Empowerment
Interplay among patient empowerment and clinical and person-centered outcomes in type 2 diabetes. The BENCH-D study

https://doi.org/10.1016/j.pec.2015.05.012Get rights and content

Highlights

  • Measurement of empowerment and patient-centered outcomes can be standardized.

  • Empowerment is efficiently measured by DES-SF questionnaire.

  • Empowerment is associated with clinical and psychosocial outcomes and self-care.

  • DES-SF mean scores varies between centers due to difference in clinical practice.

  • DES-SF can be an indicator to monitor implementation of chronic care model.

Abstract

Objective

We evaluated empowerment in T2DM and identified its correlates.

Methods

A sample of individuals self-administered the Diabetes Empowerment Scale-Short Form (DES-SF) and other 9 validated instruments (person-centered outcomes). Correlates of DES-SF were identified through univariate and multivariate analyses. For person-centered outcomes, ORs express the likelihood of being in upper quartile of DES-SF (Q4) by 5 units of the scale.

Results

Overall, 2390 individuals were involved. Individuals in Q4 were younger, more often males, had higher levels of school education, lower HbA1c levels and prevalence of complications as compared to individuals in the other quartiles. The likelihood of being in Q4 was directly associated with higher selfreported self-monitoring of blood glucose (SDSCA6–SMBG) (OR = 1.09; 95% CI: 1.03–1.15), higher satisfaction with diabetes treatment (GSDT) (OR = 1.15; 95% CI: 1.07–1.25), perceived quality of chronic illness care and patient support (PACIC-SF) (OR = 1.23; 95% CI: 1.16–1.31), and better person-centered communication (HCC-SF) (OR = 1.10; 95% CI: 1.01–1.19) and inversely associated with diabetes-related distress (PAID-5) (OR = 0.95; 95% CI: 0.92–0.98). Adjusted DES-SF mean scores ranged between centers from 69.8 to 93.6 (intra-class correlation = 0.10; p < 0.0001).

Conclusions

Empowerment was associated with better glycemic control, psychosocial functioning and perceived access to person-centered chronic illness care. Practice of diabetes center plays a specific role.

Practice implications

DES-SF represents a process and outcome indicator in the practice of diabetes centers.

Introduction

Chronic non-communicable diseases such as cardiovascular diseases, cancer, diabetes, and pulmonary chronic diseases represent the main causes of death and disability worldwide [1]. The rising incidence of non-communicable diseases is the result of improved standards of living and medical practices and increased longevity, but also a dangerous drain on resources for healthcare systems [2]. The recognition of this growing crisis is the impetus for modifying healthcare policies and care systems, especially in relation to the concept of patient responsibilities [3]. A wide consensus has been reached about the centrality of patients and their engagement in self-management to improve outcomes while reducing costs [4]. In particular, the person-centered Chronic Care Model, which includes the informed, empowered patient as an essential element, is recognized as a highly effective organizational system to ensure the desired results [5].

In their earlier work, Funnell et al. [6] defined empowerment as the discovery and development of one’s inherent ability to be responsible for one’s own diabetes. They further identify that the purpose of using an empowerment-based approach in diabetes care and education is to support the ability of patients to make informed decisions about diabetes self-management and care [7]. Among people with diabetes, those with higher levels of self-efficacy tend to be more actively engaged in self-management and have better glycemic outcomes [8]. While self-management behaviors do not always result in improved glycemia [9] due to a variety of physiological factors and inadequate medical treatments, self-care remains an important aspect in the treatment of diabetes [10].

Therefore, a challenge for healthcare systems is to provide diabetes self-management education and support (DSME/S) to teach the interplay among healthy lifestyle, use of medications, emotional/physical stress and behavior-change strategies in order to respond appropriately and continually to those factors related to the achieving and maintaining optimal metabolic control [11]. Multiple approaches have been tested, differing by setting (individual or group based), medium (written, oral, video, or computer support), or duration and intensity. Evidence shows that patient education produces positive results, confirming a potential impact on public health if implemented throughout health care systems [12]. The main principles of DSME/S have been summarized in guidelines, where it is emphasized that self-management takes place in participants’ daily lives and not in clinical or educational settings; therefore, self-management education and support needs to focus on helping patients formulate a plan to find resources to support their ongoing diabetes self-management efforts [11].

In spite of this evidence, too many people with diabetes receive inadequate care, education, and support to enable them to achieve optimal health and well-being. Ten years after the first DAWN study [13], the DAWN2 study conducted in 17 countries confirmed a lack of self-management education, as well as a lack of critical resources, particularly skills, time and adequate referral sources among health care professionals for delivering appropriate self-management support [14]. Qualitative analyses of testimonials of people with diabetes from the global DAWN2 study has highlighted the importance to people with diabetes of feeling able to manage his or her own disease and to have psychosocial support for managing the condition [15]. The integration of patient educational programs in the local care system and community services remains a main issue [1] and access to diabetes self-management education and optimal care deliver remains inadequate [13], [14].

