Patients with type 2 diabetes are increasingly living with multiple concurrent conditions and complicated medical regimens. For these patients, diabetes management decisions and treatment goals must be addressed within the larger context of other competing health concerns. In parallel, clinical advances have led to a substantial increase in the number of tasks that primary care providers must perform during each visit. These twin trends of patient and visit complexity present a formidable challenge to effective diabetes primary care. Although there are a variety of non-visit strategies that can and are being instituted to address these issues, the primary care visit remains a vital opportunity fo catalyzing changes in diabetes care. To achieve this change, efficient and scalable tools to support more productive primary care encounters are needed. We hypothesize that among patients with type 2 diabetes and elevated HbA1c, a systematic approach that enables patients to explicitly prioritize their top diabetes and non-diabetes related health concerns before the primary care visit will result in more effective diabetes care over time. To test this hypothesis, our proposal's aims are to:1) Design and implement a web-based tool linked to the electronic medical record that will enable complex patients to indicate, and PCPs to review, patients' top health priorities for their upcoming visit; 2) Conduct a randomized clinical trial among patients with type 2 diabetes and elevated HbA1c testing the impact on intermediate care outcomes (medication adherence, medication intensification) compared to usual care and HbA1c (primary clinical outcome), blood pressure, and lipid control (secondary clinical outcomes) compared to usual care; 3) Among a sub-set of intervention participants (patients and PCPs), use mixed qualitative and quantitative methods to examine the impact of pre-visit prioritization on the content of subsequent visit discussions and examine the influence of patient and PCP factors on these discussions. The key conceptual innovation of this study is to test a replicable, low-cost approach to improving diabetes primary care that explicitly integrates non-diabetes problems into the process of diabetes management. We will implement an easy-to-use web-based tool linked to our EPIC(R)-based electronic medical record. This patient-centered care model has the potential to significantly improve the design of primary care systems responsible for providing patient-centered care and offers an innovative approach to improving the care of increasingly complex patients with type 2 diabetes. This study addresses the three NIH priorities of translating evidence into practice, improving medication adherence, and understanding health care disparities. If successful, we will work to actively disseminate the tool throughout our system and to other U.S. care organizations.
Type 2 diabetes is increasing in prevalence, cost, and impact on our health system. A growing number of patients with type 2 diabetes live with multiple concurrent conditions that require complicated medical regimens and daily self-management behaviors. We propose to implement and evaluate a novel, patient-centered intervention designed to facilitate communication between patients and their primary care providers with the goal of enabling more effective primary care for complex patients with poorly controlled diabetes.
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