Research ArticleOriginal Research

The Psychosocial Needs of Patients Participating in Diabetes Shared Medical Appointments

Andrea L. Nederveld, Dennis Gurfinkel, Patrick Hosokawa, R. Mark Gritz, L. Miriam Dickinson, Phoutdavone Phimphasone-Brady, Jeanette A. Waxmonsky and Bethany M. Kwan
The Journal of the American Board of Family Medicine December 2022, 35 (6) 1103-1114; DOI: https://doi.org/10.3122/jabfm.2022.220062R1

Article Figures & Data

Tables

  • Table 1.

    Participant Sociodemographics Overall and by Practice Type

    VariableAll Patients (n = 616)FQHC (n = 345)Non-FQHC (n = 271)FQHC vs Non-FQHC Difference
    Age in years
     Mean (SD)61.8 (11.0)57.7 (11.1)66.9 (8.6)<0.0001* <0.0001†
     Min-Max18 to 8818 to 8831 to 84<0.0001‡ <0.0001§
    Gender N (%)
     Men252 (40.9%)127 (36.8%)125 (46.1%)0.02‖ 0.05
     Women364 (59.1%)218 (63.2%)146 (53.9%)
    Race/Ethnicity N (%)
     Black18 (3.9%)10 (5.1%)8 (3.0%)<0.0001‖ 0.002
     Hispanic100 (21.6%)76 (38.6%)24 (9.0%)
     Non-Hispanic White320 (69.0%)90 (45.7%)230 (86.1%)
     Asian20 (4.3%)17 (8.6%)3 (1.1%)
     Other/Declined6 (1.3%)4 (2.0%)2 (0.8%)
    Primary Language N(%)
     English505 (84.2%)250 (72.7%)255 (99.6%)<0.0001‖ n/a
     Spanish95 (15.8%)94 (27.3%)1 (0.4%)
    Food availability N (%)
     No lack of food security363 (58.9%)163 (47.3%)200 (73.8%)<0.0001‖ <0.0001
    Health Literacy
     Median score (IQR)3.66 (3.0 to 3.7)3.3 (2.7 to 3.7)3.67 (3.0 to 3.67)0.11‡ 0.17§

    • Abbreviations: IQR, interquartile range, 25th-75th percentile; FQHC, Federally Qualified Health Centers; SD, standard deviation.

    • ↵*t test with assumption of normality.

    • ↵†CLM – Clustered linear model with testing FQHC/Non-FQHC flag.

    • ↵‡Wilcoxon Rank Sum.

    • ↵§Clustered linear model with testing FQHC/Non-FQHC flag regressed against value ranks.

    • ↵‖χ2 test.

    • ↵Rao-Scott Categorical test accounting for facility clustering.

  • Table 2.

    Bivariate Correlations Among Patient-Reported Outcomes Measures

    PRO MeasureDDS-17 Total (L)DDS-17 Emotional Burden (L)DDS-17 Health-Care Navigation (L)DDS-17 Regimen (L)DDS-17 Inter-Personal (L)HCCQ Autonomy Support (L)Perceived Competence (H)Health Literacy (H)SDSCA Diet (H)SDSCA Exercise (H)SDSCA Glucose Monitor (H)SDSCA Smoking (L)SDSCA Foot Care (H)SDSCA Med Adherence (H)
    DDS-17 Total--0.79 (<0.0001)0.51 (<0.0001)0.80 (<0.0001)0.68 (<0.0001)0.35 (<0.0001)−0.37 (<0.0001)−0.06 (<0.0001)−0.28 (<0.0001)−0.19 (<0.0001)−0.06 (0.13)0.11 (0.01)−0.10 (0.01)−0.04 (0.44)
    DDS-17 Emotional Burden--0.33 (<0.0001)0.57 (<0.0001)0.45 (<0.0001)0.22 (<0.0001)−0.31 (<0.0001)−0.03 (0.44)−0.20 (<0.0001)−0.16 (<0.0001)0.07 (0.07)0.09 (0.03)−0.07 (0.07)−0.04 (0.33)
    DDS-17 Health-care navigation--0.31 (<0.0001)0.41 (<0.0001)0.39 (<0.0001)−0.14 (0.0005)−0.09 (0.03)−0.06 (0.16)−0.02 (0.62)−0.04 (0.30)−0.03 (0.55)−0.07 (0.08)−0.04 (0.40)
    DDS-17 Regimen--0.47 (<0.0001)0.33 (<0.0001)−0.34 (<0.0001)−0.04 (0.37)−0.35 (<0.0001)−0.21 (<0.0001)−0.20 (<0.0001)0.13 (0.003)−0.15 (0.0003)−0.06 (0.16)
    DDS-17 Inter-personal--0.28 (<0.0001)−0.24 (<0.0001)−0.04 (0.28)−0.18 (<0.0001)−0.09 (0.03)0.00 (0.99)0.06 (0.18)−0.06 (0.17)0.01 (0.76)
    HCCQ Autonomy support--−0.21 (<0.0001)0.02 (0.58)−0.17 (<0.0001)−0.09 (0.02)−0.09 (0.02)0.04 (0.41)−0.17 (<0.0001)−0.10 (0.03)
    Perceived competence--0.08 (0.04)0.37 (<0.0001)0.21 (<0.0001)0.07 (0.09)−0.07 (0.10)0.08 (0.06)0.08 (0.10)
    Health Literacy--0.04 (0.29)0.02 (0.60)0.08 (0.06)0.02 (0.72)0.03 (0.45)−0.02 (0.60)
    SDSCA Diet--0.35 (<0.0001)0.21 (<0.0001)−0.06 (0.15)0.19 (<0.0001)0.06 (0.17)
    SDSCA Exercise--0.07 (0.08)0.05 (0.29)0.10 (0.01)−0.02 (0.65)
    SDSCA Glucose Monitor--0.03 (0.55)0.24 (<0.0001)0.24 (<0.0001)
    SDSCA Smoking (N)--−0.01 (0.75)0.04 (0.41)
    SDSCA Foot Care--0.08 (0.09)
    SDSCA Med Adherence--

