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Beyond hemoglobin A1c: a videographic analysis of conversations about quality of life and treatment burden during clinical encounters for diabetes care

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Abstract

Purpose

Diabetes care has largely focused on reducing the risk of complications by achieving hemoglobin A1c (HbA1c) targets; yet, whole-person care may be more effective and desirable. We sought to determine the nature of discussions about quality of life, burden of treatment, hypoglycemia, sexual function, and social support during diabetes-focused clinical encounters.

Methods

We analyzed 41 previously recorded clinical encounters with patients with type 2 diabetes from the control arms of practice-based trials of shared decision-making. Two coders evaluated videos for discussions about aspects of life with diabetes: quality of life, burden of treatment, hypoglycemia, sexual function, and social supports. When an aspect was raised, coders evaluated the nature of the conversation, clinician responses, and time spent on discussing the aspect.

Results

Median length of the encounter was 15 min, 6 s (IQR: 11:16–20:23 min). Overall, 35 of 41 encounters (85.4%) included some discussion of quality of life (58.5%), burden of treatment (51.2%), social support (2.4%), or hypoglycemia (9.8%). Sexual function was not discussed. On average, 4.5% (1.4–5.5%) of the encounter time involved conversations about HbA1c, whereas 15.0% (0–25%) of the encounter time was spent on some aspect of quality of life, burden of treatment, social support, or hypoglycemia. If a topic related to quality of life was raised, clinicians most often responded by acknowledging patient’s concern without providing a solution (45.8%).

Conclusions

A significant part of the patient–clinician encounter involves discussion of quality of life and burden of treatment, but clinicians rarely address these issues by providing solutions.

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Data availability

Videos for analysis were obtained from prior studies and approved for use by Mayo Clinic IRB.

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Funding

This study was funded by a National Institute on Aging R21 grant (1R21AG061427). The funding body did not have a role in the study design and will not take part in data collection, analysis, or interpretation for the study. Funding body did not participate in writing this manuscript.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA

    Shanzay Haider & Kasia Lipska

  2. Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA

    Omar El Kawkgi, Jennifer Clark, Maggie Breslin, Kasey R. Boehmer & Victor Montori

Authors
  1. Shanzay Haider
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  2. Omar El Kawkgi
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  3. Jennifer Clark
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  4. Maggie Breslin
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  5. Kasey R. Boehmer
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  6. Victor Montori
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  7. Kasia Lipska
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Contributions

Conception and design of the work, interpretation of data for the work, revision for critically important intellectual content, and final approval of the version to be published: all authors. Acquisition of data: V.M. Data analysis: S.H. and O.E.K. Drafting of the manuscript: S.H. Funding and supervision were provided by V.M. and K.J.L.

Corresponding author

Correspondence to Kasia Lipska.

Ethics declarations

Conflict of interest

K.J.L. reports that she received support from the Centers for Medicare & Medicaid Services to develop and evaluate publicly reported quality measures. Other authors declare that they have no competing interests.

Consent to participate

Informed consent was obtained prior to interview and video recording.

Consent for publication

Participants signed informed consent about publication of data.

Ethics approval

All procedures were approved by the Mayo Clinic IRB under protocols: (#19-004560), (#09-008640), and (#10-006952).

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Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendices

Appendix 1

QBSAFE videographic codebook: the purpose of this codebook is to help identify aspects and examples of quality of life, burden of treatment, social support, hypoglycemia, and sexual dysfunction for the use of coders analyzing clinician video encounters

QBSAFE

Definition

Examples in clinician encounter

Health-related quality of life [QOL]

 

“An individual’s or group’s perceived physical and mental health over time…includes physical and mental health perceptions and their correlates…” [1].

• Overall general health

• Physical well-being

• Mental health, i.e., mood, depression, anxiety, stress, etc.

• Pain

 ○ Code as QOL if diet/exercise limited by pain

 ○ Numbness/tingling

• Fatigue

 ○ Code as QOL if diet/exercise limited by fatigue

• Visual impairment

• Difficulty in carrying out daily activities due to disability, i.e., weakness from prior stroke, amputation, etc.

• Mention of other comorbid condition affecting any of the above aspects

Burden of treatment [BoT]

 

“The workload of healthcare experienced by those with long-term conditions and the impact it has on well-being” [3].

• Difficulties in administering and/or taking meds

• Difficulties in frequency of drug administration

• Trouble with self-monitoring

• Problems with attending or keeping doctor appointments

• Issues with transportation to and from appointments

• Problems with scheduling doctor follow ups

• Financial burden of disease

• Difficulties in relationships secondary to BoT

• Difficulties in compliance with diet and exercise otherwise not attributable to QOL

Hypoglycemia

 

Defined as an episode of blood glucose reading less than 70.

> Did not include episodes where patients felt hypoglycemic but had normal blood glucose levels.

> Did not include episodes where patients described symptoms and did not check blood glucose levels.

• Reduced awareness of hypoglycemia

• Frequency of hypoglycemia

• Severity of hypoglycemia

Social support

 

Includes both objective absence of social contact as well as perceived loneliness.

• Feeling of loneliness

• Lack of social network

• Difficulty connecting with social network/circle

• Reports issues in spending time with friends and family not otherwise related to BoT

Sexual dysfunction

 

Any report of sexual dysfunction in any cohort of patients.

• Erectile dysfunction

• Decreased libido

• Other issues related to sexual dysfunction

Appendix 2

Video analysis questions

If an aspect of quality of life, burden of treatment, hypoglycemia, and social support was brought up during the clinical scenario, the following questions were used to analyze the scenario.

What aspect was brought up? [i.e., QOL, BoT, hypoglycemia]

Who initiated the conversation?

What was the nature of the concern? [refer to Table 1]

When conversation was initiated, did the clinician address the problem?

 [This was defined as the clinician asking any follow up questions or further discussion of the topic.]

If the clinician addressed the problem, how did they go about addressing it:

 Acknowledge without proposing a solution.

 Propose to monitor and/or observe.

 Order additional testing.

 Referral to specialist.

 Change of medication regiment or treatment.

 [including addition of new medication or diet/exercise recommendations]

 Change of frequency or method of monitoring.

 Change in frequency of follow up.

Time spent on each aspect brought up.

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Haider, S., El Kawkgi, O., Clark, J. et al. Beyond hemoglobin A1c: a videographic analysis of conversations about quality of life and treatment burden during clinical encounters for diabetes care. Endocrine 73, 573–579 (2021). https://doi.org/10.1007/s12020-021-02757-3

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