Patients' experiences of the diabetes annual review

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1 Patients' experiences of the diabetes annual review A. Riazi, S. Hammersley, C. Eiser*, J.R. Eiser, J.E. Tooke ABSTRACT Immediately following their annual review at a specialist diabetes clinic, 175 individuals (79 type 1 and 96 type 2 diabetes) completed a questionnaire to assess their satisfaction with the consultation and understanding of the information given. The majority (84.6%) reported satisfaction with the way in which information was presented. Patients who reported greater understanding, and who felt able to discuss or ask during their consultation, expressed higher satisfaction (both p<0.01). Patients with hypertension reported less understanding of information, perhaps suggesting that they were particularly confused about the signi cance of blood pressure changes and its treatment. The following groups of patients all reported increased motivation to manage their diabetes as a result of the visit: (i) patients with poor control, (ii) those who felt they were given more education about the condition, (iii) those with whom changes in treatment had been discussed and (iv) those who believed they were at greater risk of retinopathy and neuropathy. These ndings suggest ways of improving organisation of the annual review to enhance patient satisfaction. Copyright # 2000 John Wiley & Sons, Ltd. Practical Diabetes Int 2000: 17(7); 226±230 KEY WORDS diabetes mellitus; annual review; patient satisfaction; motivation; vulnerability; understanding; doctor± patient communication Introduction A standard recommended feature of diabetes management is that all patients undergo an annual review or health check, which may be conducted either at a specialist clinic or by their A. Riazi, Ph.D., Post-Doctoral Research Fellow, C. Eiser, Ph.D., Professor of Health Psychology, J.R. Eiser, PhD., Professor of Psychology, School of Psychology, University of Exeter, UK S. Hammersley, RGN, Research Nurse, J.E. Tooke, D.M., Professor of Vascular Medicine and Consultant Diabetologist, Diabetes and Vascular Health Centre, Royal Devon and Exeter Healthcare NHS Trust, UK *Correspondence to: Professor C. Eiser Dept of Psychology, University of Shef eld, Western Bank, Shef eld. S10 2TP. UK. Submitted: 11 March 1999 Accepted in revised form: 7 February 2000 GP. Although the emphasis may vary by site, the purpose of such a review is to screen for complications, assess long term requirements, discuss educational needs and produce an agreed patient plan for the coming year. 1 It is not clear whether patients share these goals, although in an audit of the diabetes annual review process, a large majority of patients reported it to be helpful. 2 Many studies have demonstrated relationships between the doctor±patient interaction and patient satisfaction. Increased information giving, meeting of expectations and expression of empathy affect patients' satisfaction with their medical care more than the technical competence of the physician. 3±5 In one study, primary care patients who preferred a more active role in decision making were less satis ed with their medical care overall and with the way decisions were made than those who did not want an active role. 6 Among patients with type 2 diabetes, those who wanted more personal control were less satis ed and those who wanted more clinician control were more satis ed with their care. 7 One study examined patients' experiences and expectations of communication with a diabetes team. 8 A signi cant number of patients reported that communication lacked support, adequate explanations and realistic advice. Patients expected the team to show interest in them as individuals and to provide more information. 8 These ndings suggests that many patients with diabetes may desire more information exchange in their medical visits than they actually experience. There is also evidence from the literature to suggest that patients' experience of consultations in uences various medical outcomes. 9 In patients with type 2 diabetes, attempts by healthcare professionals to exert considerable control during consultations have been found to be counterproduc- 226

2 tive and contribute to poorer outcomes (in terms of HbA 1c ). 10 Their ndings also indicated that patientcentred behaviours (e.g. encouraging the patient's involvement, respecting the patient's opinion and offering support) facilitate the patient's ability to be an active participant in the consultation. Patient-centred care in those newly diagnosed with type 2 diabetes has also been found to be associated with better communication with doctors and greater satisfaction and well-being. 11 The study reported here, conducted at a diabetes specialist clinic in a diabetes centre at a district hospital, aimed to (i) explore experience of the annual review from the patients' perspective, (ii) identify areas in which patients' information needs may not be met, (iii) identify any changes in patients' perception of risks of diabetesrelated health problems as a result of the annual review, (iv) identify any changes in motivation in diabetes management as a result of the annual review and (v) relate the outcomes of the annual review (e.g. changes in medication, whether education and advice were given) to patients' own experiences of the review. Method Patients The sample consisted of 235 patients attending the outpatient diabetes clinic of the Royal Devon and Exeter Hospital during a 5 month period. Patients were approached by a research nurse or