    • Abbreviations: H, higher numbers mean more desirable outcomes; L, lower numbers mean more desirable outcomes; DDS-17, Diabetes Distress Scale; HCCQ, Health Care Climate Questionnaire; SDSCA, Summary of Diabetes Self-Care Activities.

  • Table 3.

    Differences in Patient-Reported Diabetes Self-Care Behaviors and Motivation Measures Overall and Between Patients in Federally Qualified Health Centers (FQHCs) and Non-FQHCs

    Measure StatisticAll Patients (n = 616)FQHC (n = 345)non-FQHC (n = 271)FQHC vs Non-FQHC Difference (p-value)
    Health Care Climate Questionnaire  (HCCQ)1.7 (1.0 to 2.2)1.7 (1.0 to 2.2)1.8 (1.0 to 2.2)0.26*
     Median score (IQR)0.40†
    Perceived Competence Scale4.3 (3.3 to 6.0)4.0 (3.0 to 6.0)4.5 (3.3 to 6.0)0.48*
     Median score (IQR)0.51†
    Summary of Diabetes Self-Care  Activities (SDSCA) -  Median score (IQR)
     Diet3.2 (2.0 to 4.2)3.2 (2.0 to 4.2)3.3 (2.2 to 4.3)0.81*
    0.85†
     Exercise2.5 (1.0 to 4.0)2.5 (1.0 to 4.0)3.0 (0.5 to 4.5)0.52*
    0.37†
     Glucose Monitoring3.5 (0.5 to 7.0)3.5 (1.0 to 7.0)3.0 (0.0 to 7.0)0.22*
    0.23†
     Foot Care3.5 (1.0 to 6.0)3.5 (1.0 to 7.0)3.0 (1.0 to 4.5)0.02*
    0.002†
     Medication Taking7.0 (5.5 to 7.0)7.0 (5.2 to 7.0)7.0 (5.7 to 7.0)0.32*
    0.67†
     Current smoking - yes57 (10.3%)46 (14.3%)11 (4.7%)0.0002‡
     N (%)n/a§
     Insulin Use - yes182 (38.0%)138 (48.9%)44 (22.3%)<0.0001‡
     N (%)n/a§
     Current blood glucose medication  - yes389 (82.8%)228 (82.0%)161 (83.9%)0.60‡
     N (%)0.73§

    • Abbreviation: IQR, interquartile range, 25th-75th percentile.

    • Notes: For the HCCQ, lower numbers indicate more perceived autonomy support in the health care context. For the Perceived Competence Scale, higher numbers indicate greater confidence in one’s ability to manage diabetes (perceived competence). For the SDSCA, numbers represent average number of days per week following the recommended regimen.

    • ↵*Wilcoxon Rank Sum.

    • ↵†Clustered linear model with testing FQHC/Non-FQHC flag regressed against value ranks.

    • ↵‡χ2 test.

    • ↵§Rao-Scott Categorical test accounting for facility clustering.

  • Table 4.

