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Currently submitted to: Journal of Medical Internet Research

Date Submitted: Jul 27, 2020
Open Peer Review Period: Jul 27, 2020 - Sep 21, 2020
(currently open for review)

Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.

Using structural equation modelling in routine clinical data: Depression, diabetes, and use of A&E

  • Mark Charles Freestone; 
  • Amy Ronaldson; 
  • Haoyuan Zhang; 
  • William Marsh; 
  • Kamaldeep Bhui; 



Large datasets comprising routine clinical data are becoming increasingly available for use in health research. These datasets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of ‘research friendly’ clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data.


SEM was applied to a large dataset of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilisation, and increased healthcare costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical datasets.


Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and A&E use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge.


The results provided partial support for the application of SEM to routine clinical data. 19% of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β = 0.034, p <.0001) and increased A&E use (β = 0.071, p <.0001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β = -0.055, p <.0001), and receipt of mental health treatment did not impact upon diabetic control (p = 0.392). Receipt of diabetes care was associated with better diabetic control (β = -0.072, p <.0001), having depression (β = 0.018, p = .007), and receiving mental health treatment (β = 0.046, p <.0001), which might suggest that comprehensive integrated care packages are being delivered in East London.


Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this dataset. Clinical Trial: n/a


Please cite as:

Freestone MC, Ronaldson A, Zhang H, Marsh W, Bhui K

Using structural equation modelling in routine clinical data: Depression, diabetes, and use of A&E

JMIR Preprints. 27/07/2020:22912

DOI: 10.2196/preprints.22912


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