The association between patient-reported self-management behavior, intermediate clinical outcomes, and mortality in patients with type 2 diabetes: results from the KORA-A study

Frailty in Community-Dwelling Adults Aged 40 Years and over with Type 2 Diabetes: Association with Self-Management Behaviors

Background: Evidence is lacking on risk factors for frailty and prefrailty and their relationship with self-management behaviors in patients ≥40 years of age with type 2 diabetes. Methods: Participants were selected as a cross-sectional cohort at five communities in Shanghai, China during January−March 2021. The modified FRAIL scale and the Summary of Diabetes Self-Care Activities (SDSCA) measure were used. Results: Of the 558 participants, 10.2% were classified as frailty and 34.1% as prefrailty. The prevalence of frailty was higher in males than in females (p = 0.009), whereas females were associated with higher odds of prefrailty (aOR 1.67, 95% CI [1.08−2.60]). Multimorbidity, ≥3 chronic diseases, and hospitalization in the past year were considered risk factors for both frailty and prefrailty. Each point earned on SDSCA and physical activity were associated with lower odds of frailty (aOR 0.95, 95% CI [0.92−0.98]) and prefrailty (aOR 0.52, 95% CI [0.31−0.85]), respectively. Frail participants performed significantly worse self-care practice than prefrail and non-frail ones, especially on diet, physical activity, and medication adherence (p < 0.001). Conclusions: Frail patients ≥40 years of age with type 2 diabetes reported poorer self-care performance. Further interventional studies are warranted to clarify their causal relationship.

[Effectiveness and Ethical Evaluation of Nudging to Promote the Self-Management in Diabetes Mellitus Type 2]

Hintergrund Nudges bieten vielfältige Möglichkeiten zur Förderung von gesundheitsbezogenem Verhalten im Alltag, die klassische Public Health-Maßnahmen ergänzen können. Vor diesem Hintergrund führten wir vorläufige Untersuchungen zur Wirksamkeit und zu ethischen Aspekten verschiedener Nudges zur Förderung des Selbstmanagements von Patienten mit Diabetes mellitus Typ 2 im Kontext von Disease-Management-Programmen (DMPs) durch.

Methodik Die ethische Bewertung der Nudges erfolgte im systematischen Rahmen von Marckmann et al. (2015) zur Public Health-Ethik. Die bisherige Evidenz zur Wirksamkeit von Nudges wurde mittels einer narrativen Literaturübersicht zusammenfassend dargestellt.

Ergebnisse Zielvereinbarungen mit Umsetzungsplänen, Erinnerungen, Feedback, Sammeltermine bei Ärzten, Peer Mentoring sowie Verhaltensverträge sind Nudging-Interventionen mit mäßiger Eingriffstiefe in die Persönlichkeitsrechte der Patienten und ethisch relativ unproblematischen Voraussetzungen, die sich in verschiedenen Kontexten bewährt haben. Automatische Einschreibungen zu Patientenschulungen, Einbindung der Lebenspartner, Konfrontation mit sozialen Normen und Verwendung von Schockbildern können ebenfalls wirksam sein, greifen jedoch tiefer in die Freiheit und Privatsphäre der Patienten ein und unterliegen stärkeren ethischen Voraussetzungen und Beschränkungen. Die Evidenzlage ist insbesondere bei Maßnahmen zur sozialen Unterstützung durch Angehörige und Peers noch unzureichend.

Schlussfolgerungen Nudging bietet ein breites Spektrum gezielter Interventionen zur Förderung des Selbstmanage-ments von Patienten mit chronischen Erkrankungen, dessen Potenzial bislang noch zu wenig erschlossen wurde. Besonders vielversprechende Maßnahmen sollten in Pilotstudien auf ihre Akzeptanz, Wirksamkeit und Kosteneffektivität im Rahmen von DMPs evaluiert werden.

Participation in structured diabetes self-management education programs and its associations with self-management behaviour - a nationwide population-based study

OBJECTIVE

To evaluate the relationship between participation in structured diabetes self-management education programs (DSME) and self-management behaviour (SMB) in routine care.

METHODS

The study included 864 ever- and 515 never-DSME participants from the population-based survey German Health Update (GEDA) 2014/2015. SMB and clinical care variables were: Following a diet plan, keeping a diabetes diary, holding a diabetes pass, self-monitoring of blood glucose (SMBG), foot self-examination (FSE), retinopathy screening, haemoglobin A1c (HbA1c) measurement and examination of the feet by clinicians (FEC). We conducted logistic regression analyses for association of DSME-participation with SMB, adjusting for various variables.

