
==== Front
BMJ Ment Health
BMJ Ment Health
bmjment
bmjment
BMJ Mental Health
2755-9734
BMJ Publishing Group BMA House, Tavistock Square, London, WC1H 9JR

39182922
10.1136/bmjment-2024-301061
bmjment-2024-301061
Original Research
Psychosocial Interventions
1506
Putting person-centred psychosocial diabetes care into practice: two psychosocial care pathways based on outcome preferences of people with diabetes and healthcare professionals
http://orcid.org/0000-0001-7651-2967
Porth Ann-Kristin 1ann-kristin.porth@meduniwien.ac.at

Seidler Yuki 23yuki.seidler@univie.ac.at

Long Preston Alexander 2preston.long@meduniwien.ac.at

Stamm Tanja 24tanja.stamm@meduniwien.ac.at

Huberts Anouk S 5a.huberts@erasmusmc.nl

Hamilton Kathryn 6kathryn.hamilton@kcl.ac.uk

http://orcid.org/0000-0002-3520-4105
Kautzky-Willer Alexandra 1alexandra.kautzky-willer@meduniwien.ac.at

1 Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna, Wien, Austria
2 Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
3 Science for Society Hub, Central European University, Wien, Austria
4 Ludwig Boltzman Institute for Athritis and Rehabilitation, Wien, Austria
5 Department of Quality and Patientcare, Erasmus Medical Center, Rotterdam, The Netherlands
6 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
DrTanjaStamm, Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, 1090, Austria; tanja.stamm@meduniwien.ac.at
None declared.

2024
24 8 2024
27 1 e30106104 3 2024
31 7 2024
Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Abstract

Background

Diabetes increases the risk of psychosocial health problems. Person-centred psychosocial care is therefore advocated. However, several barriers to implementation exist, including uncertainty about how to approach psychosocial problems in consultations.

Objective

We aimed to explore which psychosocial outcomes patients and healthcare professionals consider important and whether certain characteristics are associated with this. We propose strategies for facilitating psychosocial diabetes care on this basis.

Methods

The results of an international Delphi study aimed at achieving multi-stakeholder consensus on a diabetes outcome set were analysed. We compared the importance ratings of the two stakeholder groups for each psychosocial outcome. A multivariable linear regression analysis tested whether certain characteristics would predict the importance attributed to outcomes that were not generally considered important.

Findings

Patients and healthcare professionals agreed on the importance of regularly assessing psychological well-being, diabetes distress and diabetes-specific quality of life, while they regarded it as less important to monitor depression, anxiety, eating problems, social support and sexual health. Being a woman, younger and living with type 1 diabetes were associated with considering it important to assess eating problems.

Conclusions

We propose two psychosocial care pathways that reflect the outcome preferences of patients and healthcare providers. They follow a stepped approach, starting with the assessment of psychological well-being and quality of life and proceeding from there.

Clinical implications

Adopting this approach can facilitate the implementation of person-centred psychosocial diabetes care by reducing the burden and making psychosocial issues more accessible. This approach should be tested for feasibility, safety and effectiveness.

Cross-Sectional Studies
Depression & mood disorders
Anxiety disorders
Eating disorders
Data Interpretation, Statistical
http://dx.doi.org/10.13039/501100010767 Innovative Medicines Initiative 945345-2
==== Body
pmcWHAT IS ALREADY KNOWN ON THE TOPIC

It has long been known that psychosocial aspects, including behaviour, affect and cognition, have an impact on diabetes and its self-management. Providing psychosocial care to people with diabetes is recommended with the aim of helping to maintain health and quality of life, for example, by addressing different psychological issues, such as diabetes distress, depression, anxiety and disordered eating. However, the implementation of these recommendations in clinical practice has proved difficult and remains limited.

WHAT THIS STUDY ADDS

We identified which psychosocial outcomes people with diabetes and healthcare professionals think are most important to monitor regularly as part of routine diabetes care and which they think are secondary. Based on our findings, we propose two psychosocial care pathways that follow a stepwise approach with the aim of addressing psychological well-being and quality of life in general for all adults with diabetes but with varying granularity. The objective was to facilitate the implementation of more person-centred psychosocial care for people with diabetes by reducing its burden and improving its accessibility.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Our exploratory study should be considered hypothesis-generating. Future research should test the two psychosocial care pathways we propose in terms of their feasibility, safety and effectiveness. Provided they are confirmed, our findings may facilitate and enable the provision of psychosocial care in routine diabetes care on a large scale and have an influence on future guidelines and policies.

