Application and research advances of cumulative complexity model in the treatment burden of type 2 diabetes mellitus_West China Medical Journal

Authors：

LI Juan ^1,2 ,  MA Lihua ^1,3 , YANG Fang ³ , LI Qi ⁴ , SHI Yujie ⁵

1. School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, P. R. China;
2. Department of Pediatrics, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, P. R. China;
3. Department of Endocrinology, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, P. R. China;
4. Department of Neurology, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, P. R. China;
5. School of Public Health Lanzhou University, Lanzhou, Gansu 730000, P. R. China;

Corresponding author：

MA Lihua, Email: mlhfmmu@163.com

Keywords：

Cumulative complexity model; type 2 diabetes mellitus; treatment burden; review

DOI：

10.7507/1002-0179.202503129

Video：

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Abstract Full text Figures/Tables Video References Cited by

Patients with type 2 diabetes mellitus often face significant treatment burden, which substantially impacts their quality of life and health outcomes. Reducing treatment burden represents a critical component for improving patient prognosis and enhancing treatment adherence. Based on the cumulative complexity model, this article systematically examines the conceptual connotation and multidimensional characteristics of treatment burden in type 2 diabetes mellitus patients, explores the theoretical extension and application value of cumulative complexity model in the type 2 diabetes mellitus field, elucidates its specific applications and recent advances in treatment burden research, evaluates the limitations of existing assessment tools while proposing a multidimensional assessment framework, and ultimately develops cumulative complexity model based intervention strategies. The findings provide theoretical references for optimizing patient-centered diabetes management approaches and offer novel perspectives for treatment burden intervention.

Citation： LI Juan, MA Lihua, YANG Fang, LI Qi, SHI Yujie. Application and research advances of cumulative complexity model in the treatment burden of type 2 diabetes mellitus. West China Medical Journal, 2025, 40(8): 1340-1345. doi: 10.7507/1002-0179.202503129 Copy

