Thirty-six-item short-form outcomes following a randomized controlled trial in type 2 diabetes

The impact of a disease management programme for type 2 diabetes on health-related quality of life: multilevel analysis of a cluster-randomised controlled trial

BACKGROUND

Type 2 diabetes is a chronic disease associated with poorer health outcomes and decreased health related quality of life (HRQoL). The aim of this analysis was to explore the impact of a disease management programme (DMP) in type 2 diabetes on HRQoL. A multilevel model was used to explain the variation in EQ-VAS.

METHODS

A cluster-randomized controlled trial-analysis of the secondary endpoint HRQoL. Our study population were general practitioners and patients in the province of Salzburg. The DMP "Therapie-Aktiv" was implemented in the intervention group, and controls received usual care. Outcome measure was a change in EQ-VAS after 12 months. For comparison of rates, we used Fisher's Exact test; for continuous variables the independent T test or Welch test were used. In the multilevel modeling, we examined various models, continuously adding variables to explain the variation in the dependent variable, starting with an empty model, including only the random intercept. We analysed random effects parameters in order to disentangle variation of the final EQ-VAS.

RESULTS

The EQ-VAS significantly increased within the intervention group (mean difference 2.19, p = 0.005). There was no significant difference in EQ-VAS between groups (mean difference 1.00, p = 0.339). In the intervention group the improvement was more distinct in women (2.46, p = 0.036) compared to men (1.92, p = 0.063). In multilevel modeling, sex, age, family and work circumstances, any macrovascular diabetic complication, duration of diabetes, baseline body mass index and baseline EQ-VAS significantly influence final EQ-VAS, while DMP does not. The final model explains 28.9% (EQ-VAS) of the total variance. Most of the unexplained variance was found on patient-level (95%) and less on GP-level (5%).

CONCLUSION

DMP "Therapie-Aktiv" has no significant impact on final EQ-VAS. The impact of DMPs in type 2 diabetes on HRQoL is still unclear and future programmes should focus on patient specific needs and predictors in order to improve HRQoL.Trial registration Current Controlled trials Ltd., ISRCTN27414162.

Outcomes of a health coaching intervention delivered by medical students for older adults with uncontrolled type 2 diabetes

Effective strategies are needed to address the health behaviors of older patients with diabetes. One approach is health coaching, the practice of health education and health promotion through a structured partnership designed to enhance well-being and facilitate the achievement of individuals' health-related goals. The aim of this study was to describe the development of a pilot health coaching curriculum, investigate its effects on geriatric patient outcomes, and examine qualitative feedback by older patients and medical students to the curriculum. This mixed-methods study involved 29 first-year medical students randomly paired with 29 older adults with uncontrolled Type 2 diabetes. Health-related quality of life (HRQoL), stage of change movement, diabetes knowledge, locus of control, Body Mass Index (BMI), and glycosylated hemoglobin (HbA1c) were assessed. Focus groups were used to evaluate patients' and medical students' experiences. Results showed significant increases in patients' HRQoL and stage of change for exercise improved significantly over time. There were no significant changes in stage of change for healthy diet and medication, diabetes knowledge, BMI, and HbA1c from baseline to end of study. Focus group data indicated positive responses by older patients and the medical students. A health coaching curriculum may improve patient outcomes and can provide medical students the skills needed to provide compassionate care for geriatric patients.

Identification of Patients With Diabetes Who Benefit Most From a Health Coaching Program in Chronic Disease Management, Sydney, Australia, 2013

Introduction

Chronic disease management programs (CDMPs) that include health coaching can facilitate and coordinate diabetes management. The aim of this study was to assess changes in patients’ general knowledge of diabetes, self-reported health status, diabetes distress, body mass index (BMI), and glycemic control after enrollment in a face-to-face CDMP group health coaching session (with telephone follow-up) compared with participation in telephone-only health coaching, during a 12-month period.

Methods

Patients with diabetes were enrolled in a health coaching program at Royal North Shore Hospital, Sydney, Australia, in 2013. Questionnaires were administered at baseline and at 3, 6, and 12 months, and the results were compared with baseline. Glycemic control, measured with glycated hemoglobin A_1c (HbA_1c) and BMI, were measured at baseline and 12 months.