In recent years, many healthcare organizations have been developing initiatives for continuous monitoring and improvement of the quality of diabetes care based on the use of standardized process and outcome indicators [16]. In Italy, the Associazione Medici Diabetologi (AMD) has implemented since 2006 a continuous improvement effort involving a large network of diabetes clinics throughout the country (AMD Annals) [17]. The periodic dissemination of Annals has been effective in improving several clinical indicators over a few years [17], [18]. On the other hand, the lack of agreed measures against which the effectiveness of educational interventions can be evaluated is recognized as a major deficiency [19]. In addition, it is not known if person-centered outcomes can be improved through benchmarking.

Given these premises, in the context of the AMD Annals and the DAWN2 initiatives, the BENCH-D study (Benchmarking Network for Clinical and Humanistic Outcomes in Diabetes) was launched aiming to test a model of regional benchmarking to monitor and improve not only clinical indicators, but also person-centered outcomes. Besides the AMD clinical indicators for the evaluation of the quality of care, the BENCH-D study used validated questionnaires, largely derived from the DAWN2 study, for measuring person-centered dimensions, including patient empowerment.

The purpose of this paper is to discuss the complex interplay among patient empowerment and socio-demographic characteristics, clinical outcomes and a wide set of person-centered dimensions in order to provide useful elements for improving educational programs and outcomes. We postulated that higher levels of empowerment be associated with better metabolic control, better self-care, lower levels of diabetes-related distress and higher satisfaction with treatment. Furthermore, we expected that higher levels of empowerment could reduce the perception of barriers to diabetes treatment. We also hypothesized that better person-centered communication and better quality of chronic illness care be associated with higher levels of empowerment. In addition to medical care, we wanted to assess whether better social support could contribute in increasing the level of empowerment. Finally, we explored if the expected benefits deriving from higher levels of empowerment had a broader impact on physical and psychological well-being.

To assist with the benchmarking process for individual sites, the role of the “center effect” was also assessed.

Section snippets

Methods

A detailed description of the study protocol is published elsewhere [20]. Briefly, a random sample of 2390 patients with type 2 diabetes (T2DM) stratified by diabetes treatment (oral agents, insulin + oral agents, insulin) was considered. Following the AMD Annals methodology [16], [17], data were extracted from electronic databases of diabetes clinics, including information on body mass index (BMI), diabetes duration, HbA1c, blood pressure and lipid profile values, glucose-lowering,

Results

Between January 2010 and July 2011, 26 diabetes clinics enrolled 2390 people with T2DM, of whom 2357 (98.6%) could be evaluated for the DES-SF. Participants had the following characteristics: mean age of 65.0 ± 10.2 years, mean diabetes duration of 13.8 ± 15.2 years, 59.9% males, 48.6% treated with oral agents only, 25.3% treated with oral agents plus insulin, and 24.3% with insulin only.

Table 2 shows participant socio-demographic and clinical characteristics and mean scores of the person-centered

Main findings

The BENCH-D study allows a detailed description of a wide set of person-centered measures made possible by the adoption of validated and standardized instruments. We found a different degree of empowerment in a large population of individuals with T2DM cared for by diabetes clinics in Italy, with DES-SF mean scores showing a marked variation according to patient characteristics and by center.

As for patient characteristics, higher levels of empowerment are more commonly found in men, in younger

Conflict of interest

AN is a member of the advisory board of Novo Nordisk, Novartis, Merk Sharp & Dohme. He has received speaker fees from Novo Nordisk, Novartis, Merk Sharp & Dohme; MF is a member of the advisory board of Eli Lilly, Bristol-Myers Squibb/AstraZeneca Diabetes, Novo Nordisk, Omada Health. AB is an employee of Novo Nordisk, Rome, Italy; SES is an employee of Novo Nordisk A/S, Copenhagen, Denmark. MCR, GL, BP, SG, MS, GV declare that they have no conflict of interest.

Funding

The study was supported by an unconditional grant from Novo Nordisk SpA, Rome.

Authors’ contribution

AN conceived the study, AN and MCR designed the study protocol, and SG and GV contributed to the study design. GV and BP researched data. MCR and BP coordinate the study. AB supported the study.

MCR, AN, and MF wrote the manuscript, GL and MS performed the statistical analyses. BP, SS, SG, AB, and GV revised critically and approved the manuscript. AN is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and

Acknowledgments

We acknowledge all participating centers and Novo Nordisk SpA, Italy for the unconditional support to the study.

