Do time preferences predict diabetes outcomes? A combined survey and register-based study.

Identifying determinants of heterogeneity in health outcomes continues to be a focus in the health economic literature. In this study, we analyze whether time preferences predict health outcomes in individuals with type 1 diabetes (T1D) who use insulin pump therapy to manage their condition. We collect data on time preferences using a hypothetical matching task and estimate aggregate as well as individual-level discounting parameters using the exponential, hyperbolic, and quasi-hyperbolic discounting models. These parameters are then regressed against essential diabetes-related health outcomes obtained from registries and medical records, including glycemic control, kidney function, BMI, and number of hospital contacts. Our analyses indicate that all three discounting models fit the data equally well. Except for hospital contacts, we find robust evidence that impatience, as reflected by higher discounting, predicts worse health outcomes. Additionally, present bias is associated with worse kidney function. Our findings suggest that time preferences can explain some of the heterogeneity in health among individuals with T1D and call for increased attention on the role of time preferences in the design of disease management programs for individuals with chronic conditions.

Associations between insulin pump self-management and HbA1c in type 1 diabetes.

AIMS: Insulin pump self-management is important for glycaemic outcomes. We aimed to investigate associations between self-management factors and HbA1c. METHODS: Adult insulin pump users with type 1 diabetes (n = 770) completed an online questionnaire. The latest HbA1c and demographics were extracted from national registries. Associations between HbA1c and self-management (use of advanced features, timing of infusion set change, timing of meal bolus, data-upload and pump settings adjustments) were investigated using backward selected linear regression models. RESULTS: Of the 699 responders eligible for this study, 60% were women; the median age and diabetes duration were 49 and 25 years, respectively. Significant associations with HbA1c were found for changing infusion set every 0-4 days relative to 5-10 days (-5 mmol/mol (-0.4%), p = 0.003), and for never/rarely missing a bolus (-6 mmol/mol (-0.5%), p < 0.001) relative to often missing a bolus. Timing insulin 10-15 min before meal relative to after meal start was also associated with lower HbA1c (-3 mmol/mol (-0.3%), p = 0.023). Self-adjusting pump settings showed the strongest association with lower HbA1c (-6 mmol/mol (-0.6%), p < 0.001) relative to health care professionals doing all adjustments. CONCLUSION: Self-adjusting insulin pump settings, optimal timing and few omissions of meal boluses, and timely change of infusion set are associated with lower HbA1c.

Flexible inclusion of dialogue about psychosocial aspects of life with type 1 diabetes in routine consultations: A study of a questionnaire-based dialogue tool to promote person-centred support.

AIMS: To explore (1) experiences among people with type 1 diabetes and diabetologists of using a questionnaire-based dialogue tool in routine consultations to identify and address psychosocial challenges and (2) experiences of person-centredness in this group compared with a group who did not use the tool. METHODS: In all, 42 people with type 1 diabetes (mean age 54 years, mean diabetes duration 31 years and 60% women) were interviewed and completed an evaluation questionnaire following a routine consultation with the use of a dialogue tool including PAID-5, WHO-5 and open-ended questions. A comparison group of 42 people with type 1 diabetes attending routine consultations without the use of dialogue tools completed evaluation questionnaires. All consultations were audio recorded. Diabetologists were interviewed after completing all test consultations. Interviews were analysed using thematic text condensation. Evaluation questionnaires were analysed using descriptive statistics, chi square tests and Student's two-sided t-tests. RESULTS: Most participants found questions in the dialogue tool relevant to discuss with the diabetologist, and two-thirds were satisfied with the time spent on that. Experiences of people with type 1 diabetes and diabetologists were related to three pathways: (1) the tool supported valuable conversations with the diabetologist, (2) conversations with the diabetologist were unchanged and (3) the tool derailed conversations. All participants reported high levels of person centredness; however, significantly more in the comparison group reported that the diabetologist made them feel at ease (80 vs. 55%) and discussed and planned specific changes with them (93 vs. 67%). CONCLUSION: A questionnaire-based dialogue tool in consultations can support the discussion of psychosocial issues of people with type 1 diabetes. However, flexible and tailored use of the dialogue tool is crucial as consultations may otherwise be derailed.