RESULTS

DSME-participation was significantly associated with SMB including following a diet plan (OR 1.88 [95% CI 1.21-2.92]), keeping a diabetes journal (OR 3.83 [2.74-5.36]), holding a diabetes health passport (OR 6.11 [4.40-8.48]), SMBG (OR 2.96 [2.20-3.98]) and FSE (OR 2.64 [2.01-3.47]) as well as retinopathy screening (OR 3.30 [2.31-4.70]), HbA1c measurement (OR 2.58 [1.88-3.52]), and FEC (OR 3.68 [2.76-4.89]) after adjusting for confounders.

CONCLUSION

DSME-participation is associated with higher frequencies of various SMB and clinical care variables in routine care. Never-DSME attenders are more likely not to receive retinopathy screening, FEC and HbA1c measurements as recommended.

PRACTICE IMPLICATIONS

Clinicians should refer diabetes patients to a DSME and ensure a regular follow up for never-DSME attenders.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

Use of health locus of control on self-management and HbA1c in patients with type 2 diabetes

Aim

To assess the effects of health locus of control‐based education programme (HLCEP) on self‐management, health locus of control and glycated haemoglobin (HbA1c) among type 2 diabetes mellitus (T2DM).

Design

Quasi‐experimental study.

Methods

The study recruited 120 T2DM participants from May–September 2020. The control group received one‐week in‐hospital care and 12‐week follow‐up. The intervention group received additional HLCEP. The self‐management and the health locus of control were measured by using the Summary of Diabetes Self‐care Activities and the Multidimensional Health Locus of Control at baseline and the 4th and 12th week after discharge. The HbA1c was collected at baseline and the 12th week after discharge. The generalized estimating equation analysis was performed to assess the intervention effects.

Results

The intervention group has statistically significantly higher scores on the overall level of self‐management, dietary management, foot care, medication management and internal health locus of control, while a lower HbA1c level than the control group.

Self-Care Experiences of Empty-Nest Elderly Living With Type 2 Diabetes Mellitus: A Qualitative Study From China

Background

The number of type 2 diabetes mellitus (T2DM) cases among empty-nest elderly increases with increasing aging in China. Self-care plays an important role in preventing and reducing adverse outcomes of diabetes; however, few studies focus on self-care experiences of empty-nest elderly with T2DM.

Objective

To explore self-care experiences for a chronic disease among empty-nest elderly patients with T2DM in mainland China.

Methods

A descriptive phenomenological design was used in this study. Semi-structured interviews were conducted for 15 empty-nesters with T2DM. Interviews were implemented in department of endocrinology at a tertiary teaching hospital located in Shandong province, east of China.

Results

The participants were poorly adept with monitoring their blood glucose and lacked the ability to deal with abnormal blood glucose levels. Most participants had a good relationship with medication and physical activity. Living without children was perceived as a benefit that improved dietary management and is a disadvantage in terms of economic and emotional support and access to medical resources. Elderly empty-nesters also lacked knowledge about diabetes and paid little attention to potential complications.

Conclusion

Empty-nest elderly patients with T2DM value medication compliance and lifestyle modification more than blood glucose monitoring, complication prevention, and coping with negative emotions. Friends and spouses play indispensable roles in patients' self-care motivation and maintenance. Diabetes education on self-care, access to medical resources, and social support is needed for better diabetes management.

Psychometric Properties of the Persian Version of the Diabetes Self-Management Questionnaire for Patients with Type 2 Diabetes in Iran

Background:

Diabetes self-management questionnaire (DSMQ) is among the relatively new tools with comprehensive structure measuring various dimensions of self-care behaviors in diabetic patients. This study was carried out to evaluate psychometric properties of Persian version of DSMQ.

Methods:

A cross-sectional study was carried out from January to March 2017 among patients with type 2 diabetes mellitus (T2DM) referred to urban health centers, in Kerman, southeastern Iran. Data were collected from 589 patients using DSMQ. The DSMQ was translated into Persian by forward and backward translation method. Cronbach's alpha method and intraclass correlation coefficient (ICC) were used to measure internal consistency and test-retest reliability, respectively. In addition, construct validity was assessed by confirmatory factor analysis and exploratory factor analysis (EFA).

Results:

The sum-scale Cronbach's α of DSMQ was equal to 0.82 for 30 participants. The mean inter-item correlation and mean item-total correlation of “Sum Scale” (SS) were equal to 0.21 (standard deviation (SD) = 0.22) and 0.53 (SD = 0.19), respectively. All items had item-total correlations higher than 0.30 except items 7, 11, and 15. For “SS,” ICC was obtained as 0.93. EFA revealed a four-factor model accounting for 62.5% of the total variance. All indices were acceptable for the modified DSMQ with four factors (χ² = 134.33, degrees of freedom = 89, P = 0.001, comparative fit index = 0.97, root mean square error of approximation = 0.044, Tucker-Lewis index = 0.96, and normal fit index = 0.92).

