Use of eye care services by people with diabetes: the Melbourne Visual Impairment Project

AIM: The use of eye care services by people with and without diabetes was investigated in the Melbourne Visual Impairment Project (VIP), a population based study of eye disease in a representative sample of Melbourne residents 40 years of age and older. METHODS: A comprehensive interview was employed to elicit information on history of diabetes, medication use, most recent visit to an ophthalmologist and optometrist, and basic demographic details. Presence and extent of diabetic retinopathy was determined by dilated fundus examination. RESULTS: The Melbourne VIP comprised 3271 people who ranged in age from 40 to 98 years; 46.2% of them were male. Of 3189 people who had the fundus examination and knew their diabetes status, 162 (5.1%) reported having been previously diagnosed with diabetes and, of these, 37 (22.2%) were found to have diabetic retinopathy. Seven people (4.3%) had developed diabetes before age 30. The mean duration of diabetes was 9.2 years. People with diabetes were significantly more likely to have visited an ophthalmologist ever or in the past 2 years than people without diabetes. However, 31.8% of people with diabetes had never visited an ophthalmologist. The proportion of people who had never seen an ophthalmologist was 47.1% for people without diabetes, 34.2% for people with diabetes but without diabetic retinopathy, and 25% for people with diabetic retinopathy. Sixty one per cent of people with diabetic retinopathy had seen an ophthalmologist in the past year and a further 3% within the past 2 years. People with diabetes were not significantly more likely to have visited an optometrist than people without diabetes (p = 0.51). Overall, 37.7% of people with diabetes and 32.9% of people without diabetes had visited an optometrist within the past year (chi 2 = 2.25, 1 df, p = 0.13). Information concerning retinal examinations was available for 135 individuals (83.3% of people with diabetes). Only 74 (54.8%) could recall ever having a dilated fundus examination; 10 (14%) by an optometrist, 62 (86%) by an ophthalmologist, and five (7%) by a general practitioner. Of those 68 people who had seen an ophthalmologist in the past 2 years, 48 (71%) reported a dilated fundus examination during that time. This compares with 28 (43%) reported dilated fundus examinations in the 65 people who had seen an optometrist in the past 2 years. This finding is statistically significant (chi 2 = 10.2, 1 df, p < 0.005). CONCLUSION: These results indicate that nearly half of people with diabetes in Melbourne are not receiving adequate screening or follow up for diabetic retinopathy, despite universal health care.

The efficacy of a clinician referral and 12 week physical activity program among men living with prostate cancer: a multicentre cluster randomised controlled trial

BACKGROUND : The purpose of this study was to determine the efficacy of a clinician referral and exercise program in improving exercise levels and quality of life for men with prostate cancer.

METHODS : This was a multicenter cluster randomized controlled trial in Melbourne, Australia comprising 15 clinicians: 8 clinicians were randomized to refer eligible participants (n = 54) to a 12-week exercise program comprising 2 supervised gym sessions and 1 home-based session per week, and 7 clinicians were randomized to follow usual care (n = 93). The primary outcome was self-reported physical activity; the secondary outcomes were quality of life, anxiety, and symptoms of depression.

RESULTS : A significant intervention effect was observed for vigorous-intensity exercise (effect size: Cohen's d, 0.46; 95% confidence interval [CI], 0.09-0.82; P = .010) but not for combined moderate and vigorous exercise levels (effect size: d, 0.08; 95% CI, −0.28 to 0.45; P = .48). Significant intervention effects were also observed for meeting exercise guidelines (≥150 min/wk; odds ratio, 3.9; 95% CI, 1.9-7.8; P = .002); positive intervention effects were observed in the intervention group for cognitive functioning (effect size: d, 0.34; 95% CI, −0.02 to 0.70; P = .06) and depression symptoms (effect size: d, −0.35; 95% CI, −0.71 to 0.02; P = .06). Eighty percent of participants reported that the clinician's referral influenced their decision to participate in the exercise program.

