Background Despite widespread advocacy for shared decision making (SDM), the empirical evidence regarding its effectiveness to improve patient outcomes has not been systematically reviewed. Purpose To systematically review the empirical evidence linking patient outcomes and SDM, when the decision-making process has been explicitly measured, and to identify under what measurement perspectives SDM is associated with which types of patient outcomes (affective-cognitive, behavioral, and health). Data Sources PubMed (through December 2012) and hand search of article bibliographies. Study Selection Studies were included if they empirically (1) measured SDM in the context of a patient-clinician interaction, and (2) evaluated the relationship between SDM and at least one patient outcome. Data Extraction Study results were categorized by SDM measurement perspective (patient-reported, clinician-reported, or observer-rated) and outcome type (affective-cognitive, behavioral, or health). Data Synthesis Thirty-nine studies met inclusion criteria. Thirty-three used patient-reported measures of SDM, six used observer-rated, and two used clinician-reported. Ninety-seven unique patient outcomes were assessed; 51% affective-cognitive, 28% behavioral, and 21% health. Only 43% of assessments (n=42) found a significant and positive relationship between SDM and the patient outcome. This proportion varied by SDM measurement perspective and outcome category. 52% of outcomes assessed with patient-reported SDM were significant and positive, compared to 21% with observer-rated and 0% with clinician-reported SDM. Regardless of measurement perspective, SDM was most likely to be associated with affective-cognitive patient outcomes (54%), compared to 37% of behavioral, and 25% of health outcomes. Limitations The relatively small number of studies, precludes meta-analysis. The study inclusion and exclusion criteria requiring both an empirical measure of SDM as well as an assessment of the association between that measure and a patient outcome, resulted in most included studies being observational in design. Conclusions SDM, when perceived by patients as occurring, tends to result in improved affective-cognitive outcomes. Evidence is lacking for the association between empirical measures of SDM and patient behavioral and health outcomes.

OBJECTIVE -Although poor medication adherence may contribute to inadequate diabetes control, ways to feasibly measure adherence in routine clinical practice have yet to be established. The present study was conducted to determine whether pharmacy claims-based measures of medication adherence are associated with clinical outcomes in patients with diabetes.RESEARCH DESIGN AND METHODS -The study setting was a large, integrated delivery and financial system serving the residents of southeastern Michigan. The study population consisted of 677 randomly selected patients aged Ն18 years with a diagnosis of diabetes, hypercholesterolemia, and hypertension and who filled at least one prescription for either an antidiabetic, lipid-lowering, or antihypertensive drug in each of the 3 study years (1999 -2001). The main outcome measures were HbA 1c , LDL cholesterol levels, and blood pressure.RESULTS -Nonadherent patients had both statistically and clinically worse outcomes than adherent patients. Even after adjusting for demographic and clinical characteristics, nonadherence was significantly associated with HbA 1c and LDL cholesterol levels. A 10% increase in nonadherence to metformin and statins was associated with an increase of 0.14% in HbA 1c and an increase of 4.9 mg/dl in LDL cholesterol levels. Nonadherence to ACE inhibitors was not significantly associated with blood pressure.CONCLUSIONS -Claims-based measures of medication adherence are associated with clinical outcomes in patients with diabetes and may therefore prove to be useful in clinical practice. More research is needed on methods to introduce claims-based adherence measurements into routine clinical practice and how to use these measurements to effectively improve adherence and health outcomes in chronic care management. Diabetes Care 27:2800 -2805, 2004N onadherence to medications is a common problem in clinical practice, especially among patients with asymptomatic chronic conditions such as diabetes, hypertension, and hypercholesterolemia (1-4). A recent meta-analysis has showed that the average adherence in patients with diabetes is 67.5%, which is lower than that found among many conditions (5). Also, recently, a specific systematic review on adherence to medications for diabetes showed that average adherence to oral hypoglycemic agents ranged from 36 to 93% (6). In general, poor adherence to medications has been shown to be associated with the development of complications, disease progression, avoidable hospitalizations, premature disability, and death. In total, the costs associated with poor medication adherence are estimated to approach $100 billion per year (7). Despite these known consequences, adherence rates have remained unchanged since the 1970s (1,8).Nonadherence is the result of a complex interaction among the social environment, the patient, and the health providers (9). Adherence to medications is not routinely measured in clinical practice, and a gold standard that can be easily implemented, even for research purposes, does not exist (1,5,...

