The relationship between diabetes-related emotional distress and illness perceptions among Indian patients with Type II diabetes

AimsTo examine the relationship between diabetes-related emotional distress (DED) and illness perceptions among Indian patients with Type II diabetes (T2D).Material and methods92 patients with T2D completed questionnaires on their demographic and medical details, DED and illness perceptions. Multiple regression analysis was conducted to examine the association between demographic, medical and illness perceptions variables and DED.ResultsIncreased number of children, personal control and illness-related concern were associated with increased levels of DED.ConclusionsAdditional support is needed for Indian patients with T2D who have more children, greater sense of personal control and higher levels of diabetes-related worry.     

Inequalities in glycaemic control in patients with Type 2 diabetes in primary care.

AIMS: To quantify relationships between patient and practice factors and glycaemic control in patients with Type 2 diabetes. METHODS: A cross-sectional study involving 1534 patients with Type 2 diabetes from 42 general practices in Nottingham, UK was undertaken. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by a questionnaire. The outcome measure was serum HbA(1c) concentration measured at entry to the study. Random effects linear regression was used to model patient and practice factors associated with glycaemic control. RESULTS: In multivariable regression analysis, HbA(1c) increased with increasing body mass index (BMI) [change in HbA(1c) for one unit increase in BMI: 0.03%, 95% confidence interval (CI) 0.01, 0.04], and was higher in those using oral medication (mean difference 0.75%, 95% CI 0.59, 0.92) or insulin compared with diet (mean difference 1.36%, 95% CI 1.10, 1.62). There was a dose-response relationship between HbA(1c) and increasing time since diagnosis. HbA(1c) was negatively associated with age (change per year -0.01%, 95% CI -0.02, -0.004). Patients registered at the most deprived practices had higher HbA(1c) values than those in the least deprived practices (mean difference 0.42%, 95% CI 0.14, 0.71), as did those in practices where annual reviews were carried out by the nurse alone (mean difference 0.24%, 95% CI 0.04, 0.44). CONCLUSIONS: Several patient and practice factors are related to glycaemic control. Poorer glycaemic control was associated with practice level deprivation and nurses undertaking annual reviews alone. Further research is required to explore outcomes of annual reviews undertaken by nurses alone. Greater resources may be needed by primary care teams working in deprived areas to address inequalities in diabetic control.     

Patients' perspectives on the management of emotional distress in primary care settings

Objective  To investigate how important treatment for emotional distress is to primary care patients in general and to primary care patients with depression, and to evaluate the types of mental health interventions they desire. Design  Patient surveys. Setting  Five private primary care practices. Measurements and main results  Patients' desire for treatment of emotional distress and for specific types of mental health interventions were measured, as well as patients' ratings of the impact of emotional distress, the frequency of depressive symptoms, and mental health functioning. Of the 403 patients, 33% felt that it was “somewhat important” and 30% thought it was “extremely important” that their physician tries to help them with their emotional distress. Patient desire for this help was significantly related to a diagnosis of depression (P<.001), perceptions about the impact of emotional distress (p<.001), and mental health functioning (p<.001). Among patients with presumptive diagnoses of major and minor depression, 84% and 79%, respectively, felt that it was at least somewhat important that they receive this help from their physician. Sixty-one percent of all primary care patients surveyed and 89% of depressed patients desired counseling; 23% of all patients and 33% of depressed patients wanted a medication; and 11% of all patients and 5% of depressed patients desired a referral to a mental health specialist. Conclusions  A majority of these primary care patients and almost all of the depressed patients felt that it was at least somewhat important to receive help from their physician for emotional distress. The desire for this help seems to be related to the severity of the mental health problem. Most of the patients wanted counseling, but relatively few desired a referral to a mental health specialist. Funded by grant R01 MH51067 from the National Institute of Mental Health.     

Emotional distress is associated with poor self care in type 2 diabetes mellitus

Background: The aim of the present study was to evaluate possible clinical and psychosocial variables that influence diabetes self‐care management in patients with type 2 diabetes mellitus (T2DM). Methods: A total of 150 individuals with T2DM who had had diabetes for at least 6 months were recruited to this cross‐sectional study. Levels of self‐care and psychosocial status were determined using the Self‐Care Inventory (SCI) and Problem Areas in Diabetes (PAID) scale. The PAID scores were calculated using a five‐point Likert scale with options ranging from 0 (not a problem) to 4 (serious problem). Data were evaluated using non‐parametric and parametric tests as appropriate. Results: The mean age of the study participants was 69.97 ± 8.68 years. Cronbach’s α for SCI and PAID scores was 0.85 and 0.98, respectively. People with poor glycemic control had significantly higher mean (±SD) total PAID scores than individuals with good glycemic control (29.5 ± 30.9 vs 16.7 ± 26.9, respectively; P = 0.012). There was a significant relationship between PAID scores and glycemic control (r = 0.2; P = 0.012). Conclusions: The present study demonstrates that psychosocial factors directly influence glycemic control and diabetes self‐care habits. In addition, diabetes‐specific distress in study population was unrelated to the duration of diabetes, the age of the patients and anthropometric indices.     

Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients

AimsTo assess the association of diagnosed musculoskeletal (MS) pain (low back, neck, shoulder, and knee pain; and the number of pain sites) with the achievement of targets for glycosylated haemoglobin A1c (HbA1c), low-density-lipoprotein cholesterol (LDL), and systolic blood pressure (SBP) among primary care patients with type 2 diabetes (T2D).MethodsThe cross-sectional study population consisted of 3478 patients with a registry-based T2D diagnosis and available registry-based data on MS pain diagnoses, covariates, and outcomes between 2016 and 2019. Logistic regression analysis was used to evaluate the study aims.ResultsOverall, 22% had at least one of the four types of MS pain, and 73%, 57%, and 51% achieved the treatment targets of HbA1c, LDL, and SBP, respectively. T2D patients with or without MS pain did not differ in their achievement of T2D treatment goals. Of pain locations, low back pain was associated with higher rates of achievement of the LDL target (OR 1.29, 95% CI 1.01–1.65), but the association was attenuated in the adjusted model.ConclusionsMS pain was relatively prevalent among primary care patients with T2D, but did not influence the achievement of T2D treatment goals.     

Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study

Aims Diabetes distress (DD) is a condition distinct from depression that is related to diabetes outcomes. In those without distress initially, little is known about what indicators place patients at risk for subsequent distress over time. Methods From a community‐based, three‐wave, 18‐month study of Type 2 diabetic patients (n = 506), we identified patients with no DD at T1 who displayed DD at T2, T3 or both (n = 57). Using logistic regression with full and trimmed models, we compared them with patients with no DD at all three time points (n = 275) on three blocks of variables: patient characteristics (demographics, depression, extra‐disease stress), biological (HbA_1c, body mass index, comorbidities, complications, blood pressure, non‐high‐density lipoprotein‐cholesterol), and behavioural variables (diet, exercise). Selected interactions with stress and major depressive disorder (MDD) were explored. Results The odds of becoming distressed over time were higher for being female, previously having had MDD, experiencing more negative events or more chronic stress, having more complications, and having poor diet and low exercise. Negative life events increased the negative effects of both high HbA_1c and high complications on the emergence of distress over time. Conclusions We identified a list of significant, independent direct and interactive predictors of high DD that can be used for patient screening to identify this high‐risk patient cohort. Given the impact of high DD on diabetes behavioural and biological indicators, the findings suggest the usefulness of regularly appraising both current life and disease‐related stressors in clinical care.     

The association between satisfaction with services provided in primary care and outcomes in Type 2 diabetes mellitus.

BACKGROUND: Patient satisfaction is of increasing importance, is taken into account when planning services, and is used by healthcare providers as a measure of healthcare quality. Satisfaction with medical care, including diabetic care, has been associated with various health-related behaviours and outcomes that have a direct bearing on health and illness. The association between satisfaction and health outcomes is poorly understood. AIM: The aim of the study was to determine whether there is an association between satisfaction in patients with Type 2 diabetes and the outcome of their diabetic care, and to determine the contribution of different aspects of satisfaction with the primary care. METHODS: Patients with Type 2 diabetes were identified from two general practices in Leeds. PATIENTS: scores on the General Practice Assessment Survey Questionnaire (GPAS) were correlated with the outcome of care, as measured by HbA1c level collected from patients' medical records. RESULTS: Data from 106 patients were analysed. There was a generally high satisfaction rate for all GPAS domains. The correlation between different GPAS domains and HbA1c level showed significant positive correlations (P < 0.001) for continuity of care, trust and overall satisfaction; and positive correlations (P < 0.01) for access, receptionists, interpersonal care, communication skills, knowledge of patient about the doctor, technical care, and practice nursing. CONCLUSION: The findings from this study demonstrate that there is an association between satisfaction and outcome in diabetes, which goes across all the GPAS domains. This suggests that processes that can act to increase patient satisfaction may be contributing to improved clinical outcomes. More development work is needed in this field to explore and elucidate the complex relationship between satisfaction and clinical outcomes.     

Setting and negotiating targets in people with Type 2 diabetes in primary care: a cross sectional survey.

