A Simple Tool Can Enhance How Patients With Diabetes Take Their Medications

Main Category: Compliance
Also Included In: Diabetes
Article Date: 30 May 2007 - 0:00 PDT

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Though diabetes contributes to nearly a quarter million deaths in the United States annually, patients with chronic ailments don't always take their medication as prescribed. A Mayo Clinic research team has designed a simple tool to improve compliance with life-saving medications. The tool is clearly effective and preferred by 84 percent of patients, according to a study published in the May 28 issue of the Archives of Internal Medicine.

Victor Montori, M.D., an endocrinologist at Mayo Clinic and lead investigator of the study, recommends using this tool as a decision aid to spark conversation between doctors and patients about medication. It consists of an easy-to-follow guide with answers to four questions tailored to individual patients: (1) What is your risk of having a heart attack in 10 years? (2) What are the benefits of taking statins as compared to not taking statins? (3) What side effects can you expect from statins? (4) What do you want to do now?

"Conversations with patients about prescription medications tend to be brief and incomplete, but we found that when a decision aid was introduced, it was the start of a conversation in which the patient -- now better equipped with information -- felt empowered to participate in deciding whether a statin would be appropriate for them," Dr. Montori says.

How They Did It

The study was done in concert with Mayo's SPARC Innovation Program. SPARC (See, Plan, Act, Refine and Communicate) is a laboratory that identifies innovative and effective ways to improve health care. Dr. Montori is director of research and education at SPARC.

This preliminary study focused on compliance with statins among diabetes patients. (Statins are used to lower cholesterol and thus, lower the risk of developing heart disease, which is often a complicating factor with diabetes.) Dr. Montori videotaped 98 sessions between doctors and patients. Only half the patients expressed satisfaction with the way they get information now, compared to 84 percent of patients who were satisfied with the decision aid.

Patient-doctor visits took on an entirely new dimension after the decision aid was introduced: body postures changed as patient and physician leaned in to focus on the material and both listened intently during the ensuing conversation.

"The first thing that is apparent in the videotape: the nature of the conversation changes when the decision aid is introduced. Without the decision aid, their body language was not in synch; but with this tool, their postures changed while they both focused on the decision aid. The quality of the communication, both verbal and nonverbal, improved as did the relationship," Dr. Montori says.

The decision aid plainly and simply displays for a patient his or her risk of heart attack in the next 10 years with and without a statin. Is the risk worth it? "That much people understand," he says. "If my risk of having a heart attack is very small, a pill that reduces that risk may not be worth it for me, but if my risk is really high, a pill that reduces that risk sounds compelling." Once a patient has a sense of the potential benefits, they can look at the potential downsides (side effects and costs) and make an informed choice with their clinician.

Among the decision-aid users, the number of patients still taking a statin after three months increased threefold. The decision aid had a greater impact on patients with a high risk of heart attack as compared to low risk patients. The high-risk group was more likely to start using statins than low-risk patients

Conversation is Critical

So why don't these conversations take place in the absence of a decision aid?

"That's a good question as we put forward that having an open and candid conversation with your physician is a primary reason for the visit. But clinicians are not necessarily trained to help patients make decisions using quantitative information. Secondly, we don't have tools available to routinely do this in a meticulous way. Thirdly, there is no perceived need for this despite scores of patients who start medication but don't follow through or even fill the prescription," Dr. Montori says.

"Time is the universal barrier in any effort to improve the health care experience. Society needs to have this discussion: How should we dedicate the time in the visit? If we have programs to improve the quality of care, should those programs include tools like this to ensure that patients make better decisions with their clinician and take their medications as prescribed or would that visit be better spent in other ways?" Dr. Montori asks.

Dr. Montori and his research team continue to study the effectiveness of this and other decision aids for diabetes patients. In addition, they are currently developing decision aids for patients with other chronic conditions. Mayo researchers plan to collaborate with researchers at Mount Sinai Hospital in New York City, which serves a disproportionately high number of Hispanics with diabetes, to conduct.

The study was funded by Mayo Clinic and the American Diabetes Association. Study co-authors include: Audrey Weymiller; Lesley Jones; Sandra C. Bryant; Teresa Christianson; Rebecca Mullan; Steven A. Smith, M.D., all of Mayo Clinic's Knowledge and Encounter Research Unit; and Amiram Gafni, Ph.D.; and Gordon H. Guyatt, M.D.; both of McMaster University in Hamilton, Ontario.

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