Association of patient-rated severity with other outcomes in patients with painful diabetic peripheral neuropathy

Diabetes severity measured by treatment control status and number of anti-diabetic drugs affects presenteeism among workers with type 2 diabetes

BACKGROUND

The number of people with diabetes is increasing and resulting in major economic losses. Presenteeism accounts for the majority of economic losses, so measures against presenteeism are important. This study investigated the relationship between severity of type 2 diabetes and presenteeism.

METHODS

A cross-sectional study was conducted among workers over 40 years of age. Participants were classified as normal group or diabetic treatment group using their medical examination results and health insurance claims data. Diabetic treatment groups were described by degree of treatment control: Good (HbA1c < 7%), Intermediate (7% ≤ HbA1c < 8%), and Poor (8% ≤ HbA1c). Therapy type was also divided into monotherapy and combination therapy. Logistic regression analysis was performed to predict presenteeism loss using the Quantity and Quality method.

RESULTS

Data on 13,271 workers were analyzed. Presenteeism loss was significantly higher in all treatment control groups compared with the normal group, particularly for the intermediate and poor control groups. The monotherapy group did not differ from the normal group, but presenteeism loss was significantly higher in the combination therapy group than the normal group.

CONCLUSIONS

Presenteeism loss in workers with diabetes may be affected by diabetes severity, and even if treatment control were good, presenteeism loss could occur when the number of anti-diabetic drugs was high. Therefore, it is important to provide early intervention and continuous support as a preventive measure against not only diabetes and diabetes-related complications but also presenteeism.

Prevalence and associated factors of painful diabetic peripheral neuropathy among diabetic patients on follow up at Jimma University Medical Center

BACKGROUND

Despite having significant impact on the patient's quality of life, painful diabetic peripheral neuropathy (PDPN) is usually underdiagnosed. Screening for PDPN in patients with diabetes is needed in order to get timely identification and management. Hence, the purpose of this study was to assess the prevalence and determinants of PDPN among diabetes patients attending outpatient at Jimma University Medical Center from September 1 November 10, 2019.

METHODS

Hospital based cross-sectional study was conducted and douleur neuropathique-4 was used to identify the presence of PDPN. Data were collected using pretested structured questionnaire and entered into EPI data 3.1 and exported to SPSS version 20 for analysis. Both bivariate and multivariate binary logistic regression was employed to identify factors associated with PDPN. Variable having a p value of <0.25 in the bivariate model were considered as candidates for multivariable regression. Adjusted odds ratios were calculated at 95%CI and considered significant with a p value of <0.05.

RESULTS

A total of 366 diabetic patients were enrolled into the study and their mean duration of diabetes was 6.8 ± 5.3 years. The study finding showed that the prevalence of PDPN was 14.5%. According to the multivariate logistic regression analysis smoking [current smoker(AOR = 6.17; 95%CI:2.25,16.86),former smoker(AOR = 3.22;95%CI:1.29,8.03)],diabetes duration[5 to 10 years (AOR = 3.32;95%CI:1.29,8.53), ≥ 10 years (AOR = 8.86;95% CI: 3.49,22.5)] and comorbid hypertension [AOR = 2.54; 95%CI:1.17,5.49] were independent predictors of PDPN among study participants.

CONCLUSION

The overall prevalence of PDPN in this study was 14.5% and it was significantly associated with smoking, comorbid hypertension and diabetes duration of above 5 years. Early detection and appropriate interventions are important for high risk patients identified in the current study.

Painful and Painless Diabetic Neuropathies: What Is the Difference?

PURPOSE OF REVIEW

The prevalence of diabetes mellitus and its chronic complications are increasing to epidemic proportions. This will unfortunately result in massive increases in diabetic distal symmetrical polyneuropathy (DPN) and its troublesome sequelae, including disabling neuropathic pain (painful-DPN), which affects around 25% of patients with diabetes. Why these patients develop neuropathic pain, while others with a similar degree of neuropathy do not, is not clearly understood. This review will look at recent advances that may shed some light on the differences between painful and painless-DPN.