CONCLUSIONS : The clinician referral and 12-week exercise program significantly improved vigorous exercise levels and had a positive impact on mental health outcomes for men living with prostate cancer. Further research is needed to determine the sustainability of the exercise program and its generalizability to other cancer populations.

Australians living with and managing hepatitis C

This paper discusses the psychosocial impact of being diagnosed with hepatitis C virus (HCV). The paper clarifies some of the key misconceptions about the virus, especially the impact HCV has on people who have been recently diagnosed. An individual's reaction to the HCV diagnosis and the subsequent lifestyle challenges to maintain health, well-being, family, and social networks are discussed, particularly the issues surrounding mental health in respect to a recent chronic illness diagnosis and how to manage the trajectory of the illness in the community and individually. HCV disclosure and its effect on intimacy are also detailed.

For people living with both a diagnosed mental illness and HCV, managing the illness can be complicated. Not only are these individuals concerned about their mental illness, its treatment, and the social stigma and discrimination associated with it, they also may be alarmed over their future physical health. The paper is preliminary to research using the psychotherapeutic approach of Cognitive Behavioural Therapy (CBT) in groups of persons with a dual diagnosis of mental illness and HCV.

Retinal thickness profile of individuals with diabetes

PURPOSE: To examine the retinal thickness profiles of individuals with and without diabetic retinopathy (DR).

METHODS: Full retinal thickness in the central zone, overall and hemisphere thicknesses of the parafovea and perifovea, ganglion cell complex (GCC) thickness and retinal nerve fibre layer (RNFL) thickness were assessed in 185 individuals using spectral domain optical coherence tomography (88 individuals with diabetes but no DR, 55 with DR, and 42 non-diabetic controls). The DR group comprised of 60% of participants with very mild non-proliferative diabetic retinopathy (NPDR) (representing microaneurysms only) and 40% with mild NPDR (hard exudates, cotton-wool spots, and/or mild retinal haemorrhages). Regression analysis was performed to determine the factors associated with retinal tissue thickness, taking into account, age, sex, presence of DR, duration of diabetes, HbA1c levels and type of diabetes.

RESULTS: The mean (S.D.) of the overall parafoveal thickness was 306 (16) in the DR group and 314 (14) in the control group (p = 0.02). The mean (S.D.) of the superior hemisphere parafoveal thickness was 309 (16) in the DR group and 318 (14) in the control group (p = 0.02). The mean (S.D.) of the inferior hemisphere parafoveal thickness was 303 (17) in the DR group and 311 (15) in the control group (p = 0.02). There were no significant differences in retinal thickness between groups in the central zone (p = 0.27) or perifovea (p > 0.41). Neither the overall nor the hemisphere RNFL (p > 0.75) and GCC thickness (p > 0.37) were significantly different between the groups. Regression analysis revealed that parafoveal thickness in diabetic individuals was reduced in association with presence of DR (B = -5.9 μm, p = 0.02) and with advancing age (B = -4.5 μm, p = 0.004, for every 10 year increase in age) when adjusted for sex, duration of diabetes, HbA1c levels and type of diabetes.

CONCLUSION: The inner macula is thinner in the presence of clinical signs of diabetic retinopathy and is compounded by advancing age. The influence of any macular oedema or that by cotton-wool spots could not be ruled out and may still confound these results.

Burden of diabetes in Australia: life expectancy and disability-free life expectancy in adults with diabetes.

