Which Aspect of Patient-Provider Relationship Affects Acceptance and Adherence of Insulin Therapy in Type 2 Diabetes Mellitus? A Qualitative Study in Primary Care

Enhancing care in the initiation and management of insulin in older people with diabetes: A collaborative journey with older individuals and their caregivers using Experience-Based Co-Design

INTRODUCTION

Initiating insulin therapy in older individuals with type 2 diabetes (T2DM) poses unique challenges and requires a nuanced understanding of the age-related factors that impact safety and efficacy. This study employed Experience-Based Co-Design (EBCD) to enhance the insulin initiation and management experience for this population, emphasising a collaborative approach involving patients, caregivers, and healthcare professionals.

AIM

The primary aim of the research was to develop a tailored care pathway, utilising co-design and the Behaviour Change Wheel (BCW), which addressed issues specific to older adults on insulin therapy. The study sought to identify key challenges, propose practical interventions, and construct a logic model illustrating a pathway for enhanced insulin treatment experiences.

METHODS

An adapted EBCD process was used which integrated the Medical Research Council (MRC) Framework and BCW. The study involved thematic synthesis, video interviews, and feedback focus groups with patients, caregivers, and healthcare professionals. The 'Crazy Eights' brainstorming method, as part of the co-design workshop, generated practical solutions which informed subsequent logic model development.

RESULTS

Focus group findings revealed distressing insulin initiation experiences, inconsistent dietary advice, and perceived disparities in care between type 1 and type 2 diabetes. The co-design workshop identified eight key challenges, leading to proposed interventions aligned with the BCW. The logic model illustrates a pathway for older individuals undergoing insulin treatment, emphasising behaviour change among patients, caregivers, and healthcare professionals.

CONCLUSION

The collaborative efforts of participants contributed valuable insights in terms of the unique educational and emotional needs of patients, the importance of care continuity and of improving access to specialist services. Findings from this study can be used to inform and enhance tailored support strategies for older adults with T2DM during their insulin transition and ongoing management.

Concordance in the healthcare context: A concept analysis

Background

The concept of concordance and its usage are indicative of patient-centered healthcare, which encourages an equitable collaboration between patients and clinicians. However, there is a lack of clarity in understanding concordance, and an analysis of this concept is warranted.

Objective

This paper seeks to explore the essence of the concordance concept in the healthcare context.

Methods

Walker and Avant's eight-step method of concept analysis was applied. A literature search was conducted using concordance AND concord as keywords on CINAHL, MEDLINE, PubMed, ProQuest, Cochrane database, and ScienceDirect databases, published between 2006 and 2022.

Results

The attributes of concordance include communication process, therapeutic partnership, and agreement on treatment regimens. Antecedents of concordance comprise provider-patient relationship, patients' beliefs, healthcare providers' characteristics, and complexity of treatment plans. Consequences are improved adherence and compliance, improved clinical outcomes, and better quality of life.

Conclusion

This paper offers clarification of concordance by presenting its antecedents, attributes, and consequences. The findings serve as a basis for developing assessments and nursing interventions to promote patient concordance. Nurses can use the findings to encourage concordance by establishing a trusty relationship during health encounters that respects patients' beliefs and effectively communicating to improve patients' understanding in dealing with complex treatment plans.

Factors Affecting Adherence in Allergic Disorders and Strategies for Improvement

Addressing patient adherence is a key element in ensuring positive health outcomes and improving health-related quality of life for patients with atopic and immunologic disorders. Understanding the complex etiologies of patient nonadherence and identifying real-world solutions is important for clinicians, patients, and systems to design and effect change. This review serves as an important resource for defining key issues related to patient nonadherence and outlines solutions, resources, knowledge gaps, and advocacy areas across five domains: health care access, financial considerations, socioenvironmental factors, health literacy, and psychosocial factors. To allow for more easily digestible and usable content, we describe solutions based on three macrolevels of focus: patient, clinician, and system. This review and interactive tool kit serve as an educational resource and call to action to improve equitable distribution of resources, institutional policies, patient-centered care, and practice guidelines for improving health outcomes for all patients with atopic and immunologic disorders.

Associations Between Patient Comfort with a Primary Care Provider and Three Measures of Behavioral Health Services Utilization

BACKGROUND

Behavioral health services (BHS) can help improve and treat mental and emotional health problems. Yet, attitudinal and/or structural barriers often prevent individuals from accessing and benefiting from these services. Positive provider-patient interactions in healthcare, encompassing patient comfort with a primary care provider (PCP), which is often enhanced by shared decision-making, may mitigate the stigma associated with seeing a mental health professional; this may improve BHS utilization among patients who need these services. However, few studies have examined how patient comfort with a PCP, often through shared decision-making, may influence patients' BHS utilization in the real world. This study sought to address this gap in practice.

