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Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study

Veterans Affairs Center for Practice Management and Outcomes Research, VA Ann Arbor Health System, Ann Arbor, MI, Department of Internal Medicine, University of Michigan; Michigan Diabetes Research and Training Center, Ann Arbor, MI, USA, mheisler{at}umich.edu

E. Tierney

Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA

R.T. Ackermann

Indiana University School of Medicine, Indianapolis, Indianapolis, IN, USA

C. Tseng

Pacific Health Research Institute, Honolulu, HI, Department of Family Medicine and Community Health, University of Hawaii, Honolulu, HI, USA

K.M. Venkat Narayan

Emory University, Atlanta, GA, USA

J. Crosson

Department of Family Medicine, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA

B. Waitzfelder

Pacific Health Research Institute, Honolulu, HI, USA

M.M. Safford

University of Alabama at Birmingham, Birmingham, AL, USA

K. Duru

University of California—Los Angeles, Los Angeles, CA, USA

W.H. Herman

Department of Internal Medicine, University of Michigan, Michigan Diabetes Research and Training Center, Ann Arbor, MI, USA

C. Kim

Department of Internal Medicine, University of Michigan; Department of Obstetrics & Gynecology, University of Michigan, Michigan Diabetes Research and Training Center, Ann Arbor, MI, USA

Objectives: In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians’ diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive.

Methods: 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n = 4198) in 10 US health plans across the country and their physicians (n = 1217). We characterized physicians’ diabetes care PDM preferences and practices as ‘no patient involvement,’ ‘physician-dominant,’ ‘shared,’ or ‘patient-dominant’ and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patients’satisfaction with physician communication; and (3) whether patients’ A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control.

Results: Most physicians preferred ‘shared’ PDM (58%) rather than ‘no patient involvement’ (9%), ‘physiciandominant’ (28%) or ‘patient dominant’ PDM (5%). However, most reported practicing ‘physician-dominant’ PDM (43%) with most of their patients, rather than ‘no patient involvement’ (13%), ‘shared’ (37%) or ‘patient-dominant’ PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred ‘shared’ PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03—3.07] and patients of physicians who preferred ‘patient-dominant’ treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04—2.39] than those of providers who preferred ‘no patient involvement’ in treatment decision-making. There were no differences in patients’ satisfaction with their doctor’s communication or control of A1c, SBP or LDL depending on their physicians’ PDM preferences. Physicians’ self-reported PDM practices were not associated with any of the examined aspects of diabetes care in multivariate analyses.

Conclusions: Patients whose physicians prefer more patient involvement in decision-making are more likely than patients whose physicians prefer more physician-directed styles to receive some recommended risk factor screening tests, an important first step toward improved diabetes outcomes. Involving patients in treatment decision-making alone, however, appears not to be sufficient to improve biomedical outcomes.

Key Words: Diabetes • Quality of Care • Patient-Physician relations • Medical decision-making

This version was published on September 1, 2009

Chronic Illness, Vol. 5, No. 3, 165-176 (2009)
DOI: 10.1177/1742395309339258


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