The diabetes mellitus medication choice decision aid: a randomized trial

Impact on decisions to start or continue medicines of providing information to patients about possible benefits and/or harms: a systematic review and meta-analysis

BACKGROUND

The impact of providing information about medicines to patients on decisions about starting or continuing them is unknown.

PURPOSE

To estimate the impact on decisions to start or continue medicines, of providing information to patients about possible benefits and/or harms.

DATA SOURCES

Electronic searches from 1980 to October 2010; reference and citation searches of included studies.

STUDY SELECTION

Two investigators assessed studies' eligibility against inclusion criteria: randomized or pseudorandomized trials; participants older than 16 years and deciding for themselves; one group received information about possible benefits and/or harms of a potentially beneficial medicine, compared with another who did not; d) a measure of decision about starting or continuing a medicine.

DATA EXTRACTION

One investigator extracted all data, checked by a second.

DATA SYNTHESIS

Eight studies were included, covering a range of medicines. There was no consistent impact of interventions on decisions about whether to start or continue medicines (pooled odds ratio 1.08; 95% confidence interval [CI], 0.69-1.70; P = 0.74). Among those who received more information, knowledge was increased (pooled mean difference 8.47; 95% CI 2.17-14.77; P = 0.008), and decisional conflict was reduced (pooled mean difference -0.15; 95% CI -0.24 to -0.06; P = .001).

LIMITATIONS

A small number of studies across different clinical contexts, of uncertain heterogeneity, were included.

CONCLUSIONS

Providing information to patients about possible benefits and/or harms has no consistent effect on the number who decide to start or continue medicines, although it increases patients' knowledge and reduces their decisional conflict.

Effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes: a systematic review

EXECUTIVE SUMMARY

Background As a chronic condition, the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications, an essential component of self-management, has been shown to improve glycaemic control. However compliance with oral medication adherence remains poor. Educating people with Type 2 diabetes is an important strategy to enhance self-management ability, including medication-taking behaviour.Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes.

INCLUSION CRITERIA

Types of participants Studies involving adults over 18 years old with Type 2 diabetes, with or without co-morbidities, currently taking oral hypoglycaemic medication without insulin treatment, and with aglycated haemoglobin (HbA1c) > 7.0% prior to the intervention were considered. Aglycated haemoglobin (HbA1c) concentration of less than 7.0%, is important in order to delay or prevent diabetes-related complications. Participants could be from the primary, tertiary or acute care setting.Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aimed at improving participants' knowledge.Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c, fasting blood glucose levels and other relevant indicators.Types of studies Studies that were randomized controlled trials (RCTs) or case-control studies were considered.Search strategy A three-stage search strategy was employed. Papers in English and between the years 1990-2009 were searched in the following databases: CINAHL, Medline, Mosby's Nursing Consult, PsycINFO, PubMed, ScienceDirect, Scopus, TRIP and Web of Science. Full text was retrieved when the titles and abstracts of studies fulfilled the inclusion criteria.Methodological quality Full papers were assessed for methodological quality independently by two reviewers using critical appraisal checklists from the Joanna Briggs Institute (JBI). A third reviewer was consulted whenever there were disagreements between the two reviewers.Data collection/extraction Details of each study included in the review were extracted using standardized data extraction forms developed by JBI. Extraction was conducted independently by two reviewers.Data synthesis Meta-analysis was not possible due to methodological and statistical heterogeneity of the included studies. Hence study findings are presented in narrative form.Results Seven studies included in the final review consisted of seven RCTs. Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care. These included pharmacist-led interventions, individual diabetes education provided by nurses and diabetes group education based on a self-management approach. Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions. However, small samples in some studies limited generalization of results.

CONCLUSIONS

Implications for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence. Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence. Educational interventions focusing on self-management strategies appear more likely to achieve positive outcomes.Implications for research Further trials involving larger samples and populations with poor glycaemic control are needed. The effects of educational interventions, influence of additional take-home written material, the optimal interval length of follow-up and duration of education sessions, and specific processes of individual or group education which have been identified as effective need further exploration.

Translating comparative effectiveness into practice: the case of diabetes medications

BACKGROUND

In recent years, there has been significant interest and investment in conducting comparative effectiveness research (CER) of medical treatments to improve the quality of care and reduce costs. The Agency for Healthcare Research and Quality (AHRQ) has been leading this effort and has invested a significant amount of resources to advance CER. However, little is known about translating the findings from CER into routine practice such that it provides value to the patients, clinicians, and the healthcare system.