AIMS/HYPOTHESIS: The aim of this work was to estimate the life expectancy (LE) and disability-free life expectancy (DFLE) for adults with and without diabetes. METHODS: The Chiang method and the adapted Sullivan method were used to estimate LE and DFLE by age and sex. Mortality data in 2011 were available from the National Diabetes Services Scheme for diabetes and from standard national mortality datasets for the general population. Data on prevalence of disability and severe or profound core activity limitation were derived from the 2012 Australian Survey of Disability, Ageing and Carers (SDAC). The definitions of disability used in the SDAC followed the International Classification of Functioning, Disability and Health. Data on diabetes prevalence were derived from the Australian Diabetes, Obesity and Lifestyle study. RESULTS: The estimated LE and DFLE (with 95% uncertainty interval [UI]) at age 50 years were 30.2 (30.0, 30.4) and 12.7 (11.5, 13.7) years, respectively, for men with diabetes, and the estimates were 33.9 (33.6, 34.1) and 13.1 (12.3, 13.9) years, respectively, for women with diabetes. The estimated loss of LE associated with diabetes at age 50 years was 3.2 (3.0, 3.4) years for men and 3.1 (2.9, 3.4) years for women, as compared with their counterparts without diabetes. The corresponding estimated loss of DFLE was 8.2 (6.7, 9.7) years for men and 9.1 (7.9, 10.4) years for women. Women with diabetes spent a greater number of absolute years and a greater proportion of their life with disability as compared with men with diabetes and women without diabetes. The gains in LE and DFLE across the whole population at age 50 years after hypothetically eliminating diagnosed diabetes were 0.6 (0.5, 0.6) years and 1.8 (1.0, 2.8) years. CONCLUSIONS/INTERPRETATION: In adults, diabetes results in a modest reduction in LE and a substantial reduction in DFLE. Efforts to identify the specific causes of disability and effective interventions are needed.

Attending a single care site associated with improved glycaemic control in people with diabetes

Question:Does continuity of care improve control of clinical risk factors in people with diabetes?Study design:Cross-sectional community-based survey.Main results:85.5% of participants had continuity of care (single care site and usual provider), 9.3% had a single care site but different providers, and 5.2% had no usual source of care. Good glycaemic control was more likely with continuity of care or single care site compared with no usual source of care (continuity of care: OR 4.62, 95% CI 2.02 to 10.60; single care site: OR 6.13, 95% CI 2.08 to 18.04). There were no significant differences between groups with a usual site. There was no increased likelihood of good control of blood pressure or lipid level among groups.Authors’ conclusionsThere is evidence that good glycaemic control is more likely among people whose diabetic care is provided from one site, regardless of whether it is provided by the same practitioner.

'Are you sure you're going to have another one of those?': a qualitative analysis of the social control and social support models in type 2 diabetes

While there is evidence that spouses can impact the self-management of adults with type 2 diabetes mellitus, less is known about the influence of the wider social network. This qualitative study explored the perceived impact of the family as well as friends and work colleagues on type 2 diabetes mellitus self-management. A total of 25 adults with type 2 diabetes mellitus participated in semi-structured interviews regarding their social experiences of living with diabetes. Deductive thematic analysis was applied to the data. Pre-existing themes of health-related social control and social support were identified in the wider social network, with additional themes of non-involvement and unintentional undermining also emerging.

Physical activity preferences for people living with multiple myeloma : a qualitative study.

Although physical activity (PA) has significant benefits for people living with multiple myeloma (MM), participation rates are low. Examination of PA preferences will provide important information to clinicians and assist in the development of interventions to increase participation in PA for people living with MM. OBJECTIVE: The aim of this study is to gain an in-depth understanding of the PA preferences for people living with MM, including the preferred role of clinicians. METHODS: Semistructured interviews were conducted with patients treated for MM within the preceding 2 to 12 months. Interviews were analyzed using content analysis, where coding categories were derived directly from the text data. RESULTS: Twenty-four interviews were conducted (women, 54%; age: mean [SD], 62 [8.8] years); 16 (67%) participants had an autologous stem cell transplant. Light- to moderate-intensity PA during and after treatment was feasible, with the strongest preference for a program 2 to 8 months after treatment. The timing of information delivery was important, as was input from clinicians and organizations with knowledge of MM. Preferences for location, structure, and timing of programs varied. CONCLUSIONS: Low- to moderate-intensity PA after treatment is likely to interest people with MM. Programs need to be flexible and consider individual differences in PA preferences, functional status, and treatment schedules. IMPLICATIONS: An individually tailored PA program should form part of clinical care, involving clinicians and organizations with expertise in MM. Options for home-based PA are also important. Further research, including a population-based study of people living with MM, is necessary to further quantify PA preferences.

