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ORIGINAL ARTICLE

Patients Evaluation of the Quality of Diabetes Care(PEQD): development and validation of a new instrumentF Pouwer, F J Snoek

. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .Qual Saf Health Care2002;11:131136

Objectives: To develop a brief measure of patients evaluation of the quality of diabetes care and tostudy predictors of consumers rating of the quality of diabetes care.Design: A prospective design.Subjects: 176 adults with type 1 (39%) or type 2 (61%) diabetes.Main measures: Demographic variables, HbA1c, number of diabetes complications, satisfaction withdiabetes care, diabetes related distress, and fear of hypoglycaemia were assessed by self-report. Inaddition, satisfaction with diabetes care and evaluations about quality of the care were measured at16 month follow up. Statistical analysis comprised principal component analyses, Cronbachs alpha, ttests, Pearsons correlation, and linear regression analyses.Results: Results in the literature were used to develop the 14 items of the Patients Evaluation of theQuality of Diabetes Care (PEQD) scale, assessing the most important aspects of the quality of diabetescare as delivered by the specialist in internal medicine (internist) and the diabetes nurse specialist(DNS). Two principal components analyses (internist/DNS) both yielded one 14 item factor with a highinternal consistency. Satisfaction with diabetes care, fewer diabetes related complications, fewer treat-ment related problems, and a low level of worries about hypoglycaemia were predictors of a morepositive evaluation of diabetes care delivered by the internist. Sociodemographic variables were notrelated to the patients evaluations of the quality of diabetes care.Conclusions: The PEQD comprises different aspects of quality of diabetes care and can be regardedas a suitable instrument for evaluating patients judgements about the quality of their care.

It has been shown in different patient groups thatdissatisfaction with medical care is associated with non-compliance of the treatment regimen and discontinuation

of care.1 2 Consumer satisfaction and the perceptions ofpatients with regard to the quality of their medical care cantherefore be considered as important outcomes of health careand as essential elements of quality assessment andimprovement. 1 3

In patients with diabetes,discontinuation of care was foundto be associated with worse glycaemic control4 and anincreased risk of complications.5 6 In the new guidelines forquality diabetes care the European Diabetes Policy Grouprecently recommended provision of a system of quality devel-opment using feedback from diabetic patients on service per-formance with regular review.7

One method of obtaining patients views on the quality ofdiabetes care is by the use of a validated self-report question-naire. With such a standardised questionnaire, aspects of carethat do not meet the expectations of patients can be detectedby clinicians for internal quality improvement. This instru-ment would also be useful for researchers assessing patients

evaluations of the quality of their diabetes care.Patients evaluation of the quality of their diabetes care was

planned to be one of the primary outcomes in a recentrandomised controlled trial in which we tested the hypothesisthat monitoring and discussion of psychological wellbeing bydiabetes nurse specialists (DNSs) leads to improved outcomesof diabetes care.811 We searched Medline (196696) andPsycLit (197096) for an instrument that could be used in thetrial to measure patients evaluation of the quality of diabetescare using the words consumer satisfaction, treatment sat-isfaction, diabetes, and psychometrics. The literaturesearch yielded two measures.12 13 The first12was used to ratetheperformance of four professionals (hospital doctor, practicenurse, general practitioner, or diabetes liaison sister) in

relation to seven aspects of diabetes care covering knowledge,communication, convenience, and accessibility. However, the

development of the items of the instrument was not fully

described. Moreover, a psychometric evaluation of the validityand reliability of this instrument was not provided. In the sec-

ond study13 the literature and in depth interviews with 16patients with diabetes and four diabetologists were used to

develop a list of nine items associated with quality of diabetes

care. Using this instrument, diabetes patients ranked state-ments about quality aspects of diabetes care to obtain a prior-

ity list. However, this instrument assesses the patients evalu-

ations of diabetes carepriorities, and cannot beusedto quantifythe patients rating of the quality of diabetes care.

We concluded that there was no brief validated instrument

available to assess patients evaluations of the quality of theirdiabetes care and therefore aimed to develop and validate a

new questionnaire, the Patients Evaluation of the Quality of

Diabetes Care (PEQD). In this study we investigate the factorstructure as well as the internal consistency and the

convergent and discriminant validity of this new measure.

METHODSDevelopment of the PEQDPerhaps the greatest challenge facing us in the assessment of

patient experiences with health care is focusing assessmentson the most relevant unit of analysis. 14 Some services (e.g.

parking, cleanliness) are prominent in satisfaction question-

naires, but are seen as distinct from quality of care by mostpatients. Other issues such as being involved in treatment

decisions and being treated with respect are fundamental

issues for patients, yet these topics are frequently not includedin satisfaction measures.14 Furthermore, studies suggest that

the very concept of satisfaction is not adequate. Satisfactiononly implies that expectations have been met. Patients can be

See end of article forauthors affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Dr F Pouwer, DiabetesResearch Group, Institutefor Research in ExtramuralMedicine (EMGO-Institute),Vrije Universiteit Medical

Centre, Van derBoechorststraat 7, 1081BT, Amsterdam, theNetherlands;f.pouwer.emgo@med.vu.nl

Accepted for publication22 January 2002. . . . . . . . . . . . . . . . . . . . . . .