RECENT FINDINGS

Gender, clinical pain phenotyping, serum biomarkers, brain imaging, genetics, and skin biopsy findings have been reported to differentiate painful- from painless-DPN. Painful-DPN seems to be associated with female gender and small fiber dysfunction. Moreover, recent brain imaging studies have found neuropathic pain signatures within the central nervous system; however, whether this is the cause or effect of the pain is yet to be determined. Further research is urgently required to develop our understanding of the pathogenesis of pain in DPN in order to develop new and effective mechanistic treatments for painful-DPN.

Factors of occurrence and improvement methods of presenteeism attributed to diabetes: A systematic review

Objective

A systematic review was performed to study factors of occurrence and improvement methods of presenteeism attributed to diabetes.

Methods

We set 2 clinical questions; (a) how comorbidities and complications of diabetes induce presenteeism and (b) what interventions or conditions effectively improve presenteeism. Then, we conducted a comprehensive search with MEDLINE/PubMed and Scopus databases and extracted those that met the clinical questions.

Results

Eighteen papers studied occurrence of presenteeism by comorbidities and complications of diabetes. Most studies were cross‐sectional and had a low quality of evidence. However, the associations of hypoglycemia, diabetic neuropathy, and mood disorders with presenteeism were relatively well studied. The papers that discussed effective interventions or conditions for improving presenteeism were very limited.

Conclusions

Our review suggests that presenteeism attributed to diabetes is mainly caused by hypoglycemia, diabetic neuropathy, and mood disorders. There are very limited evidences, but available information suggests that improving glycemic control, adjusting treatment regimen by evaluating the impact on work, providing psychological support, and developing suitable work accommodations may effectively reduce presenteeism.

Discordance Between Physician- and Patient-Reported Disease Severity in Adults with Atopic Dermatitis: A US Cross-Sectional Survey

Background

There is limited understanding of severity rating of atopic dermatitis in clinical practice.

Objectives

To evaluate the agreement between physician- and patient-rated severity of atopic dermatitis.

Methods

Data were collected from the 2014 Adelphi US Atopic Dermatitis Disease Specific Programme, a cross-sectional survey of physicians and their patients with a history of moderate-to-severe atopic dermatitis; patients voluntarily completed a questionnaire. Current disease severity (mild/moderate/severe), based on personal judgment, was rated independently by patients and their physicians. The weighted kappa statistic identified level of agreement between physicians and patients. Bivariate analyses characterized agreement; multi-nomial logistic regression identified factors associated with discordance.

Results

Overall, 678 patients were included (369 [54.4%] were women, 525 [77.4%] were White, mean age was 39.3 years). Agreement was moderate (weighted kappa = 0.52): compared with physician ratings, patient-rated severity was higher in 76 patients (11.2%), lower in 137 patients (20.2%), and matched in 465 patients (68.6%). There were no differences in the rates of agreement between physician and patient ratings based on physician specialty (p = 0.6781), objective severity measures [Eczema Area and Severity Index score (p = 0.5308), percent body surface area affected (p = 0.9872), and current systemic immunosuppressant use (p = 0.9197)]. Multivariate analysis showed patients with a worse quality of life (Dermatology Life Quality Index) were more likely to rate a higher severity (relative risk ratio 1.04, 95% confidence interval 1.00–1.08; p = 0.0460). Physicians were more likely to rate a higher severity with a greater physician-reported sleep disturbance (relative risk ratio 1.71, 95% confidence interval 1.01–2.89; p = 0.0440).

Conclusions

Almost one-third of patients rated atopic dermatitis severity differently from their physicians, supporting the importance of the patient perspective in the severity assessment of atopic dermatitis and the need for greater communication between patients and physicians.

Electronic supplementary material

The online version of this article (doi:10.1007/s40257-017-0284-y) contains supplementary material, which is available to authorized users.

