Association Between Dissatisfaction With Care and Diabetes Self-Care Behaviors, Glycemic Management, and Quality of Life of Adults With Type 2 Diabetes Mellitus

Abstract

Purpose

The purpose of the study was to examine the associations between patient dissatisfaction and diabetes outcomes among patients with type 2 diabetes.

Methods

Primary data from 615 adults with type 2 diabetes from 2 adult primary care clinics completed validated questionnaires. Patient dissatisfaction was measured by asking participants to what degree over the past 12 months were they very dissatisfied with the care they received from their primary care provider. Diabetes outcomes included self-care behaviors, quality of life, and A1C.

A1C was abstracted from the medical record. Multiple linear regression models were used to assess associations between patient dissatisfaction, self-care, blood glucose, and quality of life.

Results

After adjusting for covariates, this study demonstrated that higher patient dissatisfaction was significantly associated with poor general diet, worse blood glucose levels, and lower mental component score for quality of life.

Conclusions

In patients with type 2 diabetes, patient dissatisfaction had a significant association with higher blood glucose levels, poor general diet, and low quality of life. Demographic factors driving patient dissatisfaction included young age, low income, and low health literacy. Future studies should investigate how to address patient satisfaction in an effort to improve health outcomes.

Diabetes, the 7th leading cause of death in the US, is a chronic disease affecting more than 29 million people, or about 9.3% of the total population.¹ This number continues to rise as 1.7 million new cases of diabetes are diagnosed in the US every year. Diabetes is estimated to cost the US economy $245 billion annually.¹ Evidence in the literature demonstrates the importance of self-care behaviors with regards to diabetes treatment and management.^1–6 These behaviors include healthful food choices, exercise, medications, and routine glucose monitoring.^1–6 Because diabetes management is complex and multifaceted, comprehensive evaluation is needed to understand factors that impact both self-care behaviors and outcomes such as A1C, patient satisfaction, and quality of life, which is regarded as one of the most important clinical and research outcomes.^6–8

Patient satisfaction and dissatisfaction are important measures for the quality of health care services and health-related behaviors.^9,10 Patient satisfaction is a complex phenomenon that influences many aspects of health care, including health system properties, individual expectations, health status, and personal attributes.^11,12 Satisfaction is related to how an individual’s experience compares with his or her expectations.¹³ Expressions of dissatisfaction by patients are arguably more valuable than expressions of satisfaction because dissatisfaction responses are noted to be more variable and longer in duration, thereby providing more feedback.¹⁴ However, less evidence exists regarding patient dissatisfaction.

The importance of patient satisfaction transcends throughout the medical field regardless of disease and recently has become increasingly important within the medical community since implementation of the Patient Protection and Affordable Care Act.^7,15,16 Studies show satisfaction influences medication-taking behavior, patient-physician interactions, and health outcomes.^7,17,18 Lower patient satisfaction has been associated with more severe clinical conditions.^9,18 Specifically, in patients with diabetes, satisfaction has been associated with blood glucose levels, managing treatment plans, and treatment evaluations.^19–22 However, there is a gap in knowledge in terms of patient dissatisfaction and its association with diabetes-related outcomes. The purpose of the study was to examine the associations between patient dissatisfaction and diabetes outcomes among patients with type 2 diabetes. Based on previous research, this study hypothesized that patient dissatisfaction will be associated with poorer self-care behaviors, A1C, and quality of life.

Research Design

This is a cross-sectional study with a total 615 participants who completed validated questionnaires capturing demographic information, diabetes self-care behaviors, health literacy, and dissatisfaction with care.

Sample and Setting

Participant recruitment took place at an academic medical center in the southeastern US. Two adult primary care clinics were used as recruitment sites within the medical center. After receiving institutional review board approval, 2 recruitment methods were used. In the first approach, research coordinators sent letters of invitation to eligible participants who received care within the primary care clinics. Interested participants contacted the research coordinators and scheduled a visit to complete the survey. The second approach was in person recruitment where research coordinators approached potential participants in the clinic waiting rooms to discuss the study. Those interested completed a paper-based survey with the research coordinator while waiting to be seen by their provider or scheduled a visit to complete the survey at another time. Patients were eligible if they were age 18 years or older and had a clinical diagnosis of type 2 diabetes based on their medical record and were able to communicate in English. All participants were provided a detailed explanation of the study prior to consent. Patients were ineligible to participate in the study if they were determined to be cognitively impaired due to significant dementia or active psychosis through interaction or chart documentation.

