Metrics details. The results of using status measures to identify any changes in treatment satisfaction strongly suggest a need for specific change instruments designed to overcome the ceiling effects frequently observed at baseline. Status measures may leave little room to show improvement in situations where baseline ceiling effects are observed. Two multinational, openlabel, randomised-controlled trials one for patients with type 1 diabetes, the other for type 2 compared new, longer-acting insulin glargine with standard NPH basal insulin. Results for Perceived Hyper- and Hypoglycaemia also demonstrated important differences between the questionnaires in the detection of treatment effects. Tests of effect sizes showed these differences in response to change to be significantly in favour of the DTSQc.
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The efficacy of diabetes treatment should not be evaluated solely by HbA1c levels as they should also focus on patient-reported outcomes PROs , such as patient satisfaction, wellbeing and quality of life. DTSQ has been translated into more than languages and is widely used in many countries, since it is relatively easy to answer and is used for both patients with and without medical therapy.
Novel therapeutic options, such as insulin analogs, incretin-based therapy and sodium-glucose cotransporter 2 SGLT2 inhibitors, have been shown to improve patient satisfaction using DTSQ for assessments. DTSQ is not only used for comparisons between different medications or treatment strategies, but also can be used to assess the quality of diabetes care in clinical settings.
In this review, we summarize the current topics in DTSQ, introducing our own experience, and discuss the role of PROs in diabetes treatment. The goal of diabetes treatment is the prevention of the onset and progression of micro- and macrovascular complications as well as the achievement of quality of life QOL and longevity equivalent to people without diabetes.
However, the outcome of diabetes treatments should not be evaluated only by HbA1c levels as the evaluation of the psychological aspects of patients, including treatment satisfaction, wellbeing and quality of life QOL , are also important, which are referred to as patient-reported outcomes PROs Table 1 [ 6 , 7 , 8 , 9 ].
DTSQ is now translated into more than languages, including Japanese [ 11 ], and is one of the most widely used questionnaires in the field of diabetes. In this review, we summarize the significance and the limitations of the use of DTSQ for the assessment of diabetes treatment and discuss the role of treatment satisfaction in diabetes care.
Major questionnaires for PROs used internationally in patients with diabetes. This table was modified and adopted from reference [ 7 ]. It is composed of eight questions, each of which is scored by patients on a scale ranging from zero e. The questionnaire is composed of two different factors. The first factor assesses treatment satisfaction and consists of six questions Q 1, 4, 5, 6, 7 and 8.
These six questions showed good internal consistency, with a Cronbach alpha score of 0. Treatment satisfaction is assessed as the sum of the scores of the six questions on the first factor total score 36 , with a higher score indicating higher treatment satisfaction. The other reasons for this wide usage of DTSQ include the following: 1 it is able to assess treatment satisfaction irrespective of the treatment methods used, including dietary therapy, therapy with oral hypoglycemic agents OHAs or insulin therapy; 2 it is relatively easy to answer and places a smaller burden on patients, since the questions are simple and there are only eight items, which is fewer compared to other questionnaires; and 3 the results can be directly compared to those obtained in other countries internationally.
One of the best examples showing the efficacy of DTSQ is the assessment of insulin analogs. Rapid-acting insulin analogs have been shown to improve postprandial glycemic excursion and reduce hypoglycemia compared with regular insulin due to their rapid onset of action [ 12 ].
They also allow patients to inject at mealtimes, which promotes convenience when compared with regular insulin, which requires injection 30 mins before a meal. However, studies have shown the same efficacy of rapid-acting insulin analogs compared with regular insulin in terms of HbA1c levels.
These results emphasize the importance of patient satisfaction in the assessment of diabetes treatment, which cannot be fully assessed by glycemic indices, including HbA1c. To date, the assessment of PROs, including DTSQ, is essential for evaluating the efficacy of novel anti-diabetic agents and assessing the glucose-lowering effect related to HbA1c levels.
The improvement in patient satisfaction has been also shown in the patients treated with incretin-related agents [ 8 , 15 , 16 ], sodium-glucose cotransporter 2 SGLT2 inhibitors [ 17 ], fixed-dose combination tablets [ 18 ] and weekly dipeptidyl peptidase-4 DPP-4 inhibitors [ 19 ].
The results have been reported previously. However, although the original articles were written in Japanese, we would like to describe the study briefly [ 20 , 21 ]. Questionnaires regarding the clinical parameters were also conducted simultaneously and the relationships of these clinical parameters with DTSQ scores were assessed.
The questionnaires were filled out anonymously and the patients answered the questionnaires in the waiting room outside the examination room. With the exception of Q 2 and 3, the six questions related to the first factor were significantly correlated with each other as well as with the total score Table 2 [ 20 ].
There was also a significant positive correlation between Q 2 and 3. Q 2 was negatively correlated with Q 1, while Q 3 was negatively correlated with Q 4, 5, 8 and the total score.
These results suggest that the patients who experience a greater burden of hyperglycemia also tend to experience a greater burden of hypoglycemia, while the burden of hypoglycemia is more strongly correlated with reduced treatment satisfaction compared to the burden of hyperglycemia.