OBJECTIVE -The purpose of this study was to longitudinally examine the effect of diabetes on labor market outcomes.RESEARCH DESIGN AND METHODS -Using secondary data from the first two waves (1992 and 1994) of the Health and Retirement Study, we identified 7,055 employed respondents (51-61 years of age), 490 of whom reported having diabetes in wave 1. We estimated the effect of diabetes in wave 1 on the probability of working in wave 2 using probit regression. For those working in wave 2, we modeled the relationships between diabetic status in wave 1 and the change in hours worked and work-loss days using ordinary least-squares regressions and modeled the presence of health-related work limitations using probit regression. All models control for health status and job characteristics and are estimated separately by sex.RESULTS -Among individuals with diabetes, the absolute probability of working was 4.4 percentage points less for women and 7.1 percentage points less for men relative to that of their counterparts without diabetes. Change in weekly hours worked was not statistically significantly associated with diabetes. Women with diabetes had 2 more work-loss days per year compared with women without diabetes. Compared with individuals without diabetes, men and women with diabetes were 5.4 and 6 percentage points (absolute increase), respectively, more likely to have work limitations.CONCLUSIONS -This article provides evidence that diabetes affects patients, employers, and society not only by reducing employment but also by contributing to work loss and healthrelated work limitations for those who remain employed. Diabetes Care 28:2662-2667, 2005T he medical care costs associated with diabetes create a considerable economic burden for patients, families, and society (1,2). Productivity losses from diabetes have been estimated to be almost half ($40 billion) of the medical costs ($92 billion) associated with diabetes in 2002 (1). As the prevalence of diabetes in the U.S. has increased (3), so too have associated economic burdens (4). The increased prevalence (5) among younger individuals suggests that diabetes will become more common in the working-age population. Consequently, employment and work productivity of individuals with diabetes are important issues for patients, families, employers, and policy makers. In this study, we examine the effect of diabetes on labor market outcomes of employed U.S. adults aged 51-61 using longitudinal data from the Health and Retirement Study (HRS).Several studies have found negative associations between diabetes and employment outcomes (6 -10). The magnitude of the effect of diabetes on employment varies from 4 to 22 percentage points. Diabetes can affect employment in a number of ways. First, diabetes complications may prevent working entirely or increase absenteeism for those who work (11). Second, productivity while at work may also be impaired (12). Third, individuals with diabetes may face employment discrimination. In some cases, especially because of the risk of hypogl...

No abstract

RATIONALE: Chicago's low-income minority children have some of the highest rates worldwide for asthma and asthma related morbidity. Recent studies show that direct observed therapy (DOT) administered by nurses at school may help. This study examines DOT administered by non-medical school personnel in the inner-city. METHODS: In this prospective randomized controlled study, two groups of underserved children were compared using information collected from diaries and questionnaires, over 6 visits, during the 2003-04 school year. Participants were aged 6-15 years, had a diagnosis of persistent asthma and attended a Chicago public or parochial school. The intervention group (I) received one dose of their controller medication (fluticasone or fluticasone/salmeterol diskus) daily at school, with other doses given at home. The control group (C) received their controller only at home. Albuterol use was the primary outcome. RESULTS: Thirty-five of thirty-nine participants completed the study. During the baseline period, albuterol use was 1.45 + 0.27 and 1.11 + 0.24 treatments/day in I and C, respectively. Comparisons to baseline were made at each follow-up visit. There were no significant decreases in albuterol use or school absences in C at each of the follow-up visits. At the last visit, there was a significant decrease in albuterol use to 0.39 + 0.15 treatments/day (73%, p< 0.05) in I. School absences were significantly decreased at all visits in I (84% by last visit, p<0.05). CONCLUSIONS: When considering the limited resources of inner-city schools, DOT by non-medical school personnel may be a practical option to improve asthma outcomes.

