Download Helping patients understand their laboratory results

Sharing personalised clinical
information with diabetes patients
prior to their consultation:
results of a pilot study
and future work
Presented by Dr Máire O’ Donnell
on behalf of
Dr YY Hong, Dr YY Lim, Dr SY Lim and Dr SF Dinneen
Diabetes Centre, University Hospital Galway
Department of Medicine, NUIG
Outline of talk
• Present results from pilot study conducted
in 2007
• Outline some thoughts on how we can
progress this work
Background (1)
• Patient centredness
– Patient involvement in decisions about their
health care
– Consideration of individual patient
preferences and circumstances
Mead N, Bower P. Patient Educ Counselling 2002;48:51-61
Background (2)
• Patient centredness and chronic diseases
– Diabetes requires active patient involvement
in self management for improved clinical
outcomes
– Effective communication during the clinical
consultation essential in enabling the patient
to self manage
Person with
diabetes
Diamond
Primary
Care
Specialist
care
Aim
To measure the impact of sharing
personalised clinical information in written
format with patients on the clinical
consultation
Intervention
• Already in Use: Diamond-generated
proforma (for doctors)
• New: A Clinical Information Sheet was
developed (for patients)
– Standardised format
– Personalised information
– Brief explanation regarding medical terms
– Prompt question
Topics
•
•
•
•
•
•
•
•
•
Weight
BMI
BP
Blood sugar range
Exercise
Diet
HbA1c
ACR
Creatinine
•
•
•
•
•
•
•
•
Cholesterol
LDL
TG
HDL
Diabetic medication
Diabetic complication
Other problems
Other medications
Clinical Information Sheet (1)
The following is a brief summary of information on your diabetes.
Please take the time to read it. All members of our team will be happy
to answer any of your questions.
Below are explanations of the medical terms used in this form. If you
need further clarification, please ask a member of the healthcare team.
HbA1C is a blood test used to monitor long term blood sugar control.
ACR (Albumin Creatinine Ratio) and creatinine are indicators of your
kidney function.
Cholesterol is the main type of fat that we worry about in the blood. LDL
and TG (triglyceride) are the bad cholesterol. HDL is the good
cholesterol.
‘Onsets’ refer to date of onset of complications of your diabetes, if you
have any.
Please consider the following question:
What do I wish to get out of today’s visit to the Diabetes clinic?
Clinical Information Sheet (2)
Patient name:
Address:
Date of clinic:
Date of pre-assessment:
Board number
Date of birth:
Type of diabetes
Duration:
Consultant:
Seen by
Clinic type:
Alcohol:
Height:
Smoking status:
Postcode:
GP name:
Address:
Postcode:
Phone:
To be seen by:
Date:
DSN: Yes/No
Weight
BMI
Targets
31/07/2007
08/09/1950
Type 2
3 years
Diabetes clinic
1.76
Past smoker
Dietitian Yes/No
HbA1c
7.5
BP sys
130
BP dia
80
AER
Male
Sex
Podiatrist Yes/No
ACR
3.5
Creat
106
Chol
4.5
LDL
HDL
TG
2.5
1.0
2.0
68
5.1
3.1
1.2
.1.3
5.0
3.0
1.1
2.0
Current
23/07/2007
15/05/2007
23/04/2007
23/01/2007
16/01/2007
Treatment:
95.70
97.10
30.90
31.30
143/77
152/81
6.9
95.90
31.00
130/80
7.0
Type 2
Blood sugar range:
No onsets:
Problem list:
Non-Diabetic Drugs:
Tablets
Metformin
Hypos:
Break
Lunch
850
850
Frequency:
Tea
850
Rheumatic fever (13 years), Hypertension
Aspirin 75 mg od, Atenolol 100mgs od, Irbesartan 150/125, Pravastatin 20 mgs nocte
Supper
Methods
• Subjects – Patients attending Diabetes
Clinics in Galway University Hospitals
• Recruitment over a 5 week period
• 6 intervention clinics and 3 control clinics
• Total patients = 106 (65 males and 41
females)
Patient check-in
Intervention (n = 63)
Clinical information sheet
and a brief explanation is
given to patient when in
waiting room
Control (n = 43)
No clinical information
sheet is given to the
patient
Investigators sit in the consultation
observing and measuring the doctorpatient interaction
Methods
Data were recorded in 3 ways
– The percent of patients initiating each
individual topic
– The number of topics initiated by each
individual patient
– The patients’ conversation time vs.