psychologist immediately prior to their consultation with the diabetologist. If patients agreed to participate, they were asked to complete a questionnaire immediately after they had seen the doctor. Questionnaires were completed in clinic where possible or returned in a freepost envelope. Questionnaires and procedures were approved by the local research ethics committees. Of the 235 patients who were approached, 175 completed the questionnaire (74% response rate). Nonrespondents included those who declined, those who initially agreed to participate but who left the clinic without seeing the researchers and those who never returned the questionnaire. Non-respondents did not differ signi cantly from respondents in either demographic (age, gender, duration of diabetes, diabetes type and treatment type) or clinical variables (HbA 1c, and presence of diabetesrelated complications, including nephropathy, neuropathy, retinopathy). Measures Questionnaire The questionnaire was organised as follows. Satisfaction. Satisfaction with the consultation was assessed by three separate items: (i) `Did you nd the consultation helpful?' (responses: `yes', `no', `don't know'); (ii) `What did you nd helpful/not helpful?' (open-ended response) and (iii) `How satis ed are you with the consultation?' (responses on a ve-point scale from `not at all', 1, to `extremely', 5). Understanding. Understanding of information given during the consultation was assessed by ve items: (i) `Was there anything that wasn't clear?'; (ii) `Did you get all of the information that you needed?' (responses `yes', `no', `don't know'); (iii) `What did you want to know more about?' (open-ended response); (iv) `To what extent did you understand all the information that was given to you?' and (v) `To what extent were you able to discuss or ask that you wanted to?' (responses `not at all', 1, to `extremely', 5). Motivation. motivation to manage diabetes as a result of the visit were assessed by the single question: `To what extent did the visit motivate you to get your diabetes better controlled?'(responses on a vepoint scale from `not at all', 1, to `extremely', 5). Perceived vulnerability to complications. Patients were also asked whether their perception of their chances of developing each of the speci c complications of kidneys, eyes and feet had changed as a result of the annual review: `As a result of the meeting, how much did your feeling about your chances of developing each of these health problems (kidneys, eyes and feet) change?'. For each of these three items, ratings were made on a ve-point scale from `less likely to develop', 1, to `much more likely to develop', 5. Clinical data Medical information was taken from the `annual review form' completed by the doctor at the same time. This included information about diabetes control (HbA 1c levels) and diabetic complications. For the purpose of this study, the following diabetic complications were classi ed on the basis of patients' records: retinopathy (background retinopathy, maculopathy, pre-proliferative and proliferative retinopathy), neuropathy (VST>25v) and hypertension (lying blood pressurei160/90 and/or on hypertensive treatment). For nephropathy, separate criteria were used for type 1 and type 2 patients. For type 1 patients, diagnosis was already made by the doctor based on ACRs (albumin±creatinine ratios) and simple exclusion of other causes of albuminuria. For type 2 patients, where other pathology is common and the link between micoralbuminuria and renal function is unclear, a creatinine concentration above the normal range (i.e. >120 mmol/l) in the presence of protein leak (i.e. ACR>2.5) were used as the criteria. Doctor's record of action taken at review For each patient, the doctor recorded action to be taken as follows: (i) refer for education and advice, (ii) changes in diabetes treatment, (iii) treatment for cholesterol or (iv) changes in hypertensive treatment, (v) referrals to the eye, (vi) foot or (vii) other specialists, and (viii) discharge from care. 227

3 Data analysis Data were analysed using SPSS for Windows. Chi-square tests were used for categorical data. Non-parametric correlations (Spearman's rho) were used to test associations between variables. Mann±Whitney U tests and non-parametric analysis of variance by ranks (Kruskal±Wallis) were used for comparisons between subgroups of patients. Results Characteristics of sample Of those who completed the postconsultation questionnaire, 98 (56%) were men and 77 were women (44%). The age range was 18±85 years, with a mean age of 58.2 years (s.d.=16.48). Duration of diabetes ranged from 1 to 59 years with a mean of years (s.d.=12.93). Of the sample, 96 (54.9%) were treated for type 2 and 79 (45.1%) for type 1 diabetes. Mean HbA 1c at the time of the annual review was 7.83% (s.d=1.45; normal range=4±6%), with a range between 4.7 and 15.1%. Demographic information and clinical variables for type 1 and type 2 patients are shown in Table 1. Patients with type 2 diabetes were signi cantly more likely than those with type 1 diabetes to present with hypertension, as well as neuropathy, and to be on hypertensive medication. Questionnaire: open-ended Items requiring yes/no or unsure responses were analysed rst. The majority of patients (91.4%) found the consultation helpful. Patients reported `being reassured' (25.2%), `being given useful advice' (19.7%), `being happy with doctor's attitude' (17.3%) and `being able to talk about worries' (15.0%). When the patients were asked what they found not helpful, `not receiving enough information' (25.0%) and `already knew what doctor said' (25.0%) were the most frequent responses. Most patients (89.7%) felt that there was nothing unclear in the consultation and that they received all the information they needed (88.1%). The remainder wanted further information, particularly regarding kidney problems, blood pressure, foot care and impotence. The majority of patients reported no change in their understanding of their own chances of developing complications; 76.2% of patients felt that their feelings about their chances of developing kidney problems remained the same after their consultation. 