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

• Present results from pilot study conducted in 2007
• Outline some thoughts on how we can progress this work

• 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

• 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
Primary
Care
Diamond
Specialist care

To measure the impact of sharing personalised clinical information in written format with patients on the clinical consultation

• 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

• Weight
• BMI
• BP
• Blood sugar range
• Exercise
• Diet
• HbA1c
• ACR
• Creatinine
• Cholesterol
• LDL
• TG
• HDL
• Diabetic medication
• Diabetic complication
• Other problems
• Other medications

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?

Patient name:
Address:
Postcode:
GP name:
Address:
Postcode:
Phone:
To be seen by:
Date:
Date of clinic: 31/07/2007
Date of pre-assessment:
Board number
Date of birth: 08/09/1950 Male Sex
Type of diabetes
Duration:
Consultant:
Seen by
Clinic type:
Alcohol:
Height:
Smoking status:
Type 2
3 years
Diabetes clinic
1.76
Past smoker
DSN: Yes/No Dietitian Yes/No Podiatrist
Weight BMI HbA1c BP sys BP dia AER ACR Creat
Yes/No
Chol LDL HDL
Targets
Current
7.5 130 80 3.5 106
TG
4.5 2.5 1.0 2.0
23/07/2007
15/05/2007
23/04/2007
23/01/2007
16/01/2007
95.70 30.90
97.10 31.30
95.90 31.00
6.9
152/81
7.0
143/77
130/80
Treatment: Type 2
Blood sugar range:
No onsets:
Problem list: Rheumatic fever (13 years), Hypertension
Tablets
Metformin
Hypos:
Non-Diabetic Drugs:
68 5.1 3.1 1.2 .1.3
5.0 3.0 1.1 2.0
Break Lunch Tea
850 850 850
Frequency:
Aspirin 75 mg od, Atenolol 100mgs od, Irbesartan 150/125, Pravastatin 20 mgs nocte
Supper

• 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

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
Intervention group (n ═ 63)
Male
Female
Age
≤39 yrs
40−64yrs
65+ yrs
Control group %(n)
65(28)
35(15)
14 (6)
42(18)
44(19)
59 (37)
41(26)
14(9)
44(28)
41(26)
Diabetes type
Type 1
Type 2
Other
Diabetes duration
Under 1 year
1 −5 years
>5−10 yrs
10 yrs+
19 (8)
79 (34)
2 (1)
7(3)
35 (15)
23 (10)
35(15)
27(17)
73 (46)
0(0)
11(7)
22 (14)
32(20)
35 (22)

60%
50%
40%
30%
20%
10%
0%
W eig ht
BM
I
BP
Blo od
Su ga r R an ge
Ex er cis e
Die t
Hb
A1
C
AC
R
Cr ea tin in e
Ch ole st er ol
LDL HDL
Tr ig ly
Dia be ce rid e tic
M
Dia ed ica tio n be tic
C om plic at io
O th er n
P ro ble m s er
M ed ic
O th at io ns
Intervention
Control

Mean patient score
Control group = 1 (range 0-4)
Intervention group = 5 (range 0-14)
No topics raised
Control group (49%)
Intervention group (16%)

10
8
6
4
2
0
20
18
16
14
12
P>0.05
P<0.05
Total Consultation
Time
Patient Conversation
Time
Intervention Control

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

The clinical information sheet facilitates patient involvement in the consultation

• 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

• 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?

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

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.

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

Historical control
Pre-intervention
Randomisation
General clinical information just prior to consultation
General plus personalised clinical information just prior to consultation

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(?)

• Audiotaping of consultations
• Patient questionnaires
• Medical record data extraction

• 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

• Demographics (Age, Gender, education)
• Psychosocial measures
• Quality of life
• Self care behaviour
• Diabetes self efficacy
• Depression/anxiety
• Preference for involvement in the consultation

• Patient perceived involvement in the consultation
• Patient satisfaction with the consultation
• Patient perception of facilitation of involvement

• Quality of life
• Self care/self management
• Diabetes self efficacy
• Depression/anxiety
• Preference for involvement in the consultation

Baseline data
• Number of previous visits
• Duration of Diabetes
• On insulin or medication
• Co morbidities

Post intervention
• At 6 months(?) or whenever patients next visit to clinic is?
– HbA1c
– Cholesterol
– BMI

Aim
To explore the nature of patient engagement in the consultation and how this impacts on clinician behaviour

• 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?