total consultation time
Table 1 Baseline characteristics of patients in control and intervention groups
Control group %(n)
Intervention group (n ═ 63)
65(28)
35(15)
59 (37)
41(26)
14 (6)
42(18)
44(19)
14(9)
44(28)
41(26)
Diabetes type
Type 1
19 (8)
27(17)
Type 2
Other
79 (34)
2 (1)
73 (46)
0(0)
Diabetes duration
Under 1 year
1 −5 years
>5−10 yrs
10 yrs+
7(3)
35 (15)
23 (10)
35(15)
11(7)
22 (14)
32(20)
35 (22)
Male
Female
Age
≤39 yrs
40−64yrs
65+ yrs
od
t
AC
R
LD
L
ea
ti
Ch nine
ol
es
te
ro
l
Cr
Hb
A1
C
et
Di
Su
BP
ga
rR
an
ge
Ex
er
cis
e
BM
I
eig
h
ab
e
Di
HD
Tr
igl
L
yc
t
e
i
Di
rid
ab c M
e
e
et
di
ic
c
at
Co
io
m
n
pli
ca
Ot
ti
he
r P on
Ot
ro
he
r M ble
m
ed
s
ic a
tio
ns
Bl
o
W
Percent of Patients Initiating
Individual Topics
60%
50%
40%
30%
20%
Intervention
Control
10%
0%
Patient score
Mean patient score
Control group = 1 (range 0-4)
Intervention group = 5 (range 0-14)
No topics raised
Control group (49%)
Intervention group (16%)
Patient Conversation Time vs.
Total Consultation Time
20
18
Time (Minutes)
16
14
12
P>0.05
Total Consultation
Time
10
Patient Conversation
Time
8
6
4
2
P<0.05
0
Intervention
Control
Summary
A personalised clinical information sheet in
routine clinical practice is associated with:
– Increase in number of patients initiating
individual topics
– Increase in number of topics being initiated
by individual patients
– Increase in patient conversation time
– No significant lengthening of consultation
Conclusion
The clinical information sheet
facilitates patient involvement in the
consultation
Study Limitations
• Not a randomised controlled trial
• No data collected on patients clinical or
psychosocial outcomes
• No control for possible confounding factors
– Patients demographic, clinical, psychosocial factors
– Doctors characteristics
• Doctors not blinded to patients in the
intervention group
• Risk of observer bias
Further questions
• Does the type of clinical information
shared with patients influence their
involvement in the consultation
(personalised clinical information V
general information on topics)?
• How does such involvement impact on
clinician behaviour?
Proposed research
Quantitative study
Aim
– To explore the impact of sharing different
types of clinical information with Type 2
diabetes patients on patient involvement in
the consultation and patient-related outcomes
Hypotheses
1. Patients receiving an information
intervention will be more involved in the
consultation and have better outcomes
than those in the control group
2. Patients who receive personalised
clinical data will be more involved in the
consultation than those that receiving
general clinical information only.
Study design (1)
Randomisation
Control group
Standard Care
No written clinical
information
General
clinical information
just prior to
consultation
General plus
personalised
clinical information
just prior to
consultation
Study design (2)
Historical
control
Pre-intervention
Randomisation
General
clinical information
just prior to consultation
General plus
personalised
clinical information
just prior to
consultation
Outcome measures
Quantitative study
• Primary outcome
– Patient involvement in the consultation
• Patient outcomes
– Patient satisfaction with the consultation
– Quality of life measure
– Self care behaviour (e.g. adherence to medication, blood
glucose testing, exercise, diet)
– Diabetes self efficacy measure
– Depression/Anxiety
• Secondary outcome measures
– HbA1c
– Cholesterol (?)
– Body mass index(?)
Data collection
• Audiotaping of consultations
• Patient questionnaires
• Medical record data extraction
Audiotaping of consultations
• The percent of patients initiating each
individual topic
• The number of topics initiated by each
individual patient
• The patients’ conversation time vs. total
consultation time
Baseline questionnaire
Baseline
• Demographics (Age, Gender, education)
• Psychosocial measures
• Quality of life
• Self care behaviour
• Diabetes self efficacy
• Depression/anxiety
• Preference for involvement in the
consultation
Patient questionnaire straight
after consultation
• Patient perceived involvement in the
consultation
• Patient satisfaction with the consultation
• Patient perception of facilitation of
involvement
Patient questionnaire 6 weeks
post consultation
Psychosocial measures
• Quality of life
• Self care/self management
• Diabetes self efficacy
• Depression/anxiety
• Preference for involvement in the
consultation
Medical record data (1)
Baseline data
• Number of previous visits
• Duration of Diabetes
• On insulin or medication
• Co morbidities
Medical record data (2)
Post intervention
• At 6 months(?) or whenever patients next
visit to clinic is?
– HbA1c
– Cholesterol
– BMI
Qualitative study
Aim
To explore the nature of patient engagement
in the consultation and how this impacts on
clinician behaviour
Methods
• Data analyses
In-depth analyses of the nature of patients
involvement in the consultation and how
doctors respond to such involvement
Thanks
Any thoughts/comments?