models, differences between patient groups and relationships with cardiovascular and diabetes complication risk factors, in a combined registry and survey study in Sweden

PURPOSE

The Swedish National Diabetes Register (NDR) has developed a diabetes-specific questionnaire to collect information on individuals' management of their diabetes, collaboration with healthcare providers and the disease's impact on daily life. Our main objective was to develop measures of well-being, abilities to manage diabetes and judgements of diabetes care, and to detect and quantify differences using the NDR questionnaire.

DESIGN, SETTING AND PARTICIPANTS

The questionnaire was analysed with using responses from 3689 participants with type 1 and 2 diabetes, randomly sampled from the NDR population, combined with register data on patient characteristics and cardiovascular and diabetes complication risk factors.

METHODS

We used item response theory to develop scales for measuring well-being, abilities to manage diabetes and judgements of diabetes care (scores). Test-retest reliability on the scale level was analysed with intraclass correlation. Associations between scores and risk factor levels were investigated with subgroup analyses and correlations.

RESULTS

We obtained scales with satisfactory measurement properties, covering patient reported outcome measures such as general well-being and being free of worries, and patient reported experience measure, for example, access and continuity in diabetes care. All scales had acceptable test-retest reliability and could detect differences between diabetes types, age, gender and treatment subgroups. In several aspects, for example, freedom of worries, type 1 patients report lower than type 2, and younger patients lower than older. Associations were found between some scores and glycated haemoglobin, but none with systolic blood pressure or low-density lipoprotein cholesterol. Clinicians report positive experience of using scores, visually presented, in the patient dialogue.

CONCLUSIONS

The questionnaire measures and detects differences in patient well-being, abilities and judgements of diabetes care, and identifies areas for improvement. To further improve diabetes care, we conclude that patient-reported measures are important supplements to cardiovascular and diabetes complication risk factors, reflecting patient experiences of living with diabetes and diabetes care.

De-Intensification Of Blood Glucose Lowering Medication In People Identified As Being Over-Treated: A Mixed Methods Study

AIM

To evaluate if, one year after notification of possible overtreatment, diabetes care providers de-intensified glucose-lowering medications and to gain insight into the opinions and beliefs of both care providers and patients regarding de-intensification.

METHODS

Mixed methods using routine care data from five health-care centres in the Netherlands. Patient characteristics and medication prescription of patients, previously identified as possibly over-treated, were extracted from patients' medical records. Opinions of care providers were obtained through interviews. Patients received questionnaires about their diabetes treatment and were asked to participate in focus groups.

RESULTS

A total of 64 elderly patients with type 2 diabetes were previously identified as possibly over-treated and included; 57.8% male, median age 75 years (IQR=72-82), median diabetes duration 12 years (IQR=8-18). De-intensification was implemented in more than half (n=36) of them. Care providers preferred person-centred care above just setting general HbA1c target values, considering patient characteristics (such as comorbidity) and patient's preference. Patients valued glucose levels as most important in determining their treatment. Both patients and care providers felt that de-intensification should occur gradually.

CONCLUSION

Treatment had been de-intensified in more than half of the patients (56.3%). Insight in reasons for not de-intensifying elderly patients is important since treatment for them can be "person-centred care". De-intensification is an iterative and time-intensive process.

Does Time-in-Range Matter? Perspectives From People With Diabetes on the Success of Current Therapies and the Drivers of Improved Outcomes

IN BRIEF After assessing patient perspectives on the success of current diabetes therapies and the factors that have the greatest impact on daily life, we show that time-in-range is a crucial outcome for people with diabetes and that current therapies are falling short on this metric. We also show that patients feel significant stress and worry, and they believe they are falling short in diet, exercise, and weight maintenance. In addition, they believe diet and exercise and in-range blood glucose are the biggest drivers of improved diabetes management and mindset. Together, these findings support the need for therapies that improve outcomes including and beyond A1C.

Resources and organisation in primary health care are associated with HbA1c level: A nationwide study of 230958 people with Type 2 diabetes mellitus

AIMS

To examine the association between personnel resources and organisational features of primary health care centres (PHCCs) and individual HbA_1c level in people with Type 2 diabetes mellitus (T2DM).