Conclusions:

The Persian version of DSMQ was found to have acceptable reliability and validity for assessing self-management among patients with T2DM.

Patterns and associated factors of diabetes self-management: Results of a latent class analysis in a German population-based study

OBJECTIVE

Few studies on diabetes self-management considered the patterns and relationships of different self-management behaviours (SMB). The aims of the present study are 1) to identify patterns of SMB among persons with diabetes, 2) to identify sociodemographic and disease-related predictors of SMB among persons with diabetes.

RESEARCH DESIGN AND METHODS

The present analysis includes data of 1,466 persons (age 18 to 99 years; 44.0% female; 56.0% male) with diabetes (type I and II) from the population-based study German Health Update 2014/2015 (GEDA 2014/2015-EHIS). We used latent class analysis in order to distinguish different patterns of self-management behaviours among persons with diabetes. The assessment of SMB was based on seven self-reported activities by respondents (dietary plan, diabetes-diary, diabetes health pass, self-assessment of blood glucose, self-examination of feet, retinopathy-screenings and assessment of HbA1c). Subsequent multinomial latent variable regressions identified factors that were associated with self-management behaviour.

RESULTS

Latent class analysis suggested a distinction between three patterns of SMB. Based on modal posterior probabilities 42.8% of respondents showed an adherent pattern of diabetes self-management with above-average frequency in all seven indicators of SMB. 32.1% showed a nonadherent pattern with a below-average commitment in all seven forms of SMB. Another 25.1% were assigned to an ambivalent type, which showed to be adherent with regard to retinopathy screenings, foot examinations, and the assessment of HbA1c, yet nonadherent with regard to all other forms of SMB. In multivariable regression analyses, participation in Diabetes Self-Management Education programs (DSME) was the most important predictor of good self-management behaviour (marginal effect = 51.7 percentage points), followed by attentiveness towards one's personal health (31.0 percentage points). Respondents with a duration of illness of less than 10 years (19.5 percentage points), employed respondents (7.5 percentage points), as well as respondents with a high socioeconomic status (24.7 percentage points) were more likely to show suboptimal forms of diabetes self-management.

DISCUSSION

In the present nationwide population-based study, a large proportion of persons with diabetes showed suboptimal self-management behaviour. Participation in a DSME program was the strongest predictor of good self-management. Results underline the need for continual and consistent health education for patients with diabetes.

Associations between self-management behavior and sociodemographic and disease-related characteristics in elderly people with type 2 diabetes - New results from the population-based KORA studies in Germany

AIMS

Self-management behavior (SMB) is an important aspect in the management of diabetes. This study aimed to identify sociodemographic and disease-related factors associated with good SMB in people with type 2 diabetes (T2D).

METHODS

We used data from 479 people with T2D aged 65 or older from the population-based KORA (Cooperative Health Research in the Area of Augsburg) Health Survey 2016 in Southern Germany. We estimated Poisson and logistic regression models testing the cross-sectional relationship between individual or disease-related characteristics and an established SMB sum index comprising six SMB dimensions stratified according to insulin treatment status.

RESULTS

Mean age in the sample was 75 and mean diabetes duration was 13 years. The overall level of SMB was low. Higher SMB index scores were associated with higher age, treatment with insulin, participation in a diabetes education program, and, for people with insulin treatment, with a BMI below 30 kg/m². Single item analyses generally supported these findings.

CONCLUSIONS

SMB in people with T2D needs to be improved with efficient interventions. Targeting obese individuals and those at an early stage of the disease with low-barrier, regular education or self-management programs may be a preferred strategy.

Association between unrealistic comparative optimism and self-management in individuals with type 2 diabetes: Results from a cross-sectional, population-based study

BACKGROUND AND AIMS

Unrealistic comparative optimism (UO), as the erroneous judgement of personal risks to be lower than the risks of others, could help explain differences in diabetes self-management. The present study tested the hypothesis that individuals with type 2 diabetes who underestimate their comparative heart attack risk, have a lower adherence regarding recommended self-management.

METHODS

We used data from individuals with type 2 diabetes participating in the German KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 (self-administered health questionnaire 2016) study. UO was estimated by comparing participants' subjective comparative risk for having a heart attack within the next 5-years (ie, "higher than others," "average," "lower than others"), with their objective comparative 10-year cardiovascular disease risk based on the Framingham equations. We estimated binary logistic and linear regression models to analyze which characteristics were associated with UO and to test the association between UO and participants' self-management behaviors (ie, regular self-monitoring of body weight, blood sugar, and blood pressure, regular foot care, keeping a diabetes diary, and having a diet plan), and their sum score, respectively. All models were adjusted for socio-demographic and disease-related variables.