This was modified and adopted from reference [ 20 ]. Total score was calculated as the sum of scores of Q 1, 4, 5, 6, 7 and 8. When the associations between the DTSQ score and other clinical parameters were examined, there was a weak negative correlation between the total score of DTSQ and the intensity of treatment i. This suggests a negative association between treatment burden and treatment satisfaction, although a previous study reported an improvement in the DTSQ score after implementation of insulin therapy in poorly-controlled patients with T2DM [ 22 ].
There was no apparent correlation between total DTSQ score and age or sex in our cohort. Correlations between total DTSQ score and clinical parameters. No or only modest associations between HbA1c levels and DTSQ score have also been reported [ 11 , 13 , 14 ], which is consistent with our results. This indicates that treatment satisfaction is not necessarily related to glycemic control.
This suggests that patients with higher treatment satisfaction also experience higher self-efficacy, resulting in better adherence to therapy. These results indicate that the assessment of treatment satisfaction with DTSQ may predict dropout from therapy.
On the contrary, an improvement in treatment satisfaction, which can be assessed with DTSQ, may reduce the risk of dropout. In our cohort, the total DTSQ score was also negatively correlated with waiting time in the hospital Table 3 , suggesting that treatment satisfaction assessed with DTSQ is not only affected by treatment itself, but is also affected by other factors, such as waiting time, distance from the hospital and cost.
Of note, we found that the satisfaction with their attending doctor showed the strongest association with the total DTSQ score among the clinical parameters. Hence, DTSQ is a powerful tool that can compare treatment satisfaction between different medications or treatment strategies.
However, the relationship between a patient and doctors medical staff , rather than medications or treatment strategies, may have a major impact on treatment satisfaction.
As with other questionnaires, there are limitations of the DTSQ. If DTSQ score at baseline is already high enough, it will be difficult to detect further improvement in treatment satisfaction after intervention.
To overcome this issue, DTSQ changed version DTSQc has been proposed [ 23 ], in which the patients are asked to consider their satisfaction with their current treatment compared with their previous treatment, which aims to more effectively assess change after interventions. The results of DTSQ are not limited to a specific medication or treatment strategy, but rather the overall satisfaction with the treatment of diabetes. As discussed above, DTSQ scores may also be affected by various factors, including waiting time and satisfaction with consultation with medical staff.
Therefore, DTSQ scores assessed in different institutions with different medical staff or under different conditions may not be directly comparable and thus, caution is needed when interpreting the results.
Finally, DTSQ is a tool to assess treatment satisfaction that is specifically related to diabetes. Furthermore, as co-morbidities may affect the results of DTSQ, the use of more than two different measures should be considered to comprehensively evaluate PROs. It also remains unclear whether an improvement in the DTSQ score translates into an improvement in other clinical outcomes, including cardiovascular outcomes and overall mortality.
Although there has been no prospective study addressing this question to date, reducing the incidence of dropout by improving treatment satisfaction may promote long-term glycemic stability and reduce the risk of diabetic complications Figure 1.
Factors associated with treatment satisfaction and expected effects from its improvement on clinical outcomes. The efficacy of diabetes treatment should not be evaluated solely by HbA1c levels. The improvement in treatment satisfaction may also reduce the risk of dropout from treatment. Therefore, improvement in treatment satisfaction may foster the achievement of long-term glycemic stability, eventually reducing the risk of developing diabetic complications Figure 1.
The assessment of treatment satisfaction is not only performed for research purposes to compare treatments, but also should be used to assess the quality of diabetes care in clinical settings. A better understanding of the role of PROs in diabetes care and appropriate use of each questionnaire, including DTSQ, is needed for further improvement of current diabetes treatment. National Center for Biotechnology Information , U. Published online May 9.
Yoshifumi Saisho. Author information Article notes Copyright and License information Disclaimer. Received Apr 20; Accepted May 7. This article has been cited by other articles in PMC. Abstract The efficacy of diabetes treatment should not be evaluated solely by HbA1c levels as they should also focus on patient-reported outcomes PROs , such as patient satisfaction, wellbeing and quality of life.
Keywords: patient-reported outcome, treatment satisfaction, quality of life, ceiling effect. Introduction The goal of diabetes treatment is the prevention of the onset and progression of micro- and macrovascular complications as well as the achievement of quality of life QOL and longevity equivalent to people without diabetes. Table 1 Major questionnaires for PROs used internationally in patients with diabetes.
Open in a separate window. Figure 1. Conflicts of Interest The author declares no conflict of interest. References 1. Holman R. Nathan D. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. Shichiri M. Long-term results of the Kumamoto Study on optimal diabetes control in type 2 diabetic patients. Diabetes Care. Diabetes Res. Bradley C. Patient perceptions of diabetes and diabetes therapy: Assessing quality of life. Diabetes Metab.
Speight J. Not all roads lead to Rome-a review of quality of life measurement in adults with diabetes. Davies M. Patient-reported outcomes in trials of incretin-based therapies in patients with type 2 diabetes mellitus.
Diabetes Obes. Roborel de Climens A. Review of patient-reported outcome instruments measuring health-related quality of life and satisfaction in patients with type 2 diabetes treated with oral therapy.
Ishii H. Hartman I. Insulin analogs: Impact on treatment success, satisfaction, quality of life, and adherence. Home P. Insulin aspart vs.
DTSQ - Diabetes Treatment Satisfaction Questionnaire
Diabetes Treatment Satisfaction Questionnaire, status and change versions (DTSQs and DTSQc)