Mitchell Suzanne E, Kallen Michael A, Troost Jonathan P, De La Cruz Barbara A, Bragg Alexa, Martin-Howard Jessica, Moldovan Ioana, Miner Jennifer A, Jack Brian W, Carlozzi Noelle E
Department of Family Medicine, School of Medicine, Boston University, Boston, MA, United States.
Department of Family Medicine, Boston Medical Center, Boston, MA, United States.
JMIR Diabetes. 2024 Nov 22;9:e63434. doi: 10.2196/63434.
The management of type 2 diabetes mellitus (T2DM) includes mastery of complex care activities, self-management skills, and routine health care encounters to optimize glucose control and achieve good health. Given the lifelong course of T2DM, patients are faced with navigating complex medical and disease-specific information. This health-seeking behavior is a driver of health disparities and is associated with hospitalization and readmission. Given that health-seeking behavior is a potentially intervenable social determinant of health, a better understanding of how people navigate these complex systems is warranted.
To address this need, we aimed to develop new patient-reported outcome (PRO) measures that evaluate health-seeking behavior in persons with T2DM. These new PROs were designed to be included in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system, which includes several other PROs that capture the importance of social determinants of health.
Overall, 225 participants with T2DM completed 56 self-report items that examined health-seeking behaviors. Classical Test Theory and Item Response Theory were used for measurement development. Exploratory factor analysis (EFA; criterion ratio of eigenvalue 1 to eigenvalue 2 being >4; variance for eigenvalue 1 ≥40%) and confirmatory factor analysis (CFA; criterion 1-factor CFA loading <.50; 1-factor CFA residual correlation >.20; comparative fit index ≥0.90; Tucker-Lewis index ≥0.90; root mean square error of approximation <0.15) were used to determine unidimensional sets of items. Items with sparse responses, low-adjusted total score correlations, nonmonotonicity, low factor loading, and high residual correlations of high error modification indices were candidates for exclusion. A constrained graded response model was used to examine item misfit, and differential item functioning was examined to identify item bias. Cronbach α was used to examine internal consistency reliability for the new PROs (criterion ≥0.70), and floor and ceiling effects were examined (criterion ≤20%).
Four unidimensional sets of items were supported by EFA (all EFA eigenvalue ratios >4; variance for eigenvalue 1=41.4%-67.3%) and CFA (fit statistics all exceeded criterion values). This included (1) "Health-Seeking Behavior: PCP-Specific" (6 items); (2) "Health-Seeking Behavior: General Beliefs" (13 items); (3) "Health-Seeking Behavior: Family or Friends-Specific" (5 items); and (4) "Health-Seeking Behavior: Internet-Specific" (4 items). All items were devoid of differential item functioning for age, sex, education, or socioeconomic status factors. "Health-Seeking Behavior: General Beliefs" was developed to include both a computer adaptive test and a 6-item short form version; all other PROs were developed as static short forms. The psychometric reliability of these new PROs was supported; internal consistency ranged from acceptable to excellent (Cronbach α=.78-.91), and measures were free of significant floor or ceiling effects (floor effects range: 0%-8.9%; ceiling effects range: 0%-8.4%).
The new REDD-CAT Health-Seeking Behavior PROs provide reliable assessments of health-seeking behaviors among those with T2DM.
2型糖尿病（T2DM）的管理包括掌握复杂的护理活动、自我管理技能以及常规医疗保健接触，以优化血糖控制并实现良好健康状态。鉴于T2DM的终身病程，患者面临着处理复杂的医疗和疾病特定信息的问题。这种寻求健康行为是健康差距的一个驱动因素，并且与住院和再入院相关。鉴于寻求健康行为是一个潜在可干预的健康社会决定因素，有必要更好地了解人们如何在这些复杂系统中进行导航。
为满足这一需求，我们旨在开发新的患者报告结局（PRO）指标，以评估T2DM患者的寻求健康行为。这些新的PRO旨在纳入糖尿病重新设计出院计算机自适应测试（REDD-CAT）测量系统，该系统包括其他几个捕捉健康社会决定因素重要性的PRO。
总体而言，225名T2DM参与者完成了56项检查寻求健康行为的自我报告项目。经典测试理论和项目反应理论用于测量开发。探索性因素分析（EFA；特征值1与特征值2的标准比率>4；特征值1的方差≥40%）和验证性因素分析（CFA；标准1因素CFA负荷<.50；1因素CFA残差相关性>.20；比较拟合指数≥0.90；塔克-刘易斯指数≥0.90；近似均方根误差<0.15）用于确定单维项目集。具有稀疏反应、低调整总分相关性、非单调性、低因素负荷以及高误差修正指数的高残差相关性的项目是排除的候选对象。使用约束分级反应模型检查项目不拟合情况，并检查项目功能差异以识别项目偏差。Cronbach α用于检查新PRO的内部一致性可靠性（标准≥0.70），并检查地板效应和天花板效应（标准≤20%）。
EFA（所有EFA特征值比率>4；特征值1的方差=41.4%-67.3%）和CFA（拟合统计量均超过标准值）支持了四组单维项目。这包括（1）“寻求健康行为：初级保健医生特定”（6项）；（2）“寻求健康行为：一般信念”（13项）；（3）“寻求健康行为：家人或朋友特定”（5项）；以及（4）“寻求健康行为：互联网特定”（4项）。所有项目在年龄、性别、教育或社会经济地位因素方面均无项目功能差异。“寻求健康行为：一般信念”被开发为包括计算机自适应测试和一个6项简短形式版本；所有其他PRO均开发为静态简短形式。这些新PRO的心理测量可靠性得到支持；内部一致性范围从可接受到优秀（Cronbach α=.78-.91），并且测量没有显著的地板效应或天花板效应（地板效应范围：0%-8.9%；天花板效应范围：0%-8.4%）。
新的REDD-CAT寻求健康行为PRO为T2DM患者的寻求健康行为提供了可靠的评估。
