Diabetes Distress and Diabetes Outcomes: the Association between Distress and Patient-Provider Communication, Quality of Life, and Glycemic Control

Abstract

Background: Diabetes-related distress is defined as the emotional burden associated with living with diabetes. In prior studies, elevated levels of diabetes distress, independent from depression, have been associated with worse glycemic control, as well as worse self-management and poorer medication adherence. Poor patient-provider communication has also been associated with worsened diabetes control and poorer diabetes self-care. The relationship between diabetes distress and patient-provider communication has not been examined in the primary care setting. We hypothesized that higher diabetes distress would be associated with worse health outcomes, including glycemic control and health-related quality of life. We further postulated that diabetes distress may be associated with worse patient-provider communication. Methods: This is a cross-sectional descriptive analysis of baseline survey data obtained in the Peer-AID study, a randomized controlled trial conducted by a partnership between the VA Puget Sound Healthcare System and Public Health Seattle King County (PHSKC), evaluating a 12-month community health worker intervention for low-income people with poorly controlled diabetes. Diabetes distress was measured using the 17-item diabetes distress scale (DDS). Health-related quality of life was assessed using the Diabetes-39 tool, the SF-12 mental health (MCS) and physical health (PCS) composite scores, as well as a single question ranking overall quality of life. The quality of patient-provider communication was assessed using a subsection of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) questionnaire as well as the three Communication with Physician (CP) questions. Results: Of 287 participants, 116 (40.4%) were categorized as no/low distress, 97 participants (33.8%) were considered moderate distress, and 74 participants (25.8%) were considered to have high diabetes distress. High-distress participants had a higher HbA1c than moderate or low distress groups (9.7% vs. 8.8% vs. 8.8%, p=0.001) and were less likely to adhere to their medications or eat a healthy diet than those in other categories. High-distress participants also reported a lower diabetes-related and overall quality of life, and had lower self-efficacy than other participants. When adjusted for age, gender, and race, a one-level increase in diabetes distress category was associated with a 0.46% higher HbA1c (95% CI, 0.19-0.74; p=0.001). Higher diabetes distress was also associated with worsened quality of life and a significant decline in patient-provider communication, as measured by both CAHPS score (-0.19, 95%CI -0.29, -0.00; p <0.001) and Communication with Physicians rating (-1.04, 95% CI -1.88, -0.21; p = 0.014). Discussion: In this multi-site, multilingual study of low-income people with poorly-controlled diabetes, diabetes distress was found to have a significant association with HbA1c and quality of life. Our work also establishes a novel association between diabetes distress and patient perception of communication with their providers. These findings persisted after adjustment for depression, insulin use, diabetes duration, and presence of diabetes complications and demographic characteristics. This study confirms documented associations between diabetes distress and health outcomes in a low-income population and establishes a new link between diabetes distress and patient-provider communication. Further research into the nature of this association may yield new targets for interventions to improve diabetes outcomes.