OBJECTIVEAppropriate glycemic control is fundamental to diabetes care, but aggressive glucose targets and intensive therapy may unintentionally increase episodes of hypoglycemia. We quantified the burden of severe hypoglycemia requiring medical intervention in a well-defined population of insured individuals with diabetes receiving care in integrated health care delivery systems across the U.S.RESEARCH DESIGN AND METHODSThis observational cohort study included 917,440 adults with diabetes receiving care during 2005 to 2011 at participating SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) network sites. Severe hypoglycemia rates were based on any occurrence of hypoglycemia-related ICD-9 codes from emergency department or inpatient medical encounters and reported overall and by age, sex, comorbidity status, antecedent A1C level, and medication use.RESULTSAnnual rates of severe hypoglycemia ranged from 1.4 to 1.6 events per 100 person-years. Rates of severe hypoglycemia were higher among those with older age, chronic kidney disease, congestive heart failure, cardiovascular disease, depression, and higher A1C levels, and in users of insulin, insulin secretagogues, or β-blockers (P < 0.001 for all). Changes in severe hypoglycemia occurrence over time were not clinically significant in the cohort as a whole but were observed in subgroups of individuals with chronic kidney disease, congestive heart failure, and cardiovascular disease.CONCLUSIONSRisk of severe hypoglycemia in clinical settings is considerably higher in identifiable patient subgroups than in randomized controlled trials. Strategies that reduce the risk of hypoglycemia in high-risk patients are needed.

recommends that shared decision making (SDM) involving a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening (LCS) with low-dose computed tomography. The Centers for Medicare & Medicaid Services require an SDM visit using a decision aid as a prerequisite for LCS coverage. However, little is known about how SDM about LCS occurs in practice. OBJECTIVE To assess the quality of SDM about the initiation of LCS in clinical practice. DESIGN, SETTING, AND PARTICIPANTS A qualitative content analysis was performed of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for LCS, recorded between April 1, 2014, and March 1, 2018, that were identified within a large database. MAIN OUTCOMES AND MEASURES Independent observer ratings of communication behaviors of physicians using the OPTION (Observing Patient Involvement in Decision Making) scale, a validated 12-item measure of SDM (total score, 0-100 points, where 0 indicates no evidence of SDM and 100 indicates evidence of SDM at the highest skill level); time spent discussing LCS during visits; and evidence of decision aid use. RESULTS A total of 14 conversations about initiating LCS were identified; 9 patients were women, and 5 patients were men; the mean (SD) patient age was 63.9 (5.1) years; 7 patients had Medicare, and 8 patients were current smokers. Half the conversations were conducted by primary care physicians. The mean total OPTION score for the 14 LCS conversations was 6 on a scale of 0 to 100 (range, 0-17). None of the conversations met the minimum skill criteria for 8 of the 12 SDM behaviors. Physicians universally recommended LCS. Discussion of harms (such as false positives and their sequelae or overdiagnosis) was virtually absent. The mean total visit length of a discussion was 13:07 minutes (range, 3:48-27:09 minutes). The mean time spent discussing LCS was 0:59 minute (range, 0:16-2:19 minutes), or 8% of the total visit time (range, 1%-18%). There was no evidence that decision aids or other patient education materials for LCS were used. CONCLUSIONS AND RELEVANCE In this small sample of recorded encounters about initiating LCS, the observed quality of SDM was poor and explanation of potential harms of screening was virtually nonexistent. Time spent discussing LCS was minimal, and there was no evidence that decision aids were used. Although these findings are preliminary, they raise concerns that SDM for LCS in practice may be far from what is intended by guidelines.

Objective To compare patient-reported and observer-rated shared decision making (SDM) use for colorectal cancer (CRC) screening and evaluate patient, physician and patient-reported relational communication factors associated with patient-reported use of shared CRC screening decisions. Methods Study physicians are salaried primary care providers. Patients are insured, aged 50-80 and due for CRC screening. Audio-recordings from 363 primary care visits were observer-coded for elements of SDM. A post-visit patient survey assessed patient-reported decision-making processes and relational communication during visit. Association of patient-reported SDM with observer-rated elements of SDM, as well as patient, physician and relational communication factors were evaluated using generalized estimating equations. Results 70% of patients preferred SDM for preventive health decisions, 47% of patients reported use of a SDM process, and only one of the screening discussions included all four elements of SDM per observer ratings. Patient report of SDM use was not associated with observer-rated elements of SDM, but was significantly associated with female physician gender and patient-reported relational communication. Conclusion Inconsistencies exist between patient reports and observer ratings of SDM for CRC screening. Practice Implications Future studies are needed to understand whether SDM that is patient-reported, observer-rated or both are associated with informed and value-concordant CRC screening decisions.