The relationship between pain severity and patient-reported outcomes among patients with chronic low back pain in Japan

Objective

The aim of this study was to quantify the impact of pain severity on patient-reported outcomes among individuals diagnosed with chronic low back pain in Japan.

Methods

Data were provided by the 2012 Japan National Health and Wellness Survey (N=29,997), a web-based survey of individuals in Japan aged ≥18 years. This analysis included respondents diagnosed with low back pain of ≥3-month duration. Measures included the revised Medical Outcomes Study 36-Item Short-Form Survey Instrument, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 scale, the Work Productivity and Activity Impairment: General Health questionnaire, and self-reported all-cause health care visits (6 months). Generalized linear models were used to assess the relationship between outcomes and severity of pain in the past week as reported on a numeric rating scale ranging from 0 (no pain) to 10 (pain as bad as you can imagine), controlling for length of diagnosis, sociodemographics, and general health characteristics.

Results

A total of 290 respondents were included in the analysis; mean age was 56 years, 41% were females, and 56% were employed. Pain severity was 3/10 for the first quartile, 5/10 for the median, and 7/10 for the third quartile of this sample. Increasing severity was associated with lower scores for mental and physical component summaries and Short-Form 6D health utility, higher depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) scores, greater absenteeism and presenteeism, greater activity impairment, and more health care provider visits (all P<0.0001).

Conclusion

The impact of chronic low back pain on health-related quality of life, depression and anxiety symptoms, impairment to work and daily activities, and health care use increases with the severity of pain. Interventions reducing the severity of pain may improve numerous health outcomes even if the pain cannot be eliminated.

Longitudinal patient-oriented outcomes in neuropathy: Importance of early detection and falls

OBJECTIVE

To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis.

METHODS

The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients ≥65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls.

RESULTS

We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32% vs 25%, p = 0.008), 5.0 years for pain (36% vs 27%, p = 0.002), and 5.0 years for good to excellent self-rated health (61% vs 74%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed.

CONCLUSIONS

In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome.

Development and validation of a tactile sensitivity scale for peripheral neuropathy screening

One of the difficult of the hands peripheral neuropathy screening uncertainty is that the current diagnosis is based not on assessments obtained by accurate and repeatable devices, but mostly on the clinical examination. So, in this paper the authors present a tactile pins-array scale determined with well-defined parameters assessed by non-invasive DITA device (Dynamic Investigation Test-rig on hAptics). This high resolution scale permits to screen the gradual tactile sensory deficit of patients affected by neuropathic diseases. The work has started with an experiment on healthy subjects penalizing their bare finger tactile sensitivity with five different pins-arrays. So, a pins-array scale divided in six levels (grouped in three ranges: low, uncertain and normal tactile sensitivity) was created. The scale was validated with a pilot study on six subjects affected by neuropathic disease. Results show an important role of the scale, supporting the clinical screening and reducing the uncertainty.

Measurement properties of painDETECT by average pain severity

Background

Since the burden of neuropathic pain (NeP) increases with pain severity, it is important to characterize and quantify pain severity when identifying NeP patients. This study evaluated whether painDETECT, a screening questionnaire to identify patients with NeP, can distinguish pain severity.

Materials and methods

Subjects (n=614, 55.4% male, 71.8% white, mean age 55.5 years) with confirmed NeP were identified during office visits to US community-based physicians. The Brief Pain Inventory – Short Form stratified subjects by mild (score 0–3, n=110), moderate (score 4–6, n=297), and severe (score 7–10, n=207) average pain. Scores on the nine-item painDETECT (seven pain-symptom items, one pain-course item, one pain-irradiation item) range from −1 to 38 (worst NeP); the seven-item painDETECT scores (only pain symptoms) range from 0 to 35. The ability of painDETECT to discriminate average pain-severity levels, based on the average pain item from the Brief Pain Inventory – Short Form (0–10 scale), was evaluated using analysis of variance or covariance models to obtain unadjusted and adjusted (age, sex, race, ethnicity, time since NeP diagnosis, number of comorbidities) mean painDETECT scores. Cumulative distribution functions on painDETECT scores by average pain severity were compared (Kolmogorov–Smirnov test). Cronbach’s alpha assessed internal consistency reliability.

