Reliability and Validity of Noncognitive Ecological Momentary Assessment Survey Response Times as an Indicator of Cognitive Processing Speed in People's Natural Environment: Intensive Longitudinal Study.

BACKGROUND: Various populations with chronic conditions are at risk for decreased cognitive performance, making assessment of their cognition important. Formal mobile cognitive assessments measure cognitive performance with greater ecological validity than traditional laboratory-based testing but add to participant task demands. Given that responding to a survey is considered a cognitively demanding task itself, information that is passively collected as a by-product of ecological momentary assessment (EMA) may be a means through which people's cognitive performance in their natural environment can be estimated when formal ambulatory cognitive assessment is not feasible. We specifically examined whether the item response times (RTs) to EMA questions (eg, mood) can serve as approximations of cognitive processing speed. OBJECTIVE: This study aims to investigate whether the RTs from noncognitive EMA surveys can serve as approximate indicators of between-person (BP) differences and momentary within-person (WP) variability in cognitive processing speed. METHODS: Data from a 2-week EMA study investigating the relationships among glucose, emotion, and functioning in adults with type 1 diabetes were analyzed. Validated mobile cognitive tests assessing processing speed (Symbol Search task) and sustained attention (Go-No Go task) were administered together with noncognitive EMA surveys 5 to 6 times per day via smartphones. Multilevel modeling was used to examine the reliability of EMA RTs, their convergent validity with the Symbol Search task, and their divergent validity with the Go-No Go task. Other tests of the validity of EMA RTs included the examination of their associations with age, depression, fatigue, and the time of day. RESULTS: Overall, in BP analyses, evidence was found supporting the reliability and convergent validity of EMA question RTs from even a single repeatedly administered EMA item as a measure of average processing speed. BP correlations between the Symbol Search task and EMA RTs ranged from 0.43 to 0.58 (P<.001). EMA RTs had significant BP associations with age (P<.001), as expected, but not with depression (P=.20) or average fatigue (P=.18). In WP analyses, the RTs to 16 slider items and all 22 EMA items (including the 16 slider items) had acceptable (>0.70) WP reliability. After correcting for unreliability in multilevel models, EMA RTs from most combinations of items showed moderate WP correlations with the Symbol Search task (ranged from 0.29 to 0.58; P<.001) and demonstrated theoretically expected relationships with momentary fatigue and the time of day. The associations between EMA RTs and the Symbol Search task were greater than those between EMA RTs and the Go-No Go task at both the BP and WP levels, providing evidence of divergent validity. CONCLUSIONS: Assessing the RTs to EMA items (eg, mood) may be a method of approximating people's average levels of and momentary fluctuations in processing speed without adding tasks beyond the survey questions.

Glycemic Risk Index Profiles and Predictors Among Diverse Adults With Type 1 Diabetes.

BACKGROUND: The Glycemia Risk Index (GRI) was introduced as a single value derived from the ambulatory glucose profile that identifies patients who need attention. This study describes participants in each of the five GRI zones and examines the percentage of variation in GRI scores that is explained by sociodemographic and clinical variables among diverse adults with type 1 diabetes. METHODS: A total of 159 participants provided blinded continuous glucose monitoring (CGM) data over 14 days (mean age [SD] = 41.4 [14.5] years; female = 54.1%, Hispanic = 41.5%). Glycemia Risk Index zones were compared on CGM, sociodemographic, and clinical variables. Shapley value analysis examined the percentage of variation in GRI scores explained by different variables. Receiver operating characteristic curves examined GRI cutoffs for those more likely to have experienced ketoacidosis or severe hypoglycemia. RESULTS: Mean glucose and variability, time in range, and percentage of time in high, and very high, glucose ranges differed across the five GRI zones (P values < .001). Multiple sociodemographic indices also differed across zones, including education level, race/ethnicity, age, and insurance status. Sociodemographic and clinical variables collectively explained 62.2% of variance in GRI scores. A GRI score ≥84.5 reflected greater likelihood of ketoacidosis (area under the curve [AUC] = 0.848), and scores ≥58.2 reflected greater likelihood of severe hypoglycemia (AUC = 0.729) over the previous six months. CONCLUSIONS: Results support the use of the GRI, with GRI zones identifying those in need of clinical attention. Findings highlight the need to address health inequities. Treatment differences associated with the GRI also suggest behavioral and clinical interventions including starting individuals on CGM or automated insulin delivery systems.

Impact of a Telephonic Intervention to Improve Diabetes Control on Health Care Utilization and Cost for Adults in South Bronx, New York.