Caring for people with diabetes at the end of life

End-of-life care planning is assuming global significance. While general end-of-life care guidelines apply to diabetes, there are some diabetes-specific issues that need to be considered. These include the usual long trajectory to end-of-life care that enables clinicians and people with diabetes to proactively discuss when to change the focus of care from preventing diabetes complications (tight control) to a palliative approach. Palliative care aims to promote comfort and quality of life and reduce the unnecessary burden of care on individuals and their families. The aim of this paper is to discuss common disease trajectories and their relationship to diabetes care, outline strategies for proactively discussing these issues and suggest indications that palliative care is warranted.

Perceptions of individuals living with spinal cord injury toward preference-based quality of life instruments : a qualitative exploration

BACKGROUND: Generic preference-based health-related quality of life instruments are widely used to measure health benefit within economic evaluation. The availability of multiple instruments raises questions about their relative merits and recent studies have highlighted the paucity of evidence regarding measurement properties in the context of spinal cord injury (SCI). This qualitative study explores the views of individuals living with SCI towards six established instruments with the objective of identifying 'preferred' outcome measures (from the perspective of the study participants). METHODS: Individuals living with SCI were invited to participate in one of three focus groups. Eligible participants were identified from Vancouver General Hospital's Spine Program database; purposive sampling was used to ensure representation of different demographics and injury characteristics. Perceptions and opinions were solicited on the following questionnaires: 15D, Assessment of Quality of Life 8-dimension (AQoL-8D), EQ-5D-5L, Health Utilities Index (HUI), Quality of Well-Being Scale Self-Administered (QWB-SA), and the SF-36v2. Framework analysis was used to analyse the qualitative information gathered during discussion. Strengths and limitations of each questionnaire were thematically identified and managed using NVivo 9 software. RESULTS: Major emergent themes were (i) general perceptions, (ii) comprehensiveness, (iii) content, (iv) wording and (v) features. Two sub-themes pertinent to content were also identified; 'questions' and 'options'. All focus group participants (n = 15) perceived the AQoL-8D to be the most relevant instrument to administer within the SCI population. This measure was considered to be comprehensive, with relevant content (i.e. wheelchair inclusive) and applicable items. Participants had mixed perceptions about the other questionnaires, albeit to varying degrees. CONCLUSIONS: Despite a strong theoretical underpinning, the AQoL-8D (and other AQoL instruments) is infrequently used outside its country of origin (Australia). Empirical comparative analyses of the favoured instruments identified in this qualitative study are necessary within the context of spinal cord injury.

Concerns and worries in people living with inflammatory bowel disease (IBD): A mixed methods study.

OBJECTIVE: This mixed-methods study aimed to explore concerns and worries related to living with inflammatory bowel disease (IBD). METHODS: Overall, 294 patients with a clinically established diagnosis of IBD were enrolled in this cross-sectional study. Concerns and worries were measured with one open-ended question. Measures of anxiety and depressive symptoms and disease activity were also administered. A thematic analysis was conducted and thematic map created. Spearman's rho was used to identify univariate correlations between predictors and the main themes. Binary logistic regression was used to test the predictors of the main themes. RESULTS: Despite the majority of study participants being in IBD remission (74%, n=217), all but 11 reported significant IBD-related concerns. Twenty two percent reported symptoms of depression and 41% of anxiety. Four themes were identified: Quality of life (51%); Unpredictability (35%); Symptoms (34%) and Treatments (19%). Males and older people were less concerned about Quality of life (OR=.597, 95% CI: .363-.980 and OR=.980, 95% CI: .965-.995, respectively). Those in remission were less concerned about Symptoms (OR=.510, 95% CI: .281- .926) while those with longer disease duration worried more about the Symptoms (OR=1.035, 95% CI: 1.010-1.061). Males were less concerned about Treatments (OR=.422, 95% CI: .229-.777). CONCLUSION: IBD patients report significant disease-related concerns even when in remission. Further exploration of what predicts patient concerns may help in shaping health-care delivery so that it better addresses patient needs.

Attitudes towards antidepressants among people living with inflammatory bowel disease: an online Australia-wide survey.

