The design of a decision aid about diabetes medications for use during the consultation with patients with type 2 diabetes

https://doi.org/10.1016/j.pec.2008.07.024Get rights and content

Abstract

Objective

To describe the process used to develop a medication choice decision aid (DA) for patients with type 2 diabetes.

Methods

We developed the DA through active collaboration with patients, clinicians, and designers, direct observations of clinical encounters, literature review, and collaborative development of design criteria. Insights from these processes informed the iterative creation of prototypes that were reviewed and field tested in actual consultations.

Results

The goal of the DA was to facilitate a conversation between the clinician and the patient about diabetes medication options. Four iterations of the DA were developed and field-tested before arriving at issue cards that organized the data for five medications around glucose control, hypoglycemia, weight changes, daily routine, self-monitoring and side effects. These cards successfully generated conversations during consultations. An ongoing clinical trial will determine if this DA affects patient adherence and outcomes.

Conclusions

A collaboratively developed DA designed to create a conversation about diabetes medications may lead to more patient-centered treatment choices.

Practice implications

If effective, this DA could replace disease-centered treatment algorithms for patient-centered conversations that enhance the management of patients with type 2 diabetes.

Introduction

Patients with type 2 diabetes and their clinicians constantly face the challenge of achieving adequate glycemic control. The priority placed on this challenge results from the expectation that tighter glucose control, i.e., lower HbA1c levels, through lifestyle modification and judicious use of antihyperglycemic medications, will reduce the risk of diabetes complications [1].

In the last 10 years, new antihyperglycemic agents have joined insulin and sulfonylureas in the pharmacological armamentarium. This has increased the complexity of managing type 2 diabetes with medications. For instance, clinicians need to choose which agents to use, when, and in what sequence as they intensify therapy over time [2]. Clinicians have reported feeling unsupported and confused about this choice [3]. To address this concern, experts have proposed algorithms of treatment that do not explicitly incorporate patient preferences [4].

In applying treatment algorithms [2], [4], clinicians focus on the HbA1c levels, inform patients that this level needs to be reduced, and suggest a course of action (the rationale for which is not always made explicit to the patient), which may be the addition of a new medication or adjustments to current therapies. The patients leave the consultation with new orders and prescriptions. It is only after the visit that these patients decide whether to fill the prescription, to take it as prescribed, or to take it at all according to their preferences [5], [6], [7]. In fact, patient preferences may surprise clinicians: some patients perceive the impact of diabetes medications on their quality of life to exceed that of diabetes complications [8].

In what may be a common scenario in practice, we observed that patients’ delayed decisions come after busy clinicians with limited communication skills and disempowered patients have brief, hurried, and disorganized visits in which patients do not ask questions or challenge the clinicians’ recommendations. In making a choice after the visit, the patient's decision making happens without accessing the clinician's rich knowledge base and expert judgment, which might be able to counter misconceptions. Clinicians are denied the opportunity to offer alternatives knowing that the one recommended failed to meet patient's needs and wants. Poor patient and clinician communication can harm their partnership, a critical component in the care of patients with chronic conditions [9]. Indeed, the shared treatment decision making model for patients with chronic conditions, including diabetes, starts with partnership building and includes sharing of information, shared deliberation and decision making [9].

It was with this disconnect in mind that we set out to develop a diabetes medication decision aid that would encourage patients to consider and voice their questions, concerns and issues to the clinician, effectively shifting the timing of the patient's decision to occur during the consultation. In this article, we present the process we followed to create a decision aid that could get patients and clinicians to have a conversation about diabetes medication choices during the consultation.

Section snippets

The team

The development team for this project represented a unique partnership between researchers, clinicians, patients, and designers. We approached the development of the decision aid with an improvisational spirit that encouraged each to bring the methodologies and ideas from their own disciplines and experiences to the table. The approach we used, with foundations in the design discipline and sometimes called design research, shares common elements with participatory action research and field

Design criteria

The first step in creating this type of decision aid was to understand the participants, environment and nature of the current conversation. We did this by observing about 25 consultations in which clinicians offered treatment recommendations about diabetes medications. From those observations, we collaboratively developed the following insights to guide the development process:

  • Clinicians bring to the consultation clinical expertise that combines medical knowledge with practice experience. This

Discussion

In this paper we have described the process we used to generate a novel decision aid to help patients with diabetes and their clinicians have a conversation about diabetes medications. These conversations, we hypothesize, would lead to patient-centered decisions made during the visit.

In conducting this process, we made some choices that warrant discussion. Our goal of generating a conversation about diabetes medications may have also furthered the partnership between patients and clinicians, an

Conflict of interest

The authors have no conflict of interest to declare; in particular no member of the investigative team has now or has had in the past any financial ties with any pharmaceutical company.

Acknowledgments

We are grateful for the generous contribution of members of the Patient Advisory Group, and of volunteer clinicians and patients who were willing to try the iterations of our prototype decision aids during their consultations while allowing our direct observation. We also appreciate the support of our colleagues from the SPARC Innovation Program, the Knowledge and Encounter Research Unit, and the Section of Illustration and Design at Mayo Clinic specifically Chad Ridgeway, Daryl Luepke and

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