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satisfied with low quality care or can be dissatisfied with high

quality care.14 Thus, in the construction of the PEQD, we have

built upon the results of two studies that have investigated thehealth care priorities for diabetes.12 13 The following aspects of

diabetes care were found to be valued the most in a sample ofpatients with type 2 diabetes (not on insulin): getting clear

information, health care provider knowledgeableabout your

problems with diabetes and easy to get hold of, easy totalk to, knowledgeable about diabetes, good at

listening.12 The second study reported that patients with type

1 or type 2 diabetes rated treatment has favourable effect ondiabetes as the most important aspect of diabetes care,

followed by seeing same health care provider, getting allinformation needed, knowledgeable, enough time for the

patient, provider tries to understand patient, patient can

visit doctor soon after making appointment, patient canmake choices between different types of treatment.13We used

the results of both studies and a meta-analysis of the

treatment satisfaction literature in general15 to develop 14

items (see Appendix). Subjects were requested to evaluate the

quality of diabetes care provided by their doctor as well astheir DNS during the past 12 months using two separate 14

item scales. A 5 point evaluation scale (poor to excellent) was

used.16

SubjectsA group of 176 patients with diabetes who had participated ina larger study in 199710 11 were invited to complete anadditional set of questions in 1998. All subjects were patient

members of the Dutch Diabetes Association (DVN, Diabetes

Vereniging Nederland) and formed a heterogeneous sample who received medical treatment from different healthcare

providers across the Netherlands. The subjects were matched

to the experimental group of the aforementioned randomisedclinical trial on sex, age, type of diabetes, and income.8 The

study protocol was approved by the ethics committee of theVrije Universiteit Medical Center.

Other measuresAt baseline (1997) in the earlier study10 11 subjects had already

completed questions regarding demographic data, medi-

cation, glycaemic control, age at onset of diabetes, andcomplications of diabetes. Satisfaction with diabetes care was

assessed at both interviews using the item: How satisfied are

you in general with your diabetes care? This question couldbe responded to on a 5 point Likert scale ranging from very

satisfied to very dissatisfied. Subjects also completed the

Problem Areas in Diabetes (PAID) survey, a 20 item measure ofdiabetes related emotional distress.17 18 The subscales diabetes

related emotional problems (12 items), treatment relatedproblems(three items), food related problems (three items),

and social support related problems (two items) were also

calculated.18 The 13 item worry scale of the HypoglycaemiaFear Survey (HFS) was used to measure fear of

hypoglycaemia.19 20 The subsales Negative Wellbeing, Energy,and Positive Wellbeing of Bradleys W-BQ12 were used to

measure general psychological wellbeing.

911

At follow up in1998 the subjects filled out the PEQD scales for the internist(PEQD-I) and DNS (PEQD-DNS).

Statistical analysesIn case of 13 missing values (721% of all 14 items) for thePEQD, the subjects mean score on the remaining PEQD items

in the same a priori scale was used to estimate the missingvalue(s). The paired Students t test was used to compare the

means of the 14 PEQD item scores regarding the care by the

internist and the care provided by the DNS and to exploreassociations with demographic variables. Principal component

analysis was used to investigate the structure of both scales.

The Kaiser-Guttman criterion (eigenvalue >1) was used to

decide on the number of factors to be retained.21 Homogeneityof these factors was determined by calculating item total cor-

relations and internal consistency by Cronbachs alpha.

Evidence of construct validity was sought by calculating Pear-sons correlation coefficients between PEQD and overall satis-

faction with diabetes care, age, and years of education. In case

of skewed distribution, Spearman rank correlation was used.Stepwise linear regression analyses (with forward selection)

were conducted to explore the relationship between baselinesatisfaction with diabetes care, physical and psychological

wellbeing, and the patients evaluations of the quality of

diabetes care at follow up.

RESULTS

All 176 subjects had already completed the baseline assess-ment and 155 (88%) of them returned the second follow upquestionnaire a mean (SD) of 15.6 (0.7) months after the

baseline assessment. The mean (SD) age was 55 (14) years;

most of the patients were women and most had type 2diabetes (treated with insulin, see table 1). One hundred and

twenty four subjects completed all 14 questions regarding the

treatment by their internist; 18 subjects had 13 missingvalues (12%) and 13 had more than three missing values. For

the DNS items, 84 subjects had no missing values, 13 had 13missing values (12%), and 10 had more than three missing

values. Forty eight subjects did not complete the items evalu-

ating the DNS because they did not visit a DNS during theprevious 12 months.