METHODS

We present the role of shared decision making for patient-centered CER translation and its application to diabetes medications. CER of oral diabetes medications suggests that all medications are similar in their effects on glycemic control, but there is variability in side-effects, which may affect medication adherence and treatment intensification. Shared decision making, facilitated by tools such as decision aids, may enhance the quality of diabetes care by activating patients, enhancing the patient-clinician communication, and improving uptake and adherence to the medication that is determined to be consistent with patients' goals, values, and preferences. We describe the iterative, multidisciplinary process for developing and testing a diabetes medication decision aid, and examine the implications for CER translation.

RESULTS

In our pilot study we found the decision aid to be acceptable to patients and providers and effective for knowledge translation; however, it did not impact short-term outcomes.

DISCUSSION

Our pilot trial found that decision aids enhanced the discussion about diabetes medications without any adverse effects on the outcomes. Further issues related to the use of decision aids to translate CER need to be addressed in larger trials to understand the effectiveness and efficiency of translating evidence into routine practice in unique contexts of patients, providers, and healthcare systems.

The Chest Pain Choice trial: a pilot randomized trial of a decision aid for patients with chest pain in the emergency department

BACKGROUND

Chest pain is a common presenting complaint in the emergency department (ED). Despite the frequency with which clinicians evaluate patients with chest pain, accurately determining the risk of acute coronary syndrome (ACS) and sharing risk information with patients is challenging. The aims of this study are (1) to develop a decision aid (CHEST PAIN CHOICE) that communicates the short-term risk of ACS and (2) to evaluate the impact of the decision aid on patient participation in decision-making and resource use.

METHODS/DESIGN

This is a protocol for a parallel, 2-arm randomized trial to compare an intervention group receiving CHEST PAIN CHOICE to a control group receiving usual ED care. Adults presenting to the Saint Mary's Hospital ED in Rochester, MN USA with a primary complaint of chest pain who are being considered for admission for prolonged ED observation in a specialized unit and urgent cardiac stress testing will be eligible for enrollment. We will measure the effect of CHEST PAIN CHOICE on six outcomes: (1) patient knowledge regarding their short-term risk for ACS and the risks of radiation exposure; (2) quality of the decision making process; (3) patient and clinician acceptability and satisfaction with the decision aid; (4) the proportion of patients who decided to undergo observation unit admission and urgent cardiac stress testing; (5) economic costs and healthcare utilization; and (6) the rate of delayed or missed ACS. To capture these outcomes, we will administer patient and clinician surveys after each visit, obtain video recordings of the clinical encounters, and conduct 30-day phone follow-up.

DISCUSSION

This pilot randomized trial will develop and evaluate a decision aid for use in ED chest pain patients at low risk for ACS and provide a preliminary estimate of its effect on patient participation in decision-making and resource use.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT01077037.

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).

Protocol for the Osteoporosis Choice trial. A pilot randomized trial of a decision aid in primary care practice

Background

Bisphosphonates can reduce fracture risk in patients with osteoporosis, but many at-risk patients do not start or adhere to these medications. The aims of this study are to: (1) preliminarily evaluate the effect of an individualized 10-year osteoporotic fracture risk calculator and decision aid (OSTEOPOROSIS CHOICE) for postmenopausal women at risk for osteoporotic fractures; and (2) assess the feasibility and validity (i.e., absence of contamination) of patient-level randomization (vs. cluster randomization) in pilot trials of decision aid efficacy.

Methods/Design

This is a protocol for a parallel, 2-arm, randomized trial to compare an intervention group receiving OSTEOPOROSIS CHOICE to a control group receiving usual primary care. Postmenopausal women with bone mineral density T-scores of <-1.0, not receiving bisphosphonate therapy, and receiving care at participating primary care practices in and around Rochester, Minnesota, USA will be eligible to participate in the trial. We will measure the effect of OSTEOPOROSIS CHOICE on five outcomes: (a) patient knowledge regarding osteoporosis risk factors and treatment; (b) quality of the decision-making process for both the patient and clinician; (c) patient and clinician acceptability and satisfaction with the decision aid; (d) rate of bisphosphonate use and adherence, and (e) trial processes (e.g., ability to recruit participants, collect patient outcomes). To capture these outcomes, we will use patient and clinician surveys following each visit and video recordings of the clinical encounters. These video recordings will also allow us to determine the extent to which clinicians previously exposed to the decision aid were able to recreate elements of the decision aid with control patients (i.e., contamination). Pharmacy prescription profiles and follow-up phone interviews will assess medication start and adherence at 6 months.

Discussion

This pilot trial will provide evidence of feasibility, validity of patient randomization, and preliminary efficacy of a novel approach -- decision aids -- to improving medication adherence for postmenopausal women at risk of osteoporotic fractures. The results will inform the design of a larger trial that could provide more precise estimates of the efficacy of the decision aid.

Trial registration

Clinical Trials.gov Identifier: NCT00578981