Results

Overall, 238 patients attended a face-to-face CDMP session with telephone follow-up (n = 178) or participated in telephone-only health coaching (n = 60). We found no change in BMI in either group; however, HbA_1c levels in patients with baseline above the current recommended target (>7%) decreased significantly from 8.5% (standard deviation [SD], 1.0%) to 7.9% (SD, 1.0%) (P = .03). Patients with the lowest self-reported health status at baseline improved from 4.4 (SD, 0.5) to 3.7 (SD, 0.9) (P = .001). Diabetes knowledge improved in all patients (24.4 [SD, 2.4] to 25.2 [SD, 2.4]; P < .001), and diabetes distress decreased among those with the highest levels of distress at baseline (3.0 [SD, 0.4] vs 3.8 [SD, 0.6]; P = .003).

Conclusion

Diabetes health coaching programs can improve glycemic control and reduce diabetes distress in patients with high levels of these at baseline.

A double-blind, randomised, placebo-controlled trial of Ganoderma lucidum for the treatment of cardiovascular risk factors of metabolic syndrome

This study aimed to evaluate the efficacy and safety of Ganoderma lucidum for the treatment of hyperglycaemia and other cardiovascular risk components of metabolic syndrome using a prospective, double-blind, randomised, placebo-controlled trial. Eighty-four participants with type 2 diabetes mellitus and metabolic syndrome were randomised to one of three intervention groups: Ganoderma lucidum, Ganoderma lucidum with Cordyceps sinensis, or placebo. The dosage was 3 g/day of Ganoderma lucidum, with or without Cordyceps sinensis, for 16 weeks. The primary outcome measure was blood glucose (glycosylated haemoglobin [HbA1c] and fasting plasma glucose [FPG]); a number of secondary outcome measures were also tested. Data from the two intervention groups were combined. The combined intervention had no effect on any of the primary (baseline-adjusted difference in means: HbA1c = 0.13%, 95% CI [-0.35, 0.60], p = 0.60; FPG = 0.03 mmol/L, 95% CI [-0.90, 0.96], p = 0.95) or secondary outcome measures over the course of the 16-week trial, and no overall increased risk of adverse events with either active treatment. Evidence from this randomised clinical trial does not support the use of Ganoderma lucidum for treatment of cardiovascular risk factors in people with diabetes mellitus or metabolic syndrome. This Clinical Trial was registered with the Australian New Zealand Clinical Trials Registry on November 23, 2006. Trial ID: ACTRN12606000485538 and can be accessed here: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81705.

A workplace intervention designed to interrupt prolonged occupational sitting

Purpose

– The purpose of this paper is to investigate the effectiveness of a workplace intervention designed to interrupt prolonged occupational sitting time (POST) and its impact on the self-reported health of a cohort of desk-based employees.

Design/methodology/approach

– In total, 43 participants received an interactive computer-based software intervention for 26 weeks. For the first 13 weeks the intervention passively prompted the participants to interrupt POST and perform brief bouts of non-purposeful movement. The second 13 weeks involved the passivity of the intervention being removed, with the intervention only accessible voluntarily by the participant. This approach was adopted to determine the sustainability of the intervention to change workplace health behaviour.

Findings

– ANOVA results revealed a significant interaction between group and test occasion, F(2, 42)=2.79, p < 0.05, such that the experimental group increased their total health from pre-test to post-test (13 weeks), and to second post-test (26 weeks) with a medium effect size of Cohen’s d=0.37.

Research limitations/implications

– An action research approach was implemented for this study, and hence the participants were organised into one group. Based on a communitarian model, the intervention aimed to monitor how desk-based employees adapted to specific health behaviours, and therefore a control group was not included.

Practical implications

– Passively prompting desk-based employees to interrupt POST and perform non-purposeful movement at work improved self-reported health. Participant perceptions of health were maintained following the removal of the passive feature of the intervention.