RESULTS

The studied sample included n = 633 individuals with type 2 diabetes (mean age 70.7 years, 45% women). Smokers and males were more likely to show UO than nonsmokers and females. Furthermore, a higher blood pressure and a higher body mass index were associated with a higher likelihood of UO regarding heart attack risk. However, UO was not significantly associated with patient self-management.

CONCLUSIONS

Unfavorable health behavior and risk factors are associated with UO. However, our results suggest that UO with regard to perceived heart attack risk may not be a relevant factor for patient self-management in those with type 2 diabetes.

Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis

AIMS

To investigate the relationship between depression and self-care behaviours in older individuals with multimorbidity.

DESIGN

Cross-sectional study. Data were collected between April 2017 - June 2019.

METHODS

Patients were enrolled from community and outpatient settings and included if they were ≥65 years, affected by heart failure, diabetes mellitus or chronic obstructive pulmonary disease and at least another chronic condition. They were excluded if they had dementia and/or cancer. Patient Health Questionnaire-9 was used to measure depression and Self-Care of Chronic Illness Inventory was used to measure self-care maintenance, monitoring, and management. The relationship between depression and self-care was evaluated by performing two sets of univariate analyses, followed by multivariate and step-down analyses. The second set was performed to control for the number of chronic conditions, age, and cognitive function.

RESULTS

The sample (N = 366) was mostly female (54.2%), with a mean age of 76.4 years. Most participants (65.6%) had mild to very severe depressive symptoms. Preliminary analysis indicated a significant negative association between depression and self-care maintenance and monitoring and a significant negative association between depression and multivariate self-care. Step-down analysis showed that self-care maintenance was the only dimension negatively associated with depression, even after controlling for the number of chronic conditions, age, and cognitive function.

CONCLUSION

In multimorbid populations, depression is more likely to be associated with self-care maintenance than the other self-care dimensions. Therefore, self-care maintenance behaviours (e.g., physical activity and medication adherence) should be prioritized in assessment and focused on when developing interventions targeting depressed older adults with multimorbidity.

IMPACT

The results of this study may help guide clinical practice. In patients with depressive symptoms, self-care maintenance behaviours should be assessed first, as a potential first indicator of poor self-care.

Diabetes pay-for-performance program can reduce all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus

This study aimed to examine the effect of a diabetes pay-for-performance (P4P) program on all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Using a Taiwanese representative nationwide cohort, we recruited 5478 patients with newly diagnosed type 2 diabetes enrolled in the P4P program within 5 years after a diagnosis of diabetes between January 1, 2002 and December 31, 2010 and individuals not enrolled in the P4P program were recruited as the control group matched 1:1 with the study group. We used multivariate Cox proportional hazard models analysis to investigate the effect of the P4P program and adherence on all-cause mortality. A total of 250 patients died in the P4P group compared to 395 in the control group (mortality rate 104 vs 169 per 10,000 person-years, respectively, P < .0001). The control group also had more comorbidities. Patients enrolled in the P4P program demonstrated significant long-term survival benefits, of which the adjusted hazard ratio (aHR) for all-cause mortality was 0.58 [95% CI (0.48-0.69)]. In the study group, better adherence to the P4P program resulted in a greater reduction in mortality, with aHRs [95% CI] of 0.48 [0.38-0.62] and 0.36 [0.26-0.49] in subjects with a minimum 1-year and 2-year good P4P adherence, respectively. Participating in the P4P program within 5 years after the diagnosis of diabetes resulted in a significant reduction in all-cause mortality, and this effect was particularly pronounced in the patients with better adherence to the P4P program.

Performance of the UKPDS Outcomes Model 2 for Predicting Death and Cardiovascular Events in Patients with Type 2 Diabetes Mellitus from a German Population-Based Cohort

BACKGROUND AND OBJECTIVE

Accurate prediction of relevant outcomes is important for targeting therapies and to support health economic evaluations of healthcare interventions in patients with diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) risk equations are some of the most frequently used risk equations. This study aims to analyze the calibration and discrimination of the updated UKPDS risk equations as implemented in the UKPDS Outcomes Model 2 (UKPDS-OM2) for predicting cardiovascular (CV) events and death in patients with type 2 diabetes mellitus (T2DM) from population-based German samples.

METHODS

Analyses are based on data of 456 individuals diagnosed with T2DM who participated in two population-based studies in southern Germany (KORA (Cooperative Health Research in the Region of Augsburg)-A: 1997/1998, n = 178; KORA-S4: 1999-2001, n = 278). We compared the participants' 10-year observed incidence of mortality, CV mortality, myocardial infarction (MI), and stroke with the predicted event rate of the UKPDS-OM2. The model's calibration was evaluated by Greenwood-Nam-D'Agostino tests and discrimination was evaluated by C-statistics.