Background

Diabetes mellitus can have an impact on behaviour, emotional well-being, and social life. This relationship is bidirectional, in that better psychosocial well-being can contribute to better health outcomes.1 2 Maintaining a high quality of life and promoting physical and psychological well-being are therefore considered to be of equal importance to reaching biomedical treatment goals, such as normal-range blood glucose levels.3 Indeed, the provision of ‘psychosocial care’ is now recognised as one of the pillars of state-of-the-art diabetes care.1 4 However, the implementation of this principle in routine clinical practice has proven difficult. Consequently, clinical diabetes management continues to be based primarily on biomedical outcomes such as HbA1c or time in glycaemic target range as measured by continuous glucose monitoring.5 6

Research studies report high comorbidity of diabetes and depression (10–20%)7, distress (44.6%),7 anxiety (28%)8 and eating disorders (6–50% depending on the criteria used)2 and show a link between these issues and metabolic outcomes.9 For this reason, current diabetes practice guidelines advocate person-centred psychosocial care, including empathic communication, individualised treatment and education, as well as psychological screening with patient-reported outcome measures (PROMs) assessing symptoms of depression, diabetes distress, anxiety, eating disorders and cognitive abilities.1 3 4 However, several barriers to translating these recommendations into practice have been reported, including limited time and resources, tensions with established medical and personal routines, and uncertainty and a lack of skills in assessing and dealing with psychosocial problems10 11 due to a lack of training and viable care pathways.5

There is additionally a lack of clarity about which psychosocial factors are considered relevant, useful, acceptable, and beneficial by people with diabetes.11 12 Indeed, many PROMs were developed for use in clinical research and there is limited evidence of benefits from their routine use in clinical practice.11 13 To address this issue, it is crucial to involve people with diabetes and healthcare professionals in the development of PROMs for clinical practice, their implementation, and the design of health service delivery,6 such as psychosocial care. However, so far, there is little evidence on how these stakeholders perceive and evaluate psychosocial screening procedures as part of diabetes care.14

Objective

We therefore aimed to investigate the importance that people with diabetes and healthcare providers place on the regular monitoring and use of various psychosocial outcomes in routine diabetes care. We also sought to determine whether certain individual characteristics were associated with these preferences, specifically when stakeholders did not unanimously consider routine monitoring and use of an outcome to be particularly important. The objective was to identify these outcome preferences based on voting results from a recent Delphi study undertaken to agree on a person-centred outcome set for diabetes care15 and use this information to inform a strategy for facilitating the implementation of psychosocial diabetes care in routine clinical practice.

Methods

Data source and participants

We used the final voting results of a recent international Delphi exercise, which aimed to achieve multi-stakeholder consensus on a set of diabetes-relevant outcomes for use in routine care.15 People with diabetes and healthcare professionals as well as representatives of the industry and authorities participated in a three-round questionnaire-based consensus process in which they rated the importance of including diabetes-relevant outcomes in the outcome set.15 These included eight psychosocial outcomes: psychological well-being, depression, anxiety, eating problems, diabetes distress, diabetes-specific quality of life, social support and sexual health (which included physiological and psychosocial aspects, such as sexual dysfunction, sexuality and family planning). All outcomes had been pre-selected based on a systematic literature review,16 focus groups with people with diabetes and healthcare providers, a national diabetes register17 and the ICHOM diabetes outcome set.18

The subset of participants included in this study were people with type 1 and type 2 diabetes (N=60) and healthcare professionals (N=45) who completed the third survey round. They were from 13 European countries, including Austria, Belgium, Denmark, France, Germany, Italy, the Netherlands, Norway, Romania, Spain, Sweden, Switzerland and the UK; 53% were women and 48% were >60 years old (table 1). Initial data analysis showed associations between stakeholder groups and diabetes type with healthcare professionals being typically experts for both diabetes types (62%) and people with diabetes living predominantly with type 2 (58%). Women who participated in the study were generally younger than men, people with diabetes were older and the proportion of men among them was higher than among healthcare professionals.

Table 1 Participant characteristics

	People with diabetes	Healthcare professionals	
Gender			
 Women	27 (45%)	29 (64%)	
 Men	33 (55%)	16 (36%)	
Age (years)			
 18–40	10 (17%)	9 (20%)	
 41–60	13 (22%)	23 (51%)	
 >60	37 (62%)	13 (29%)	
Diabetes type			
 Type 1	24 (40%)	9 (20%)	
 Type 2	35 (58%)	6 (13%)	
 Both	1 (2%)*	28 (62%)	
 Other	0 (0%)	2 (5%)	
* Both people living with diabetes and community advocates were included in the stakeholder group ‘Ppeople with diabetes’, which explains why one individual in this group chose the ‘both‘ option for diabetes types, indicating that they represent both people living with type 1 and type 2 diabetes.