Measurements

Demographic and General Health Information

Age, race, sex, marital status, employment, education, income, and insurance were measured using previously validated items from the 2002 National Health Interview Survey.²³ Duration of diabetes was collected by asking the number of years the patient had been diagnosed with diabetes. Health status was measured using the validated item from the 2010 Medical Expenditure Panel Survey Household Component, asking participants to rate their health according to the following categories: excellent, very good, good, fair, and poor.²⁴ Health literacy was measured using the literacy component of the abbreviated version of the Test of Functional Health Literacy in Adults (S-TOFHLA).²⁵

Dissatisfaction With Care

Dissatisfaction with care was measured using a single item that asked participants the following: “Looking over the past 12 months, I can say that I am very dissatisfied with the care received from my primary care provider.” Responses ranged from strongly agree to strongly disagree. Participants selecting a response of strongly agree were considered to be experiencing dissatisfaction with care. This item is a reliable and valid measure of dissatisfaction with care in the literature and has been validated across national surveys.^24,26,27

Self-Care Behaviors

Self-care behaviors were measured using the Summary of Diabetes Self-Care Activities scale (SDSCA).²⁸ The SDSCA is an 11-item self-reported questionnaire including items assessing diet, exercise, blood glucose test, foot care, and smoking status. The SDSCA measures diabetes self-care behaviors over the past 7 days. Example questions include asking participants “How many of the last 7 days have you followed a healthful eating plan?” and “On how many of the last 7 days did you test your blood sugar?” Scores are calculated for each individual item (diet, exercise, blood glucose test, foot care, and smoking status). Higher scores indicate more engagement in self-care behaviors. This scale has been standardized and demonstrated interitem correlations (M = 0.47) and moderate test-retest correlations (M = 0.40), indicating that the SDSCA is a reliable and valid measure of diabetes self-care behaviors.²⁸

Quality of Life

Quality of life was assessed using the Short-Form Version 12 (SF-12) version 1—a valid and reliable scale providing physical health (PCS) and mental health (MCS) components of quality of life (Cronbach’s α = .89).^29,30 MCS includes assessment across: (1) vitality (energy), (2) social functioning (social time), (3) role emotional (accomplished less, not focused), and (4) mental health (feeling peaceful or blue and sad). PCS includes assessment across: (1) functioning (physical activities), (2) role physical (being limited physically or accomplished less), (3) bodily pain (having pain interfere with activities), and (4) general self-rated health. MCS and PCS are calculated as separate continuous scores, with higher scores indicating better quality of life.^29,30

Blood Glucose Levels

The most recent A1C within the previous 6 months was abstracted from the electronic medical record.

Methodology

Statistical Analysis

After calculating sample percentages and evaluating whether data met assumptions of linear regression analysis, both unadjusted and adjusted analyses were completed using Stata version 13. Multiple linear regression models were used to assess the independent association between dissatisfaction and self-care behaviors (general diet, specific diet, physical activity, blood glucose check, and foot care), quality of life (physical and mental components), and blood glucose levels. For each adjusted regression analysis, dissatisfaction was the primary independent variable, and age, sex, race, site, marital status, education, employment, income, diabetes duration, health status, and health literacy were included as covariates. A two-tailed α of .05 was used to determine significance.

Results

Table 1 shows the sample demographics for the 615 individuals with type 2 diabetes included in this analysis. Mean age was 61.3 years, and mean duration of diabetes was 12.3 years. The majority were non-Hispanic black (64.9%) and male (61.6%). Nearly 42% reported income lower than $20,000 per year, and 76.9% reported health status of fair or good. Mean A1C was 7.9%, mean mental component of quality of life (MCS) was 56.6, and mean physical component of quality of life (PCS) was 56.3.

Table 1.

