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Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial

  • Michelle T. Vo
  • Connie S. Uratsu
  • Karen R. Estacio
  • Andrea Altschuler
  • Eileen Kim
  • Stacey E. Alexeeff
  • Alyce S. Adams
  • Julie A. Schmittdiel
  • Michele Heisler
  • Richard W. GrantEmail author
Original Research

Abstract

Background

Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.

Objective

To test the hypothesis that a “Pre-Visit Prioritization” secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.

Design

We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.

Participants

Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal.

Interventions

Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.

Main Measures

Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.

Key Results

During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms.

Conclusions

A “light touch” email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.

Trial Registry

NCT02375932

KEY WORDS

clinical trials doctor-patient relationships diabetes primary care health information technology 

Notes

Author Contributions

All contributing individuals met requirements for authorship of this manuscript.

Funding Information

This work is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK099108, P30DK092926, and K24DK109114).

Compliance with Ethical Standards

The Kaiser Foundation Research Institute Institutional Review Board (IRB) approved the waiver for written informed consent from patients of providers enrolled in our study.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4756_MOESM1_ESM.docx (86 kb)
ESM 1 (DOCX 85 kb)

References

  1. 1.
    Centers for Disease Control and Prevention. Diabetes Report Card 2017. Atlanta: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2018.Google Scholar
  2. 2.
    Grant RW, Kirkman MS. Trends in the Evidence Level for the American Diabetes Association’s “Standards of Medical Care in Diabetes” from 2005 to 2014. Diabetes Care. 2015;38:6–8.CrossRefGoogle Scholar
  3. 3.
    Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of Goals in U.S. Diabetes Care, 1999–2010. N Engl J Med. 2013;368:1613–24.CrossRefGoogle Scholar
  4. 4.
    Shahraz S, Anastassios, G. P., Saadati, M., Thomas, C.P., Lundquist, C. M., Kent, D. M. Change in Testing, Awareness of Hemoglobin A1c Result, and Glycemic Control in US Adults, 2007-2014. JAMA. 2017;318:1825–7.CrossRefGoogle Scholar
  5. 5.
    Schneider KM, O'Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States’ Medicare population. Health Qual Life Outcomes. 2009;7:82.CrossRefGoogle Scholar
  6. 6.
    Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med. 2008;23:2058–65.CrossRefGoogle Scholar
  7. 7.
    Barnes CS, Ziemer DC, Miller CD, et al. Little time for diabetes management in the primary care setting. Diabetes Educ. 2004;30:126–35.CrossRefGoogle Scholar
  8. 8.
    Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209–14.CrossRefGoogle Scholar
  9. 9.
    Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42:1871–94.CrossRefGoogle Scholar
  10. 10.
    Bohlen K, Scoville E, Shippee ND, May CR, Montori VM. Overwhelmed patients: a videographic analysis of how patients with type 2 diabetes and clinicians articulate and address treatment burden during clinical encounters. Diabetes Care. 2012;35:47–9.CrossRefGoogle Scholar
  11. 11.
    Adams JR, Elwyn G, Legare F, Frosch DL. Communicating with physicians about medical decisions: a reluctance to disagree. Arch Intern Med. 2012;172:1184–6.CrossRefGoogle Scholar
  12. 12.
    Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ. 2000;320:1246–50.CrossRefGoogle Scholar
  13. 13.
    Kowalski C, McQuillan DB, Chawla N, et al. ‘The Hand on the Doorknob’: A Qualitative Study of Preparation, Prioritization, and Agenda Setting by Complex Patients and Their Physicians during Primary Care Visits. J Am Board Fam Med. 2018; 31(1):29–37.CrossRefGoogle Scholar
  14. 14.
    Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243–52.CrossRefGoogle Scholar
  15. 15.
    Peek ME, Wilson SC, Gorawara-Bhat R, Odoms-Young A, Quinn MT, Chin MH. Barriers and facilitators to shared decision-making among African-Americans with diabetes. J Gen Intern Med. 2009;24:1135–9.CrossRefGoogle Scholar
  16. 16.