Results

Unadjusted mean scores were 15.2 for mild, 19.8 for moderate, and 24.0 for severe pain for the nine items, and 14.3, 18.6, and 22.7, respectively, for the seven items. Adjusted nine-item mean scores for mild, moderate, and severe pain were 17.3, 21.3, and 25.3, respectively; adjusted seven-item mean scores were 16.4, 20.1, and 24.0, respectively. All pair-wise comparisons of scores between pain-severity groups showed sizable and statistically significant differences (P<0.0001). Cumulative distribution functions showed distinct separation between severity (P<0.0001). Cronbach’s alphas were 0.76 and 0.80 for the nine- and seven-item scales, respectively.

Conclusion

This study provides strong psychometric evidence on the validity and reliability of painDETECT for distinguishing average pain severity in patients with NeP.

Pain severity and the economic burden of neuropathic pain in the United States: BEAT Neuropathic Pain Observational Study

Background

As with many chronic conditions, patients with neuropathic pain (NeP) are high consumers of health care resources. However, limited literature exists on the economic burden of NeP, including its impact on productivity. The aim of this study was to characterize health care resource utilization, productivity, and costs associated with NeP by pain severity level in US adults.

Methods

Subjects (n=624) with painful diabetic peripheral neuropathy, human immunodeficiency virus-related peripheral NeP, post-trauma/post-surgical NeP, spinal cord injury with NeP, chronic low back pain with NeP, and small fiber neuropathy were recruited during routine office visits to US community-based general practitioners and specialists. Clinicians captured clinical characteristics, NeP-related medications, and health care resource utilization based on 6-month retrospective medical chart review. Subjects completed questionnaires on demographics, pain/symptoms, costs, and productivity. Brief Pain Inventory pain severity scores were used to classify subjects by mild, moderate, or severe pain. Annualized NeP-related costs (adjusted for covariates) were estimated, and differences across pain severity groups were evaluated.

Results

In total, 624 subjects were recruited (mean age 55.5±13.7 years; 55.4% male), and 504/624 (80.8%) reported moderate or severe pain. Statistically significant differences were observed across pain severity levels for number of comorbidities, prescription medications, physician office visits, and lost productivity (all P≤0.0001). At all pain severity levels, indirect costs were the primary cost driver. After adjusting for demographic and clinical variables, total mean (95% confidence interval [CI]) annualized direct medical costs to payers, direct costs to subjects, and indirect costs per subject were US$6,016 (95% CI 5,316–6,716), US$2,219 (95% CI 1,919–2,519), and US$19,000 (95% CI 17,197–20,802), respectively, with significant differences across pain severity levels.

Conclusion

Subjects with NeP, mainly those showing moderate or severe pain, had significant associations between pain severity and NeP-related health care resource utilization, productivity, and costs. The economic burden, particularly indirect costs, was highest among those with severe pain and higher than previously reported in studies of specific NeP conditions.

Painful diabetic peripheral neuropathy: results of a survey characterizing the perspectives and misperceptions of patients and healthcare practitioners

Background

Little information exists on the understanding and management of painful diabetic peripheral neuropathy (pDPN) between patients and healthcare practitioners (HCPs).

Objective

The objective of this study was to characterize the patient perspective of pDPN and identify gaps in patient and HCP perceptions of pDPN.

Methods

An online survey of patients with type 1 or 2 diabetes mellitus who reported experiencing any symptoms consistent with diabetic peripheral neuropathy (DPN) and HCPs who treat diabetes was conducted in 2012 in the USA. Patients were recruited via the Survey Sampling national consumer research panel, and HCPs were recruited from Epocrates’ national research panel. Survey questions focused on the impact, understanding, and management of pDPN, and interactions between patients and their HCPs. Respondents who reported pain were re-contacted to obtain further information on pain severity using a numerical rating scale (0 = no pain, 10 = most pain).