OBJECTIVE: Self-management education and support are essential for improved diabetes control. A 1-year randomized telephonic diabetes self-management intervention (Bronx A1C) among a predominantly Latino and African American population in New York City was found effective in improving blood glucose control. To further those findings, this current study assessed the intervention's impact in reducing health care utilization and costs over 4 years. RESEARCH DESIGN AND METHODS: We measured inpatient (n = 816) health care utilization for Bronx A1C participants using an administrative data set containing all hospital discharges for New York State from 2006 to 2014. Multilevel mixed modeling was used to assess changes in health care utilization and costs between the telephonic diabetes intervention (Tele/Pr) arm and print-only (PrO) control arm. RESULTS: During follow-up, excess relative reductions in all-cause hospitalizations for the Tele/Pr arm compared with PrO arm were statistically significant for odds of hospital use (odds ratio [OR] 0.89; 95% CI 0.82, 0.97; P < 0.01), number of hospital stays (rate ratio [RR] 0.90; 95% CI 0.81, 0.99; P = 0.04), and hospital costs (RR 0.90; 95% CI 0.84, 0.98; P = 0.01). Reductions in hospital use and costs were even stronger for diabetes-related hospitalizations. These outcomes were not significantly related to changes observed in hemoglobin A1c during individuals' participation in the 1-year intervention. CONCLUSIONS: These results indicate that the impact of the Bronx A1C intervention was not just on short-term improvements in glycemic control but also on long-term health care utilization. This finding is important because it suggests the benefits of the intervention were long-lasting with the potential to not only reduce hospitalizations but also to lower hospital-associated costs.

Assessment of medication management capacity in a predominantly African American and Caribbean American sample of adults with intractable epilepsy.

INTRODUCTION: Suboptimal or partial adherence to antiepileptic drugs (AEDs) is an avoidable cause of seizures and deleterious outcomes in epilepsy. As self-rated adherence may be unreliable, suboptimal adherence may go undetected. This study assessed generalizability of a performance-based measure of medication management to patients with intractable epilepsy. MATERIALS AND METHODS: Participants were 50 adults (age = 42 ±â€¯14 years, 60% female, 82% Black, 20% Hispanic/Latino) with ≥2 seizures in the preceding 6 months. Antiepileptic drug adherence was electronically monitored for one month via Medication Event Monitoring Systems (MEMS) and self-rated (1 = very poor to 6 = excellent). The Medication Management Ability Assessment (MMAA) was administered at follow-up and scored by raters blind to adherence results. Spearman correlations and Poisson regressions assessed their associations. RESULTS: On average, participants self-reported good-to-very good adherence. According to MEMS, participants took AEDs as prescribed 73% of the time; most participants (58%) missed ≥3 doses. The MMAA demonstrated strong internal consistency (Kuder-Richardson 20 = 0.81) and was associated with MEMS: percentage of days doses were taken correctly (rs = 0.29, p = 0.04) and frequency of missed doses (rs = -0.31, p = 0.03). The MMAA was not associated with self-rated adherence. Poisson regressions showed that self-ratings and MMAA performance accounted for unique variance in frequency of missed AED doses. CONCLUSIONS: These findings provide evidence of the MMAA's criterion validity as a measure of capacity to manage AEDs. It may prove useful in cases where suboptimal adherence is suspected but unreported by patients. Its lack of significant association with self-rated adherence is consistent with prior reports; however, future studies should replicate these findings with larger samples.

Diabetes burden and diabetes distress: the buffering effect of social support.

BACKGROUND: Few studies have examined protective factors for diabetes distress. PURPOSE: This study aimed to examine the moderating role of social support in the relationship between the burden of diabetes and diabetes distress. METHODS: Adults with type 2 diabetes (N = 119; 29 % Latino, 61 % Black, 25 % White) completed validated measures of diabetes distress and social support. Multiple linear regression evaluated the moderating role of social support in the relationship between diabetes burden, indicated by prescription of insulin and presence of complications, and distress. RESULTS: Greater support satisfaction was significantly associated with lower distress after controlling for burden. Support satisfaction and number of supports significantly moderated the relationship between diabetes burden and distress. Post hoc probing revealed a consistent pattern: Insulin was significantly associated with more diabetes distress at low levels of support but was not at high levels of support. CONCLUSION: Findings support the stress-buffering hypothesis and suggest that social support may protect against diabetes distress.

The influence of diabetes on a clinician-rated assessment of depression in adults with type 1 diabetes.

PURPOSE: The purpose of the study was to examine the role of diabetes and diabetes-related distress within clinician-administered depression interviews of adults with type 1 diabetes. METHODS: This mixed-methods study coded responses to a structured clinical interview of depressive symptom severity administered to adults with type 1 diabetes (n = 34; 65% female; 56% white, 38% African American, 27% Hispanic). Pearson correlations and t tests assessed relationships between interview-based and self-reported ratings of diabetes-related distress and depression. RESULTS: Among participants endorsing depressive symptoms in the interview, 73% mentioned diabetes as a contributing factor. Themes emerged relating to (1) a link between diabetes symptoms and distress, including problems with appetite, sleep, concentration, and social relationships; (2) overlapping symptoms between diabetes and depression; and (3) the perceived interconnectedness of mood and blood glucose levels. Clinician-assessed depression ratings were strongly associated with self-reported ratings of depression and self-reported diabetes-related distress. Interview-based diabetes-related distress was significantly associated with self-reported diabetes-related distress. Those with a diagnosis of major depressive disorder (44%) reported more diabetes-related distress. CONCLUSIONS: Results suggest that diabetes may influence the evaluation of depression, even in standardized clinical interviews administered by trained professionals, the gold standard of assessment. Findings highlight a need for improved conceptualization and measurement of distress in individuals with diabetes to distinguish between symptoms caused by illness burden and those indicating a psychiatric disorder.