METHOD

Multivariable regression analyses, using weighted data from an internet panel survey of Los Angeles County adults (n = 749), were carried out to examine the associations between patient comfort with a PCP and three measures of BHS utilization. Subsequent analyses were conducted to explore the extent to which shared decision-making moderated these associations.

RESULTS

Participants who reported an intermediate or high comfort level with a provider had higher odds of reporting that they were likely to see (aOR = 2.10 and 3.84, respectively) and get advice (aOR = 2.75 and 4.76, respectively) from a mental health professional compared to participants who reported a low comfort level. Although shared decision-making influenced participants' likelihood of seeing and getting advice from a mental health professional, it was not a statistically significant moderator in these associations.

CONCLUSION

Building stronger relationships with patients may improve BHS utilization, a provider practice that is likely underutilized.

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

BACKGROUND

Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

OBJECTIVE

This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

METHODS

The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

RESULTS

A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

CONCLUSIONS

This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

The mediating effect of self-efficacy on the relationship between social support and medication adherence in adults with type 2 diabetes

Objective

To evaluate the status of medication adherence in diabetic patients and its effective factors.

Methods

A cross-sectional descriptive study was conducted with 170 diabetic patients in Iran. Participants were assessed for medication adherence, self-efficacy, and social support. Descriptive statistics, bivariate analyses, and multiple stepwise regression were conducted to explore predictors for medication adherence.

Results

Regression analysis showed that 48% of medication adherence changes stemmed from the four variables including social support, self-efficacy, income, and education levels, (R2adj = 0.480, F = 39.943, p < 0.001). According to the model, the highest effects were related to income level (β = 0.332, t = 5.493, p ⩽ 0.001) and self-efficacy (β = 0.330, t = 4.789, p ⩽ 0.001), respectively. Based on the final model, only the social support variable showed no significant relationship with adherence (β = 0.002, t = 0.032, p = 0.947).

Conclusion

Social support and self-efficacy were related to medication adherence in diabetic patients, and social support can improve medication adherence in patients with diabetes by affecting self-efficacy. Healthcare workers who interact with individuals with diabetes should take into account the factors mentioned above when designing health promotion interventions to address the needs of these individuals.

Education, trust, and likelihood to vaccinate against COVID-19 among patients with diabetes in the American South

OBJECTIVE

The purpose of this study was to explain the relationship among education, likelihood to vaccinate for COVID-19, and trust in healthcare providers among patients living with diabetes in the American South.

METHODS

Explanatory iterative sequential mixed methods design combined retrospective chart review, self-report surveys, and qualitative interviews.

RESULTS

Analysis of covariance revealed that severity of diabetes was not linked to vaccine acceptance. Overall, patients reported higher likelihood to vaccinate if their healthcare providers strongly recommend the vaccine. People with "some college" education reported lowest likelihood to vaccinate, before and after their healthcare providers' strong recommendation. Integrated analysis revealed the complexity of patient-provider trust and vaccination decisions.

CONCLUSIONS

In the context of COVID vaccination, particularly as conspiracy theories entered the mainstream, measures of trust in the system may be a clearer indicator of vaccine decision making than trust in personal physician.

PRACTICE IMPLICATIONS

The nonlinear relationship between education and likelihood to vaccinate challenges providers to talk to patients about knowledge and understanding beyond a superficial, quantitative screening question about education. Health systems and public health officials need to find strategies to build trusting relationships for patients across systems, such as community health workers.

How is Patient Adherence Possible? A Novel Mechanistic Model of Adherence Based on Humanities

Patient non-adherence is a major contemporary medical issue because of its consequences in terms of frequency, morbidity and mortality, and health care costs. This article aims to propose a mechanistic model of adherence based on the tenet that non-adherence is the default option, as long-term adherence in chronic diseases requires sustained effort. The real question becomes, how is patient adherence possible? By focusing on adherent patients, the paper explains the mental mechanisms of adherence using concepts largely drawn from humanities, philosophy of mind, and behavioral economics and presents the findings of empirical studies supporting these hypotheses. The analysis first demonstrates the relationship between patient adherence and temporality and the influence of character traits. Further, it points out the importance of habit, which allows adherence to become non-intentional, thereby sparing patients' cognitive efforts. Finally, it points out the importance of the quality of the interaction between the person with a chronic disease and the health professional. These features explain why adherence is a syndrome (the healthy adherer phenotype), separating people into those who are safe and those who are at risk of non-adherence, non-control of diabetes, and complications. The concepts presented in this article summarize 20 years of personal clinical and philosophical reflection on patient adherence. They are mainly illustrated by examples from diabetes care but can be applied to all chronic diseases. This novel model of adherence has major practical and ethical implications, explaining the importance of patient education and shared medical decision-making in chronic disease management.