1.	The Lancet. Diabetes: a defining disease of the 21st century. Lancet, 2023, 401(10394): 2087.
2.	Redondo MJ, Hagopian WA, Oram R, et al. The clinical consequences of heterogeneity within and between different diabetes types. Diabetologia, 2020, 63(10): 2040-2048.
3.	González-Saldivar G, Millan-Alanis JM, González-González JG, et al. Treatment burden and perceptions of glucose-lowering therapy among people living with diabetes. Prim Care Diabetes, 2022, 16(4): 568-573.
4.	Vijan S, Hayward RA, Ronis DL, et al. Brief report: the burden of diabetes therapy: implications for the design of effective patient-centered treatment regimens. J Gen Intern Med, 2005, 20(5): 479-482.
5.	杨志鹏, 王皓翔, 欧文森, 等. 基于 Ordinal Logistic 回归分析的慢性非传染性疾病患者治疗负担的现状研究. 中国全科医学, 2019, 22(5): 559-563.
6.	Herzig L, Zeller A, Pasquier J, et al. Factors associated with patients’ and GPs’ assessment of the burden of treatment in multimorbid patients: a cross-sectional study in primary care. BMC Fam Pract, 2019, 20(1): 88.
7.	Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med, 2014, 174(7): 1095-1107.
8.	赵莹, 王晨, 孙玉倩, 等. 住院老年慢性病病人治疗负担现状及其影响因素研究. 现代预防医学, 2022, 49(6): 1078-1081, 1117.
9.	Sav A, King MA, Whitty JA, et al. Burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expect, 2015, 18(3): 312-324.
10.	Brod M, Hammer M, Christensen T, et al. Understanding and assessing the impact of treatment in diabetes: the treatment-related impact measures for diabetes and devices (TRIM-diabetes and TRIM-diabetes device). Health Qual Life Outcomes, 2009, 7: 83.
11.	Ishii H, Shin H, Tosaki T, et al. Reproducibility and validity of a questionnaire measuring treatment burden on patients with type 2 diabetes: diabetic treatment burden questionnaire (DTBQ). Diabetes Ther, 2018, 9(3): 1001-1019.
12.	Spencer-Bonilla G, Serrano V, Gao C, et al. Patient work and treatment burden in type 2 diabetes: a mixed-methods study. Mayo Clin Proc Innov Qual Outcomes, 2021, 5(2): 359-367.
13.	Serrano V, Spencer-Bonilla G, Boehmer KR, et al. Minimally disruptive medicine for patients with diabetes. Curr Diab Rep, 2017, 17(11): 104.
14.	Lin K, Yao M, Andrew L, et al. Exploring treatment burden in people with type 2 diabetes mellitus: a thematic analysis in china’s primary care settings. BMC Primary Care, 2024, 25(1): 88.
15.	Shippee ND, Shah ND, May CR, et al. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol, 2012, 65(10): 1041-1051.
16.	Lin PJ, Kent DM, Winn A, et al. Multiple chronic conditions in type 2 diabetes mellitus: prevalence and consequences. Am J Manag Care, 2015, 21(1): e23-e34.
17.	Fishman SR, Fernandez Galvis MA, Linnell J, et al. Diabetes-related quality of life: learning from individuals making lifestyle changes to improve type 2 diabetes control. Sci Diabetes Self Manag Care, 2023, 49(2): 136-149.
18.	Ellahham S. Artificial intelligence: the future for diabetes care. Am J Med, 2020, 133(8): 895-900.
19.	Grunberger G, Sherr J, Allende M, et al. American association of clinical endocrinology clinical practice guideline: the use of advanced technology in the management of persons with diabetes mellitus. Endocr Pract, 2021, 27(6): 505-537.
20.	戴炜, 关阳, 李韵, 等. 基于动态血糖监测的糖尿病远程管理系统设计. 医疗卫生装备, 2023, 44(09): 42-48.
21.	Veatch RM. Models for ethical medicine in a revolutionary age. What physician-patient roles foster the most ethical realtionship?. Hastings Cent Rep, 1972, 2(3): 5-7.
22.	Pilla SJ, Jalalzai R, Tang O, et al. A national survey of physicians’ views on the importance and implementation of deintensifying diabetes medications. J Gen Intern Med, 2023, 39(6): 992-1001.
23.	Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making, 2015, 35(1): 114-131.
24.	Brown A, Dornhorst A, McGowan B, et al. Low-energy total diet replacement intervention in patients with type 2 diabetes mellitus and obesity treated with insulin: a randomized trial. BMJ Open Diabetes Res Care, 2020, 8(1): e001012.
25.	Ojo TK, Joshua OO, Ogedegbe OJ, et al. Role of intermittent fasting in the management of prediabetes and type 2 diabetes mellitus. Cureus, 2022, 14(9): e28800.
26.	Dong C, Liu R, Huang Z, et al. Effect of exercise interventions based on family management or self-management on glycaemic control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis. Diabetol Metab Syndr, 2023, 15(1): 232.
27.	Zhao L, Xu F, Zheng X, et al. Mediation role of anxiety on social support and depression among diabetic patients in elderly caring social organizations in China during COVID-19 pandemic: a cross-sectional study. BMC Geriatr, 2023, 23(1): 790.
28.	Schram MT, Assendelft WJJ, van Tilburg TG, et al. Social networks and type 2 diabetes: a narrative review. Diabetologia, 2021, 64(9): 1905-1916.
29.	Boehmer KR, Gionfriddo MR, Rodriguez-Gutierrez R, et al. Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis. BMC Fam Pract, 2016, 17(1): 127.
30.	Hanlon P, Bryson I, Morrison H, et al. Self-management interventions for type 2 diabetes: systematic review protocol focusing on patient workload and capacity support. Wellcome Open Res, 2021, 6: 257.
31.	Lin K, Yaomi, Chenzhang, et al. Conceptual framework and responding approach of treatment burden of type 2 diabetes: a video recording-based. Chinese General Practice, 2023, 26(34): 4302-4307.
32.	Schmitt A, Gahr A, Hermanns N, et al. The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes, 2013, 11: 138.
33.	李超群, 井坤娟, 刘昱莹, 等. 糖尿病自我管理量表的汉化及信效度评价. 现代预防医学, 2018, 45(24): 4477-4481.
34.	Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care, 2000, 23(7): 943-950.
35.	李延飞, 陈伟菊, 许万萍, 等. 2 型糖尿病患者自我管理行为量表的改良及其信效度检验. 现代医院, 2011, 11(3): 148-150.
36.	Breslin M, Mullan RJ, Montori VM. The design of a decision aid about diabetes medications for use during the consultation with patients with type 2 diabetes. Patient Educ Couns, 2008, 73(3): 465-472.
37.	Boehmer KR, Hargraves IG, Allen SV, et al. Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid. BMC Health Serv Res, 2016, 16(1): 514.
38.	Mei Y, Yang X, Li Y, et al. Validity and reliability of the chinese version of the diabetes treatment burden questionnaire (DTBQ) among patients with type 2 diabetes. Diabetes Metab Syndr Obes, 2023, 16: 663-675.
39.	Eton DT, Yost KJ, Lai JS, et al. Development and validation of the patient experience with treatment and self-management (PETS): a patient-reported measure of treatment burden. Qual Life Res, 2017, 26(2): 489-503.
40.	Tran VT, Montori VM, Eton DT, et al. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med, 2012, 10: 68.
41.	林恺, 郭丽红, 黄周红, 等. 糖尿病自我管理量表的汉化及信效度评价. 中华全科医学, 2022, 20(6): 974-977, 1011.
42.	Espinoza P, Varela CA, Vargas IE, et al. The burden of treatment in people living with type 2 diabetes: a qualitative study of patients and their primary care clinicians. PloS One, 2020, 15(10): e0241485.
43.	Gao CC, Espinoza Suarez NR, Toloza FJK, et al. Patients’ perspective about the cost of diabetes management: an analysis of online health communities. Mayo Clin Proc Innov Qual Outcomes, 2021, 5(5): 898-906.

