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Patient-centred diabetes care

 

Doctors and nurses do not deal with diseases; they deal with people who are concerned about their health. A growing interest in a patient-centred approach to care and treatment reflects this and encourages clinicians to think about ways of integrating patients' perceptions into consultations. There is growing evidence that this integrated approach improves outcomes. But what is the best way to encourage clinicians to think and behave differently? Most of the studies so far about patient-centred care have been based in secondary care. How can these approaches be adopted in primary care? This was the question a study based in Wessex has sought to answer. Could additional training lead to better communications between clinicians and patients and improved health outcomes?

Reference

AL Kinmonth et al. Randomised controlled trial of patient-centred care of diabetes in general practice: impact on current wellbeing and future disease risk. BMJ 1998; 317:1202-8.

How was the question tackled?

A Medline search identified no previous trials of using training programmes for clinicians to increase patient involvement in primary care. The team chose to set up a randomised-controlled trial in which the intervention group would be trained to give patient-centred care and a comparison group trained to give routine care for patients with newly diagnosed type 2 diabetes. The approach to care was based on national diabetes guidelines. Additional training was provided for the intervention group: one and a half days for the nurses and half a day for the doctors. Material for the intervention group included a booklet for patients Diabetes in your hands and a booklet for clinicians describing approaches to behaviour change. Other later, support sessions allowed nurses in the intervention group to review their new skills in the light of experience. Nurses in the control group were offered sessions on the use of guidelines and educational materials.

The trial was based in Wessex. Inclusion criteria for the trial sought mid-size practices with 4 medical partners, with list sizes of about 7,000 patients, and a diabetes service registered with the health authority. 52% (245) practices met the criteria and 41 practices agreed to take part in the trial: 21 practices in the intervention group and 20 in the control group. Teams in the intervention practices had 23 doctors and 32 nurses and teams in the control group 20 and 32 respectively. No attempt was made to ensure that clinicians committed to patient-centred care were in the intervention group. For twelve months nurses reported all newly diagnosed patients to the trial office. Patients aged 30-70 years were asked to sign consent forms if they were willing to be included in the trial. Criteria were set to exclude certain groups of patients, for example those housebound or mentally ill.

A careful approach was taken to measuring outcomes, to establish the baseline situation in the intervention and control groups and to assure the quality of the data collected. Data was collected before the trial started by nurses from clinical notes; year one data was collected by research nurses and summarised at three levels: patient, practitioner and practice level. There were no significant differences between the two groups for important baseline measures at these three levels.

Processes measured included the use of skills and materials, patients' ratings of communications with clinicians, satisfaction with treatment and patients' knowledge. Principal outcomes included lifestyle, blood glucose control and psychological status. Clinical status was determined using a range of clinical tests, such as percentage of glycated haemoglobin and total plasma cholesterol concentration. Several measures of functional and psychological status were used, such as the audit of diabetes dependent quality of life ADDQoL). Some of these measures were developed for the study; others modified from published sources

What did the trial show?

During the trial, the 41 practice teams diagnosed type 2 diabetes in 522 patients of whom 360 were eligible for inclusion in the trial. 250 of these patients completed the study: 142 in the intervention group and 108 in the control group. Non-respondents were equally distributed across the two groups. All trained nurses who responded (28/32) used the booklet Diabetes in your hands and at the end of the trial 75% of patients in the intervention group recognised it - compared with 2% in the control group. All responding trained nurses (28/32) and doctors (19/23) reported using patient centred consulting with the majority reporting extensive use of the approach.

Communications and satisfaction were rated highly by patients in both groups. Patients in the intervention group were more likely to report excellent communications with doctors and greater satisfaction with treatment. Agreement between patients and practitioners on main concerns discussed over the year were similar in both groups. Knowledge scores were significantly lower in the intervention group with differences confined to patients prescribed hypoglycaemic drug treatment. For lifestyle measures, diet and exercise, the scores were similar in both groups. The results of the clinical measures at one year were encouraging, confirming that patient-centred care can be adopted without loss of glycaemic control.

What has the study told us?

The trial showed some improvements in processes and outcomes but did not achieve the better control of diabetes, healthier lifestyles and knowledge of self-care anticipated. There were no signs that management improved with experience, i.e. Haemoglobin A concentrations among patients in whom type 2 diabetes was diagnosed later in the study were no lower at one year. Moreover, knowledge scores for patients were lower and weight and other cardiovascular risk factors higher among those attending trained practice teams.

There are no definitive reasons why more improvements were not achieved - but the report of the study offers several possible reasons. For example, was the study underpowered to detect the small differences in blood glucose concentrations achievable one-year after diagnosis?

This is an interesting study that is refreshingly frank: too few studies that have minimal or little effect tend to be well reported. It has shown the power of the consultation to affect patients' health and well being. But there are clear signals to remind clinicians committed to the benefits of patient-centred care that they should not loose the essential focus on the disease while paying attention to the unique needs of the individual patient.