The practice of evidence-based medicine can be especially challenging when managing patients with diabetes. Patients’ care needs are frequently discussed in routine clinical encounters, but little is known about how patients feel about their burden of treatment (BOT) or if conversations on this topic occur with regularity. In addition, BOT can be interpreted differently by healthcare providers and patients. Issues with BOT may lead providers to intensifying treatments for patients so that they achieve therapeutic targets. Patients, on the other hand, may view BOT more in the context of problems with access to care, side effects, or daily self-care demands.
Intriguing New Data on Diabetes Treatment Burden
In the January 2012 issue of Diabetes Care, my colleagues and I analyzed videos of primary care encounters between patients with type 2 diabetes and clinicians. Our objective was to see if patients with type 2 diabetes and their clinicians discussed BOT, the characteristics of these discussions, and attempts to address and reduce BOT during visits. Two coders independently reviewed videos of primary care visits from patients with type 2 diabetes. Verbalizations concerning BOT were identified and then classified by topic and by whether BOT was addressed.
Of the 46 visits analyzed, 43 (93.5%) contained BOT discussions. BOT was explicitly addressed only 30% of the time by clinicians, even though patients initiated 55% of the BOT discussions observed in the analysis. Our results suggest that patients with diabetes routinely discuss BOT with clinicians, but often with no effect. Access to care was prevalently addressed, but administration and monitoring were largely unaddressed. This finding suggests that there may be concern among patients about the day-to-day self-care demands associated with appropriate diabetes care.
Important Contributions: “Real-Time” Patient Visits
Few studies have addressed how patients talk about BOT and clinician responses to such discussions, but it’s important to explore this patient-experienced phenomenon further. More work is needed to further develop and validate BOT domains in future analyses. The current shortcomings in knowledge about BOT may be overcome with the development of validated measures and qualitative inquiries. The data we collected offer important strengths and contributions. Unlike surveys, the direct observation and data collected was from “real-time” patient visits. This helps negate the need for retrospective analysis. Participants were also unaware of the purpose of the study during their visits.
Minimizing the Diabetes Treatment Burden
Minimally disruptive medicine is a term that refers to the practice of medicine which seeks to design effective treatment programs for patients while minimizing BOT. The purpose is to establish treatment programs that fit with patients’ goals in the context of making such programs a “normal” part of their life. My colleagues and I have created a blogging website—www.minimallydisruptivemedicine.org—to provide a forum for providers and patients to understand and implement minimally disruptive medicine programs. The website is available for free, and we’re hoping the information it provides helps to close gaps in BOT in patients with diabetes and other chronic conditions.
More Work Ahead
In the context of type 2 diabetes, failure to take action after BOT is articulated represents a lost opportunity to offset preventable non-adherence and costs and to perhaps enhance quality of life for patients. Greater education on strategies for discussing and addressing BOT with patients may be of great value as the overall burden of diabetes continues to increase.
Readings & Resources (click to view)
Bohlen K, Scoville E, Shippee ND, et al. Overwhelmed patients: a videographic analysis of how patients with type 2 diabetes and clinicians articulate and address treatment burden during clinical encounters. Diabetes Care. 2102;35:47-49. Available at: http://care.diabetesjournals.org/content/35/1/47.
Mullan RJ, Montori VM, Shah ND, et al. The diabetes mellitus medication choice decision aid: a randomized trial. Arch Intern Med. 2009;169:1560-1568.
Vijan S, Hayward RA, Ronis DL, Hofer TP. Brief report: the burden of diabetes therapy: implications for the design of effective patient-centered treatment regimens. J Gen Intern Med. 2005;20:479-482.
Brod M, Hammer M, Christensen T, et al. Understanding and assessing the impact of treatment in diabetes: the Treatment-Related Impact Measures for Diabetes and Devices (TRIM-Diabetes and TRIM-Diabetes Device). Health Qual Life Outcomes. 2009;7:83.
Van Dulmen AM, Bensing JM. Health promoting effects of the physician-patient encounter. Psychol Health Med. 2002;7:289-300.
Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002;15:25-38.
Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153:69-75.