Methodological issues in the assessment of diabetes treatment adherence.

Improving treatment adherence in patients with diabetes remains an important objective of behavioral science research. However, progress is often limited by the heterogeneity in methods used to measure treatment adherence and difficulties in generalizing across methodologies. Various measurement methods are often used with little attention paid to questions regarding validity. Doubts about validity of adherence measurement often lead investigators to measure distal clinical outcomes instead, such as glycemic control, resulting in a loss of information. This article provides an overview of the literature on diabetes medication adherence, with a focus on measurement issues. We also consider work conducted in other chronic illnesses, particularly HIV/AIDS, that may have value in guiding future directions of diabetes medication adherence research. We highlight the need for focused investigation on how characteristics of self-report methodologies affect the validity of patient responses and conclude with practical recommendations based on the current state of the science.

Depression and treatment nonadherence in type 2 diabetes: assessment issues and an integrative treatment approach.

Research has found that depression is more common among individuals with diabetes and is associated with worse diabetes outcomes including treatment nonadherence, worse glycemic control, higher risk of diabetes complications, greater functional impairment, and increased risk of mortality. These patterns of association have led to an increase in research investigating the relationship between diabetes and depression. There remain important questions about the relationship between depression and diabetes and an unmet need for treatment approaches that are successful in ameliorating depression and improving diabetes outcomes. The current commentary discusses several conceptual issues related to the measurement of depression in diabetes, argues for the importance of health behavior and treatment adherence in approaching the problem of depression in diabetes, and provides an example of a treatment approach that incorporates the treatment of depression with strategies aimed at improving treatment adherence in order to maximize effects on diabetes outcomes.

Latinos and HIV/AIDS: examining factors related to disparity and identifying opportunities for psychosocial intervention research.

Latinos maintain an AIDS case rate more than 3 times higher than whites, a greater rate of progression to AIDS, and a higher rate of HIV/AIDS-related deaths. Three broad areas are reviewed related to these disparities: (1) relevant demographic, socioeconomic, and socio-cultural factors among Latinos; (2) drug abuse and mental health problems in Latinos relevant to HIV/AIDS outcomes; and (3) opportunities for psychosocial intervention. Latinos living with HIV are a rapidly growing group, are more severely impacted by HIV than whites, and confront unique challenges in coping with HIV/AIDS. A body of research suggests that depression, substance abuse, treatment adherence, health literacy, and access to healthcare may be fruitful targets for intervention research in this population. Though limited, the current literature suggests that psychosocial interventions that target these factors could help reduce HIV/AIDS disparities between Latinos and whites and could have important public health value.

Patient Interpretation of Neuropathy (PIN) questionnaire: an instrument for assessment of cognitive and emotional factors associated with foot self-care.

OBJECTIVE: Using the common-sense model of illness behavior, we developed and validated a self-report instrument for assessment of patients' cognitive and emotional representations of diabetic peripheral neuropathy (DPN) influencing foot self-care. RESEARCH DESIGN AND METHODS: The Patient Interpretation of Neuropathy (PIN) questionnaire, generated from discussions with clinicians and interviews with patients with DPN, was administered to patients with DPN attending U.K. (n = 325) and U.S. (n = 170) diabetes centers. Psychometric tests of the PIN questionnaire comprised factor analysis, internal consistency, and test-retest reliability. Partial correlations and multivariate regressions established construct and criterion-related validity. The associations of PIN scales to past foot ulceration and foot self-care behaviors were compared with those using a generic measure of illness perception and emotion, the Revised Illness Perception Questionnaire (IPQ-R), which was adapted to neuropathy. RESULTS: Factor analysis of the PIN questionnaire produced 11 scales, which explained 69% of item variance. Nine factors measured patients' common-sense beliefs about DPN and their levels of understanding of DPN-related medical information. Two factors assessed the emotions of worry about potential consequences and anger at practitioners. Most scales demonstrated adequate internal (Cronbach's alpha = 0.62-0.90) and test-retest reliability (Pearson's r = 0.51-0.64). Partial correlations between the PIN and IPQ-R scales in corresponding domains were significant but modest (rp = 0.15-0.26). Finally, PIN scales showed significant associations with past foot ulceration and foot self-care behaviors, thereby confirming criterion validity. CONCLUSIONS: The 39-item PIN questionnaire is a reliable and valid measure of patients' cognitive and emotional representations of neuropathy affecting foot self-care.