79.5% of patients reported their chances of developing eye problems remained the same, and 75.0% reported the same for their feet problems. Intercorrelations The ve-point scale measures of satisfaction, understanding, ability to discuss or ask, motivation and vulnerability to complications were then intercorrelated using Spearman's rho. As may be seen in Table 2, the rst three of these measures were signi cantly correlated with each other, as were the three measures of vulnerability. Motivation was not associated with the other items. Differences in satisfaction, understanding and motivation by demographic and clinical variables Satisfaction, understanding and motivation were compared between the subgroups of patients identi ed by diabetes type, gender and presence or absence of complications. None of the subgroups differed in their level of satisfaction. Patients with hypertension understood less information than those who were not hypertensive (by Mann±Whitney, z=x3.13; p<0.01), and patients who were on hypertensive medication understood less information than those who were not on hypertensive medication (z=x2.09; p<0.05). Compared with those without hypertension, patients with hypertension also reported less ability to discuss or ask during the consultation (z=x2.36; p<0.05). Age, duration of diabetes and HbA 1c were then correlated with satisfaction, understanding and motivation using rank order correlations (Spearman's rho). Motivation correlated signi cantly with HbA 1c (r=0.29; p<0.01), suggesting that patients with poorer control of their diabetes reported greater motivation to improve their diabetes control as a result of the visit. No other correlations were signi cant. Perceptions of personal vulnerability Patients with retinopathy reported increased vulnerability to eye problems (z=x2.58; p<0.05) compared to patients without retinopathy, whereas patients with neuropathy reported increased vulnerability to foot problems (z=x2.22; p<0.05) compared to patients without neuropathy. Male patients reported more vulnerability to kidney (z=x2.20; p<0.05) and feet problems (z=x2.17; p<0.05) compared with females. In addition, type 2 patients with nephropathy reported increased vulnerability to kidney problems as a result of the visit (z=x2.12; p<0.05) compared to type 2 patients without nephropathy. Relationship between motivation to manage diabetes and changes in vulnerability Patients were then divided into three groups according to their vulnerability. Comparisons were then made between these three groups of patients: those who reported (i) less, (ii) no change and (iii) more vulnerability as a result of the visit. This analysis was performed separately for each complication: retinopathy, nephropathy and neuropathy. Retinopathy The three groups of patients differed signi cantly in their motivation to look after the diabetes as a result of the visit (Kruskal±Wallis H=7.94; p<0.05). Those who reported the 228

4 Table 1. Differences in type 1 and type 2 patients as a function of demographic and clinical variables most vulnerability to retinopathy reported the most motivation. Patients whose vulnerability did not change as a result of the visit reported the least motivation. Those who reported less vulnerability to retinopathy reported motivation levels that were in between the other two groups. Nephropathy There were no signi cant differences in motivation among patients who differed in their vulnerability to nephropathy. Total group Type 1 Type 2 n n % n % Sex Men Treatment Insulin ** Retinopathy Yes Nephropathy (type 1 criteria) Yes ± ± ± ± Nephropathy (type 2 criteria) Yes ± ± ± ± Hypertension Yes ** Hypertensive treatment Yes * Neuropathy Yes ** *p<0.01; **p< x 2 Neuropathy Motivation also differed among the three groups as a function of vulnerability to neuropathy (Kruskal±- Wallis H=8.48; p<0.05). Patients who reported no change in their vulnerability to neuropathy reported the lowest motivation compared with the other two groups. Action taken by doctor The frequency data for the eight main outcomes of the annual review as reported by the doctor are shown in Table 3. Most patients were given education and advice. Changes to their diabetes treatment were discussed with more than half of all patients. Changes to their anti-hypertensive or cholesterol treatment were discussed less frequently. Referral to eye, feet or other specialists was rare and, as would be expected, very few patients were discharged from the care of this district hospital diabetes centre. These outcomes were not associated with patients' satisfaction, but were related to their understanding and motivation. Patients whose hypertensive treatment was changed reported less understanding of information during the consultation (z=x3.15; p<0.05), as well as less ability to discuss or ask (z=x2.03; p<0.05) when compared to patients whose hypertensive treatment did not change. On the other hand, patients who were