Data analysis

We used the same consensus threshold as applied in the original study, which was defined as ≥70% of both stakeholder groups rating an outcome ≥7 on a 10-point Likert scale (ranging from 1, meaning ‘not relevant at all’, to 10, meaning ‘of highest importance’).15 Therefore, we assumed that the participants of a stakeholder group considered an outcome important for holistic diabetes care if ≥70% of them rated it ≥7, whereas we assumed that an outcome was considered less important if <70% rated it ≥7. We created a binary variable for each outcome with the values ‘important’ (votes 7–10) and ‘less important’ (votes 1–6) and used cross-tabulation to compare the voting results of the two stakeholder groups for each outcome.

Multivariable linear regression analyses were performed for the outcomes that were considered less important (i.e., those that received <70% of votes ≥7) in one or both stakeholder groups to test the association between age, gender and/or diabetes type and the importance rating they received. The intention was to identify whether these outcomes might be regarded as important by certain subgroups of people with diabetes or healthcare providers, for example, depending on their age, gender, or the diabetes type they are living with and/or an expert for.

We conducted a residual analysis to test residual distribution and model misspecification. Where model assumptions were violated, we estimated the CI using a robust variance (sandwich estimator). For the regression models, we report global adjusted R2, regression coefficients and their 95% CIs. The importance of variables in the model was assessed by means of standardised regression coefficients and the change in R2. All analyses were done in R.19

Findings

Evaluations of psychosocial diabetes outcomes

For all eight outcomes included in the analysis, either positive (N=3) or negative (N=5) consensus was reached between people with diabetes and healthcare professionals, meaning that either ≥70% of both groups (positive consensus) or <70% of both groups (negative consensus) considered an outcome as ‘important’ (votes ≥7). There was no disagreement between the two stakeholders on any of the outcomes.

People with diabetes and healthcare professionals agreed on the importance of regularly assessing psychological well-being, diabetes distress, and diabetes-specific quality of life to achieve holistic diabetes management. They further agreed that it was less important to regularly assess depression, anxiety, eating problems, social support, and sexual health in this context. For most outcomes, the proportion of votes ≥7 was similar for people with diabetes and healthcare professionals, differing by a few percentage points (pp) only (0.6–4.4 pp). However, the difference was more pronounced for the importance placed on monitoring depression (62% of people with diabetes vs 52% of healthcare providers), distress (85% of people with diabetes vs 71% of healthcare providers) and social support (67% of people with diabetes vs 47% of healthcare providers) (table 2).

Table 2 Proportion of people with diabetes and healthcare professionals who rated each outcome as ‘important’

Outcome	People with diabetes (% of votes ≥7)	Healthcare professionals (% of votes ≥7)	Difference (pp)	
Psychological well-being*	78%	80%	1.7	
Depression	62%	53%	8.3	
Anxiety	52%	51%	0.6	
Eating problems	60%	56%	4.4	
Diabetes distress*	85%	71%	13.6	
Quality of life*	87%	84%	2.2	
Social support	67%	47%	20.0	
Sexual health	65%	62%	2.8	
Following the original Delphi study,15 a threshold of 70% was used, that is, if ≥70% of participants in a stakeholder group considered an outcome to be ‘important’ (rating 7–10), then it was assumed that it was relevant for this group to regularly assess it as part of diabetes care, whilstwhile if this proportion was lower, it was assumed that the group considered it less relevant. Outcomes that reached positive consensus, meaning ≥70% of both stakeholder groups rated it ≥7, are marked with *.

pppercentage points

Outcomes with relevance for specific subgroups

Multivariable linear regression analyses were performed for the five outcomes that had received <70% of votes ≥7 in both stakeholder groups. The aim was to investigate whether age, gender, and/or diabetes type can predict the importance attached to monitoring these outcomes in each of the stakeholder groups. Table 3 shows the regression coefficients and measures of model fit for each of the analyses. The model predicting the importance that people with diabetes attribute to regular assessment of eating problems was the only one to reach statistical significance (p=.02). It was able to explain 11.4% of the variability in how the importance of the outcome was rated. The variable most substantially associated with importance rating, indicated by a change in R2, was gender (change in R2=24.2%), followed by age (change in R2=8.7%) and diabetes type (change in R2=6.3%) (table 4). The model indicates that being a woman, being younger and living with type 1 diabetes are associated with a higher rating of the importance of regularly assessing eating problems in diabetes care.