1. The Lancet. Diabetes: a defining disease of the 21st century. Lancet, 2023, 401(10394): 2087.
2. Redondo MJ, Hagopian WA, Oram R, et al. The clinical consequences of heterogeneity within and between different diabetes types. Diabetologia, 2020, 63(10): 2040-2048.
3. González-Saldivar G, Millan-Alanis JM, González-González JG, et al. Treatment burden and perceptions of glucose-lowering therapy among people living with diabetes. Prim Care Diabetes, 2022, 16(4): 568-573.
4. Vijan S, Hayward RA, Ronis DL, et al. Brief report: the burden of diabetes therapy: implications for the design of effective patient-centered treatment regimens. J Gen Intern Med, 2005, 20(5): 479-482.
5. 杨志鹏, 王皓翔, 欧文森, 等. 基于 Ordinal Logistic 回归分析的慢性非传染性疾病患者治疗负担的现状研究. 中国全科医学, 2019, 22(5): 559-563.
6. Herzig L, Zeller A, Pasquier J, et al. Factors associated with patients’ and GPs’ assessment of the burden of treatment in multimorbid patients: a cross-sectional study in primary care. BMC Fam Pract, 2019, 20(1): 88.
7. Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med, 2014, 174(7): 1095-1107.
8. 赵莹, 王晨, 孙玉倩, 等. 住院老年慢性病病人治疗负担现状及其影响因素研究. 现代预防医学, 2022, 49(6): 1078-1081, 1117.
9. Sav A, King MA, Whitty JA, et al. Burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expect, 2015, 18(3): 312-324.
10. Brod M, Hammer M, Christensen T, et al. Understanding and assessing the impact of treatment in diabetes: the treatment-related impact measures for diabetes and devices (TRIM-diabetes and TRIM-diabetes device). Health Qual Life Outcomes, 2009, 7: 83.
11. Ishii H, Shin H, Tosaki T, et al. Reproducibility and validity of a questionnaire measuring treatment burden on patients with type 2 diabetes: diabetic treatment burden questionnaire (DTBQ). Diabetes Ther, 2018, 9(3): 1001-1019.
12. Spencer-Bonilla G, Serrano V, Gao C, et al. Patient work and treatment burden in type 2 diabetes: a mixed-methods study. Mayo Clin Proc Innov Qual Outcomes, 2021, 5(2): 359-367.
13. Serrano V, Spencer-Bonilla G, Boehmer KR, et al. Minimally disruptive medicine for patients with diabetes. Curr Diab Rep, 2017, 17(11): 104.
14. Lin K, Yao M, Andrew L, et al. Exploring treatment burden in people with type 2 diabetes mellitus: a thematic analysis in china’s primary care settings. BMC Primary Care, 2024, 25(1): 88.
15. Shippee ND, Shah ND, May CR, et al. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol, 2012, 65(10): 1041-1051.
16. Lin PJ, Kent DM, Winn A, et al. Multiple chronic conditions in type 2 diabetes mellitus: prevalence and consequences. Am J Manag Care, 2015, 21(1): e23-e34.
17. Fishman SR, Fernandez Galvis MA, Linnell J, et al. Diabetes-related quality of life: learning from individuals making lifestyle changes to improve type 2 diabetes control. Sci Diabetes Self Manag Care, 2023, 49(2): 136-149.
18. Ellahham S. Artificial intelligence: the future for diabetes care. Am J Med, 2020, 133(8): 895-900.
19. Grunberger G, Sherr J, Allende M, et al. American association of clinical endocrinology clinical practice guideline: the use of advanced technology in the management of persons with diabetes mellitus. Endocr Pract, 2021, 27(6): 505-537.
20. 戴炜, 关阳, 李韵, 等. 基于动态血糖监测的糖尿病远程管理系统设计. 医疗卫生装备, 2023, 44(09): 42-48.
21. Veatch RM. Models for ethical medicine in a revolutionary age. What physician-patient roles foster the most ethical realtionship?. Hastings Cent Rep, 1972, 2(3): 5-7.
22. Pilla SJ, Jalalzai R, Tang O, et al. A national survey of physicians’ views on the importance and implementation of deintensifying diabetes medications. J Gen Intern Med, 2023, 39(6): 992-1001.
23. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making, 2015, 35(1): 114-131.
24. Brown A, Dornhorst A, McGowan B, et al. Low-energy total diet replacement intervention in patients with type 2 diabetes mellitus and obesity treated with insulin: a randomized trial. BMJ Open Diabetes Res Care, 2020, 8(1): e001012.
25. Ojo TK, Joshua OO, Ogedegbe OJ, et al. Role of intermittent fasting in the management of prediabetes and type 2 diabetes mellitus. Cureus, 2022, 14(9): e28800.
26. Dong C, Liu R, Huang Z, et al. Effect of exercise interventions based on family management or self-management on glycaemic control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis. Diabetol Metab Syndr, 2023, 15(1): 232.
27. Zhao L, Xu F, Zheng X, et al. Mediation role of anxiety on social support and depression among diabetic patients in elderly caring social organizations in China during COVID-19 pandemic: a cross-sectional study. BMC Geriatr, 2023, 23(1): 790.
28. Schram MT, Assendelft WJJ, van Tilburg TG, et al. Social networks and type 2 diabetes: a narrative review. Diabetologia, 2021, 64(9): 1905-1916.
29. Boehmer KR, Gionfriddo MR, Rodriguez-Gutierrez R, et al. Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis. BMC Fam Pract, 2016, 17(1): 127.
30. Hanlon P, Bryson I, Morrison H, et al. Self-management interventions for type 2 diabetes: systematic review protocol focusing on patient workload and capacity support. Wellcome Open Res, 2021, 6: 257.
31. Lin K, Yaomi, Chenzhang, et al. Conceptual framework and responding approach of treatment burden of type 2 diabetes: a video recording-based. Chinese General Practice, 2023, 26(34): 4302-4307.
32. Schmitt A, Gahr A, Hermanns N, et al. The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes, 2013, 11: 138.
33. 李超群, 井坤娟, 刘昱莹, 等. 糖尿病自我管理量表的汉化及信效度评价. 现代预防医学, 2018, 45(24): 4477-4481.
34. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care, 2000, 23(7): 943-950.
35. 李延飞, 陈伟菊, 许万萍, 等. 2 型糖尿病患者自我管理行为量表的改良及其信效度检验. 现代医院, 2011, 11(3): 148-150.
36. Breslin M, Mullan RJ, Montori VM. The design of a decision aid about diabetes medications for use during the consultation with patients with type 2 diabetes. Patient Educ Couns, 2008, 73(3): 465-472.
37. Boehmer KR, Hargraves IG, Allen SV, et al. Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid. BMC Health Serv Res, 2016, 16(1): 514.
38. Mei Y, Yang X, Li Y, et al. Validity and reliability of the chinese version of the diabetes treatment burden questionnaire (DTBQ) among patients with type 2 diabetes. Diabetes Metab Syndr Obes, 2023, 16: 663-675.
39. Eton DT, Yost KJ, Lai JS, et al. Development and validation of the patient experience with treatment and self-management (PETS): a patient-reported measure of treatment burden. Qual Life Res, 2017, 26(2): 489-503.
40. Tran VT, Montori VM, Eton DT, et al. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med, 2012, 10: 68.
41. 林恺, 郭丽红, 黄周红, 等. 糖尿病自我管理量表的汉化及信效度评价. 中华全科医学, 2022, 20(6): 974-977, 1011.
42. Espinoza P, Varela CA, Vargas IE, et al. The burden of treatment in people living with type 2 diabetes: a qualitative study of patients and their primary care clinicians. PloS One, 2020, 15(10): e0241485.
43. Gao CC, Espinoza Suarez NR, Toloza FJK, et al. Patients’ perspective about the cost of diabetes management: an analysis of online health communities. Mayo Clin Proc Innov Qual Outcomes, 2021, 5(5): 898-906.

West China Medical Journal

Application and research advances of cumulative complexity model in the treatment burden of type 2 diabetes mellitus

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