Sample Demographics (N = 615)^a

Age	61.3±0.9
Diabetes duration (y)	12.3±9.1
Education (y)	13.4±2.8
Work h/wk	12.5±19.0
Health literacy	26.1±10.2
Race
Non-Hispanic white	33.0
Non-Hispanic black	64.9
Other	2.1
Site
Academic medical center	51.2
Veteran Affairs medical center	48.8
Gender
Female	38.4
Marital status
Never married	11.2
Married	49.7
Separated/divorced	28.2
Widowed	10.9
Annual household income
$0–$9999	20.2
$10 000–$14 999	11.3
$15 000–$19 999	10.1
$20 000–$24 999	10.4
$25 000–$34 999	14.7
$35 000–$49 999	13.8
$50 000–$74 999	10.1
$75 000 or more	9.4
Insurance coverage
No insurance	9.3
Private insurance	20.2
Medicare	24.7
Medicaid	10.2
VA insurance	23.9
Other	11.7
Health status
Excellent	1.3
Very good	12.0
Good	38.2
Fair	38.7
Poor	9.8
Self-care behaviors
General diet	4.7±2.0
Special diet	4.0±1.6
Exercise	2.6±2.2
Blood sugar testing	4.6±2.5
Foot care	4.3±2.5
Clinical indicators
A1C	7.9±1.8
Mental component score of quality of life	56.6±2.6
Physical component score of quality of life	56.3±1.0

^aAll numbers represent mean ± standard deviation or percentage.

The unadjusted results are shown in Table 2, and models adjusted for age, race, sex, site, marital status, diabetes duration, education, employment, income, health status, and health literacy are shown in Table 3. In unadjusted analyses, higher dissatisfaction with care was significantly associated with lower general diet (ß = −0.27, P < .001), higher A1C (ß = 0.22, P = .001), and lower MCS (ß = −0.36, P < .001). After adjustment, these associations remained significant, with higher dissatisfaction with care associated with lower general diet (ß = −0.18, P = .02), higher A1C (ß = 0.17, P = .01), and lower MCS (ß = −0.22, P = .02).

Table 2.

Unadjusted Models of Association Between Dissatisfaction With Care and Diabetes Self-Care, Blood Glucose Levels, and Quality of Life

	β Coefficient	95% Confidence Interval	P Value
Self-care behaviors
General diet	−0.27	−0.41, −0.13	<.01*
Special diet	−0.05	−0.16, 0.05	.33
Exercise	−0.01	−0.16, 0.15	.90
Blood sugar testing	−0.04	−0.21, 0.14	.70
Foot care	−0.03	−0.20, 0.15	.76
Clinical indicators
A1C	0.22	0.09, 0.35	.01*
MCS QOL	−0.36	−0.54, −0.18	<.01*
PCS QOL	0.03	−0.04, 0.09	.44

Abbreviations: A1C, hemoglobin A1C; MCS, mental component score; PCS, physical component score; QOL, quality of life.

^*P < .05.

Table 3.

Adjusted Models of Association Between Dissatisfaction With Care and Diabetes Self-Care, Blood Glucose Levels, and Quality of Life^a

	β Coefficient	95% Confidence Interval	P Value
Self-Care behaviors
General diet	−0.18	−0.32, −0.03	.02*
Special diet	<0.01	−0.11, 0.11	.99
Exercise	0.04	−0.12, 0.20	.63
Blood sugar testing	−0.08	−0.27, 0.10	.39
Foot care	−0.05	−0.23, 0.13	.58
Clinical indicators
A1C	0.17	0.04. 0.30	.01*
MCS	−0.22	−0.39, −0.04	.02*
PCS	0.04	−0.04, 0.11	.33

^aModel adjusted for covariates including race, sex, education, income, site, age, marital status, insurance, and comorbidities. A1C, hemoglobin A1C; MCS, mental component score; PCS, physical component score; QOL, quality of life.

P < .05.