The Association of Name Recognition, Empathy Perception, and Satisfaction With Resident Physicians' Care Amongst Patients in an Academic Emergency Department

Background

Recognition of the provider's name, provider empathy, and the patient's satisfaction with their care are patient-provider rapport measures. This study aimed to determine: 1) resident physicians' name recognition by patients in the emergency department; and 2) name recognition in association with patient perception of the resident's empathy and their satisfaction with the resident's care.

Methods

This was a prospective observational study. A patient recognizing a resident physician was defined as the patient remembering a resident's name, understanding the level of training, and understanding a resident's role in patient care. A patient's perception of resident physician empathy was measured by the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE). Patient satisfaction of the resident was measured utilizing a real-time satisfaction survey. Multivariate logistic regressions were performed to determine the association amongst patient recognition of resident physicians, JSPPPE, and patient satisfaction after adjustments were made for demographics and resident training level.

Results

We enrolled 30 emergency medicine resident physicians and 191 patients. Only 26% of studied patients recognized resident physicians. High JSPPPE scores were given by 39% of patients recognizing resident physicians compared to 5% of those who were not recognized (P = 0.013). High patient satisfaction scores were recorded in 31% of patients who recognized resident physicians compared to 7% who did not (P = 0.008). The adjusted odds ratios of patient recognition of resident physicians to high JSPPPE and high satisfaction scores were 5.29 (95% confidence interval (CI): 1.33 - 21.02, P = 0.018) and 6.12 (1.84 - 20.38, P = 0.003) respectively.

Conclusions

Patient recognition of resident physicians is low in our study. However, patient recognition of resident physicians is associated with a higher patient perception of physician empathy and higher patient satisfaction. Our study suggests that resident education advocating for patient recognition of their healthcare provider's status needs to be emphasized as part of patient-centered health care.

Comparison of simplicity, convenience, safety, and cost-effectiveness between use of insulin pen devices and disposable plastic syringes by patients with type 2 diabetes mellitus: a cross-sectional study from Bangladesh

INTRODUCTION

Insulin pen devices and disposable plastic insulin syringes are two common tools for insulin administration. This study aims to compare the simplicity, convenience, safety, and cost-effectiveness of insulin pens versus syringe devices in patients with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted at 14 diabetes clinics throughout Bangladesh from November 2021 to April 2022 among adults with T2DM injecting insulin by pen devices or disposable insulin syringes at least once a day for at least one year by purposive sampling. The simplicity, convenience, and safety of insulin devices were assessed using a structured questionnaire, and the study subjects were scored based on their answers; higher scores indicated a poorer response. Total scores for simplicity, convenience, and safety were obtained by adding the scores for relevant components. Their average monthly medical expense and cost of insulin therapy were recorded. The median values of the total scores and monthly expenses were compared between pen devices and disposable syringe users.

RESULTS

737 subjects were evaluated; 406 were pen users, and 331 were vial syringe users. The pen users had lower median scores for simplicity [6.0 (5.0-8.0) vs. 7.0 (5.0-9.0), p = 0.002], convenience [4.0 (3.0-6.0) vs. 5.0 (4.0-6.0), p < 0.001], and safety [7.0 (6.0-8.0) vs. 7.0 (6.0-9.0), p = 0.008] than vial syringe users. Pen devices were more expensive than vial syringes in terms of average medical expense per month [BDT 5000 (3500-7000) vs. 3000 (2000-5000), p < 0.001], the total cost of insulin therapy per month [BDT 2000 (1500-3000) vs. 1200 (800-1700), p < 0.001] and cost per unit of insulin used [BDT 2.08 (1.39-2.78) vs. 0.96 (0.64-1.39), p < 0.001]. Non-significant differences in favor of pens were observed in HbA1c levels [8.7 (7.8-10) vs. 8.9 (7.9-10)%, p = 0.607] and proportions of subjects having HbA1c < 7% (6.9 vs. 6.3%, p = 0.991).

CONCLUSION

Insulin pens are simpler, more convenient, and safe but more expensive than vial syringes. Glycemic control is comparable between pen and syringe users. Long-term follow-up studies are needed to determine the clinical and economic impacts of such benefits of insulin pens.