@Article{info:doi/10.2196/63434,
author="Mitchell, Suzanne E
and Kallen, Michael A
and Troost, Jonathan P
and De La Cruz, Barbara A
and Bragg, Alexa
and Martin-Howard, Jessica
and Moldovan, Ioana
and Miner, Jennifer A
and Jack, Brian W
and Carlozzi, Noelle E",
title="Four New Patient-Reported Outcome Measures Examining Health-Seeking Behavior in Persons With Type 2 Diabetes Mellitus (REDD-CAT): Instrument Development Study",
journal="JMIR Diabetes",
year="2024",
month="Nov",
day="22",
volume="9",
pages="e63434",
keywords="diabetes mellitus; social determinants of health; patient-reported outcome measures; outcomes assessment; health care; patient reported; health-seeking behavior; type 2 diabetes; hospitalization; diabetes computer adaptive test; primary care; socioeconomic; assessments",
abstract="Background: 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. Objective: 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. Methods: 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 $\alpha$ was used to examine internal consistency reliability for the new PROs (criterion ≥0.70), and floor and ceiling effects were examined (criterion ≤20{\%}). Results: 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 $\alpha$=.78-.91), and measures were free of significant floor or ceiling effects (floor effects range: 0{\%}-8.9{\%}; ceiling effects range: 0{\%}-8.4{\%}). Conclusions: The new REDD-CAT Health-Seeking Behavior PROs provide reliable assessments of health-seeking behaviors among those with T2DM. ",
issn="2371-4379",
doi="10.2196/63434",
url="https://diabetes.jmir.org/2024/1/e63434",
url="https://doi.org/10.2196/63434",
url="http://www.ncbi.nlm.nih.gov/pubmed/39576685"
}