Table 3 Regression coefficients and measures of model fit for all linear regression analyses

Model	Variable	Regression coefficient	95% CI	Global adjusted R2	P value	
People with diabetes	
 Depression	Gender	0.342	−0.793 to 1.478	2.3%	.237	
Age	−0.576	−1.359 to 0.207	
Diabetes type	−0.415	−1.579 to 0.750	
 Anxiety	Gender	−0.396	−1.579 to 0.786	2.5%	.222	
Age	−0.984	−1.856 to −0.113	
Diabetes type	1.149	−0.144 to 2.442	
 Eating problems	Gender	−0.858	−1.895 to 0.178	11.4%	.021*	
Age	−0.429	−1.100 to 0.242	
Diabetes type	−0.502	−1.486 to 0.482	
 Social support	Gender	0.332	−0.917 to 1.580	−3.0%	.728	
Age	−0.555	−1.804 to 0.694	
Diabetes type	0.603	−1.072 to 2.278	
 Sexual health	Gender	0.155	−1.044 to 1.353	−3.0%	.682	
Age	0.551	−0.673 to 1.776	
Diabetes type	−0.682	−2.132 to 0.767	
Healthcare professionals	
 Depression	Gender	0.145	−1.302 to 1.592	6.4%	.952	
Age	0.244	−0.834 to 1.322	
Diabetes type	−0.156	−0.986 to 0.675	
 Anxiety	Gender	0.287	−1.037 to 1.611	6.0%	.912	
Age	−0.307	−1.312 to 0.697	
Diabetes type	0.028	−0.742 to 0.798	
 Eating problems	Gender	0.087	−1.327 to 1.501	5.2%	.844	
Age	−0.456	−1.487 to 0.577	
Diabetes type	0.044	−0.783 to 0.872	
 Social support	Gender	−0.547	−1.913 to 0.819	1.9%	.542	
Age	−0.555	−1.495 to 0.385	
Diabetes type	0.160	−0.579 to 0.899	
 Sexual health	Gender	−0.493	−1.745 to 0.758	4.3%	.759	
Age	0.383	−0.586 to 1.352	
Diabetes type	−0.075	−0.811 to 0.662	
* Eating problems among people with diabetes was the only regression model that reached statistical significance (pp<.05), indicating that being a woman, being younger, and living with type 1 diabetes were associated with a higher importance rating of this psychosocial outcomes.

Table 4 Linear regression model for the perceived importance among people with diabetes of regularly assessing eating problems in diabetes care

Model	Variable	Regression coefficient	95% CI	Standardised regression coefficient	Global adjusted R2	Change in R2	
Eating problems	Gender	−0.858	−1.895 to 0.178	−0.431	0.114	24.2%	
Age	−0.429	−1.100 to 0.242	−0.330	8.7%	
Diabetes type	−0.502	−1.486 to 0.482	−0.263	6.3%	
For interpretation: Tthe following values existed for the three predictor variables: gender: 0 – —‘woman’, 1 – —‘man’; age: 1 – —‘18–40’, 2 – —‘41–60’, 3 – —‘60+’; diabetes type: 1 – —‘type 1’, 2 – —‘type 2’, 3 – —‘both’.

Discussion

We set out to explore which diabetes-relevant psychosocial outcomes people with diabetes and healthcare professionals consider particularly important for routine diabetes care. We did so to inform a strategy for facilitating the routine provision of psychosocial diabetes care. We found that people with diabetes and healthcare professionals expressed the same opinion about which outcomes they wanted to regularly assess and use for diabetes management, including psychological well-being, quality of life, and diabetes distress. Likewise, they agreed that depression, anxiety, eating problems, social support, and sexual health were aspects that were less important to assess on a regular basis.

Interpretation

Our findings fit well with the positive, affirmative approach to psychosocial diabetes care called for by members of the Psychosocial Aspects of Diabetes Study Group (PSAD) who have criticised the problem-oriented focus that still prevails in diabetes practice.20 In fact, there is evidence that some people with diabetes may reject screening for psychological disorders because of stigma or fear of them.14 20 Diabetes stigma and the experience of discrimination are still commonplace for people with diabetes.21 Being associated with or experiencing other health conditions that are subject to stereotyping and stigmatisation, such as psychological disorders, can lead to experiencing ‘intersecting stigma’.22 The fear of additional (i.e., intersecting) stigma might have influenced the decision of the people with diabetes in our study to (perhaps unconsciously) place less importance on regularly screening for depression, anxiety, and eating disorders.