RESULTS

Of the 456 participants with T2DM (mean age 65 years, mean diabetes duration 8 years, 56% male), over the 10-year follow-up time 129 died (61 due to CV events), 64 experienced an MI, and 46 a stroke. The UKPDS-OM2 significantly over-predicted mortality and CV mortality by 25% and 28%, respectively (Greenwood-Nam-D'Agostino tests: p < 0.01), but there was no significant difference between predicted and observed MI and stroke risk. The model poorly discriminated for death (C-statistic [95% confidence interval] = 0.64 [0.60-0.69]), CV death (0.64 [0.58-0.71]), and MI (0.58 [0.52-0.66]), and failed to discriminate for stroke (0.57 [0.47-0.66]).

CONCLUSIONS

The study results demonstrate acceptable calibration and poor discrimination of the UKPDS-OM2 for predicting death and CV events in this population-based German sample. Those limitations should be considered when using the UKPDS-OM2 for economic evaluations of healthcare strategies or using the risk equations for clinical decision-making.

"I Try to Keep That Sugar Down." Experiences of Homebound Older Adults With Type 2 Diabetes: Barriers to Self-Management

Objectives: To study the experiences and challenges of type 2 diabetes (T2D) self-management among homebound older adults who regularly receive home-delivered meals and services.Methods: Participants (n = 31) were recruited by telephone screening and were selected by purposive sampling. Semi-structured interviews were subsequently conducted within participants' homes. The interpretive methodology utilized in this study was developed to systematically assess T2D self-management.Results: Thematic analysis shows that participants felt mostly responsible for their health status, but attributed any noncompliance to lack of social and economic assistance. Most of the seniors in this study felt competent, but often did not have the opportunity to engage in protective measures due to a number of economic, physical, and social barriers.Conclusions: These results contribute to a better understanding of how to approach, support, and motivate homebound older adults with T2D while addressing challenges. Findings offer insight into the development of diabetes self-management education (DSME) and interventions for this population.

Improving outcomes in patients with prediabetes through a lifestyle modification program

BACKGROUND AND PURPOSE

Type 2 diabetes and obesity are prevalent throughout the United States, and they occur at even higher rates in some southern states. This project aimed at improving outcomes for overweight/obese patients with prediabetes, thus reducing their risk of progression to type 2 diabetes.

METHODS

Twenty-four adults with a diagnosis of prediabetes and body mass index ≥ 25 completed this 3-month program. The Rapid Eating Assessment for Patients (REAPs) tool was used to assess eating habits and physical activity levels. The Single-Item Literacy Screener was used to screen for limited reading ability. The following preintervention and postintervention data were obtained: weight, A1c, REAP score, and REAP Physical Activity question (REAP-PA).

INTERVENTION

Monthly group educational sessions were conducted followed by individualized goal setting. The content of the sessions encompassed a lifestyle modification program based on the first five sessions of the Centers for Disease Control and Prevention "Prevent T2"curriculum, incorporating the Southern-style diet, food choices, and activity resources available in the local community.

RESULTS

Results revealed a significant (p < 0.05) decrease in weight (average 4.0 ± 4.2 kg), REAP score (average 17.6 ± 16.6), and REAP-PA (average 0.6) after intervention. A1c values decreased slightly but were not statistically significant, which may be due to the limited sample size. Those with limited reading ability showed a slightly greater A1c loss than those with adequate literacy.

CONCLUSIONS

A 3-month lifestyle modification program resulted in improvement in weight, eating habits, physical activity level, and A1c in overweight/obese patients at risk for type 2 diabetes.

A survey on patients' characteristics, perception of family support and diabetes self-management among type 2 diabetes patients in South-West Nigeria

AIM

To determine the association between patients' characteristics, perception of family support and diabetes self-management (DSM) behaviours among type 2 diabetes patients.

DESIGN

A descriptive cross-sectional design was used and data were collected between July-September 2016. The study is part of a larger quasi-experimental study.

METHODS

One hundred and ninety-seven diabetes mellitus (DM) patients from two teaching hospitals in south-west Nigeria participated. Questionnaire was used in collecting information on sociodemographic, clinical data, DSM and perception of family support.

RESULTS

Most (71.6%) of the participants were females and 35% were on insulin therapy. Mean age was 60.7 (SD: 11.3) years and 11.7% had had DM for over 20 years. Overall, DSM was positively influenced by previous diabetes education and duration of diabetes. Perception of family support was also positively associated with and influenced DSM.

Determinants for quality of life trajectory patterns in patients with type 2 diabetes

PURPOSE

The purpose of the study was to identify quality of life (QoL) trajectory patterns and the determinants in patients with Type 2 diabetes (T2DM).

