Abstract
BackgroundPatient-centered diabetes care requires shared decision making (SDM). Decision aids promote SDM, but their efficacy in nonacademic and rural primary care clinics is unclear.MethodsWe cluster-randomized 10 practices in a concealed fashion to implement either a decision aid (DA) about starting statins or one about choosing antihyperglycemic agents. Each practice served as a control group for another practice implementing the other type of DA. From April 2011 to July 2012, 103 (DA=53) patients with type 2 diabetes participated in the trial. We used patient and clinician surveys administered after the clinical encounter to collect decisional outcomes (patient knowledge and comfort with decision making, patient and clinician satisfaction). Medical records provided data on metabolic control. Pharmacy fill profiles provided data for estimating adherence to therapy.ResultsCompared to usual care, patients receiving the DA were more likely to report discussing medications (77% vs. 45%, p<.001), were more likely to answer knowledge questions correctly (risk reduction with statins 61% vs. 33%, p=.07; knowledge about options 57% vs. 33%, p=.002) and were more engaged by their clinicians in decision making (50. vs. 28, difference 21.4 (95% CI 6.4, 36.3), p=.01). We found no significant impact on patient satisfaction, medication starts, adherence or clinical outcomes, in part due to limited statistical power.ConclusionDAs improved decisional outcomes without significant effect on clinical outcomes. DAs designed for point-of-care use with type 2 diabetes patients promoted shared decision making in nonacademic and rural primary care practices.Trial RegistrationNCT01029288
Highlights
Patient-centered diabetes care requires shared decision making (SDM)
* Correspondence: montori.victor@mayo.edu 1Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA 2Division of Health Care Policy and Research, Department of Health Sciences Research Mayo Clinic, Rochester, MN, USA Full list of author information is available at the end of the article team, including clinicians and patients with diabetes, we have developed decision aids to support the choice of antihyperglycemic agents and about using statins to reduce cardiovascular risk [3,4]
We excluded 2 ineligible patients incorrectly enrolled, and 2 patients enrolled to the usual care arm of the aspirin decision aid
Summary
Patient-centered diabetes care requires shared decision making (SDM). Decision aids promote SDM, but their efficacy in nonacademic and rural primary care clinics is unclear. While these trials provided evidence of efficacy of decision aids in patients with diabetes receiving care in academic clinics, little is known about the effectiveness of these tools in routine clinical practice, in rural clinics. In this context of imperfect knowledge, state legislation in Washington and Minnesota and provisions in the Patient Protection and Affordable Care. The National Quality Forum recommends measuring SDM as part of its framework for assessing quality of care in patients with multiple chronic conditions [11] These legislative efforts require improvements in the evidence base about the effect of implementing SDM in usual clinical settings
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