Social implications

– Interventions predicated on a social ecological model that modify how employees interact with the workplace environment might provide a framework for health behaviour change in populations where sitting is customary.

Originality/value

– The passive approach used in this study removed the individual decision-making process to engage in health behaviour change, and established a sustainable effect on participant health.

Gastric bypass significantly improves quality of life in morbidly obese patients with type 2 diabetes

OBJECTIVE

To evaluate the impact of Roux-en-Y gastric bypass (RYGB) on quality of life in obese diabetic patients compared to standard medical therapy for type 2 diabetes mellitus.

METHODS

We prospectively studied two matched obese populations with type 2 diabetes. Thirty patients underwent laparoscopic RYGB and 31 received standard medical therapy combined with a diabetes support and education program (DSE), consisting of educational sessions on diet and exercise. Groups were matched by age, gender, weight, glucostatic parameters, and use of glucose-lowering medications (oral agents and insulin therapy). Health-related quality of life (HRQOL) was assessed using the normalized SF-36 questionnaire, and data were collected at baseline and at 12-month follow-up.

RESULTS

Diabetic patients who underwent RYGB experienced a statistically significant increase in their overall HRQOL. However, the role-physical and mental health domains increased but did not reach statistical significance. Diabetic patients in the medical therapy and DSE group did not show any significant increase in HRQOL. The between-group differences for the HRQOL changes from baseline were significant, other than for role-physical and mental health domains. Percentage changes in glucostatic parameters, discontinuation of glucose-lowering medications, and T2DM remission were not found to predict the percentage change in SF-36 scores at 12 months after RYGB.

CONCLUSIONS

For the first time, with a prospective matched control study, we demonstrate a significant improvement in HRQOL in obese diabetic patients who underwent RYGB, but not in those who were offered standard medical therapy and DSE.

The effect of depression symptoms and social support on black-white differences in health-related quality of life in early pregnancy: the health status in pregnancy (HIP) study

BACKGROUND

Lower physical and social functioning in pregnancy has been linked to an increased risk of preterm delivery and low birth weight infants, butt few studies have examined racial differences in pregnant women's perception of their functioning. Even fewer studies have elucidated the demographic and clinical factors contributing to racial differences in functioning. Our objective was to determine whether there are racial differences in health-related quality of life (HRQoL) in early pregnancy; and if so, to identify the contributions of socio-demographic characteristics, depression symptoms, social support and clinical factors to these differences.

METHODS

Cross-sectional study of 175 women in early pregnancy attending prenatal clinics in urban setting. In multivariate analysis, we assessed the independent relation of black race (compared to white) to HRQoL scores from the eight domains of the Medical Outcomes (SF-36) SURVEY: Physical Functioning, Role-Physical, Bodily Pain, Vitality, General Health, Social Functioning, Role-Emotional, and Mental Health. We compared socio-demographic and clinical factors and depression symptoms between black and white women and assessed the relative importance of these factors in explaining racial differences in physical and social functioning.

RESULTS

Black women comprised 59% of the sample; white women comprised 41%. Before adjustment, black women had scores that were 14 points lower in Physical Function and Bodily Pain, 8 points lower in General Health, 4 points lower in Vitality and 7 points lower in Social Functioning. After adjustment for depression symptoms, social support and clinical factors, black women still had HRQoL scores that were 4 to 10 points lower than white women, but the differences were no longer statistically significant. Level of social support and payment source accounted for most of the variation in Physical Functioning, Bodily Pain and General Health. Social support accounted for most of the differences in Vitality and Social Functioning.

CONCLUSIONS

Payment source and social support accounted for much of the racial differences in physical and social function scores. Efforts to reduce racial differences might focus on improving social support networks and Socio-economic barriers.

Demonstrating the burden of hypoglycemia on patients' quality of life in diabetes clinical trials: measurement considerations for hypoglycemia

OBJECTIVES

To evaluate the association between hypoglycemia and health-related quality of life (HRQoL) in the context of a clinical trial using both an objectively confirmed and a patient-reported measure of hypoglycemia.

