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      Person-centered diabetes care and patient activation in people with type 2 diabetes

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          The American Diabetes Association and the European Association for the Study of Diabetes advocate a person-centered approach to enhance patient engagement in self-care activities. To that purpose, people with diabetes need adequate diabetes knowledge, motivation, skills and confidence. These prerequisites are captured by the concept ‘patient activation’. The Dutch Diabetes Federation implemented a person-centered consultation model for the annual diabetes review. To assess its relationship with patient activation, we measured the change in patient activation, and in person and disease-related factors in people with type 2 diabetes after their second person-centered annual review.

          Research design and methods

          Observational study in 47 primary care practices and six outpatient hospital clinics. Follow-up: 1 year. From 2.617 people with diabetes and capable of completing questionnaires (no additional exclusion criteria) 1.487 (56.8%) participated, 1366 with type 2 diabetes. Main outcome: patient activation (13-item Patient Activation Measure, score 0–100). Before the first and after the second review, participants completed questionnaires. Medical data were retrieved from electronic records. We performed a repeated measure analysis using a linear mixed model in 1299 participants, who completed the first set of questionnaires.


          In 1299 participants (41.6% female, mean age 66 years, median diabetes duration 10 years, median glycated hemoglobin (HbA1c) 6.8%/51 mmol/mol), the mean baseline activation level was 58.9 (SD 11.7). Independent of actual diabetes care, activation levels increased 1.53 units (95% CI 0.67 to 2.39, p=0.001). Several diabetes perceptions improved significantly; diabetes distress level decreased significantly. Body mass index (−0.22, 95% CI −0.33 to −0.10, p<0.001) and low-density lipoprotein cholesterol (−2.71 mg/dL, 95% CI −4.64 to −0.77, p=0.004) decreased, HbA1c increased 0.08% (95% CI 0.03 to 0.12) (p=0.001).


          Person-centered diabetes care was associated with a slightly higher patient activation level, improved diabetes perception and small improvements in clinical outcomes. Person-centered care may enhance patient engagement, but one should not expect substantial improvement in patient outcomes in the short term.

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          Most cited references 34

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          Development and testing of a short form of the patient activation measure.

          The Patient Activation Measure (PAM) is a 22-item measure that assesses patient knowledge, skill, and confidence for self-management. The measure was developed using Rasch analyses and is an interval level, unidimensional, Guttman-like measure. The current analysis is aimed at reducing the number of items in the measure while maintaining adequate precision. We relied on an iterative use of Rasch analysis to identify items that could be eliminated without loss of significant precision and reliability. With each item deletion, the item scale locations were recalibrated and the person reliability evaluated to check if and how much of a decline in precision of measurement resulted from the deletion of the item. The data used in the analysis were the same data used in the development of the original 22-item measure. These data were collected in 2003 via a telephone survey of 1,515 randomly selected adults. Principal Findings. The analysis yielded a 13-item measure that has psychometric properties similar to the original 22-item version. The scores for the 13-item measure range in value from 38.6 to 53.0 (on a theoretical 0-100 point scale). The range of values is essentially unchanged from the original 22-item version. Subgroup analysis suggests that there is a slight loss of precision with some subgroups. The results of the analysis indicate that the shortened 13-item version is both reliable and valid.
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            Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

            The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium–glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.
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              Measuring patient activation in the Netherlands: translation and validation of the American short form Patient Activation Measure (PAM13)

              Background The American short form Patient Activation Measure (PAM) is a 13-item instrument which assesses patient (or consumer) self-reported knowledge, skills and confidence for self-management of one’s health or chronic condition. In this study the PAM was translated into a Dutch version; psychometric properties of the Dutch version were established and the instrument was validated in a panel of chronically ill patients. Methods The translation was done according to WHO guidelines. The PAM 13-Dutch was sent to 4178 members of the Dutch National Panel of people with Chronic illness or Disability (NPCD) in April 2010 (study A) and again to a sub sample of this group (N = 973) in June 2010 (study B). Internal consistency, test-retest reliability and cross-validation with the SBSQ-D (a measure for Health literacy) were computed. The Dutch results were compared to similar Danish and American data. Results The psychometric properties of the PAM 13-Dutch were generally good. The level of internal consistency is good (α = 0.88) and item-rest correlations are moderate to strong. The Dutch mean PAM score (61.3) is comparable to the American (61.9) and lower than the Danish (64.2). The test-retest reliability was moderate. The association with Health literacy was weak to moderate. Conclusions The PAM-13 Dutch is a reliable instrument to measure patient activation. More research is needed into the validity of the Patient Activation Measure, especially with respect to a more comprehensive measure of Health literacy.

                Author and article information

                BMJ Open Diabetes Res Care
                BMJ Open Diabetes Res Care
                BMJ Open Diabetes Research & Care
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                15 December 2020
                : 8
                : 2
                [1 ]Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht , Utrecht, Netherlands
                [2 ]departmentDepartment of Internal Medicine, Division of Endocrinology , Leiden University Medical Center , Leiden, Netherlands
                Author notes
                [Correspondence to ] Professor Guy E H M Rutten; g.e.h.m.rutten@
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                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:

                Funded by: FundRef, Innovatiefonds Zorgverzekeraars;
                Award ID: 2015 / N/A
                Funded by: FundRef, Diabetes Fonds;
                Award ID: 2016 / N/A
                Clinical care/Education/Nutrition
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