Results

Respondents included 1,004 patients (53 % female, average age 55 years) and 500 HCPs (250 generalists, 150 specialists, and 100 nurses/physician assistants). While 83 % of patients reported pDPN symptoms, only 41 % of these patients had been diagnosed with DPN. Eighty-five percent of those with pDPN reported that it impacts daily activities. In contrast, HCPs estimated that of their patients who experienced any type of DPN symptom, 41 % experienced pain and 38 % had daily activity limitations because of their symptoms. Most HCPs (64 %) never had their patients complete a DPN assessment questionnaire, and only 41 % perform specific diagnostic tests on all patients who report DPN symptoms. Patients and HCPs both showed substantial clinical misperceptions regarding the cause and management of pDPN; 53 % of HCPs believed that adequate blood glucose control could reverse DPN, and 43 % of pDPN patients were not sure if DPN was reversible. There was also substantial discordance between patients and HCPs regarding discussions of DPN; only 49 % of pDPN patients reported that they speak about symptoms at “every” or “most” appointments with their HCP but 73 % of HCPs reported discussing DPN symptoms at “every” or “most” visits.

Conclusions

Not only do misperceptions exist on the cause and management of pDPN among patients and HCPs, but there are additional disparities between the patient and HCP perspectives. These results suggests a need for (1) educational initiatives on pDPN that target patients and HCPs, and (2) initiating improved dialogue between patients and their HCPs for discussing appropriate management of pDPN that is distinct from treatment of the underlying diabetes.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-013-0038-8) contains supplementary material, which is available to authorized users.

Burden of illness associated with peripheral and central neuropathic pain among adults seeking treatment in the United States: a patient-centered evaluation

Objective

The aim of this study was to evaluate patient-reported burden associated with peripheral and central neuropathic pain (NeP) by pain severity and NeP condition.

Design

Six hundred twenty-four subjects with one of six NeP conditions were recruited during routine office visits. Subjects consented to retrospective chart review and completed a one-time questionnaire (including EuroQol-5 dimensions, 12-item Short-Form Health Survey, Brief Pain Inventory-Short Form, Medical Outcomes Study Sleep Scale, Hospital Anxiety and Depression Scale, and demographic and clinical characteristics). Pain severity scores were used to stratify subjects by mild, moderate, and severe pain. Summary statistics and frequency distributions were calculated. Differences by severity level were compared using Kruskal–Wallis (continuous variables) and chi-square or Fisher's exact test (categorical variables). Effect size was computed with Cohen's d (mild vs severe).

Results

Subjects' mean age was 55.5. The majority (80.8%) had moderate or severe pain. Patient-reported outcomes (health status, physical and mental health, pain interference with function, sleep, anxiety, and depression) were significantly worse among subjects with greater pain severity (all P < 0.0001). Severe pain subjects were negatively impacted by ≥30% in each outcome compared with mild pain subjects; standardized effect size was moderate for anxiety (0.59) and large (>0.95) for all others. The observed burden was most substantial among chronic low back pain-NeP, although the pattern of disease burden was similar across the six NeP conditions.

Conclusions

Subjects across NeP conditions exhibited high pain levels, which were significantly associated with poor function, compromised health status and sleep, and increased anxiety and depression. Results indicate substantial patient burden across broad NeP, particularly among subjects with severe pain.

Are treatment benefits in neuropathic pain reflected in the Self Assessment of Treatment questionnaire?

BACKGROUND/OBJECTIVE

The Self Assessment of Treatment (SAT) questionnaire was developed to reflect key patient reported outcomes of Neuropathic Pain (NP) treatments. This study aimed to understand how patients perceived the relevance and ease of understanding of the questions in the SAT and to recommend modifications based on patient and clinician interviews.

