Kathryn Dennick

Effective interventions for reducing diabetes distress: systematic review and meta-analysis

Abstract Aims: To identify randomised controlled trials (RCTs) in which diabetes distress (DD) was assessed in adults under experimental conditions and to undertake meta-analysis of intervention components to determine effective interventions for reducing DD. Methods: Systematic review searching Medline, Psychinfo and Embase to March 2013 for studies measuring DD. Two reviewers assessed citations and full papers for eligibility based on RCT design and Problem Areas in Diabetes Scale or Diabetes Distress Scale outcome measure. Interventions were categorised by content and medium of delivery. Meta-analyses were undertaken by intervention category where ≥7 studies were available. Standardised mean differences and 95% confidence intervals were computed and combined in a random effects meta-analysis. Results: Of 16 627 citations reviewed, 41 RCTs involving 6650 participants were included. Twenty-one a priori meta-analyses were undertaken. Effective interventions were psycho-education (−0.21 [−0.33, −0.09]), generalist interventionist (−0.19 [−0.31, −0.08]), ≥6 sessions (−0.14 [−0.26, −0.03]) and ≥3 months duration (−0.14 [−0.24, −0.03]). Motivational interviewing reduced DD (−0.09 [−0.18, −0.00]) and improved baseline elevated glycaemia (−0.16 [−0.28, −0.04]). Although statistical significance was observed most effect sizes were below 0.2. Conclusion: The review signposts interventions likely to reduce elevated DD in Type 1 and Type 2 and across the age profile. Interventional research is needed and warranted targeting elevated distress.

Evaluating recovery following hip fracture: a qualitative interview study of what is important to patients

Objective To explore what patients consider important when evaluating their recovery from hip fracture and to consider how these priorities could be used in the evaluation of the quality of hip fracture services. Design Semistructured interviews exploring the experience of recovery from hip fracture at two time points—4 weeks and 4 months postoperative hip fixation. Two approaches to analysis: thematic analysis of data specifically related to recovery from hip fracture; summarising the participants experience overall. Participants 31 participants were recruited, of whom 20 were women and 12 were cognitively impaired. Mean age was 81.5 years. Interviews were provided by 19 patients, 14 carers and 8 patient/carer dyad; 10 participants were interviewed twice. Setting Single major trauma centre in the West Midlands of the UK. Results Stable mobility (without falls or fear of falls) for valued activities was considered most important by participants who had some prefracture mobility and were able to articulate what they valued during recovery. Mobility was important for managing personal care, for day-to-day activities such as shopping and gardening, and for maintenance of mental well-being. Some participants used assistive mobility devices or adapted to their limitations. Others maintained their previous limited function through increased care provision. Many participants were unable to articulate what they valued as hip fracture was perceived as part of their decline with age. The fracture and problems from other health conditions were an inseparable part of one health experience. Conclusions Prefracture mobility, adaptations to reduced mobility before or after fracture, and whether or not patients perceive themselves to be declining with age influence what patients consider important during recovery from hip fracture. No single patient-reported outcome measure could evaluate quality of care for all patients following hip fracture. General health-related quality of life tools may provide useful information within clinical trials.

Written emotional disclosure for adults with Type 2 diabetes: a primary care feasibility study

AIM To test the feasibility of written emotional disclosure (WED) for UK primary care patients with Type 2 diabetes. BACKGROUND WED holds potential to address depressive symptoms in diabetes, yet its feasibility, and potential benefit, for primary care patients has not been established. METHOD Forty-one adults with Type 2 diabetes were randomised to WED (n=23) or neutral writing (n=18). Principal outcomes were feasibility of recruitment, compliance, acceptability and intervention fidelity. Potential benefit was assessed on between-group differences in depressive symptoms (Centre for Epidemiological Studies Depression scale), diabetes distress (Problem Areas in Diabetes scale), diabetes self-management behaviours (Summary of Diabetes Self-care Activities questionnaire) and perceived health status (EQ-5D) at three-month follow-up. FINDINGS Recruitment was modest (6%), yet an unmet treatment need was identified. Fourteen intervention (61%) and 13(72%) control participants returned their writing, while 12 in each group (89%) then completed all sessions. Intervention fidelity was confirmed. Acceptability to patients was mixed. Exploratory effectiveness analyses suggested that relative to improvement in controls, WED is associated with a potentially clinically important worsening in depressive symptoms (P=0.006) and a non-significant trend for a reduction in healthy dietary behaviour (P=0.057). There was no significant effect on other outcomes. The exploratory nature of the study, however, necessitates that the observed effects are interpreted with caution, and both the feasibility and effectiveness findings may be an artefact of the sample obtained. The evidence for the feasibility of WED in primary care diabetes was hence mixed, and in an unevaluated environment it may cause iatrogenic harm. On balance, WED is apparently not appropriate for use in this context in its current format. At most, further research with a more appropriate sample is required. The feasibility that was demonstrated and the unmet need identified suggest that this may be a worthy endeavour.