METHODS

During a phase III, double-arm, randomized study, patients completed the short form 36 health survey (SF-36), a generic HRQoL questionnaire, at baseline and at weeks 24, 52, and 104. The objectively confirmed measure of hypoglycemia was based on a combination of plasma glucose measure and presence of hypoglycemia-related symptoms. The patient-reported frequency of hypoglycemia was defined as the following item: "How often have you felt that your blood sugars have been unacceptably low recently?" The association between hypoglycemia and HRQoL was evaluated in intent-to-treat patients (N = 3059) by using repeated-measurements analyses, with SF-36 scores used as explained variables and baseline SF-36 score, age, sex, country, time, and either number of objectively confirmed hypoglycemic events (0, ≥1) or patient-reported frequency of hypoglycemia (continuous variable 0-6) as explanatory variables.

RESULTS

During study duration, less than 6% of patients experienced at least one objectively confirmed hypoglycemic event and about half the patients reported unacceptably low blood sugars "none of the time." The association between the number of objectively confirmed hypoglycemic events and HRQoL was not statistically significant, while the patient-reported frequency of hypoglycemia was statistically significantly related to all SF-36 scores (P < 0.001), except physical functioning; patients reporting greater perceived frequency of hypoglycemia had worse HRQoL.

CONCLUSIONS

Using a patient-reported measure of hypoglycemia in the context of a clinical trial could enable the burden of hypoglycemia for patients to be demonstrated.

A systematic review of patient-reported and economic outcomes: value to stakeholders in the decision-making process in patients with type 2 diabetes mellitus

BACKGROUND

The need for an approach to measuring health results that incorporates patients' and payers' perspectives has generated a wide range of health care outcomes (HCOs), but it is yet unknown whether these HCOs are appropriate or valid for the health care decision-making process.

OBJECTIVE

The goal of this study was to assess HCOs, patient-reported outcomes (PROs), and economic outcomes in terms of validity and appropriateness to health care decision making in type 2 diabetes mellitus (T2DM).

METHODS

This systematic review of studies published between January 1, 1996, and November 1, 2010, comprised an electronic literature search of MEDLINE and Centre for Reviews and Dissemination databases. Studies included were clinical trials, observational studies, economic analyses, and studies on the development and validation of HCOs in T2DM in the adult population. HCOs were assessed and classified according to their relevance for decision makers in terms of feasibility for routine use, validity, sensitivity, reliability, understanding, and scope.

RESULTS

Two independent reviewers screened 4497 citations. Of these, 281 potentially eligible full articles were retrieved, and 185 met the inclusion criteria. A total of 121 HCOs in T2DM were identified: 80 (66.1%) PROs and 41 (33.9%) economic outcomes. Only 44.6% of the outcomes assessed were appropriate and valid for health care decision making. Greater deficiencies in evidence were found for PROs (61.3%), followed by economic outcomes (43.9%).

CONCLUSIONS

A large number of HCOs are being used in the health care decision-making process, but a significant proportion of these new outcomes have not been properly validated. Despite the fact that appropriate measures will depend on the specific needs of the decision makers, researchers need to use HCOs for which evidence of quality and appropriateness is available.

Health status of older adults with Type 2 diabetes mellitus after aerobic or resistance training: a randomised trial

BACKGROUND

A prior study showed positive effects of resistance training on health status in individuals with diabetes compared to aerobic or no exercise, the exercise regimens were either different in volume, duration or rate of progression. We aimed to compare the effects of progressive resistance training (PRT) or aerobic training (AT) of similar volume over an 8-week period on health status (measured using the Short-form 36 Questionnaire) in middle aged adults with type 2 diabetes mellitus (T2DM).

FINDINGS

Sixty subjects aged 58 (7) years were randomised to PRT (n = 30) or AT (n = 30). General health and vitality were significantly improved in both groups (mean (SD) change scores for PRT were 12.2(11.5) and 10.5(18.2), and for AT, 13.3(19.6) and 10.0(13.1), respectively) and exceeded the minimally important difference of 5 points. The PRT group also had improved physical function and mental health status (mean (SD) change scores: 9.0(22.6), p < 0.05 and 5.3(12.3), p < 0.05, respectively), which was not observed in the AT group. However, the between group differences were not statistically significant.