METHODS

Semi-structured interviews were conducted with clinicians and NP patients to provide information regarding treatment attributes and the impact of pain. Patients were debriefed on the SAT, a 5-item scale evaluating pain, activity level, quality of life (QoL) and satisfaction with treatment (recommend treatment and undergo treatment again). The SAT has a recall period reflecting back to the start of treatment. The qualitative analysis software ATLAS.ti 5.0 was used to analyze patient transcripts. Changes to the SAT were integrated into the questionnaire for a second round of debriefing interviews.

RESULTS

Three NP clinicians and 44 patients (20 painful diabetic neuropathy, 16 HIV-associated neuropathy and 8 post herpetic neuralgia) with a mean age of 60.3 (12.3) years and an even gender distribution were interviewed. Patient treatment experience included anticonvulsants (73%), antidepressants (34%), opioids (25%), and topical medications (41%). Pain descriptors and treatment attributes were similar across the three NP groups. Pain relief was judged the most important treatment attribute, followed by ability to undertake activities. Sleep improvement was another important attribute. Activity limitations and QOL were perceived as too broad and non-specific, and were split into 3 concepts each (activity limitations was split into self care, daily and physical activities and QOL was split into sleep, emotions, and social function). A 7-day recall period was introduced. The item stem and response options were made consistent, and a baseline and follow-up questionnaires were developed (except for the satisfaction items) to enable monitoring onset of treatment benefit and change over time.

CONCLUSIONS

The content validity of the revised SAT was improved by the qualitative research, and NP treatment benefits are reflected in a more consistent fashion by the changes. Baseline and follow-up versions make it possible to perform assessments of change over time.

Burden of illness associated with painful diabetic peripheral neuropathy among adults seeking treatment in the US: results from a retrospective chart review and cross-sectional survey

BACKGROUND

The purpose of this study was to characterize the burden of illness among adult subjects with painful diabetic peripheral neuropathy (pDPN) seeking treatment in the US.

METHODS

This observational study recruited 112 subjects with pDPN during routine visits from general practitioner and specialist sites. Subjects completed a one-time questionnaire, which included demographics, symptom duration, health care resource use, out-of-pocket costs, employment status, and validated measures that assessed pain, functioning, sleep, anxiety and depression, health status, and productivity. Investigators completed a case report form based on a 6-month retrospective chart review to capture clinical information, pDPN-related treatments, and other pDPN-related health care resource use over the past 6 months. Annualized costs were extrapolated based on reported 6-month health care resource use.

RESULTS

The mean age of the subjects was 61.1 years, 52.7% were female, and 17.9% were in paid employment. The most common comorbid conditions were sleep disturbance/insomnia (43.8%), depressive symptoms (41.1%), and anxiety (35.7%). The mean pain severity score was 5.2 (0-10 scale), and 79.5% reported moderate or severe pain. The mean pain interference with function score was 5.0 (0-10 scale) overall, with 2.0 among mild, 5.1 among moderate, and 7.0 among severe. The mean Medical Outcomes Study sleep problems index score was 48.5 (0-100 scale). The mean health state utility score was 0.61. Among subjects employed for pay, mean overall work impairment was 43.6%. Across all subjects, mean overall activity impairment was 52.3%. In total, 81.3% were prescribed at least one medication for their pDPN; 50.9% reported taking at least one nonprescription medication. Adjusted mean annualized total direct and indirect costs per subject were $4841 and $9730, respectively. Outcomes related to pain interference with function, sleep, health status, activity impairment, prescription medication use, and direct and indirect costs were significantly worse among subjects with more severe pain (P < 0.0020).

CONCLUSION

Subjects with pDPN exhibited high pain levels, which were associated with poor sleep, function, and productivity. Health care resource utilization in pDPN was prevalent and costs increased with greater pain severity. The burden of pDPN was greater among subjects with greater pain severity.