Discussion

Dissatisfaction with care was significantly associated with poorer self-care, worse clinical outcomes, and lower quality of life. Specifically, in this sample of 615 patients with type 2 diabetes, dissatisfaction with care was significantly related to the self-care behaviors of general diet, worse blood glucose levels, and lower scores on the mental health component of quality of life after adjusting for relevant covariates. These findings suggest that attempts in improving patient satisfaction could prove beneficial when developing treatment plans and improving outcomes for adults with type 2 diabetes. Furthermore, more evidence is needed to identify the factors and reasons associated with patient dissatisfaction in order to target specific areas in which to improve satisfaction and lessen dissatisfaction.

The finding that dissatisfaction is associated with adverse outcomes in patients with type 2 diabetes is supported by previous studies in the literature. In this study, dissatisfaction was significantly associated with poorer self-care behaviors, specifically, having a poorer diet. In a cross-sectional analysis of residents with type 2 diabetes in Texas, self-care was related to patient satisfaction.³¹ Where higher scores indicated dissatisfaction with care, satisfied patients were more likely to follow a recommended diet for patients with diabetes.³¹ Similarly, when considering blood glucose levels, previous studies highlighted an association between lower satisfaction and higher A1C.^19,20 In addition, high rates of hypoglycemia have been found to be associated with lower satisfaction.²¹ Other studies have found similar results between patient satisfaction and quality of life.^19,32,33 However, other studies have come to opposite conclusions suggesting that satisfaction and quality of life are 2 distinct phenomena.³⁴

Satisfaction with care is a key driver in patient engagement and an important indicator for quality of care. When patients are engaged, treatment plans are followed, which results in better outcomes. The mechanism by which satisfaction is influenced can vary greatly depending on several factors such as the individual, the provider, the health care system or practice, and the situation. Prior reports suggest satisfaction with care centers around 3 key elements: (1) quality interactions with providers, (2) quality treatment approaches, and (3) contentment with clinical outcomes after treatment has concluded.³⁵

Implications and Relevance for Diabetes Care and Education Specialists

Evidence suggests that differences in levels of satisfaction may be rooted in personal beliefs.¹⁴ Specifically, patients often view encounters from a worldly or life perspective, whereas providers view interactions from a clinical perspective. Previous research shows patient satisfaction occurs when patient-provider agreement occurs and when patients have autonomy and feel welcomed and confident.¹⁴ Contrarily, dissatisfaction occurs when patients feel their identities of self are lost or their perceptions of self are threatened.¹⁴ These feelings often occur when patients express disagreement with providers, have feelings of inferiority or submission, or feel unequal, worthless, and ignored.¹⁴ Patients who report dissatisfaction with diabetes care often also endorse a lack of patient-centered care, which influences their ability to self-manage care. This is noteworthy to mention because the presence of dissatisfaction oftentimes means the absence of patient-centered care. A lack of patient-centered care frequently results in adverse outcomes such as suboptimal performance of self-care behaviors, worsening glycemic control, and poor quality of life.

There are study limitations that must be mentioned. First, given the cross-sectional design of the study, causal associations cannot be made. Second, there are potential confounding factors that were not controlled for in the study such as social support and diabetes knowledge; therefore, potential differences in the relationships between patient dissatisfaction, blood glucose levels, self-care behaviors, and quality of life based on those factors cannot be reported. Third, this study was conducted in participants from the southeastern US; therefore, additional research is needed to validate these findings in patients with type 2 diabetes from other geographic locations in the country.

The results of this study are important and novel because they offer new information to improve care for adults with diabetes by focusing on patient dissatisfaction and its association with 3 diabetes-related outcomes: self-care behaviors, glycemic control, and quality of life. In this sample of adults with type 2 diabetes, patient dissatisfaction was significantly associated with blood glucose levels, quality of life, and self-care behaviors after controlling for multiple covariates. These findings suggest that patient dissatisfaction is an important factor in diabetes management. Additional research is needed to understand the influence dissatisfaction has on psychosocial and clinical outcomes and to facilitate the development of policies needed to alleviate this obstacle in care. It is important for providers to be aware of patient dissatisfaction and address it with patients during clinical encounters to improve outcomes. Current research suggests that although providers do not control all factors that may influence dissatisfaction, listening to and addressing these issues might result in improved provider and health system quality of care³⁶ for patients with diseases such as type 2 diabetes.