What people with diabetes in Denmark worry about during the COVID-19 pandemic: A longitudinal study of the first 3 months of the COVID-19 pandemic.

To investigate and characterise general and diabetes-specific worries related to COVID-19 among people with diabetes in Denmark during the first 3 months of the pandemic. In a longitudinal study from March to June 2020, six online questionnaires (Q1-Q6) were distributed to 2430 adult members of two diabetes panels. Worries related to COVID-19 were measured with closed- and open-ended items. Data from closed-ended items were analysed descriptively. Open-ended responses were analysed with systematic text condensation. Using chi-squared tests, changes in proportions of worries over time were analysed, and differences in diabetes-specific worries by gender and diabetes diagnosis were explored. At Q1, 1366 individuals returned a response (Q2: 1082, Q3: 992, Q4: 977, Q5: 901, Q6: 816). In the beginning of the pandemic, 2 weeks after the first lockdown in Denmark, the most frequently reported general worries related to someone close becoming seriously ill, changes in daily life such as limitations on social interactions and uncertainty about the duration of those changes. The most frequently reported diabetes-specific worries were about severity of illness with COVID-19 due to diabetes, being identified as a member of a group at risk for COVID-19 and being unable to manage diabetes if ill with COVID-19. All concerns decreased over 3 months, as the society gradually reopened, except for persistent worries about being able to manage diabetes if ill with COVID-19. More women and people with type 1 diabetes reported worries, compared with men and people with type 2 diabetes. Our study highlights the diversity of worries related to the COVID-19 pandemic among people with diabetes and changing patterns of worry over time and across subgroups as the society reopened in Denmark. These insights can be helpful when providing support for people with diabetes during health crises.

Willingness to pay for flexibility at the workplace for people with diabetes and chronic disease: a discrete choice experiment in a population of workers in Denmark.

BACKGROUND: The number of people of working age suffering from chronic disease is increasing. Chronic diseases such as diabetes can cause negative work-related consequences in the form of early retirement or absenteeism. Providing flexible workplace accommodations may enable the person with diabetes to retain their position in the labor market. However, the successfulness of such accommodations depends largely on the perceptions of those not suffering from diabetes. The purpose of this study was to examine preferences of a population of workers in Denmark for flexibility at the workplace, for people with diabetes and for people with chronic disease in general, measured as their willingness to pay (WTP). METHODS: Respondents were drawn from online panels and randomized to answer an online survey regarding flexibility at the workplace for people with diabetes or chronic disease in general. One thousand one hundred and three respondents were included in the analysis. Based on discrete choice experiments included in the survey, we analyzed WTP for five flexibility attributes: part-time, customizing job description, additional break with pay and time off for medical visits with and without pay. We further examined perceptions of the employer's responsibility to ensure workplace flexibility for five different specific chronic diseases including diabetes. Finally, we analyzed differences in WTP for flexibility across subgroups. RESULTS: Respondents' WTP was significantly higher for chronic disease in general compared to diabetes for the possibility of part-time (81€/month vs. 47€/month, p < 0.001) and customizing job description (58€/month vs. 41€/month, p = 0.018) attributes, as well as for the overall average (49€/month vs. 36€/month, p = 0.008). Ensuring workplace flexibility for patients with a specific chronic disease other than diabetes (cancer, heart disease, arthritis and COPD) was to a higher degree considered a responsibility of the employer. Average WTP for flexibility varied across subgroups, consistently yielding a larger amount for chronic disease in general. CONCLUSIONS: The population examined in this study are willing to pay less for flexibility at the workplace for people with diabetes compared to people with chronic disease in general. This finding was evident in terms of specific flexibility attributes and on average across subgroups.

Associations between use of diabetes technology and diabetes distress: a Danish cross-sectional survey of adults with type 1 diabetes.