METHODS

People with T2DM attending 846 PHCCs (n=230958) were included in this cross-sectional study based on PHCC-level data from a questionnaire sent to PHCCs in 2013 and individual-level clinical data from 2013 for people with T2DM reported in the Swedish National Diabetes Register, linked to individual-level data on socio-economic status and comorbidities. Data were analysed using a generalized estimating equations linear regression models.

RESULTS

After adjusting for PHCC- and individual-level confounding factors, personnel resources associated with lower individual HbA_1c level were mean credits of diabetes-specific education among registered nurses (RNs) (-0.02mmol/mol for each additional credit; P<0.001) and length of regular visits to RNs (-0.19mmol/mol for each additional 15min; P<0.001). Organisational features associated with HbA_1c level were having a diabetes team (-0.18mmol/mol; P<0.01) and providing group education (-0.20mmol/mol; P<0.01).

CONCLUSIONS

In this large sample, PHCC personnel resources and organisational features were associated with lower HbA_1c level in people with T2DM.

A disease-specific questionnaire for measuring patient-reported outcomes and experiences in the Swedish National Diabetes Register: Development and evaluation of content validity, face validity, and test-retest reliability

OBJECTIVE

To describe the development and evaluation of the content and face validity and test-retest reliability of a disease-specific questionnaire that measures patient-reported outcomes and experiences for the Swedish National Diabetes Register for adult patients who have type 1 or type 2 diabetes.

METHODS

In this methodological study, a questionnaire was developed over four phases using an iterative process. Expert reviews and cognitive interviews were conducted to evaluate content and face validity, and a postal survey was administered to evaluate test-retest reliability.

RESULTS

The expert reviews and cognitive interviews found the disease-specific questionnaire to be understandable, with relevant content and value for diabetes care. An item-level content validity index ranged from 0.6-1.0 and a scale content validity/average ranged from 0.7-1.0. The fourth version, with 33 items, two main parts and seven dimensions, was answered by 972 adults with type 1 and type 2 diabetes (response rate 61%). Weighted Kappa values ranged from 0.31-0.78 for type 1 diabetes and 0.27-0.74 for type 2 diabetes.

CONCLUSIONS

This study describes the initial development of a disease-specific questionnaire in conjunction with the NDR. Content and face validity were confirmed and test-retest reliability was satisfactory.

PRACTICE IMPLICATIONS

With the development of this questionnaire, the NDR becomes a clinical tool that contributes to further understanding the perspectives of adult individuals with diabetes.

Promoting Engagement With a Digital Health Intervention (HeLP-Diabetes) Using Email and Text Message Prompts: Mixed-Methods Study

Background

Engagement with digital health interventions (DHIs) may be regarded as a prerequisite for the intervention to achieve positive health or behavior change outcomes. One method employed to promote engagement is the use of prompts such as emails and text messages. However, little is known about the characteristics of prompts that promote engagement. This study explored the association between the content and delivery mode of prompts and the users’ engagement with HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a DHI that aimed to promote self-management in adults with type 2 diabetes.

Objective

The objective of this study was to identify the characteristics of prompts, specifically the content and delivery mode, which were associated with increased engagement.

Methods

This was a mixed-methods study. Email and text message prompts were sent to the registered users of HeLP-Diabetes. Use of the intervention was recorded and examined to identify which email and text message prompts were associated with subsequent visits to the DHI. Characteristics of prompts that were identified as particularly effective or ineffective were explored through think-aloud interviews with the participants.

Results

Of a total of 39 email prompts, 49% (19/39) prompts showed a significant association with subsequent visits to the DHI. However, none of the text message prompts were associated with subsequent visits to the DHI. Furthermore, think-aloud interviews were carried out with 6 experienced participants with type 2 diabetes. The findings suggest that these participants preferred email prompts that were clear, relatively short, and empowering; used nondirective advice; included health professional references; were visually appealing; and contained news and updates.

Conclusions

The findings of this study contribute to the existing evidence supporting the role of email prompts in promoting and maintaining engagement with DHIs. This study described the content of prompts that may be engaging. However, the results should be interpreted with caution, as prompts may be context-specific interventions and the results may not be generalizable across other DHIs or other types of interventions targeting self-management of type 2 diabetes.