CONCLUSIONS

Both exercise regimens have positive impact on health status that correlated well with clinical improvement in patients with T2DM. PRT may have some additional benefits as there were significant changes in more domains of the SF-36 than that observed for the AT group.

[Assessment instruments for a Health-Related Quality of Life in diabetes mellitus]

The assessment of Health-Related Quality of Life (HRQoL) has been increasingly used to measure the overall impact of diseases in people's life. Diabetes mellitus (DM) is a chronic disease associated with high morbidity, mortality, and HRQoL impairment in patients. In longitudinal studies, the psychosocial impact of DM predicts mortality. The objective of this review is to describe and to analyze the main instruments used for the HRQoL evaluation in patients with DM. Generic instruments such, as the Quality of Well-Being Scale (QWB), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), EuroQol (EQ-5D) and specific instruments as the Diabetes Care Profile (DCP), Diabetes Quality of Life Measure (DQOL), Diabetes Impact Measurement Scales (DIMS), Appraisal of Diabetes Scale (ADS), Audit of Diabetes-Dependent Quality of Life (ADDQoL), Diabetes Health Profile (DHP-1 and DHP-18), Questionnaire on Stress in Patients with Diabetes-Revised (QSD-R), Well-Being Enquiry goes Diabetics (WED), Diabetes-Specific Quality-of-life Scale (DSQOLS), Diabetes 39 (D-39) Problems Areas in Diabetes (PAID) were analyzed. PAID is the only translated and validated instrument available in Brazil. The generic and specific instruments have their stregths and shortcomings for evaluation of HRQL in patients with DM. The combined use of both generic (such as the SF-36) and specific (such as the PAID) appears to be a consistent way to evaluate HRQoL as a construct in Brazilian patients with DM. The present article reviews a variety of instruments and emphasizes the urgent need for validation studies of such instruments to be used in Brazilian subjects with DM.

Meta-analysis of quality of life outcomes following diabetes self-management training

PURPOSE

The purpose of this meta-analysis was to meet the need to quantify the influence of diabetes self-management training on quality of life (QOL) of adult diabetes patients.

METHODS

Extensive literature searching located published and unpublished diabetes self-management intervention studies that measured QOL outcomes among at least 5 subjects with type 1 or 2 diabetes. Data were extracted from primary study reports which included interventions designed to improve diabetes self-management and adequate data to calculate effect sizes. Random-effects meta-analytic procedures were used to estimate overall effects between treatment and control groups at outcome assessment and between baseline and outcome data for both treatment subjects and control subjects.

RESULTS

Exhaustive searching yielded 20 comparisons across 1892 subjects. The comparisons between treatment and control group outcomes following interventions yielded an effect size of 0.281. The comparisons between treatment group at baseline and outcome measurement yielded an effect size of 0.312 to 0.313. Each of these effect sizes were statistically significant, meaning that the hypothesis that interventions to improve diabetes self-management results in increased QOL was supported. Control subjects did not experience improved QOL while participating in studies.

CONCLUSIONS

These findings document that people with diabetes experience improved QOL from participation in diabetes self-management training programs. Future diabetes self-management intervention studies should include quality of life outcomes so that this important outcome can be further studied. After more primary studies are available, future meta-analyses can explore important moderator analyses.

Predictors of health-related quality of life in type II diabetic patients in Greece

Background

Diabetes Mellitus (DM) is a major cause of morbidity and mortality affecting millions of people worldwide, while placing a noteworthy strain on public health funding. The aim of this study was to assess health-related quality of life (HRQOL) of Greek Type II DM patients and to identify significant predictors of the disease in this patient population.

Methods

The sample (N = 229, 52.8% female, 70.0 years mean age) lived in a rural community of Lesvos, an island in the northeast of the Aegean Archipelagos. The generic SF-36 instrument, administered by trainee physicians, was used to measure HRQOL. Scale scores were compared with non-parametric Mann-Whitney and Kruskal-Wallis tests and multivariate stepwise linear regression analyses were used to investigate the effect of sociodemographic and diabetes-related variables on HRQOL.