The healthcare professionals' voting results may have been influenced by their professional identity, which is largely formed by what is expected of them in their field and by the competencies (e.g., knowledge and skills) they acquire to fulfil this role.23 Identifying and treating certain psychological issues, a task traditionally undertaken by psychologists and psychiatrists, may feel out of scope for healthcare providers specialising in the provision of diabetes care,14 possibly explaining why the healthcare professionals in our study did not vote for regularly assessing these outcomes in diabetes care. Similar reasoning may explain the limited importance attributed to routinely asking about social support. Indeed, it was shown that both healthcare professionals and people with diabetes are reluctant to initiate conversations about social support in consultations, as this topic is often seen as outside the remit of diabetes care professionals.11 Moreover, reluctance or embarrassment may be reasons why the participants did not speak out in favour of regularly addressing sexuality in routine diabetes care.24

For diabetes care to be effective and safe it is crucial that people with diabetes and healthcare providers are comfortable with the required processes, although it is also important that (potentially unpleasant) scientific evidence is translated into practice. Indeed, the risk of experiencing depression, anxiety, and problematic eating behaviour has been shown to be elevated in people living with diabetes compared with those living without.2 Yet, these outcomes were considered less important to regularly assess by people with diabetes and healthcare professionals in this analysis. Still, evidence suggests that assessing the symptoms of these conditions should be part of psychosocial diabetes management.1 25

We believe that well-coordinated interdisciplinary care and clear care pathways can enable holistic psychosocial diabetes care that is neither perceived as stigmatising or uncomfortable by people with diabetes nor as overwhelming or out of scope by healthcare providers.

Practical implications

Based on our findings and interpretation, we propose a two-staged approach for facilitating the implementation of psychosocial diabetes care in routine clinical practice, including (1) priority outcomes assessed regularly and universally for every adult with type 1 and type 2 diabetes, and (2) outcomes assessed because of specific preconditions, for example, when irregularities in the priority outcomes are detected. Following the conceptual categorisation of outcomes into health and quality of life outcomes,26 we arrive at the following two psychosocial care pathways: (1) indications of reduced psychological well-being and/or increased levels of diabetes distress should prompt an assessment of potential psychological disorders, such as depression, anxiety and disordered eating; (2) reports of reduced quality of life should trigger inquiries about social support and/or sexual health (figure 1).

Figure 1 Psychosocial care pathways for person-centred diabetes care. *The measures proposed here are suggestions, not exhaustive and need to be adapted to different settings, circumstances and available resources.

Psychological well-being pathway

Based on our findings, we suggest that psychosocial assessment in routine diabetes care begins with an overview of the person’s psychological well-being and level of diabetes distress. This approach can ensure that the experiences of people with diabetes are not ‘over-pathologised’,20 as emotional well-being is important for everyone’s health, and diabetes distress is considered a normal, expected emotional response to living with diabetes.27 A similar approach that used the WHO Five Well-Being Index (WHO-5) and Problem Areas in Diabetes (PAID) questionnaires to monitor the mental status of people with diabetes has been shown to be feasible and acceptable in a multicentre prospective observational study.13 The WHO-5 has been valued by people with diabetes as a mood screening tool and proved to be suitable for screening depression in this group.28 The PAID is suitable for identifying clinically relevant diabetes distress and supporting meaningful conversations in diabetes consultations.29 Depressive symptoms as measured by PROMs can often be partially explained by diabetes distress causing false-positive depression screening results, but these two presentations can be distinguished in professional psychological interviews.27 30 Thus, starting with an appraisal of psychological well-being and diabetes distress before deciding whether psychological disorders should be investigated by appropriate professionals can avoid false-positive findings, which can be alarming for the individual. Indeed, a step-by-step approach based on verbal screening questions, followed by a validated screening tool and finally a clinical interview has already been recommended in some places.30

Quality of life pathway

Based on the responses in this study, we suggest that quality of life should be regularly assessed in all adults with diabetes and that inquiry about social and sexual health may be considered thereafter. Both are recognised, along with others, as important domains of diabetes-specific quality of life.31 For example, sexual dysfunction (including vaginal dryness and pain, inability to orgasm and erectile dysfunction), which is more common in men and women with diabetes than in those without, and impaired sex life due to body image or fear of hypoglycaemia can affect the quality of life.24 Moreover, it was shown that social support can mitigate the effects of stress and distress on the quality of life of people with diabetes.32