METHODS

A longitudinal design was employed. Totally, 466 patients with T2DM recruited from five diabetic clinics in Taiwan were participants of this study. Demographic and disease characteristics, biomedical factors (HbA1c levels and body mass index), psychosocial factors (self-care behaviors, social support, resilience, diabetes distress), and QoL were collected at baseline. QoL was further measured every 6 months for four waves after baseline. Latent class growth analysis was used to identify QoL trajectory patterns. The multinomial logistic regression was further applied to explore the important determinants of different QoL trajectory patterns.

RESULTS

The "steadily poor" (n = 27, 5.8%), "consistently moderate" (n = 174, 37.3%), and "consistently good" (n = 265, 56.9%) trajectory patterns were identified. The HbA1c levels (OR 2.16) and diabetes distress (OR 1.18) were important for determining participants in the "steadily poor" QoL trajectory pattern. HbA1c levels (OR 1.25) and diabetes distress (OR 1.14) were important for determining participants in the "consistently moderate" QoL trajectory pattern.

CONCLUSIONS

To prevent development of relatively worse QoL trajectory patterns in patients with T2DM in a timelier manner, healthcare providers could regularly assess the QoL and provide intervention, especially for those with high HbA1c levels and high diabetes distress. Meanwhile, early intervention for decreasing HbA1c levels and diabetes distress may improve the trajectory development of QoL in patients with T2DM.

Time preference, outcome expectancy, and self-management in patients with type 2 diabetes

BACKGROUND

Patient self-management is crucial to prevent complications and mortality in type 2 diabetes. From an economic perspective, time preference predicts short-sighted decision making and thus might help to explain non-adherence to self-anagement recommendations. However, recent studies on this association have shown mixed results.

PURPOSE

In this study, we tested whether the combination of time preference and outcome expectancy can improve the predictions of self-management behavior.

PATIENTS AND METHODS

Data from 665 patients with type 2 diabetes were obtained from the cross-sectional KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 study. Time preference and outcome expectancy were measured by one question each, which were answered on a 4-point Likert scale. Their association with six self-managing behaviors was tested in logistic and linear regression analyses. Likewise, we examined the association between self-management and the interaction of outcome expectancy and time preference.

RESULTS

A high time preference was associated with a significantly lower sum of self-management behaviors (β=-0.29, 95% CI [-0.54, -0.04]). Higher outcome expectancy was associated with a higher self-management score (β=0.21, 95% CI [-0.03, 0.45]). The interaction model showed that low time preference was only associated with better self-management when combined with a high outcome expectancy (β=0.05, 95% CI [-0.28, 0.39] vs β=0.27, 95% CI [-0.09, 0.63]).

CONCLUSION

Time preference and outcome expectancy are interrelated predictors of patient self-management and could be used to identify and to intervene on patients with a potentially poor self-management.

Influencing Pathways to Quality of Life and HbA1c in Patients With Diabetes: A Longitudinal Study That Inform Evidence-Based Practice

BACKGROUND

Determining possible associated factors and the influencing pathways to hemoglobin A1C (HbA1C) levels and quality of life (QoL) will facilitate the development of effective interventions to improve the physical and psychosocial health of patients with type 2 diabetes mellitus (T2DM).

OBJECTIVES

To test a hypothesized model that addressed the pathways among personal characteristics, social support, diabetes distress, and self-care behaviors to HbA1C and QoL.

METHODS

A total of 382 adults with T2DM were recruited. Self-reported questionnaires and medical records were used to collect data regarding personal characteristics, diabetes distress, and social support at baseline. The self-care behaviors characters were collected 6 months later, as well as QoL and HbA1C levels 1 year later.

RESULTS

The 12-month QoL directly affected 12-month HbA1C levels. The 6-month self-care behaviors directly affected 12-month QoL, and indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline diabetes distress directly affected 12-month QoL. Moreover, baseline diabetes distress indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline social support directly affected baseline diabetes distress and 6-month self-care behaviors. In addition, baseline social support indirectly affected 12-month QoL through baseline diabetes distress. Baseline social support also indirectly affected 12-month QoL through 6-month self-care behaviors.

LINKING EVIDENCE TO ACTION

Enhancing QoL is important to improve HbA1C levels. Enhancing self-care behaviors is essential to improve subsequent HbA1C control and QoL. Reducing diabetes distress is crucial to improve subsequent QoL. Improving social support is suggested a favorable strategy to reduce diabetes distress and enhance subsequent self-care behaviors in patients with T2DM.

