Promoting glycemic control through diabetes self-management: evaluating a patient activation intervention

doi:10.1016/j.pec.2003.11.008

Patient Education and Counseling

Volume 56, Issue 1, January 2005, Pages 28-34

https://doi.org/10.1016/j.pec.2003.11.008 Get rights and content

Abstract

This study compared an activation intervention to passive education in a randomized attention-control trial of 232 patients with type 2 diabetes. The activation intervention was based on Expanding Patient Involvement in Care (EPIC) trials, and was compared to time-matched passive education viewing of ADA video-tapes. Patient demographics and clinical characteristics of their diabetes were assessed with questionnaires, active involvement was assessed via ratings of taped interactions between patients and providers, and serum samples were analyzed for HbA1c. Patients in the activation condition were rated as more actively involved in discussions of diabetes self-management, and rated active involvement was predictive of improvement in glycemic control. No effect of the activation intervention was found on HbA1c. Thus, the activation intervention increased the active involvement of patients with type 2 diabetes in visits with practitioners, and active involvement led to improved glycemic control. However, the activation intervention did not improve glycemic control directly.

Introduction

Additional approaches for improving the glycemic control of patients with type 2 diabetes need to be identified, refined, and translated into care as the United Kingdom Prospective Diabetes Study (UKPDS) has demonstrated that better glycemic control results in fewer complications of diabetes. Indeed, a 0.9% improvement in HbA1c for patients with diabetes receiving intensive treatment resulted in a 25% reduction in microvascular complications (nephropathy, retinopathy, and neuropathy) over 10 years compared to those who received standard care [1]. Increasing patient active involvement in the management of their disease, as done by the Expanding Patient Involvement in Care (EPIC) intervention, may represent one approach to improving glycemic control [2].

The EPIC intervention was shown to increase patient participation in health care encounters and to improve a variety of health outcomes, including glycemic control for patients with diabetes [3]. The intervention involved research assistants (RAs) meeting with patients before each visit to encourage patients to become more involved in the management of their diabetes. This intervention was referred to as patient activation. Ratings of patient behavior from audiotapes of the visits indicated that patients given the activation intervention became more actively involved in the discussions compared to patients given a standard education session. Thus, the term active involvement represented a continuous variable that was rated by observers from patient behavior during a health care visit, and patient activation refers to the intervention used to motivate active involvement.

The present study was conducted (a) to examine the validity of rated active involvement as a construct in diabetes treatment settings and (b) to determine whether the patient activation intervention resulted in patients being rated as more active during practitioner visits, and (c) to replicate the EPIC trials’ patient activation intervention effect of improving glycemic control for patients with type 2 diabetes [3]. The patient activation intervention is hypothesized to increase rated active involvement and improve glycemic control compared to the education control. Rated active involvement was hypothesized to mediate the relationship between the intervention and glycemic control. Intention-to-treat analyses were used to determine the effects of the intervention on change in glycemic control.

A previous study of physicians providing smoking cessation counseling [4] found that “rated active involvement” could be simply and reliably measured by trained raters’ responses to three items as a global construct. In that smoking-cessation study, rated active involvement from a single physician visit was predictive of continuous abstinence from tobacco over a 30-month follow-up. However, this rating system has not been applied to patients with a chronic disease such as diabetes in a randomized controlled trial.

A separate report related to the present study [5] confirmed the self-determination theory process model of health behavior change [6], [7], [8] in the context of care for patients with diabetes. Briefly, changes in the self-determination motives of autonomy and competence were found to predict the maintenance of change in HbA1c. However, the patient activation intervention was not found to increase autonomous or competence motivation for diabetes self-management. Thus, the patient activation intervention did not promote internalization of motivation for patients with diabetes.

Section snippets

Participants

Participants were recruited with signs posted in a diabetes care center at a university affiliated community hospital between 1996 and 1999. Eligibility criteria included having type 2 diabetes with the most recent HbA1c reading being at least 1 point above the upper end of the lab reference range, having primary responsibility for self-management of diabetes, having greater than a 1-year life expectancy, and having ability to speak and read English. Of the 232 patients randomized in this

Preliminary analyses

Of the 232 patients randomized to condition, intention-to-treat analyses were conducted on 197 (85%) who completed the study, defined as having had HbA1c drawn at baseline (T1) and 12 months (T3). Patients who did not complete the study (n=35) were younger (48.7 years versus 55.7, t(225)=3.42, P<0.001), were less likely to be married or living as married (51.4% versus 70.4%, χ²=4.88, P<0.03), had had diabetes for a shorter time (6.3 years versus 10.8 years, t(221)=3.18, P<0.01), had a higher

Discussion

The primary hypothesis that activation of patients prior to their medical appointments would improve glycemic control was not supported. Patient activation did, however, increase ratings of patients’ active involvement in the visits, and active involvement, in turn, predicted improvement in HbA1c. Thus, the hypotheses were in part supported, but the effect of the activation intervention on glycemic control and its mediation by rated active involvement were not.

Possible reasons behind the

Acknowledgements

Supported by grant 1-R01-DK-50807 from NIDDK and by grant 5-M01-RR-00044 from the National Center for Research Resources to the University of Rochester General Clinical Research Center.

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Promoting glycemic control through diabetes self-management: evaluating a patient activation intervention

Abstract

Introduction

Section snippets

Participants

Preliminary analyses

Discussion

Acknowledgements

Assessing the effects of physician–patient interactions on the outcomes of chronic disease

Med. Care

Patients’ participation in medical care: effects on blood sugar control and quality in diabetes

J. Gen. Inter. Med

Activating patients for smoking cessation through physician autonomy support

Med. Care