Abstract
BackgroundCare of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and goal setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. However, these strategies have not been taken up extensively in clinical practice.ObjectivesTo systematically develop and test an interprofessional SDM and goal-setting toolkit for patients with diabetes and other chronic diseases, following the Knowledge to Action framework.Methods1. Feasibility study: Individual interviews with primary care physicians, nurses, dietitians, pharmacists, and patients with diabetes will be conducted, exploring their experiences with shared decision-making and priority-setting, including facilitators and barriers, the relevance of a decision aid and toolkit for priority-setting, and how best to integrate it into practice.2. Toolkit development: Based on this data, an evidence-based multi-component SDM toolkit will be developed. The toolkit will be reviewed by content experts (primary care, endocrinology, geriatricians, nurses, dietitians, pharmacists, patients) for accuracy and comprehensiveness.3. Heuristic evaluation: A human factors engineer will review the toolkit and identify, list and categorize usability issues by severity.4. Usability testing: This will be done using cognitive task analysis.5. Iterative refinement: Throughout the development process, the toolkit will be refined through several iterative cycles of feedback and redesign.DiscussionInterprofessional shared decision-making regarding priority-setting with the use of a decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Adhering to principles of user-centered design, we will develop and refine a toolkit to assess the feasibility of this approach.
Highlights
Care of patients with diabetes often occurs in the context of other chronic illness
Patient adherence to clinical practice guideline (CPG) recommendations is impacted by multi-morbidity, as it directly impacts selfmanagement ability [3] and competes for time and attention [4] (Yu CH: Impact of a web-based self-management intervention for patients with type 2 diabetes on self-efficacy, self-care and diabetes distress, submitted)
In a search of the published literature, we identified four patient decision aids (PtDAs) focusing on diabetes, one evaluated with a prospective observational study [33], and three evaluated through randomized controlled trials [34,35,36,37]
Summary
Care of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Incorporating interprofessional integration into practice may overcome barriers to implementation. These strategies have not been taken up extensively in clinical practice. Following the American Diabetes Association recommendations for self-management would take 143 minutes per day [1]. Patient adherence to clinical practice guideline (CPG) recommendations is impacted by multi-morbidity, as it directly impacts selfmanagement ability (e.g., depression) [3] and competes for time and attention [4] (Yu CH: Impact of a web-based self-management intervention for patients with type 2 diabetes on self-efficacy, self-care and diabetes distress, submitted). Patients with a greater overall number of comorbidities placed lower priority on diabetes, had worse diabetes self-management ability [5,6] and poor cardiometabolic control [7]. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient
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