Assessing the association of diabetes self-management education centers with age-adjusted diabetes rates across U.S.: Aspatial cluster analysis approach

The purpose of this study is to identify regions with diabetes health-service shortage. American Diabetes Association (ADA)-accredited diabetes self-management education (DSME) is recommended for all those with diabetes. In this study, we focus on demographic patterns and geographic regionalization of the disease by including accessibility and availability of diabetes education resources as a critical component in understanding and confronting differences in diabetes prevalence, as well as addressing regional or sub-regional differences in awareness, treatment and control. We conducted an ecological county-level study utilizing publicly available secondary data on 3,109 counties in the continental U.S. We used a Bayesian spatial cluster model that enabled spatial heterogeneities across the continental U.S. to be addressed. We used the American Diabetes Association (ADA) website to identify 2012 DSME locations and national 2010 county-level diabetes rates estimated by the Centers for Disease Control and Prevention and identified regions with low DSME program availability relative to their diabetes rates and population density. Only 39.8% of the U.S. counties had at least one ADA-accredited DSME program location. Based on our 95% credible intervals, age-adjusted diabetes rates and DSME program locations were associated in only seven out of thirty five identified clusters. Out of these seven, only two clusters had a positive association. We identified clusters that were above the 75th percentile of average diabetes rates, but below the 25th percentile of average DSME location counts and found that these clusters were all located in the Southeast portion of the country. Overall, there was a lack of relationship between diabetes rates and DSME center locations in the U.S., suggesting resources could be more efficiently placed according to need. Clusters that were high in diabetes rates and low in DSME placements, all in the southeast, should particularly be considered for additional DSME programming.

Quality of Diabetes Care in Germany Improved from 2000 to 2007 to 2014, but Improvements Diminished since 2007. Evidence from the Population-Based KORA Studies

Objective

Little is known about the development of the quality of diabetes care in Germany. The aim of this study is to analyze time trends in patient self-management, physician-delivered care, medication, risk factor control, complications and quality of life from 2000 to 2014.

Methods

Analyses are based on data from individuals with type 2 diabetes of the population-based KORA S4 (1999–2001, n = 150), F4 (2006–2008, n = 203), FF4 (2013/14, n = 212) cohort study. Information on patient self-management, physician-delivered care, medication, risk factor control and quality of life were assessed in standardized questionnaires and examinations. The 10-year coronary heart disease (CHD) risk was calculated using the UKPDS risk engine. Time trends were analyzed using multivariable linear and logistic regression models adjusted for age, sex, education, diabetes duration, and history of cardiovascular disease.

Results

From 2000 to 2014 the proportion of participants with type 2 diabetes receiving oral antidiabetic/cardio-protective medication and of those reaching treatment goals for glycemic control (HbA1c<7%, 60% to 71%, p = 0.09), blood pressure (<140/80 mmHg, 25% to 69%, p<0.001) and LDL cholesterol (<2.6 mmol/l, 13% to 27%, p<0.001) increased significantly. However, improvements were generally smaller from 2007 to 2014 than from 2000 to 2007. Modeled 10-year CHD risk decreased from 30% in 2000 to 24% in 2007 to 19% in 2014 (p<0.01). From 2007 to 2014, the prevalence of microvascular complications decreased and quality of life increased, but no improvements were observed for the majority of indicators of self-management.

Conclusion

Despite improvements, medication and risk factor control has remained suboptimal. The flattening of improvements and deteriorations in quality of (self-) care since 2007 indicate that more effort is needed to improve quality of care and patient self-management. Due to selection or lead time bias an overestimation of quality of care improvements cannot be ruled out.

Associations between diabetes self-management and microvascular complications in patients with type 2 diabetes

OBJECTIVES:

Diabetes is a major public health problem that is approaching epidemic proportions globally. Diabetes self-management can reduce complications and mortality in type 2 diabetic patients. The purpose of this study was to examine associations between diabetes self-management and microvascular complications in patients with type 2 diabetes.

METHODS:

In this cross-sectional study, 562 Iranian patients older than 30 years of age with type 2 diabetes who received treatment at the Diabetes Research Center of the Endocrinology and Metabolism Research Institute of the Tehran University of Medical Sciences were identified. The participants were enrolled and completed questionnaires between January and April 2014. Patients’ diabetes self-management was assessed as an independent variable by using the Diabetes Self-Management Questionnaire translated into Persian. The outcomes were the microvascular complications of diabetes (retinopathy, nephropathy, and neuropathy), identified from the clinical records of each patient. A multiple logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) between diabetes self-management and the microvascular complications of type 2 diabetes, adjusting for potential confounders.

RESULTS:

After adjusting for potential confounders, a significant association was found between the diabetes self-management sum scale and neuropathy (adjusted OR, 0.64; 95% CI, 0.45 to 0.92, p=0.01). Additionally, weak evidence was found of an association between the sum scale score of diabetes self-management and nephropathy (adjusted OR, 0.71; 95% CI, 0.47 to 1.05, p=0.09).

CONCLUSIONS:

Among patients with type 2 diabetes, a lower diabetes self-management score was associated with higher rates of nephropathy and neuropathy.