References (37)

  • S.L. Fitzpatrick et al.

    Problem solving interventions for diabetes self-management and control: a systematic review of the literature

    Diabetes Res Clin Pract

    (2013)
  • T.S. Tang et al.

    Self-management support in real-world settings: an empowerment-based intervention

    Patient Educ Couns

    (2010)
  • R.M. Anderson et al.

    Patient empowerment: myths and misconceptions

    Patient Educ Couns

    (2010)
  • D. Maher et al.

    A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem

    BMC Public Health

    (2009)
  • S. Bowman et al.

    Use of evidence to support healthy public policy: a policy effectiveness-feasibility loop

    Bull World Health Organ

    (2012)
  • T. Bodenheimer et al.

    Improving primary care for patients with chronic illness: the chronic care model, Part 2

    J Amer Med Assoc

    (2002)
  • L.M. Schouten et al.

    Cost-effectiveness of a quality improvement collaborative focusing on patients with diabetes

    Med Care

    (2010)
  • K. Coleman et al.

    Evidence on the chronic care model in the new millennium

    Health Aff (Millwood)

    (2009)
  • M.M. Funnell et al.

    Empowerment: an idea whose time has come in diabetes education

    Diabetes Educ

    (1991)
  • R.M. Anderson et al.

    Patient empowerment: results of a randomized controlled trial

    Diabetes Care

    (1995)
  • S.L. Norris et al.

    Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycaemic control

    Diabetes Care

    (2002)
  • C.M. Beckerle

    Association of self-efficacy and self-care with glycemic control in diabetes

    Diabetes Spectr

    (2013)
  • American Diabetes Association

    Standards of medical care in diabetes—2015

    Diabetes Care

    (2015)
  • L. Haas et al.

    National standards for diabetes self-management education and support

    Diabetes Care

    (2013)
  • K.D. Barnard et al.

    Psychosocial support for people with diabetes: past, present and future

    Diabetes Med

    (2012)
  • A. Nicolucci et al.

    Diabetes attitudes, wishes and needs second study (DAWN2™): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes

    Diabetes Med

    (2013)
  • H.L. Stuckey et al.

    Personal accounts of the negative and adaptive psychosocial experiences of people with diabetes in the second diabetes attitudes, wishes and needs (DAWN2) study

    Diabetes Care

    (2014)
  • P.J. O'Connor et al.

    Diabetes performance measures: current status and future directions

    Diabetes Care

    (2011)
  • Cited by (36)

    • Higher patient assessed quality of chronic care is associated with lower diabetes distress among adults with early-onset type 2 diabetes: Cross-sectional survey results from the Danish DD2-study

      2020, Primary Care Diabetes
      Citation Excerpt :

      The Patient Assessment of Chronic Illness Care (PACIC) questionnaire was developed to assess patient reported receipt of care and its congruence with elements of the CCM [14]. In people with type 2 diabetes, a higher PACIC score is associated with higher patient empowerment [15], higher patient activation [16], more self-care behaviours [17], and better glycemic control [16], and CCM guided diabetes care interventions have demonstrated positive outcomes [18]. Assessing quality of care using the PACIC may therefore be an important first step to improving outcomes in adults with early-onset type 2 diabetes.

    • Effect of an ‘implementation intention’ intervention on adherence to oral anti-diabetic medication in Brazilians with type 2 diabetes

      2020, Patient Education and Counseling
      Citation Excerpt :

      The sociodemographic and baseline clinical profiles of our sample were consistent with data from previous evaluations of adherence to medication [16,22]. The low educational level of our sample reflects the generally low level of education in the Brazilian adult population and can be a barrier to effective training in self-management of care and to effort to induce behavioral changes that will promote physical and emotional health [27,28]. Nevertheless, the sociodemographic and clinical characteristics of the participants in the IG did not prove a barrier to improvements in adherence to medication, glycemic control and emotional distress.

    • The impact of provision of self-monitoring of blood glucose supplies on self-care activities among patients with uncontrolled Type 2 diabetes mellitus: A prospective study

      2019, Diabetes Research and Clinical Practice
      Citation Excerpt :

      For healthcare professionals, SMBG readings can be utilised to assess therapy effectiveness, perform dose adjustments, and even teach patients to self-titrate their medications [10,11]. Although SMBG has shown to be directly associated with empowerment in managing diabetes [12], SMBG is often underutilised among patients with T2DM. In Asia, for example, with only an estimated 29.7% of Asian patients reporting regular SMBG usage [7,13].

    View all citing articles on Scopus
    1

    List of complete study staff in Appendix A.

    View full text