# Presentation: 727878

## Attitudes and Behaviors of Patients with Type 2 Diabetes

- By
- Jeanette Daly, RN, PhD
- Arthur Hartz, MD, PhD
- Yinghui Xu, MS
- Barcey Levy, MD, PhD
- Funded by AHRQ R03 HS014410

**Notes:**
Introduce self	   U of I
Report on research conducted on:
Thank:  Dr. Barcey Levy, my co-author

## Background

-   Patient self-care behaviors influence
-     diabetes control
-   However, little information is available about
-     the frequency of problem behaviors,
-     barriers to good behaviors, or the
-     relationship of patient self-care behaviors to
-     diabetes control

## Research Questions

- What problem behaviors are most common?
- What barriers contribute most to these behaviors?
- What patient behaviors and barriers to behaviors have the greatest impact on diabetes control?

## Design

- Selected GIM and FM patients with type 2 diabetes from the medical records in outpatient clinic at University of Iowa Carver College of Medicine
- Used a questionnaire to determine patient self-care behaviors and barriers to behaviors
- Abstracted medical record to determine HbA1c level
- Found the association of HbA1c levels with patient behaviors and attitudes

## Inclusion criteria

- Type 2 diabetes mellitus based on ICD-9 codes
- Two clinic visits within the previous year
- HbA1c lab results within 3 months of questionnaire

## Questionnaire

- 149-item questionnaire (reviewed 20 existing diabetes questionnaires)
- Includes self-care behaviors on nutrition, physical activity, glucose monitoring, medication adherence, foot care, & smoking
- Includes PHQ9 & SF-12
- Average completion time 19 minutes
- Readability Flesch-Kincaid scale 6.1 grade level

## Patient Selection

- 458 (57%) Returned Questionnaire

- _Patient Selection_

- 253 (32%) Met Inclusion Criteria

- 2,889 Potential Subjects

## Subject Characteristics 

| Age:                        29-49 years
                               50-64 years
                               65-89 years | 13% 
54% 
32% |
| --- | --- |
| Gender:                  Female | 55% |
| Marital Status:        Never married  
                               Married
                               Separated/divorced 
                               Widowed | 10%
53%
21%
14% |
| Education:              High School Grad or Less  | 48% |
| Income:                  < $20,000 
                               $20,000 - $69,999
                               > $70,000  | 53%
28%
12% |
| Race:                      Black 
                               Hispanic  | 4%
2% |

## Adherence to Recommended Behaviors

|  | 10th Percentile | Median | 90th Percentile |
| --- | --- | --- | --- |
| MEDICATION |  |  |  |
|      % Adherence | 90 | 100 | 100 |
|      Satisfaction with   
     Adherence* | 3.10 | 5 | 5 |
| MEAL PLAN |  |  |  |
|      % Adherence** | 16 | 75 | 100 |
|      Satisfaction with   
     Adherence** | 2 | 3 | 5 |

- * *P <* .05   ** *P <* .01  rs HbA1c

## Adherence to Recommended Behaviors

|  | 10th Percentile | Median | 90th Percentile |
| --- | --- | --- | --- |
| BLOOD GLUCOSE |  |  |  |
|      % Adherence | 25  | 81  | 100  |
|      Satisfaction with   
     Adherence* |  2 | 4 | 5  |
| EXERCISE (Days/Wk) |  |  |  |
|      % Adherence* |  0 | 1.5  | 6  |
|      Satisfaction with   
     Adherence** |  1 | 3  | 5  |

- * *P <* .05   ** *P <* .01 rs HbA1c

## Percentage of Patients Who Had a Strong Barrier to a Given Self-Care Behavior

|  | Medication | Meal Plan | Blood Glucose | Exercise |
| --- | --- | --- | --- | --- |
| Too Busy | 6%** | 12%** | 6%** | 14% |
| Hassle | 5%** | 15%** | 8%** | 22%** |
| Question if Helps | 8%** | 7%** | 8%** | 10% |
| Don’t Like | 6%** | 14%** | 12%** | 27%* |
| Don’t Understand | 5%** | 7%** | 5%** | 7%* |
| Forgot | 10%** | 10%** | 16%** | 12% |
| Cost | 19%** | 20%** | 12%** | 9% |
| Depression | 10%** | 10%** | 7%* | 11%* |

- For the association between the barrier and the behavior
- * *P *< .05   ** *P <* .01

## Barriers Significantly Associated with HbA1c  

|  | Medication | Meal Plan  | BG  | Exercise |
| --- | --- | --- | --- | --- |
| Too busy | .05 | .15* | .04  | .06 |
| Too much of a hassle | .05 | .27** | .14*  | .14* |
| Don’t understand what to do | .03 | .18** | .14*  | .04 |
| Forgets | .15* | .16* | .13  | .13 |
| Costs to much |   .25** |   .28** |   .25**  | .15 |
| Depression interferes | .20 | .18** | .16*  | .13* |
| Don’t like to do | .05 | .07 | .14* | .09 |
| Don’t believe it helps | .02 | .07 | .08 | .06 |

- * *P *< .05   ** *P *< .01

## Association of Self-Care Behaviors with HbA1c

- Satisfaction Taking Medication*

- Satisfaction Following Meal Plan**

- Satisfaction Testing Blood Glucose*

- Satisfaction Regular Exercise*

- * *P <* .05   ** *P *= .001

## Patient Behaviors or Attitudes Associated with HbA1c in Regression analysis 

- 					Coefficient	T-value       Sig.
- Constant			6.242		12.451	     .000
- Depression			.055		2.114	     .036
- Higher BMI			.024		2.152	     .033
- Money concerns		.146		2.337	     .021
- Medication adherence _<_ 94%     	-.839	  	-2.805        .006

## Summary

- Patients do self report problems with adherence
- Patient self reports support physician concerns about lack of adherence to self-care behaviors
- Common barriers to adherence are cost, forgets to do, too busy, hassle, doesn’t like to do, and depression

## Summary

- Associated with higher HbA1c levels:
- 	- Self-care behavior non-adherence to taking
-       medication
- 	- Patients concern about high costs
- 	- Depression
- 	- Higher BMI
- Interventions to address these barriers may improve diabetes control.