What characterises diabetes distress and its resolution? A documentary analysis

Abstract Objective Cross-sectional studies show that diabetes distress (DD) is associated with HbA1c and depressive symptoms in individuals with Type 1 and Type 2 diabetes. Evidence of association with self-management behaviour is contradictory. Little qualitative evidence exists to understand the manifestation of DD. Our objective was to understand the documented experience of DD and its resolution. Methods A psycho-social care clinic using evidence-based approaches was developed in a hospital diabetes centre serving Type 1 and Type 2 diabetes populations. People were referred by specialist diabetes clinicians when they were ‘struggling to cope’ with their diabetes. Detailed clinical notes captured the origins, characteristics and process of resolution of referred patients’ DD. Documentary clinical notes retrospective analysis used directed content analysis. DD was assessed by the Problem Areas in Diabetes Scale (PAID) at referral. Results Eighty-two people were referred and 70 people attended 202 consultations. Forty-one sets of case notes were included where people attended ≥2 appointments; of whom, 24 experienced elevated DD, 13 had elevated DD plus established psychological morbidity and 4 had general distress unrelated to their diabetes. Mean PAID score was 53. Individuals with DD only experienced mastery of their diabetes, using the psycho-social care service to increase self-care behaviours. Individuals with DD plus established psychological morbidity were unable to increase their self-care. Conclusions People ‘struggling to cope’ are most likely to be experiencing elevated DD only. People with DD only were able to resolve this through access to clinic-run psycho-social care. Practice Implications Health professionals should routinely assess for coping and distress in their care planning. Psycho-social care pathways are important for people with elevated DD.

High rates of elevated diabetes distress in research populations: A systematic review and meta-analysis

Diabetes distress has implications for diabetes end-points, hence targeted interventions are indicated; yet, preliminary work quantifying and characterising the problem is required. We sought to identify the potential magnitude and determinants of elevated diabetes distress across study populations. Databases such as Medline, PsycINFO and Embase were searched for studies (n ≥50) administering the problem areas in Diabetes scale or Diabetes Distress scale, in adults with Type 1 or 2 diabetes. Random effects meta-analysis and meta-regression estimated the average rate of elevated diabetes distress and prognostic contribution of age, gender, HbA1c, and health-care context. Of the 16,627 citations identified, adequate data were available for 58 studies. On average, 22% of participants reported elevated diabetes distress. Only female gender and secondary care predicted a higher rate of elevated diabetes distress. A quarter of people with diabetes have a level of distress likely to impact outcomes. Secondary-care practitioners should be vigilant of women with diabetes.

Improving health outcomes for young people with long term conditions: The role of digital communication in current and future patient–clinician communication for NHS providers of specialist clinical services for young people – LYNC study protocol

Background Young people living with long term conditions are vulnerable to health service disengagement. This endangers their long term health. Studies report requests for digital forms of communication – email, text, social media – with their health care team. Digital clinical communication is troublesome for the UK NHS. Aim In this article we aim to present the research protocol for evaluating the impacts and outcomes of digital clinical communications for young people living with long term conditions and provide critical analysis of their use, monitoring and evaluation by NHS providers (LYNC study: Long term conditions, Young people, Networked Communications). Methods The research involves: (a) patient and public involvement activities with 16–24 year olds with and without long term health conditions; (b) six literature reviews; (c) case studies – the main empirical part of the study – and (d) synthesis and a consensus meeting. Case studies use a mixed methods design. Interviews and non-participant observation of practitioners and patients communicating in up to 20 specialist clinical settings will be combined with data, aggregated at the case level (non-identifiable patient data) on a range of clinical outcomes meaningful within the case and across cases. We will describe the use of digital clinical communication from the perspective of patients, clinical staff, support staff and managers, interviewing up to 15 young people and 15 staff per case study. Outcome data includes emergency admissions, A&E attendance and DNA (did not attend) rates. Case studies will be analysed to understand impacts of digital clinical communication on patient health outcomes, health care costs and consumption, ethics and patient safety.