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

Participatory decision making during primary care encounters by patients with Type 2 diabetes resulted in improvements in hemoglobin A_1c levels….

Participatory decision making (PDM) is associated with improved diabetes control. The study examined a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence.

This observational study was conducted in 5 family physician offices. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their office 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 A1c, 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.

Questionnaires were mailed 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 significantly, 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.

The results suggest that PDM may contribute to such improved clinical outcomes as control of hemoglobin A_1c level, systolic blood pressure, and LDL cholesterol level through its actions on patient activation and medication adherence. The results supported all 3 hypotheses: (1) patients who report a higher level of participatory decision making are more likely to actively participate in the medical encounter; (2) active participation in the encounter is associated with medication adherence; and (3) medication adherence was associated with improvement in control of glucose and lipids, but not with blood pressure.

Multiple studies have documented the benefit of shared or participatory decision making, including better recovery from discomfort, better emotional health, and fewer diagnostic tests and referrals, better self-care activities, and improved clinical outcomes.

From the results it was concluded that 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.

Annals of Family Medicine 2010; 8(5):410-417