AIMS: To investigate the provision of diabetes care, the frequency of practices setting targets for their diabetic population, the targets set and the frequency of targets being negotiated with people with diabetes. METHODS: Cross-sectional study using a survey of 123 general practices within four Primary Care Trusts in Nottingham UK. RESULTS: Eighty per-cent (99) of practices responded. Of these, 88 and 89%, respectively, had set glycosolated haemoglobin (HbA1c) and blood pressure targets for people with Type 2 diabetes. Twenty-five per-cent (24) of practices reported negotiating targets with almost all people with Type 2 diabetes for HbA1c and 31% (30) for blood pressure. In 46% (45) of practices, the annual diabetic review for some or all of the people with Type 2 diabetes was carried out by the practice nurse alone. In these practices, targets were negotiated with a smaller proportion of people than those where the doctor was involved in the annual review for both blood pressure [43 vs. 64% negotiated blood pressure targets with almost all or many people odds ratio (OR) 0.42 (95% CI 0.19, 0.96), P = 0.04] and HbA1c [39 vs. 60% negotiated HbA1c targets with almost all or many people, OR 0.41 (95% CI 0.18, 0.94), P = 0.03]. CONCLUSIONS: Negotiating targets with people with Type 2 diabetes does not routinely occur in primary care. Targets are negotiated less often in practices where nurses undertake reviews alone and further work is needed to explore the reasons for this.     

Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme.

AIMS: To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life. METHODS: Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile. RESULTS: Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention. CONCLUSIONS: Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs.     

An integrated mobile foot and retinal screening programme for people with Type 2 diabetes managed in primary care.

AIMS: To undertake a vascular and neurological assessment on the feet of all patients with Type 2 diabetes managed solely in local primary care. METHODS: A mobile screening podiatrist (working with an existing mobile retinal screening programme) screened a selected population of 4022 patients with Type 2 diabetes managed solely in 82 general practices. Doppler pressure assessments of peripheral vasculature, bioesthesiometer and monofilament assessment of peripheral neuropathy. RESULTS: This service was administratively simple to set up and integrated well with the retinal screening service and secondary care foot clinic, and was valued by the practices. Disease prevalences were 1.04% for foot ulceration, 19% for peripheral vascular disease and up to 29% for peripheral neuropathy. CONCLUSIONS: This programme screens all patients with known diabetes managed solely in primary care within a district and describes foot morbidity and allows risk stratification. This pattern of service could be a useful template for discussing the diabetes National Service Framework with primary care groups.     

Risk factors for development of impaired renal function in Type 2 diabetes mellitus patients in primary care.

AIMS: To evaluate risk factors for the development of an impaired renal function, defined as a glomerular filtration rate (GFR) by Cockcroft-Gault formula < 50.5 ml/min, in primary care patients with Type 2 diabetes mellitus. METHODS: A case-control study of Type 2 diabetes mellitus patients with impaired renal function and age, sex and practice matched controls with Type 2 diabetes mellitus without impaired renal function in 10 Dutch family practices performing the Nijmegen Monitoring Project. Main outcome measure was the independent risk factors of impaired renal function. RESULTS: Eighty-seven individuals with impaired renal function were identified. The point prevalence of impaired renal function in the sample population on 31 March 2001 was 87/873 (10.0%; 95% confidence interval 7.0-15.1%). Of 87 cases, 23 (26.5%; 17.3-30.9%) were found to have impaired renal function at diagnosis. Conditional multiple logistic regression analysis revealed the following independent risk factors for the development of impaired renal function: duration of diabetes > or = 8 years (adjusted odds ratio 5.6 (2.5-12.5); P < 0.001), glomerular filtration rate by Cockcroft-Gault formula 50.5-80.5 ml/min at diagnosis [3.5 (1.5-8.1); P < 0.01] and existing macrovascular complications at diagnosis [2.6 (1.1-6.3); P < 0.01]. CONCLUSION: Duration of diabetes > or = 8 years, mild renal impairment at the time of diagnosis and existing macrovascular complications at the time of diagnosis are independent risk factors for the development of impaired renal function in white patients with Type 2 diabetes mellitus.     

Management of obesity in patients with type 2 diabetes mellitus in primary care

AimsObesity and being overweight is the most powerful risk factor accounting for 80–90% of patients with type 2 diabetes mellitus (T2DM). The epidemic of obesity is driving the diabetes epidemic to alarming levels and primary care is becoming an important setting for obesity management in T2DM in India. Yet many primary care providers feel ill-equipped or inadequately supported to address obesity in patients with diabetes. This article reviews the most recent and strongest evidence-based strategies that may aid physicians in management of obesity in patients with T2DM in primary care.Material and methodsA systematic literature search of MEDLINE using the search terms Obesity, Obesity in T2DM, weight loss and Primary Care was conducted. The American Diabetes Association, National Institute for Health, National Institute of Health and Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and World Health Organization websites were also searched. Most studies in this area are observational in design with few randomized controlled trials (RCTs). Articles and studies involving meta-analysis or RCTs were preferred over other types.Results and conclusionEffective weight management treatment in T2DM patient can be implemented in the primary care setting. Evidence based individualized lifestyle and pharmacologic measures supported by behavioral intervention and counseling with appropriate and informed surgical referrals has the potential to improve the success of weight management within primary care.     