    Rodriguez HP, Anastario MP, Frankel RM, et al. Can teaching agenda-setting skills to physicians improve clinical interaction quality? A controlled intervention. BMC Med Educ. 2008;8:3.CrossRefGoogle Scholar
  17. 17.
    Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev. 2012;12:CD003267.PubMedGoogle Scholar
  18. 18.
    Schoenthaler A, Kalet A, Nicholson J, Lipkin M, Jr. Does improving patient-practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence. Patient Educ Couns. 2014;96:3–12.CrossRefGoogle Scholar
  19. 19.
    Karter AJ, Moffet HH, Liu J, et al. Achieving good glycemic control: initiation of new antihyperglycemic therapies in patients with type 2 diabetes from the Kaiser Permanente Northern California Diabetes Registry. Am J Manag Care. 2005;11:262–70.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Grant RW, Adams AS, Bayliss EA, Heisler M. Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions. Healthcare. 2013;1:117–22.CrossRefGoogle Scholar
  21. 21.
    Grant RW, Uratsu CS, Estacio KR, et al. Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system. Contemp Clin Trials. 2016;47:196–201.CrossRefGoogle Scholar
  22. 22.
    Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153:69–75.CrossRefGoogle Scholar
  23. 23.
    Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511–44.CrossRefGoogle Scholar
  24. 24.
    Lorig KS, Stewart A, Ritter P, González V, Laurent D, Lynch J. Outcome Measures for Health Education and other Health Care Interventions. Thousand Oaks: Sage Publications; 1996.Google Scholar
  25. 25.
    Hargraves JL, Hays RD, Cleary PD. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health Serv Res. 2003;38(6 Pt 1):1509–27.Google Scholar
  26. 26.
    Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Medical Care. 2005;43:436–44.CrossRefGoogle Scholar
  27. 27.
    Lerman CE, Brody DS, Caputo GC, Smith DG, Lazaro CG, Wolfson HG. Patients' Perceived Involvement in Care Scale: Relationship to attitudes about illness and medical care. J Gen Intern Med. 1990;5:29–33.CrossRefGoogle Scholar
  28. 28.
    Maly RC, Frank JC, Marshall GN, DiMatteo MR, Reuben DB. Perceived efficacy in patient-physician interactions (PEPPI): Validation of an instrument in older persons. J Am Geriatr Soc. 1998;46:889–94.CrossRefGoogle Scholar
  29. 29.
    Kristjansson E, Tugwell PS, Wilson AJ, et al. Development of the effective musculoskeletal consumer scale. J Rheumatol. 2007;34:1392–400.PubMedGoogle Scholar
  30. 30.
    Morrison I. The future of physician’s time. Ann Intern Med. 2000;132:80–4.CrossRefGoogle Scholar
  31. 31.
    Parchman ML, Romero RL, Pugh JA. Encounters by patients with type 2 diabetes--complex and demanding: an observational study. Ann Fam Med. 2006;4:40–5.CrossRefGoogle Scholar
  32. 32.
    Schmittdiel JA, Gopalan A, Lin MW, Banerjee S, Chau CV, Adams AS. Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities. Curr Diab Rep. 2017;17:31.CrossRefGoogle Scholar
  33. 33.
    Greenfield S, Kaplan S, Ware JE, Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102:520–8.CrossRefGoogle Scholar
  34. 34.
    Greenfield S, Kaplan SH, Ware JE, Jr., Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448–57.CrossRefGoogle Scholar
  35. 35.
    Thorpe KE, Zwarenstein M, Oxman AD, et al. A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers. J Clin Epidemiol. 2009;62:464–75.CrossRefGoogle Scholar
  36. 36.
    Zwarenstein M, Treweek S, Gagnier JJ, et al. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ. 2008;337:a2390.CrossRefGoogle Scholar
  37. 37.
    Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624–32.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Michelle T. Vo
    • 1
  • Connie S. Uratsu
    • 1
  • Karen R. Estacio
    • 1
  • Andrea Altschuler
    • 1
  • Eileen Kim
    • 2
  • Stacey E. Alexeeff
    • 1
  • Alyce S. Adams
    • 1
  • Julie A. Schmittdiel
    • 1
  • Michele Heisler
    • 3
    • 4
  • Richard W. Grant
    • 1
    Email author
  1. 1.Division of ResearchKaiser Permanente Northern CaliforniaOaklandUSA
  2. 2.Department of Medicine, Oakland Medical CenterKaiser Permanente Northern CaliforniaOaklandUSA
  3. 3.Department of Internal MedicineUniversity of MichiganAnn ArborUSA
  4. 4.Center for Clinical Management ResearchAnn Arbor VAAnn ArborUSA

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