The effectiveness of German disease management programs (DMPs) in patients with type 2 diabetes mellitus and coronary heart disease: results from an observational longitudinal study

BACKGROUND

Although the population-based German disease management programs (DMPs) for diabetes mellitus (DM) and coronary heart disease (CHD) are among the biggest worldwide, evidence on the effectiveness of these programs is still inconclusive or missing, particularly for high risk patients with comorbidities. The objective of this study was therefore to analyze the impact of DMPs on process and outcome parameters in patients with both, type 2 DM and CHD.

METHODS

Analyses are based on two postal surveys of patients from the KORA myocardial infarction registry (southern Germany) with type 2 DM and on two postal validation studies with patients' general physicians (2006, n = 312 and 2011, n = 212). The association between DMP enrollment (being enrolled in either DMP-DM or DMP-CHD) and guideline care (defined by several process indicators) at baseline (2006) and its development until follow-up (2011) was analyzed using logistic regression models accounting for the repeated measurements structure. The impact of DMP enrollment/guideline care on cumulated (quality-adjusted) life years ((QA)LYs) over a 4-year time horizon (2006-2010) was assessed using multiple linear regression methods. Logistic regression models were applied to analyze the association between DMP status and patient self-management at follow-up.

RESULTS

Being enrolled in a DMP was associated with better guideline care at baseline [OR = 2.3 (95 % CI 1.27-4.03)], but not at follow-up [OR = 0.80 (95 % CI 0.40-1.58); p value for time-interaction <0.01]. DMP enrollment was not significantly [+0.15 LYs (95 % CI -0.07, 0.37); +0.06 QALYs (95 % CI -0.15, 0.26)], but treatment according to guideline care significantly [+0.40 LYs (95 % CI 0.21-0.60); +0.28 QALYs (95 % CI 0.10-0.45)] associated with higher (quality-adjusted) survival over the 4-year follow-up period. DMP enrollees further reported a somewhat better self-management than patients not being enrolled into a DMP.

CONCLUSIONS

The results of this study concerning the effectiveness of DMPs in patients with DM and CHD are mixed, but are weakly in favor of DMPs. However, we found a clear positive impact of guideline care on quality adjusted survival in this patient group. The development of the association between DMP enrollment and guideline care over the follow-up time indicates some external effects, which should be the subject of further investigations.

Towards patient-oriented diabetes care: results from two KORA surveys in southern Germany

OBJECTIVE

This study aims to examine the relationship of diabetes care processes and patient outcomes with an expanded set of indicators regarding patient-oriented care delivery, such as treatment satisfaction, the quality of patient-physician relationship, and a wider range of patient outcomes such as self-management, health behaviour, disease-related burden, and health-related quality of life (HRQL).

METHODS

The study population consisted of 486 participants with type 2 diabetes in two population-based follow-up surveys, conducted in 2003 to 2005 and 2006 to 2008 in Southern Germany. Data were self-reported and questionnaire-based, including the SF-12 for HRQL. Multiple regression models were used to identify associations between care processes and outcomes with adjustment for confounders.

RESULTS

Frequent medical examinations increased the likelihood of self-monitoring activities, such as foot care. A positive patient experienced relationship with their physician is associated with higher adherence to medical recommendations, such as medication intake, and the score of the SF-12 mental component. Participants with diabetes-related complications reported higher levels of medical examinations and multiprofessional care.

CONCLUSIONS

Indicators of patient-oriented care should become an indispensable part of diabetes clinical practice guidelines with the aim of striving for more effective support of patients.

Type 2 diabetes patients' perspectives on lifestyle counselling and weight management in general practice: a qualitative study

Background

Lifestyle counselling is a pivotal aspect of diabetes care. But general practitioners (GPs) often have problems in finding their role in patients’ weight management. The aims of this study were to investigate the experiences of type 2 diabetes patients with lifestyle counselling from their GPs and to explore how patients’ preferences regarding counselling are embedded in the context of self-management and wider cultural aspects of nutrition.

Methods

Narrative interviews were conducted with 35 people with type 2 diabetes aged between 35 and 77 years. The interviews were transcribed verbatim and analysed using the thematic framework method.

Results

Many patients had a strong feeling of personal responsibility for weight reduction as integral to diabetes self-management but found it difficult to integrate the changes their disease requires into their self-management activities. They attached great importance to their GPs’ advice on diet. While some patients appreciated direct communication, others regarded dramatic pictures as either unhelpful or offending. A serious problem was the incompatibility of the dietary recommendations with daily life resulting in a reluctance to adjust the whole diet to the needs of diabetes care.

Conclusions

Ambivalence towards patient self-management and tensions between the necessary changes to patients’ lifestyles and their culture, makes the GP’s role difficult and full of conflict. Instead of focusing exclusively on the guidelines of diabetes management and provision of information, GPs should explore the patients’ capabilities of self-management through open communication and accept their patients’ wishes to protect nutrition as part of their culture.