Participatory Decision Making, Patient Activation, Medication Adherence, and Intermediate Clinical Outcomes in Type 2 Diabetes: A STARNet Study

Abstract

PURPOSE Participatory decision making (PDM) is associated with improved diabetes control. We examine a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence. METHODSThis observational study was conducted in 5 family physician offi ces. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their offi ce visit. Two survey questionnaires, administered 12 months apart, elicited patients' ratings of their physician's PDM style at baseline and their level of activation and medication adherence both at baseline and at follow-up. Measures of glycated hemoglobin (hemoglobin A 1c ), systolic blood pressure, and low-density lipoprotein (LDL) cholesterol were abstracted from the medical record starting 12 months before the baseline survey to 12 months after the follow-up survey. A path analysis using a structural equation model was used to test hypotheses. RESULTSWe mailed questionnaires to 236 participants; 166 (70%) returned the baseline questionnaire, and 141 (80%) returned the follow-up questionnaire. Hemoglobin A 1c levels, systolic blood pressure, and LDL cholesterol values all declined signifi cantly, and patient activation and medication adherence improved. PDM at baseline was associated with patient activation at follow-up. Patient activation at follow-up was associated with medication adherence at follow-up, and medication adherence at follow-up was associated with change in hemoglobin A 1c levels and LDL cholesterol values but not with systolic blood pressure.CONCLUSIONS Participatory decision making during primary care encounters by patients with type 2 diabetes resulted in improvements in hemoglobin A 1c levels and LDL cholesterol values by improving patient activation, which in turn improved medication adherence.

Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes

“…For example, there is evidence from cross-sectional studies that provider behaviors can support patient activation. Patients who report that their provider helped them in very concrete and specific ways, such as helped them to learn to monitor their condition, set goals, and/or set up and exercise program, were more activated than patients who said their provider did not help them in The predicted probabilities are computed based upon full regression models presented in online appendix 2 these ways 36,37 . While not formally evaluated, some patientcentered medical homes are measuring their patients' activation levels, and using it as a "vital sign" to help them tailor patient care plans to the patient's ability to follow through on those plans.…”

2017 National Standards for Diabetes Self-Management Education and Support

“…Evidence-based communication strategies such as collaborative goal setting, action planning, motivational interviewing, shared decision making, cognitive behavioral therapy, problem solving, selfefficacy enhancement, teach-back, and relapse-prevention strategies are also effective (120,(136)(137)(138)(139). It is crucial to develop action-oriented behavior change goals and objectives (130,140).…”

Health Literacy: An Educationally Sensitive Patient Outcome

“…6 Physician skills such as participatory decision making can lead to improved patient activation and better outcomes. 7 Hibbard's Patient Activation Measure (PAM) has been shown to be a reliable measure, relatively easy to administer, and has been proposed as a health care quality measure. [8][9][10] While more definitive study is needed, we have shown that measures of patient activating skills of residents in an Objective Structured Clinical Examination (OSCE) can identify residents more likely to promote actual weight loss in obese patients.…”