BACKGROUND AND AIMS: Little research has been conducted on antidepressants (ADs) in inflammatory bowel disease (IBD) despite their widespread use and evidence that they may improve immunoregulatory activity. The present study aimed 1) To explore the use and type(s) of ADs currently prescribed to people living with IBD and to collect evidence with respect to any observed effect of ADs on the course of IBD, and 2) To explore experiences and opinions regarding the effect of ADs on IBD course and attitudes towards future trials with ADs. METHODS: A cross-sectional exploratory Australia-wide online survey was conducted. Numerical results of the survey were summarised using descriptive statistics and open-ended questions using a simple content analysis. RESULTS: Overall, 98 IBD respondents participated in the survey, 50% with Crohn's disease, and 79% females. Sixty five (66%) participants reported current and 46 (47%) reported past AD use. Of the current AD users, 51 (79%) reported that the symptoms ADs were prescribed for improved. Psychological well-being improved in 87% of participants. The majority of respondents observed no change in IBD activity while on ADs, however, 16 (25%) believed that ADs improved their IBD. Most (84%) respondents would recommend ADs to other people living with IBD, and 81% reported willingness to participate in clinical trials with ADs. CONCLUSIONS: Future clinical trials on ADs are warranted and likely to be accepted by people living with IBD in need of mental health care; however, it is yet unknown whether ADs will have a specific impact on long-term IBD activity.

Acceptability of psychotherapy, pharmacotherapy, and self-directed therapies in Australians living with chronic hepatitis C.

Despite the prevalence of psychiatric co-morbidity in chronic hepatitis C (CHC), treatment is under-researched. Patient preferences are likely to affect treatment uptake, adherence, and success. Thus, the acceptability of psychological supports was explored. A postal survey of Australian CHC outpatients of the Royal Adelaide Hospital and online survey of Australians living with CHC was conducted, assessing demographic and disease-related variables, psychosocial characteristics, past experience with psychological support, and psychological support acceptability. The final sample of 156 patients (58 % male) had significantly worse depression, anxiety, stress, and social support than norms. The most acceptable support type was individual psychotherapy (83 %), followed by bibliotherapy (61 %), pharmacotherapy (56 %), online therapy (45 %), and group psychotherapy (37 %). The most prominent predictor of support acceptability was satisfaction with past use. While individual psychotherapy acceptability was encouragingly high, potentially less costly modalities including group psychotherapy or online therapy may be hampered by low acceptability, the reasons for which need to be further explored.

Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support

Background. Health literacy is the ability to access, understand, and use information and services for good health. Among people with chronic conditions, health literacy requirements for effective self-management are high. The Optimising Health Literacy and Access (Ophelia) study engaged diverse organisations in the codesign of interventions involving the Health Literacy Questionnaire (HLQ) needs assessment, followed by development and evaluation of interventions addressing identified needs. This study reports the process and outcomes of one of the nine organisations, the Royal District Nursing Service (RDNS).

Methods. Participants were home nursing clients with diabetes. The intervention included tailored diabetes self-management education according to preferred learning style, a standardised diabetes education tool, resources, and teach-back method.

Results. Needs analysis of 113 quota-sampled clients showed difficulties managing health and finding and appraising health information. The service-wide diabetes education intervention was applied to 24 clients. The intervention was well received by clients and nurses. Positive impacts on clients' diabetes knowledge and behaviour were seen and nurses reported clear benefits to their practice.

Conclusion. A structured method that supports healthcare services to codesign interventions that respond to the health literacy needs of their clients can lead to evidence-informed, sustainable practice changes that support clients to better understand effective diabetes self-management.

Self-care perspectives of Chinese immigrants with type 2 diabetes living in Victoria, Australia

 The main finding of the qualitative study is cultural beliefs significantly influenced diabetes self-care. The findings described how Chinese immigrants with diabetes living in Victoria managed diabetes self-care by rebuilding own liveable balance through implementation of several culture-related beliefs, attitudes and strategies to maintain their life balance after they were diagnosed with diabetes.