Multidisciplinary coordinated care for Type 2 diabetes: A qualitative analysis of patient perspectives

Aims

To explore the patient perspective on coordinated multidisciplinary diabetes team care among a socioeconomically diverse group of adults with type 2 diabetes.

Evaluation of a programme of group visits and computer-assisted consultations in the treatment of adolescents with Type 1 diabetes.

AIM: To examine the effects of group visits and computer-assisted consultations on quality of life and glycaemic control in adolescents with Type 1 diabetes. METHODS: A total of 116 adolescents, aged 11-17 years, and their parents were randomly assigned to an intervention (n = 62) or a control group (n = 54). The intervention group was invited to a 15-month programme comprising group visits and computer-assisted consultations. The control group was offered traditional out-patient consultations. Outcomes included changes in HbA(1c) and the adolescents' assessment of generic and disease-specific health-related quality of life measured by the Child Health Questionnaire (CHQ-CF87) and the Diabetes Quality of Life Questionnaire (DQOL), respectively. RESULTS: One hundred and one adolescents (55/46) agreed to participate, mean age 14.2 years (sd 1.5), mean diabetes duration 6.5 years (sd 3.6, range 1-16 years), mean HbA(1c) 9.3% (sd 1.4, range 6.1-12.8%). Eighty-three (72%) completed the questionnaires at follow-up (intervention/control 45/38). There were significant age by randomization group interactions for diabetes-related impact (P = 0.018), diabetes-related worries (P = 0.004), mental health (P = 0.046) and general behaviour (P = 0.029), implying that the intervention was effective in older adolescents (above 13-14 years). No significant effects on mean HbA(1c) were identified. CONCLUSIONS: Group visits and computer-assisted consultations had beneficial effects on health-related quality of life in older adolescents, the role of this intervention being questionable in younger adolescents.     

Investigation on the association between diabetes distress and productivity among patients with uncontrolled type 2 diabetes mellitus in the primary healthcare institutions

AimsTo investigate associations between diabetes distress and productivity, and to identify the potential risk factors that could affect these particular associations.MethodsThis cross-sectional study was conducted in three outpatient healthcare institutions. Patients aged ≥21 years with uncontrolled T2DM and polypharmacy were included. The Problem Areas in Diabetes (PAID) measuring diabetes distress and Work Productivity and Activity Impairment General Health (WPAI-GH) measuring productivity were administered by trained interviewers.ResultsA total of 259 patients were analysed. Point prevalence of clinically severe diabetes distress, work productivity loss and life productivity loss were 7.7%, 45.0% and 35.1% respectively. Diabetes distress was positively associated with work productivity loss (p = 0.001) and life productivity loss (p < 0.001). Multiple linear regression analysis demonstrated that diabetes distress (p = 0.003), the total number of chronic medications (p = 0.012), insulin therapy (p = 0.027) and the presence of chronic kidney disease (p = 0.038) were significantly associated with work impairment. Diabetes distress (p = 0.001) and the presences of osteoarthritis (p = 0.039) were significantly associated with activity impairment.ConclusionHealthcare professionals should screen patients for diabetes distress to prevent productivity losses, especially in patients with polypharmacy and/or on insulin and with coexisting osteoarthritis or chronic kidney disease.     

Overtreatment of older patients with type 2 diabetes mellitus in primary care

Given that there are indications of overtreatment in older patients with type 2 diabetes in both the United States and Europe, we assessed the level of personalized diabetes treatment for older patients in primary care, focusing on overtreatment. Based on Dutch guidelines individuals aged ≥70 years were classified into 3 glycated haemoglobin (HbA1c) treatment target groups: 7% (53 mmol/mol), 7.5% (58 mmol/mol) and 8% (64 mmol/mol). In our cohort of 1002 patients (n = 319 aged ≥70 years), the 165 patients with HbA1c targets >7% had more micro‐ and macrovascular complications, more often used ≥5 medicines and were more often frail compared with those with an HbA1c target ≤7%. Of these 165 patients, 64 (38.8%) were overtreated; that is, 20% of all people aged ≥70 years. The majority of overtreated people were frail and used ≥5 medicines. Hypoglycaemia occurred in 20.3% of these patients and almost 30% reported accidents involving falls. Personalized treatment in older people with type 2 diabetes is not common practice. A substantial number of older people are overtreated, with probable harmful consequences. To prevent overtreatment, definition of lower HbA1c limits might be helpful.