Participatory Decision Making, Patient Activation, Medication Adherence, and Intermediate Clinical Outcomes in Type 2 Diabetes: A STARNet Study

Using sophisticated methods, this paper nicely connects the dots between physician communication behaviors, patient activation, adherence and intermediate outcomes and lays the ground work for next steps.

The looming question is: which way are the arrows connecting these dots pointing? Are physicians with greater participatory decision making (PDM) really activating their patients? Or are more activated patients (who are also more likely to adhere) prompting more PDM among their physicians?

Direct observation of patient visits show that physicians' communication style is affected by the patient they are seeing. Physicians tend to be more patient centered with patients they perceive as more effective communicators, more satisfied, and most importantly, more likely to adhere (1).

Findings from this study by Parchman et al do not tell us which arrow in the bidirectional relationship between patients and physician communication is bigger.

To address this question, an interventional study designed to improve physicians' PDM as a means to improve control of LDL levels and a1c is needed. The size of the arrow leading from physician to patient will determine how large a study is needed to detect an effect.

The answer has important implications for physician/clinician training and quality improvement efforts.

1.Street RL Jr. Gordon H. Haidet P. Physicians' communication and perceptions of patients: is it how they look, how they talk, or is it just the doctor?Social Science & Medicine. 2007 65(3):586-98.

Competing interests:   None declared

Attractive theories of how clinical care ought to be provided often founder on the rocks of clinical reality. There has been strong theoretical and intuitive support, for example, that “activating” patients to be more engaged partners in their diabetes care should lead to better outcomes. The consensus has been that the way to patient activation is through a physician communication style that encourages participatory decision making. As clinicians, though, we are all aware of patients who prefer to hand over responsibility to the provider and who seem to do better when “told what to do.” Would implementing interventions that increase participatory decision making with the intent of increasing patient activation lead to better outcomes? Actual research data in this area are sparse.

The current paper by Parchman et al, which builds on these investigators’ excellent track record of delving into the clinical care process to collect empiric data (1,2), directly measures these theoretical constructs. They prospectively measured patient self-rated adherence and activation levels, and patient perceptions of their provider’s participatory decision making style. They then linked these baseline and follow-up levels to hard clinical end-points of glycemic, blood pressure, and lipid control. A key finding was that patient activation mediated the relationship between participatory decision making and better clinical outcomes. This hypothesis-generating study provides evidence to support interventions that seek to transform primary care by investing in resources to activate patients in their care.

A key unanswered question is how, exactly, to accomplish this goal. While already-activated patients clearly do well, we don’t know yet how to transform “unactivated” patients into activated ones. This represents a key frontier for primary care research.

1. Katerndahl D, Parchman ML. Dynamical difference in patients encounters involving uncontrolled diabetes: an orbital decomposition analysis. J Eval Clin Pract. 2010 Feb;16(1):211-9.

2. Parchman ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med. 2007 May-Jun;5(3):196-201

Competing interests:   None declared