St. Michael's Hospital (Unity Health Toronto), Toronto, ON, Canada.
Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
J Med Internet Res. 2020 Sep 30;22(9):e16984. doi: 10.2196/16984.
Person-centered care is critical for delivering high-quality diabetes care. Shared decision making (SDM) is central to person-centered care, and in diabetes care, it can improve decision quality, patient knowledge, and patient risk perception. Delivery of person-centered care can be facilitated with the use of patient decision aids (PtDAs). We developed MyDiabetesPlan, an interactive SDM and goal-setting PtDA designed to help individualize care priorities and support an interprofessional approach to SDM.
This study aims to assess the impact of MyDiabetesPlan on decisional conflict, diabetes distress, health-related quality of life, and patient assessment of chronic illness care at the individual patient level.
A two-step, parallel, 10-site cluster randomized controlled trial (first step: provider-directed implementation only; second step: both provider- and patient-directed implementation 6 months later) was conducted. Participants were adults 18 years and older with diabetes and 2 other comorbidities at 10 family health teams (FHTs) in Southwestern Ontario. FHTs were randomly assigned to MyDiabetesPlan (n=5) or control (n=5) through a computer-generated algorithm. MyDiabetesPlan was integrated into intervention practices, and clinicians (first step) followed by patients (second step) were trained on its use. Control participants received static generic Diabetes Canada resources. Patients were not blinded. Participants completed validated questionnaires at baseline, 6 months, and 12 months. The primary outcome at the individual patient level was decisional conflict; secondary outcomes were diabetes distress, health-related quality of life, chronic illness care, and clinician intention to practice interprofessional SDM. Multilevel hierarchical regression models were used.
At the end of the study, the intervention group (5 clusters, n=111) had a modest reduction in total decisional conflicts compared with the control group (5 clusters, n=102; -3.5, 95% CI -7.4 to 0.42). Although there was no difference in diabetes distress or health-related quality of life, there was an increase in patient assessment of chronic illness care (0.7, 95% CI 0.4 to 1.0).
Use of goal-setting decision aids modestly improved decision quality and chronic illness care but not quality of life. Our findings may be due to a gap between goal setting and attainment, suggesting a role for optimizing patient engagement and behavioral support. The next steps include clarifying the mechanisms by which decision aids impact outcomes and revising MyDiabetesPlan and its delivery.
ClinicalTrials.gov NCT02379078; https://clinicaltrials.gov/ct2/show/NCT02379078.
以患者为中心的护理对于提供高质量的糖尿病护理至关重要。共同决策（SDM）是以人为本护理的核心，在糖尿病护理中，它可以提高决策质量、患者知识水平和患者风险感知。使用患者决策辅助工具（PtDAs）可以促进以人为本的护理的实施。我们开发了 MyDiabetesPlan，这是一种互动式 SDM 和目标设定 PtDA，旨在帮助个性化护理重点，并支持以跨专业方式进行 SDM。
本研究旨在评估 MyDiabetesPlan 对个体患者的决策冲突、糖尿病困扰、健康相关生活质量和慢性病护理评估的影响。
采用两步、平行、10 个地点的群组随机对照试验（第一步：仅提供提供者指导实施；第二步：提供者和患者在 6 个月后共同指导实施）进行。参与者为安大略省西南部 10 个家庭健康团队（FHT）的 18 岁及以上患有糖尿病和其他两种合并症的成年人。FHT 通过计算机生成的算法随机分配到 MyDiabetesPlan（n=5）或对照组（n=5）。MyDiabetesPlan 整合到干预实践中，临床医生（第一步）随后患者（第二步）接受了其使用的培训。对照组参与者接受了静态通用的加拿大糖尿病资源。参与者未被设盲。参与者在基线、6 个月和 12 个月时完成了经过验证的问卷。个体患者层面的主要结局是决策冲突；次要结局是糖尿病困扰、健康相关生活质量、慢性病护理和临床医生实践跨专业 SDM 的意愿。使用多层次层次回归模型。
在研究结束时，与对照组（5 个集群，n=102）相比，干预组（5 个集群，n=111）的总决策冲突略有减少（-3.5，95%CI-7.4 至 0.42）。尽管糖尿病困扰或健康相关生活质量没有差异，但慢性病护理评估有所增加（0.7，95%CI0.4 至 1.0）。
使用目标设定决策辅助工具可适度改善决策质量和慢性病护理，但不能改善生活质量。我们的发现可能是由于目标设定与实现之间存在差距，这表明需要优化患者参与和行为支持。下一步包括澄清决策辅助工具影响结果的机制，并修改 MyDiabetesPlan 及其实施。
ClinicalTrials.gov NCT02379078；https://clinicaltrials.gov/ct2/show/NCT02379078。