Both social and sex life are intimate topics, and people with diabetes and healthcare providers may feel reluctant or uncomfortable talking (or asking) about them. This barrier may be overcome by starting with a less intrusive inquiry about the quality of life and then progressing further. Using a PROM for this purpose may help overcome inhibitions and facilitate conversation about these topics.11 For instance, a short questionnaire on diabetes-specific quality of life, such as the DAWN2 Impact of Diabetes Profile (DIDP),7 could be used in a way that the subscales of physical health and/or relationships elicit questions on social support and/or sexual health. Such an approach may be realised using computerised adaptive testing, which offers more flexibility by adapting the questions to the respective situation and reduces the burden on people with diabetes and medical staff when dealing with these issues.26 Addressing these issues can significantly improve the lives of people with diabetes as it can help them and their caregivers understand their situation more holistically and take the necessary steps to improve it.24 32

Paying attention to specific subgroups

We found that the importance of assessing eating problems was rated higher by women and younger participants with type 1 diabetes. This is consistent with the fact that their prevalence is particularly high in this group, that is, young people with either diabetes type and specifically young women with type 1 diabetes.33 Diabetes care providers should therefore pay particular attention to symptoms of problematic eating behaviour in people with these characteristics and consider actively addressing these issues with them.

There is also evidence of a link between age and gender of people with diabetes and their quality of life and level of distress, with women on average experiencing a lower quality of life and a higher level of distress.32 However, the fact that this is not reflected in the outcome preferences found in our analysis has led us to believe that their importance for person-centred psychosocial care is nevertheless universal.

Limitations

This is a retrospective and exploratory study, and the analyses performed were not adjusted for multiplicity. Our results should therefore be regarded as a source of new hypotheses. Based on our findings, we suggest a practice-oriented framework for psychosocial diabetes care that consists of two clear care pathways and might help facilitate its implementation in routine practice. Its feasibility, efficacy, and safety should now be investigated in future prospective studies.

Our findings may be limited by the rather small (N=105) and homogeneous (high-income to middle-income European countries) sample they are based on.15 Only limited information was available about the participants (e.g., self-reported gender, age group, diabetes type). It might be fruitful to consider the influence of other factors such as diabetes duration, treatment regimen or blood glucose control on outcome preferences. For example, long diabetes duration and poorly controlled blood glucose levels are associated with increased diabetes distress and potential psychological disorders.2 27 If it had been possible to include these variables in the regression models, specific outcome preferences might have been identified for these groups, which would have had an influence on the care pathways developed. Moreover, participants' responses may have been influenced by the fact that they were asked to consider clinical practicability when rating outcome importance.15 It is possible that lower ratings reflect the belief that a regular assessment is more difficult to achieve for the respective outcome, which is why we believe that the step-by-step and interdisciplinary approach we propose can be helpful. Indeed, both people with diabetes and healthcare providers have expressed that it is crucial for psychosocial diabetes care that teams are interdisciplinary and that appropriate referral options are available.14

Clinical implications

We have developed two psychosocial care pathways for diabetes care based on the outcome preferences of people with diabetes and healthcare providers. We recognise that implementing new routines in healthcare takes time and effort.11 However, one can find positive examples that show that integrating psychosocial diabetes care into routine practice is both valuable and feasible. For example, a psychosocial screening and care pathway was developed and successfully integrated into routine diabetes care in Australia.34 The model is well received by patients and healthcare providers and consistent with our proposed model: it includes screening for diabetes distress and emotional well-being and provides a decision tree for following up on responses, suggesting usual care, diabetes education, or referral to a psychologist.34 This shows that previously reported implementation barriers, such as tensions with established routines and uncertainty and lack of guidance on how to respond to psychosocial screening results,10 11 35 can be overcome.

Other efforts to integrate the assessment of psychosocial outcomes into diabetes care have been hampered by a predominant focus on the use of lengthy, multidimensional PROMs,6 35 a lack of consideration of quality of life or psychological outcomes other than depression and diabetes distress,35 and limited evidence of sustainability and long-term impact.6 We believe that structuring outcome assessments according to the preferences of people with diabetes and healthcare providers in the way we have suggested can facilitate the routine and timely implementation of person-centred psychosocial care for people with diabetes. This will also require changes and support at the management and healthcare system level.

Future studies are required to test whether this is feasible, safe, and effective. It will also be important to investigate the applicability of the proposed care pathways in different health settings and in relation to available resources and refine them accordingly.