"Can you keep it real?" : Practical, and culturally tailored lifestyle recommendations by Mexican American women diagnosed with type 2 diabetes: A qualitative study

Background

The purpose of this article is to engage clinicians in a dialogue about ideas on how to provide more specific, contextually relevant, practical and culturally tailored diabetes self-management recommendations as suggested by Mexican-American women diagnosed with type 2 diabetes. Current diabetes self-management recommendations, targeting Mexican Americans in particular, remain largely broad (“reduce your calorie intake” or “cut back on carbs”), overly ambitious (“stop eating tortillas”), and relatively ineffective (Svedbo Engström et al., BMJ Open 6(3):e010249, 2016; Johansson et al., Int J Qual Stud Health Well-being 11, 2016; Oomen et al., The Diabetes Educ 25:220-225, 1999; Franek, Ont Health Technol Assess Ser 13(9):1-60, 2013; Purnell et al. Patient 9:349, 2016).

Methods

A secondary and focused analysis (N = 12) was performed on data gathered from a larger qualitative study (N = 16), which explored diabetes among Mexican-American women residing in rural South Texas.

Results

Findings from the secondary analysis were that study informants elicited more realistic or contextually relevant, specific self-management strategies that reflected the cognitive, emotive, and behavioral areas but were reframed within the context of the Mexican-American culture. Self-management strategies fell into the categories of: (a) environmental controls, (b) avoiding overeating, (c) lifestyle changes, (d) cooking tips, and (e) active self-management.

Conclusions

Diabetes remains a serious health threat to Mexican Americans, women in particular. Few individuals attain glycemic control, likely due in part to the disconnect between global and non-contextual self-management recommendations offered by health care providers and the need for more detailed and realistic guidance required for the day-to-day self-management of diabetes.

Structure of Resilience among Japanese Adult Patients with Type 1 Diabetes: A Qualitative Study

BACKGROUND

Resilience is the process of overcoming adversities and difficulties. We clarified the structure of resilience and its motivational power among adult Japanese patients with type 1 diabetes. This is likely to help ensure effective nursing support to empower patients with diabetes and help them recuperate and improve their personal lives.

METHODS

Participants were 17 patients with type 1 diabetes, and data were collected using semi-structured interviews. Participants shared their experiences of coping with self-management and diabetes control issues, the meaning of living with diabetes, and their support from family and friends since their diagnosis. Glaser's grounded theory was used to analyze the data and the results were used to create a new model of resilience for type 1 diabetes.

RESULTS

Five categories were extracted: "suffering from a guilty conscience," "suffering from an insulin-dependent body," "social disability," "a driving force to advancement," and "possessing a strategy to live with the disease."

CONCLUSION

The five categories formed two stages: preparatory resilience and resilience formation. Once patients recognized the presence of empathetic others, they could obtain better disease comprehension and cooperation. Recognizing this support system served as a "driving force to advancement" and was termed the "resilience battery." Through the resilience battery, patients shifted from preparatory resilience to "resilience formation," or acquiring "a strategy to live with the disease." To forge patient resilience, nurses should encourage disease comprehension and cooperation among patients' significant others. We further propose that high-quality nursing care would involve supporting patients' inner resilience.

Patients' experiences of support for learning to live with diabetes to promote health and well-being: A lifeworld phenomenological study

Learning to live with diabetes in such a way that the new conditions will be a normal and natural part of life imposes requirements on the person living with diabetes. Previous studies have shown that there is no clear picture of what and how the learning that would allow persons to incorporate the illness into their everyday life will be supported. The aim of this study is to describe the phenomenon of support for learning to live with diabetes to promote health and well-being, from the patient’s perspective. Data were collected by interviews with patients living with type 1 or type 2 diabetes. The interviews were analysed using a reflective lifeworld approach. The results show that reflection plays a central role for patients with diabetes in achieving a new understanding of the health process, and awareness of their own responsibility was found to be the key factor for such a reflection. The constituents are responsibility creating curiosity and willpower, openness enabling support, technology verifying bodily feelings, a permissive climate providing for participation and exchanging experiences with others. The study concludes that the challenge for caregivers is to create interactions in an open learning climate that initiates and supports reflection to promote health and well-being.