Results

The most important predictors of impaired HRQOL were female gender, diabetic complications, non-diabetic comorbidity and years with diabetes. Older age, lower education, being unmarried, obesity, hypertension and hyperlipidaemia were also associated with impaired HRQOL in at least one SF-36 subscale. Multivariate regression analyses produced models explaining significant portions of the variance in SF-36 subscales, especially physical functioning (R² = 42%), and also showed that diabetes-related indicators were more important disease predictors, compared to sociodemographic variables.

Conclusion

The findings could have implications for health promotion in rural medical practice in Greece. In order to preserve a good HRQOL, it is obviously important to prevent diabetes complications and properly manage concomitant chronic diseases. Furthermore, the gender difference is interesting and requires further elucidation. Modifying screening methods and medical interventions or formulating educational programs for the local population appear to be steps in the correct direction.

Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes

AIMS

To characterize the determinants of diabetes-related emotional distress by treatment modality (diet only, oral medication only, or insulin).

METHODS

A total of 815 primary care patients with Type 2 diabetes completed the Problem Areas in Diabetes (PAID) Scale and other questions. We linked survey data to a diabetes clinical research database and used linear regression models to assess the associations of treatment with PAID score.

RESULTS

PAID scores were significantly higher among insulin-treated (24.6) compared with oral-treated (17.8, P < 0.001) or diet-treated patients (14.7, P < 0.001), but not different between oral- vs. diet-treated patients (P = 0.2). Group scores remained similar, but the statistical significance of their differences was reduced and ultimately eliminated after sequential adjustment for diabetes severity, HbA(1c), body mass index, regimen adherence, and self-blood-glucose monitoring. Insulin-treated patients reported significantly higher distress than oral- or diet-treated patients on 16 of 20 PAID items. 'Worrying about the future' and 'guilt/anxiety when ... off track with diabetes' were the top two serious problems (PAID >or= 5) in all treatment groups. Not accepting diabetes diagnosis was a top concern for oral- and diet-treated patients, and unclear management goals distressed diet-treated patients.

CONCLUSIONS

Primary care patients treated with insulin reported higher diabetes-related emotional distress compared with oral- or diet-treated patients. Greater distress was largely explained by greater disease severity and self-care burdens. To improve diabetes-specific quality of life, clinicians should address patients' sense of worry and guilt, uncertain acceptance of diabetes diagnosis, and unclear treatment goals.

Assessing the impact of visual acuity on quality of life in individuals with type 2 diabetes using the short form-36

OBJECTIVE

We sought to ascertain quality-of-life measures and utility values associated with visual acuity in type 2 diabetes.

RESEARCH DESIGN AND METHODS

The Medical Outcome Study Short Form with 36 items (SF-36) was administered to 4,051 individuals with type 2 diabetes who were enrolled in the Lipids in Diabetes Study, and their best attainable vision was determined using an Early Treatment of Diabetic Retinopathy Study chart, expressed as a LogMAR score. Eight domain scores and a utility value representing an overall quality-of-life score were calculated using predefined algorithms. The associations between quality of life measured and best-eye visual acuity were assessed graphically and by regression analysis.

RESULTS

All eight SF-36 domain scores were negatively associated with reduced visual acuity. The impact of lower levels of visual acuity ranged from a decline of 1.3 units for a 0.1-LogMAR increase for physical functioning and 0.6 units in mental health. Regression analysis indicated a negative association (P < 0.001) between utility and reduced visual acuity after controlling for sex, BMI, smoking status, and history of diabetes complications. Patients whose LogMAR scores equated to legally blind had, on average, 0.054 (95% CI 0.034-0.074) lower utility compared with patients with normal visual acuity.

CONCLUSIONS

Reduced visual acuity is negatively associated with quality of life. The utility scores estimated here should inform studies quantifying the burden of diabetes and those evaluating potential therapies for treating or preventing diabetic eye diseases.