The insights we have derived can also assist in adapting the diabetes outcome set on the development on which our analyses were based to ensure its clinical feasibility, acceptability, and meaningfulness in the long term. An upcoming study on the implementation of the outcome set may contribute to testing the pathways proposed here.

Acknowledgements

We would like to thank the Health Outcomes Observatory (H2O) project team and especially all members of work package 3 'Disease area 1: Diabetes' for their valuable support and expertise. Special thanks go to all those involved in conducting the Delphi study from which the data for the present study were derived and to all those who participated in the Delphi study.

Data availability statement

Data are available upon reasonable request.

Funding: This project has received funding from the Innovative Medicines Initiative (IMI) 2 Joint Undertaking under grant agreement No 945345-2. This Joint Undertaking receives support from the European Union's Horizon 2020 research and innovation program, EFPIA, Trial Nation and JDRF. The funding source was not involved in the study design; the collection, analysis and interpretation of data; the writing of the report or the decision to submit the article for publication. The manuscript reflects only the authors' views. The European Union and IMI are not responsible for any use that may be made of the information it contains. IMI is the world's most extensive public-private partnership (PPP) in the life sciences. http://www.imi.europa.eu/

Patient consent for publication: Consent obtained directly from patient(s).

Ethics approval: This study involves human participants and was approved by Medical University Vienna: EK 1803/2021. Participants gave informed consent to participate in the study before taking part.

Provenance and peer review: Not commissioned; externally peer reviewed.
==== Refs
References