INTRODUCTION: The study aimed to investigate independent and combined associations between insulin delivery method (insulin pump therapy (IPT) vs multiple daily injections (MDI)), glucose monitoring method (intermittently scanned continuous glucose monitoring (isCGM) and real-time continuous glucose monitoring (rtCGM) vs blood glucose metre (BGM)) and diabetes distress (DD) in adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS: We combined data from two Danish questionnaire-based surveys, the Steno Tech Survey (n=1591) and the Type 1 Diabetes Distress Scale (T1-DDS) validation survey (n=4205), in which individuals aged ≥18 years with T1D were invited to participate. The 28-item T1-DDS was used to measure DD and DD scores were categorised as little or no distress (score <2.0), moderate distress (2.0-2.9) and high distress (score ≥3.0). Associations between insulin delivery, glucose monitoring methods and DD were assessed using linear regression. RESULTS: Among 2068 adults with T1D who responded to one of the surveys, the use of IPT was associated with a lower total T1-DDS score (-0.09, 95% CI 0.16 to -0.03) compared with MDI and adjusted for glucose monitoring method. The use of CGM was associated with a higher total T1-DDS score (0.11, 95% CI 0.05 to 0.18) compared with BGM and adjusted for the insulin delivery method. IPT was still associated with a lower T1-DDS score, regardless of being combined with BGM (-0.17, 95% CI -0.28 to -0.06) or CGM (-0.13, 95% CI -0.21 to -0.05), compared with MDI with CGM. No association was found between the type of CGM (isCGM vs rtCGM) and DD among either IPT or MDI users when restricting analysis to individuals using CGM. CONCLUSIONS: Among Danish adults with T1D, the use of IPT was associated with lower levels of DD, while CGM use was associated with higher levels of DD. DD should be addressed when introducing people with T1D to diabetes technology, CGM in particular. TRIAL REGISTRATION NUMBER: NCT04311164 (Results).

Associations between clinical and psychosocial factors and HbA1c in adult insulin pump users with type 1 diabetes.

AIMS: Many adults with type 1 diabetes do not achieve recommended glycemic goals despite intensive insulin therapy using insulin pumps. The aim of this study was to explore associations between clinical and psychosocial factors and HbA1c in insulin pump users to identify and prioritize areas for potential intervention. METHODS: A questionnaire-based survey covering clinical and psychosocial aspects of life with type 1 diabetes was distributed to all adult (≥ 18 years) insulin pump users in the Capital Region of Denmark. Responses were combined with data from medical records and national registries. Associations with HbA1c were modeled using regression-based machine learning. RESULTS: Of 1,591 invited individuals, 770 (48.4%) responded to the survey. Mean HbA1c among responders was 7.3% (56 mmol/mmol), and 35.6% had an HbA1c < 7.0% (53 mmol/mol). Six factors were significantly associated with HbA1c: diabetes duration (0.006% (0.1 mmol/mol) lower HbA1c per 1-year increase in diabetes duration); education (0.4% (4.3 mmol/mol) lower HbA1c with long higher education vs. primary school); insulin type (0.2% (2.2 mmol/mol) lower HbA1c with ultra-rapid-acting insulin vs. rapid-acting insulin); hypoglycemia awareness status (0.2% (2.2 mmol/mol) lower HbA1c with complete unawareness vs. full awareness); insulin device satisfaction (0.2% (2.7 mmol/mol) lower HbA1c per 1-point increase in Insulin Device Satisfaction Survey score); and diabetes distress (0.3% (3.1 mmol/mol) higher HbA1c per 1-point increase in Type 1 Diabetes Distress Scale score). CONCLUSIONS: This study identified several associations between clinical and psychosocial factors and HbA1c that may be considered when developing interventions targeted people with type 1 diabetes.

How has the COVID-19 Pandemic Affected Diabetes Self-Management in People With Diabetes? - A One-Year Follow-Up Study.