discharged reported more understanding of information (z=x1.96; p<0.05) compared to patients who were not discharged. Patients who were given education and/or advice (z=x3.85; p<0.01) reported more motivation as a result of the visit, compared to those whowerenotgiveneducationand/or advice. Similarly, where changes were made to diabetes treatment (z=x2.75; p<0.01)patientsreportedmoremotivation compared with those where changes were not made, and patients who were referred to other sources (z=x3.32; p<0.01) also reported more motivation than those who were not referred. Table 2. Intercorrelations (Spearman's rho) between satisfaction, understanding, motivation and vulnerability items Able to discuss or ask Understanding Motivation vulnerability: kidney vulnerability : eyes vulnerability: feet Satisfaction 0.45 ** 0.66 ** 0.11 x0.04 x0.02 x0.01 Understanding ± 0.61 ** x0.12 x0.14 Able to discuss or ask ± ± 0.11 x0.03 x0.06 x0.04 Motivation ± ± ± x0.16 ± ± ± ± 0.40 ** 0.56 ** vulnerability : kidney vulnerability : eye ± ± ± ± ± 0.52 ** ** p<

5 Table 3. Outcomes of the annual review Yes No Missing n % n % n % Education and advice given diabetes treatment treatment for cholesterol hypertensive treatment Referred to eye unit Referred to foot specialist Other referrals Discharged or not Discussion The majority of patients were satis ed with the consultation with the doctor and reported positive evaluations. This follows the pattern found in many patient satisfaction surveys, and may re ect a norm against criticising the NHS or health professionals. 3 Patients who reported greater understanding of information, and who felt able to discuss or ask, expressed higher satisfaction. Patients who were hypertensive or on hypertensive treatment tended to report less understanding of information given to them, suggesting perhaps that patients were particularly confused about the signi cance of blood pressure changes and its treatment. More detailed information regarding this particular health problem may be of value to patients, particularly in the light of the UKPDS results advocating tighter blood pressure control, often requiring polypharmacy. 4 Some patients reported that they would have liked more information regarding kidney problems, blood pressure, impotence and foot care. Foot care has previously been identi ed as being poorly understood by patients. 5 Increased motivation to manage their diabetes as a result of the visit was reported by patients in poor control, those who were given education and discussed changes in treatment and those who believed they were at greater risk of retinopathy and nephropathy. Although patients' actual degree of adherence to the medical regimen or any associated behavioural changes were not measured, these ndings suggest that providing appropriate risk information may enhance motivation for self-care. Most patients showed no changes in vulnerability as a consequence of the annual review. However, patients with retinopathy reported increased vulnerability to eye problems as a result of the visit, and patients with neuropathy also reported increased vulnerability to foot problems. The results suggest that the annual review may serve to increase patients' perceptions of their vulnerability for those with already developed complications of the eyes and feet. However, patients with evidence of incipient or established nephropathy did not report increased vulnerability to kidney problems. Since patients also reported wanting more information regarding their kidneys, this suggests that attention needs to be paid to communicating information about kidney disease. Overall, the fact that patients who reported greater understanding of information, and who felt able to discuss or ask, expressed higher satisfaction indicates the importance of a patient-centred approach. Identifying and addressing patients' concerns in the consultation is an important part of this approach, 15 andshouldbeincorporated into practice. The results from this study suggest that clinicians should be particularly sensitive to patients' concerns regarding blood pressure, kidney problems, impotence and foot care within the consultation. In conclusion, the annual review experience is a positive one for many patients, and it facilitates motivation in certain groups of individuals. Further investigations looking speci cally at other aspects of the annual review (e.g. contact with specialist nurses, eye exam) may help to further our understanding of how each of these services contributes to the value of the annual review from a patients' perspective. Acknowledgements We thank Dr Molly Donohoe, Dr Andrew Hattersley, Dr Matthew Hawkes, Mrs Angela Hudson, Mrs Andria Kelly, Dr Brian Lee, Dr William Liddell, Dr Kenneth MacLeod, Mrs Lorraine Newton and Dr Jill Spyer for their contributions to this research. We also thank all of the patients who generously volunteered to participate in the study. References 1. Exeter Diabetes Services Advisory Group. Exeter Diabetes Care Handbook, 4th edn. Exeter: University of Exeter Postgraduate Medical School, The North Tyneside Diabetes Team. The diabetes annual review as an educational tool: assessment and learning integrated with care, screening and audit. Diabet Med 1992; 9: 389± Waitzkin H. Information giving in medical care. J Health Soc Behav 1985; 26: 81± Hall DA, Roter D, Katz N. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988; 26: 657± Roter D, Hall J. Doctors Talking with Patients/ Patients Talking with Doctors. 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