1 Young-Hyman D de Groot M Hill-Briggs F et al Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association Diabetes Care 2016 39 2126 40 10.2337/dc16-2053 27879358
2 de Groot M Golden SH Wagner J Psychological conditions in adults with diabetes Am Psychol 2016 71 552 62 10.1037/a0040408 27690484
3 Davies MJ Aroda VR Collins BS et al Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) Diabetologia 2022 65 1925 66 10.1007/s00125-022-05787-2 36151309
4 American Diabetes Association Professional Practice Committee 5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2022 Diabetes Care 2022 45 S60 82 10.2337/dc22-S005 34964866
5 Speight J Hendrieckx C Pouwer F et al Back to the future: 25 years of “Guidelines for encouraging psychological well-being” among people affected by diabetes Diabet Med 2020 37 1225 9 10.1111/dme.14165 31661183
6 Skovlund SE Lichtenberg TH Hessler D et al Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and A Case Study Curr Diab Rep 2019 19 84 10.1007/s11892-019-1190-x 31420754
7 Nicolucci A Kovacs Burns K Holt RIG Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes Diabet Med 2013 30 767 77 10.1111/dme.12245 23711019
8 Mersha AG Tollosa DN Bagade T et al A bidirectional relationship between diabetes mellitus and anxiety: A systematic review and meta-analysis J Psychosom Res 2022 162 110991 10.1016/j.jpsychores.2022.110991 36081182
9 Snoek FJ Bremmer MA Hermanns N Constructs of depression and distress in diabetes: time for an appraisal Lancet Diabetes Endocrinol 2015 3 450 60 10.1016/S2213-8587(15)00135-7 25995123
10 Joensen L Fisher L Skinner T et al Integrating psychosocial support into routine diabetes care: perspectives from participants at the Self-Management Alliance meeting 2016 Diabet Med 2019 36 847 53 10.1111/dme.13836 30315608
11 Svedbo Engström M Johansson U-B Leksell J et al Implementing the Digital Diabetes Questionnaire as a Clinical Tool in Routine Diabetes Care: Focus Group Discussions With Patients and Health Care Professionals JMIR Diabetes 2022 7 e34561 10.2196/34561 35612885
12 Hernar I Graue M Richards DA et al Use of patient-reported outcome measures (PROMs) in clinical diabetes consultations: the DiaPROM randomised controlled pilot trial BMJ Open 2021 11 e042353 10.1136/bmjopen-2020-042353
13 Snoek FJ Kersch NYA Eldrup E et al Monitoring of Individual Needs in Diabetes (MIND)-2: follow-up data from the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) MIND study Diabetes Care 2012 35 2128 32 10.2337/dc11-1326 22837364
14 Brodar KE La Greca AM Leite RO et al Patient and Provider Views on Psychosocial Screening in a Comprehensive Diabetes Center J Clin Psychol Med Settings 2023 30 92 110 10.1007/s10880-022-09867-8 35316442
15 Porth A-K Huberts AS Rogge A et al Standardising personalised diabetes care across European health settings: A person-centred outcome set agreed in a multinational Delphi study Diabet Med 2024 41 e15259 10.1111/dme.15259 38017616
16 Hamilton K Forde R Due-Christensen M et al Which diabetes specific patient reported outcomes should be measured in routine care? A systematic review to inform a core outcome set for adults with Type 1 and 2 diabetes mellitus: The European Health Outcomes Observatory (H2O) programme Pat Educ Couns 2023 116 107933 10.1016/j.pec.2023.107933
17 Gudbjörnsdottir S Cederholm J Nilsson PM et al The National Diabetes Register in Sweden: an implementation of the St. Vincent Declaration for Quality Improvement in Diabetes Care Diabetes Care 2003 26 1270 6 10.2337/diacare.26.4.1270 12663609
18 Nano J Carinci F Okunade O et al A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach Diabet Med 2020 37 2009 18 10.1111/dme.14286 32124488
19 Team RC R: A language and environment for statistical computing. R foundation for statistical computing Vienna, Austria 2021
20 Snoek FJ Hermanns N de Wit M et al Comment on Young-Hyman et al. Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016;39:2126-2140 Diabetes Care 2018 41 e31 2 10.2337/dc17-1102 29463671
21 de Wit M Trief PM Huber JW et al State of the art: understanding and integration of the social context in diabetes care Diabet Med 2020 37 473 82 10.1111/dme.14226 31912528
22 Stangl AL Earnshaw VA Logie CH et al The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas BMC Med 2019 17 31 10.1186/s12916-019-1271-3 30764826
23 Jarvis-Selinger S Pratt DD Regehr G Competency is not enough: integrating identity formation into the medical education discourse Acad Med 2012 87 1185 90 10.1097/ACM.0b013e3182604968 22836834
24 Winkley K Kristensen C Fosbury J Sexual health and function in women with diabetes Diabet Med 2021 38 e14644 10.1111/dme.14644 34252220
25 Wardian JL Kanzler KE True MW et al Is It Distress, Depression, or Both? Exploring Differences in the Diabetes Distress Scale and the Patient Health Questionnaire in a Diabetes Specialty Clinic Clin Diabetes 2019 37 124 30 10.2337/cd18-0047 31057218
26 Terwee CB Elders PJM Blom MT et al Patient-reported outcomes for people with diabetes: what and how to measure? A narrative review Diabetologia 2023 66 1357 77 10.1007/s00125-023-05926-3 37222772
27 Fisher L Polonsky WH Hessler D Addressing diabetes distress in clinical care: a practical guide Diabet Med 2019 36 803 12 10.1111/dme.13967 30985025
28 Rauwerda NL Tovote KA Peeters ACTM et al WHO-5 and BDI-II are acceptable screening instruments for depression in people with diabetes Diabet Med 2018 35 1678 85 10.1111/dme.13779 30019352
29 Chawla A Saha C Marrero DG A novel application of the Problem Areas in Diabetes (PAID) instrument to improve glycemic control and patient satisfaction Diabetes Educ 2010 36 337 44 10.1177/0145721709354607 19959745
30 Roy T Lloyd CE Pouwer F et al Screening tools used for measuring depression among people with Type 1 and Type 2 diabetes: a systematic review Diabet Med 2012 29 164 75 10.1111/j.1464-5491.2011.03401.x 21824180
31 Oluchi SE Manaf RA Ismail S et al Health Related Quality of Life Measurements for Diabetes: A Systematic Review Int J Environ Res Public Health 2021 18 9245 10.3390/ijerph18179245 34501838
32 Onu DU Ifeagwazi CM Prince OA Social support buffers the impacts of Diabetes distress on health-related quality of life among type 2 diabetic patients J Health Psychol 2022 27 2305 17 10.1177/1359105320980821 33406922
33 Broadley MM Zaremba N Andrew B et al 25 Years of psychological research investigating disordered eating in people with diabetes: what have we learnt? Diabet Med 2020 37 401 8 10.1111/dme.14197 31797439
34 Bachmeier CAE Waugh C Vitanza M et al Diabetes care: addressing psychosocial well-being in young adults with a newly developed assessment tool Intern Med J 2020 50 70 6 10.1111/imj.14355 31081194
35 Corathers S Williford DN Kichler J et al Implementation of Psychosocial Screening into Diabetes Clinics: Experience from the Type 1 Diabetes Exchange Quality Improvement Network Curr Diab Rep 2023 23 19 28 10.1007/s11892-022-01497-6 36538250