Background and Aim: In Denmark, the COVID-19 pandemic resulted in two lockdowns, one from March to May 2020 and another from December 2020 to April 2021, which had severe impact on everyday life. The aim of this study was to explore changes in diabetes self-management behaviors during the pandemic and to examine how specific population characteristics were associated with changes in diabetes management. Methods and Participants: In a cohort study from March 2020 to April 2021, two online questionnaires were collected from a total of 760 people with diabetes. Descriptive statistics were used to assess the proportion of participants experiencing improvements, deterioration, and status quo in diabetes self-management during the pandemic. Using logistic regressions, baseline characteristics were explored as potential predictors of change. Results: Approximately half of the participants reported that they experienced lower physical activity in April 2021 compared to before the pandemic, approximately one fifth reported diabetes self-management to be more difficult than prior to the pandemic, and one fifth reported eating more unhealthily than before the pandemic. Some participants reported higher frequency of high blood glucose levels (28%), low blood glucose levels (13%) and more frequent blood glucose variability (33%) compared to before. Easier diabetes self-management was reported by relatively few participants, however, 15% reported eating more healthily, and 20% reported being more physically active. We were largely unable to identify predictors of change in exercise activities. The few baseline characteristics identified as predictors of difficulties in diabetes self-management and adverse blood glucose levels due to the pandemic were sub-optimal psychological health, including high diabetes distress levels. Conclusion: Findings indicate that many people with diabetes changed diabetes self-management behaviors during the pandemic, mostly in a negative direction. Particularly high diabetes distress levels in the beginning of the pandemic was a predictor of both positive and negative change in diabetes self-management, indicating that people with high diabetes distress levels could potentially benefit from increased support in diabetes care during a period of crisis.

Psychosocial health in people with diabetes during the first three months of the COVID-19 pandemic in Denmark.

AIMS: To analyze trajectories of psychosocial health among people with diabetes during the first three months of lockdowns and reopenings of the COVID-19 pandemic in Denmark. METHODS: An online longitudinal survey of 2430 people with diabetes consisting of six questionnaire waves (Q1-Q6) was conducted between March 19 and June 25, 2020. Psychosocial outcomes assessed were COVID-19 worries, quality of life, feelings of social isolation, psychological distress, diabetes distress, anxiety, and general and diabetes-specific loneliness. Trajectories in psychosocial health were analyzed with linear multilevel mixed-effects models. Subgroup analyses were conducted. RESULTS: In total, 1366 (56%) people with diabetes responded to the first questionnaire. COVID-19 worries, feelings of social isolation, psychological distress, anxiety and general loneliness had all improved at Q6 compared to Q1 (p < 0.001). In general, improvements in psychosocial health started after the first reopening phase (April 15); however, general loneliness increased up to the first reopening phase (p ≤  0.001) before decreasing, and quality of life decreased up to the first reopening phase (p = 0.002), with no improvements to follow. Subgroup analyses revealed that women had larger decreases in feelings of social isolation (p < 0.001) and in psychological distress (p = 0.035) and increases in quality of life (p < 0.001), between Q1 and Q6, compared to men. CONCLUSIONS: Psychosocial health in people with diabetes improved following reopening of society. However, increases in loneliness and decreases in quality of life during lockdown indicates a potential need to mitigate the acute effects of such policies.

Changes in diabetes distress among people with type 2 diabetes during a risk screening programme for diabetic kidney disease - Longitudinal observations of the PRIORITY study.

AIMS: To investigate levels and changes in diabetes distress over the course of the PRIORITY (Proteomic prediction and Renin angiotensin aldosterone system Inhibition prevention Of early diabetic nephRopathy In people with TYpe 2 diabetes and normoalbuminuria) randomised controlled trial of screening for diabetic kidney disease (DKD) risk among people with type 2 diabetes (T2D) at a specialist diabetes clinic in Denmark. METHODS: Of 436 trial participants with T2D, 216 were invited to complete the 17-item diabetes distress scale at the time of screening (T1, n = 180), immediately after receiving the screening results at 6-8 weeks (T2, n = 169), and at 12 months follow up (T3, n = 107). Linear mixed models were used to explore changes in diabetes distress. RESULTS: No significant changes in diabetes distress were observed between the time of screening, receiving results, and at 12 months. Changes in diabetes distress were not influenced by diabetes empowerment, sense of coherence, or perceived support for diabetes self-management. CONCLUSIONS: In contrast to previous studies demonstrating that screening programmes can have negative psychological consequences, our findings indicate that participating in this screening programme for DKD does not influence emotional burden or physician-related distress among people with T2D.