Table 1 Characteristics of study sample (n=155)

Variable

Female 90 (58)Mean (SD) Hba1c (%) 7.6 (1.1)Type of diabetes

Type 1 60 (39)Type 2 10 (7)Type 2 (insulin) 84 (54)

Duration of diabetes (years)19 48 (31)1019 52 (34)2029 32 (21)30 or more 23 (14)

Number of complications0 80 (53)1 32 (21)2 or more 40 (26)

Diabetes complicationsRetinopathy 40 (26)Nephropathy 9 (6)Cardiovascular 26 (17)Diabetic foot 27 (18)Neuropathy 24 (16)

Marital statusMarried/living together 113 (73)Not married 22 (14)Widowed 12 (8)Divorced 8 (5)

Highest completed educationPrimary school 16 (11)Lower vocational 31 (21)General secondary 53 (37)Senior (general) secondary 16 (11)Higher vocational/university 29 (20)

Occupational statusEmployed 43 (28)Registered unemployed 2 (1)Housewife 36 (23)Retired 36 (23)Disabled 33 (21)Student 5 (3)

Data are n (%) or mean (SD). Note: numbers do not add up to 155due to missing values.

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Subjects who had visited the DNS during the 12 months

preceding the follow up assessment were significantly younger than those who did not visit the DNS during this

period (50 (15) years versus 59 (14) years, p

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I n s t r u c t i o n s : T h e f o l l o w i n g 1 4 q u e s t i o n s c o v e r d i f f e r e n t a s p e c t s o f d i a b e t e s c a r e . P e o p l e w i t h d i a b e t e s c a n u s e t h i s q u e s t i o n n a i r e t o

e x p r e s s t h e i r o p i n i o n a b o u t t h e q u a l i t y o f t h e i r d i a b e t e s c a r e b y t h e i n t e r n i s t . P l e a s e j u d g e t h e d i a b e t e s c a r e y o u h a v e r e c e i v e d d u r i n g

t h e p a s t 1 2 m o n t h s . P l e a s e t r y n o t t o s k i p a n y q u e s t i o n s . I f y o u h a v e b e e n t r e a t e d b y t w o o r m o r e d i f f e r e n t i n t e r n i s t s d u r i n g t h e p a s t

1 2 m o n t h s , p l e a s e t r y t o g i v e m e a n s c o r e f o r t h i s s p e c i a l i s m .

1 . T h e w a i t i n g t i m e b e f o r e c o n s u l t i n g t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

2 . T h e d u r a t i o n o f t h e c o n s u l t a t i o n w i t h t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

3 . T h e t i m e I h a v e t o w a i t u n t i l m y n e x t a p p o i n t m e n t w i t h t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

4 . T h e c l a r i t y o f i n f o r m a t i o n I r e c e i v e f r o m t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

5 . T h e a m o u n t o f i n f o r m a t i o n I r e c e i v e f r o m t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

6 . T h e u s e f u l n e s s o f t h e i n f o r m a t i o n I r e c e i v e f r o m t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

7 . T h e o p p o r t u n i t y t o a s k q u e s t i o n s t o t h e i n t e r n i s t d u r i n g t h e c o n s u l t a t i o n :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

8 . T h e e m o t i o n a l s u p p o r t g i v e n b y t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

9 . T h e m e d i c o - t e c h n i c a l c o m p e t e n c e o f t h e i n t e r n i s t ( e . g . k n o w l e d g e a b o u t d i a b e t e s , a b i l i t y t o m a i n t a i n / a c h i e v e f a v o u r a b l e e f f e c t s

o n y o u r d i a b e t e s ) :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

1 0 . T h e e x t e n t t o w h i c h t h e i n t e r n i s t i s i n f o r m e d a b o u t t h e ( p a s t ) t r e a t m e n t o f m y d i a b e t e s :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

1 1 . T h e e x t e n t t o w h i c h t h e d i a b e t e s c a r e p r o v i d e d b y i n t e r n i s t i s i n t e g r a t e d w i t h t h e c a r e o f o t h e r h e a l t h p r o v i d e r s t h a t I h a v e v i s i t e d

( e . g . t h e d i a b e t e s n u r s e s p e c i a l i s t o r o t h e r m e d i c a l s p e c i a l i s t s ) :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

1 2 . T h e o p p o r t u n i t y t o s h a r e d e c i s i o n s w i t h t h e i n t e r n i s t a b o u t t h e t r e a t m e n t o f m y d i a b e t e s :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

1 3 . T h e e a s e o f m a k i n g n e w a p p o i n t m e n t s w i t h t h e i n t e r n i s t :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

1 4 . T h e o v e r a l l q u a l i t y o f m y d i a b e t e s c a r e b y t h e i n t e r n i s t i s :

p o o r

1

f a i r

2

g o o d

3

v e r y g o o d

4

e x c e l l e n t

5

APPENDIX: PATIENTS EVALUATION OF THE QUALITY OF DIABETES CARE-INTERNIST VERSION (PEQD-I)

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ACKNOWLEDGEMENTSThe authors acknowledge the members and the board of the DutchDiabetes Association (Diabetes Vereniging Nederland) for their coop-eration in this study. Thestudywas financially supportedby theDutchDiabetes Research Foundation (Diabetes Fonds Nederland, grant95.805).

. . . . . . . . . . . . . . . . . . . . .

Authors affiliationsF Pouwer, F J Snoek, Department of Medical Psychology, ResearchInstitute for Endocrinology, Reproduction and Metabolism, and DiabetesResearch Group, Institute for Research in Extramural Medicine(EMGO-Institute), Vrije Universiteit Medical Centre, Amsterdam, theNetherlands

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