    Differences in Patient-Reported Diabetes Distress (Total and Domain Scores) Overall and Between Patients in Federally Qualified Health Centers (FQHCs) and Non-FQHCs

    Construct (Measure)All Patients (n = 616)FQHC (n = 345)non-FQHC (n = 271)Comparison (p-Value)
    Diabetes Distress (DDS) – Total Score
     Median Score (IQR)1.9 (1.4 to 2.6)2.1 (1.5 to 2.8)1.8 (1.4 to 2.4)0.02* 0.0003†
     No Distress N (%)320 (53%)162 (47%)158 (60%)<0.0001‡
     Moderate Distress N (%)180 (30%)100 (29%)80 (30%)
     High Distress N (%)106 (17%)81 (24%)25 (10%)
    DDS - Emotional Burden
     Median Score (IQR)2.2 (1.4 to 3.2)2.4 (1.4 to 3.5)2.0 (1.4 to 2.8)0.04* 0.0012†
     No Distress N (%)256 (42%)132 (38%)124 (47%)0.0006‡
     Moderate Distress N (%)158 (26%)80 (23%)78 (30%)
     High Distress N (%)193 (32%)131 (38%)62 (23%)
    DDS - Healthcare Navigation
     Median Score (IQR)1.0 (1.0 to 1.5)1.0 (1.0 to 1.8)1.0 (1.0 to 1.3)0.01* 0.0004†
     No Distress N (%)494 (83%)255 (76%)230 (91%)<0.0001‡
     Moderate Distress N (%)47 (8%)36 (11%)11 (4%)
     High Distress N (%)57 (10%)44 (13%)13 (5%)
    DDS - Regimen
     Median Score (IQR)2.4 (1.6 to 3.4)2.6 (1.5 to 3.6)2.4 (1.6 to 3.2)0.37* 0.22†
     No Distress N (%)212 (35%)119 (35%)93 (36%)0.04‡
     Moderate Distress N (%)173 (29%)86 (25%)87 (33%)
     High Distress N (%)215 (36%)134 (40%)81 (31%)
    DDS - Interpersonal
     Median Score (IQR)1.3 (1.0 to 2.5)1.3 (1.0 to 2.7)1.0 (1.0 to 2.0)0.01* 0.0022†
     No Distress N (%)394 (66%)203 (60%)191 (73%)0.0008‡
     Moderate Distress N (%)91 (15%)52 (15%)39 (15%)
     High Distress N (%)115 (19%)82 (24%)33 (13%)

    • Abbreviation: IQR, interquartile range, 25th-75th percentile.

    • Notes: Diabetes Distress Scale (DDS) categories: No distress = 1-1.9; Moderate distress = 2-2.9; High distress = 3-6.

    • ↵*PROC SURVEYREG run on value ranks.

    • ↵†Wilcoxon Rank Sum.

    • ↵‡χ2 test.

  • Table 5.

    Multivariable Linear Regression Models Testing Federally Qualified Health Centers (FQHC) vs Non-FQHC Practice Type Differences in Distress with and Without Adjustment for Social Determinants of Health (SDOH)

    Model TestedCoeff (SE)Coeff p-ValueFModel p-Value
    Practice type predicting distress: Overall model (n = 605)*10.70.004
     Intercept1.94 (0.07)<0.001
     FQHC vs Non-FQHC**0.36 (0.11)0.004
    Practice type predicting distress: Overall model (n = 588)9.30.006
     Intercept1.95 (0.08)<0.001
     FQHC vs Non-FQHC*0.35 (0.12)0.006
    Practice type predicting distress adjusted for SDOH: Overall  model (n = 588***)8.2<0.001
     Intercept3.06 (0.32)<0.0001
     FQHC vs Non-FQHC**−0.03 (0.10)0.74
     Age (per 10 years)−0.15 (0.04)0.0003
     Women vs Men0.19 (0.08)0.03
     Race/Ethnicity−0.44 (0.12)0.0006
     Asian vs White0.82 (0.49)0.11
     Black vs White Hispanic vs White Other vs White−0.02 (0.16)0.90
    0.14 (0.10)0.15
     English versus Spanish as Primary Language−0.29 (0.13)0.03
     Food Insecurity (Food Availability < 3)−0.36 (0.08)0.0003

    • Abbreviation: SE, standard error.

    • ↵*11 have missing DDS-17_Total so are out of the type only model (605).

    • ↵**Practice type was dummy coded FQHC = 0 and Non-FQHC = 1. Adjusted model includes practice type and SDOH variables remaining after reverse selection with alpha = 0.05.

    • ↵***17 have other missing values (16 missing language, 1 missing age) and are removed from the expanded model (588).

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