Review article
Provider–patient interaction in diabetes care: effects on patient self-care and outcomes: A systematic review

https://doi.org/10.1016/S0738-3991(02)00122-2Get rights and content

Abstract

A systematic review of the research literature using Medline, Embase, Psyclit/Psycinfo and the Cochrane Library files 1980 through 2001, identified only eight publications based on well-designed studies involving randomised controlled trials (RCTs)—testing the effects of modification of provider–patient interaction and provider consulting style on patient diabetes self-care and diabetes outcomes, in general practice or hospital outpatient settings. Review of these publications leads to the tentative conclusion that focusing on patient behaviour—directly enhancing patient participation i.e. by assistant-guided patient preparation for visits to doctors, empowering group education, group consultations, or automated telephone management—is more effective than focusing on provider behaviour to change their consulting style into a more patient-centred one. The latter proves hard to sustain, needs intensive support, and is not very effective in improving patient self-care and health outcomes when executed alone. Patient behaviour focused interventions show good efficacy and efficiency, and improve patient self-care and diabetes outcomes. More well-designed intervention studies focusing on enhancing patient participation in primary and hospital outpatient diabetes care are needed.

Introduction

A substantial proportion of type 2 diabetes patients show poor care outcomes [1], [2], [3], [4], [5]. An estimated 30–60% of the type 2 diabetes patients in routine general practice have poor metabolic control (GlyHb >8.5% or fasting blood glucose >11 mmol/l). Only intensive feedback and monitoring programs in selected practices with very motivated professionals can improve this situation [6], [7], [8]. Cardiovascular risk factors in type 2 diabetes patients at least double their risk to die from cardiovascular causes. Over the past decades, the quality of diabetes care guidelines appears to have improved, and the rate of foot amputations has decreased—but there was no major improvement of survival rates and prevention of cardiovascular and other diabetes complications. Further improvements in diabetes care are needed to produce better outcomes—in terms of glycaemic control, cardiovascular risk factors, diabetes complications, survival, health related quality of life, psychological and functional status [9], [10]. A thorough understanding of the elements that contribute to better diabetes outcomes is needed, including the role-functioning of general practitioners (GPs), and primary care and outpatient clinic diabetes teams [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28].

The role of provider–patient interaction and provider consulting style in relation to patient self-care behaviour, is gaining increasing attention in research and care [18], [29].

Studies of the effects of interventions to improve provider–patient interaction and provider consulting style on diabetes outcomes are the subject of this review article.

Enhancing the patients’ active participation in diabetes care, and their self-care behaviour, is regarded to be a key factor to outcomes improvement. Over the past decades, a shift in this direction has been advocated in books, lectures, comments, and review articles, on a wide field of health care subjects and chronic illnesses [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], including diabetes [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37]. Many researchers advocate radical changes in doctor–patient interaction in diabetes care, as this shift towards patient participation and empowerment is supposed to be necessary to enhance patient adaptation to the condition and adherence to professional advice, to help improve self-care and care outcomes [25], [29], [30], [31].

Improving outcomes of type 2 diabetes health care is impossible without improving patient self-management behaviour. Ninety-five percent or more of the many health decisions a diabetes patient must make daily are made without health care professionals even knowing them [21]. Decisions about foods and drinks, tobacco smoking, physical activity, adherence to drug prescription, insulin regimen, clinic attendance, blood glucose self-monitoring, and so on, have to be made on a daily basis. Personal, emotional, cultural and social elements play a role in this decision-making process. Type 2 diabetes is generally not a problem that requires emergency medical interventions, but support for patient health behaviour adaptations.

Health care providers and important others in the patients’ social context, are probably those who have the greatest impact on patient behaviour. Still, for one adult to do what another one tells him to do, on a continuous basis, almost certainly indicates abnormal rather than normal behaviour. And this is exactly what diabetes care providers have expected patients to do, for many decades. No wonder they often failed [21], [29]. To help patients gain real better control over their diabetes, in order to prevent (or postpone) complications, and to increase their quality of life, health care professionals should support patients by encouraging them to make informed personal decisions in their everyday life with diabetes. To reach these goals, major changes in provider–patient interaction are required, i.e. there must be movement away from interactions that are authoritarian to ones that are more supportive and sharing.

Knowledge alone is poorly related to behaviour [36], [37]. Accurate diabetes knowledge can help patients make more informed decisions, but they will not act on this information unless they are strongly motivated to do so. Thus, a focus on the patients’ motivation and intention to change health behaviour and life habits is critical and necessary.

Different health behaviour theories have been developed to understand patient self-care behaviour. Most influential have been the Health Belief Model [38], [39], the Theory of Planned Behaviour [40], [41], and the Social Cognitive (Learning) Theory [42]. Testing these models and theories in research settings showed that the three strongest determinants of patient behaviour, acting through motivation and intention, are: (1) attitudes (including patient health beliefs, perceived seriousness of the disease, outcome expectancies, perceived costs and benefits); (2) perceived social norms (opinions and beliefs of important others); and (3) perceived behavioural control, or self-efficacy (confidence in one’s power to perform required behaviour and influence the progression of the disease) [41]. Professional interventions meant to effectively influence patient diabetes behaviour by the provider–patient interaction will have to address these three patient behaviour determinants.

The major research question of this paper is: Can we identify studies with high methodological quality, testing the effects of interventions on provider–patient interaction on patient diabetes health behaviour, patient self-care, delivered diabetes care, and health outcomes? And if so, what interventions prove to be the most effective ones to reach such improvements?

Section snippets

Methods

A systematic literature search was executed to retrieve publications on studies of provider–patient interaction and communication and on provider consulting style, and their effects on (determinants of) patient self-care behaviour and diabetes outcomes. From these studies, we selected those that were methodologically well-designed.

Results

In the first stage of selection, over 720 abstracts were retrieved, resulting in the inclusion of 140 potentially relevant articles after the second selection. After applying the third stage of selection to the full text of these articles, eight remained [6], [45], [46], [47], [48], [49], [50], [51].

Table 2 shows the methodological quality scores of the selected studies, as assessed by the criteria listed in Table 1. The quality scores range from a low of 13 points to a high of 19 points

Discussion and conclusion

The research question was answered positively by this systematic literature review. Eight published studies with high methodological quality were identified and reviewed. They show that interventions on the provider–patient interaction in primary and outpatient clinic diabetes care, can improve (determinants of) patient diabetes behaviour, patient self-care, and diabetes outcomes. In this review, the most effective interventions are those with a direct approach to support patient participation

Acknowledgements

We are grateful for the contribution of Mrs. Lut Knoops, dietician and Master of Health Sciences, in our discussions on the results of the review.

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