A pilot randomised controlled trial of a preconsultation web-based intervention to improve the care quality and clinical outcomes of diabetes outpatients (DIAT)

Does a simple web-based intervention facilitate the articulation of patients' unvoiced agenda for a consultation with their diabetologists? A qualitative study

OBJECTIVE

To explore whether a preconsultation web-based intervention enables patients with diabetes to articulate their agenda in a consultation in the hospital outpatient clinic with their diabetologist.

METHODS AND DESIGN

A qualitative study embedded in a pragmatic pilot randomised controlled trial.

SETTING

Two city outpatient departments in England.

PARTICIPANTS

25 patients attending a follow-up consultation and 6 diabetologists.

INTERVENTION

The PACE-D, a web-based tool adapted for patients with diabetes to use before their consultation to generate an agenda of topics to discuss with their diabetologist.

DATA COLLECTION

25 participants had their consultation with their diabetologist audio-recorded: 12 in the control arm and 13 in the intervention arm; 12 of the latter also had their PACE-D intervention session and a consultation recorded. Semi-structured interviews with 6 diabetologists, and 12 patients (6 in the intervention group and 6 in the control group).

ANALYSIS

Thematic discourse analysis undertaken with patient representatives trained in qualitative data analysis techniques.

RESULTS

We identified four consultation types: diabetologist facilitated; patient identified; consultant facilitated and patient initiated and patient ignored. We also identified three critical aspects that explained the production and utilisation of the agenda form: existing consultative style; orientation to the use of the intervention and impact on the consultation. Where patients and diabetologists have a shared preference for a consultant-led or patient-led consultation, the intervention augments effective communication and shared decision making. However, where preferences diverge (eg, there is a mismatch in patients' and diabetologists' preferences and orientations), the intervention does not improve the potential for shared decision making.

CONCLUSION

A simple web-based intervention facilitates the articulation of patients' unvoiced agenda for a consultation with their diabetologist, but only when pre-existing consultation styles and orientations already favour shared decision making. More needs to be done to translate patient empowerment in the consultation setting into genuine self-efficacy.

TRIAL REGISTRATION NUMBER

ISRCTN75070242.

Patient involvement in qualitative data analysis in a trial of a patient-centred intervention: Reconciling lay knowledge and scientific method

BACKGROUND

We conducted a pilot study of an intervention to facilitate patients' agenda setting in clinical consultations. The primary aim of the study was to test the feasibility of running the randomized controlled trial. A secondary objective was to assess the extent to which patient and public involvement (PPI) could contribute to the process of qualitative data analysis (QDA).

AIMS

To describe a novel approach to including patient partners in QDA; to illustrate the kinds of contribution that patient partners made to QDA in this context; and to propose a characterization of a process by which patient involvement can contribute to knowledge production.

METHODS

Six patient and public representatives were supported to contribute to data analysis via a range of modalities. During a series of QDA workshops, experienced research staff role-played consultations and interviews, and provided vignettes. Workshop data and PPI diaries were analysed using thematic discourse analysis.

RESULTS

We characterized a process of thesis, antithesis and synthesis. This PPI group contributed to the rigour and validity of the study findings by challenging their own and the researchers' assumptions, and by testing the emerging hypotheses. By training PPI representatives to undertake qualitative data analysis, we transformed our understanding of doctor-patient consultations.

CONCLUSIONS

This research required changes to our usual research practices but was in keeping with the objective of establishing meaningful patient involvement for a future definitive trial. This work was informed by concepts of critical humility, and a process of knowledge production enabled via the construction of a knowledge space.

Addressing unmet needs of patients with chronic diseases: Impact of the VISIT website during consultations

RATIONALE, AIMS, AND OBJECTIVES

Patient concerns are often neglected in consultations, especially for chronic diseases where patients and providers fall into the routine of chronic disease management in consultations. One strategy to elicit patient concerns has been to ask patients to complete agenda lists before the consultation. This study aimed to explore the impact of a preconsultation agenda website in addressing patients' unmet needs during chronic disease consultations.

METHODS

Patients entered their concerns into a website (Values In Shared Interactions Tool (VISIT)). Doctors accessed this information via the electronic medical records before consultations. Individual in-depth interviews were then conducted with patients and doctors on the website's impact on consultations. Interviews were transcribed verbatim and analysed thematically.

RESULTS

The average age (years) was 65.7 for patients (n = 8) and 35.7 for doctors (n = 7). Patients in the study entered between 1 to 6 items in the website. From postconsultation interviews, we found that the website impacted the consultation in 5 ways: (1) It facilitated patients to communicate their full agenda to doctors; (2) it helped address unmet patient needs as it gave them opportunity to raise other issues besides their chronic condition; (3) it facilitated rapport between doctor and patient; (4) it facilitated doctors to organize their consultation around the concerns the patient had listed; and (5) it disrupted the doctor's usual consultation style if the list of concerns was lengthy.

CONCLUSIONS

Integrating patient concerns into electronic health records helped to facilitate patient-centred consultations. Doctors found this information useful but felt uneasy if the agenda list was too long or too complex. Areas for future studies include training doctors to manage complex agendas and formal evaluation of the VISIT tool.

A preconsultation web-based tool to generate an agenda for discussion in diabetes outpatient clinics to improve patient outcomes (DIAT): a feasibility study

OBJECTIVE

To test the feasibility of running a randomised controlled trial of a preconsultation web-based intervention (Presenting Asking Checking Expressing (PACE-D)) to improve the quality of care and clinical outcomes in patients with diabetes.

DESIGN AND SETTING

A feasibility study (with randomisation) conducted at outpatient diabetes clinics at two secondary care hospitals in Devon, UK.

PARTICIPANTS

People with diabetes (type 1 and type 2) attending secondary care general diabetes outpatient clinics.

INTERVENTION

The PACE-D, a web-based tool adapted for patients with diabetes to use before their consultation to generate an agenda of topics to discuss with their diabetologist.

OUTCOMES

The percentage of eligible patients who were recruited and the percentage of participants for whom routine glycosylated haemoglobin (HbA1c) data (the putative primary outcome) could be extracted from medical notes and who completed secondary outcome assessments via questionnaire at follow-up were reported.

RESULTS

In contrast with the planned recruitment of 120 participants, only 71 participants were randomised during the 7-month recruitment period. This comprised 18.7% (95% CI 14.9% to 23.0%) of those who were eligible. Mean (SD) age of the participants was 56.5 (12.4) years and 66.2% had type 1 diabetes. Thirty-eight patients were randomised to the intervention arm and 33 to the control arm. HbA1c data were available for only 73% (95% CI 61% to 83%) of participants at the 6 months follow-up. The questionnaire-based data were collected for 66% (95% CI 54% to 77%) of the participants at 6 months follow-up. Participants reported that the PACE-D tool was easy to use.

CONCLUSIONS

A randomised controlled trial of the preconsultation web-based intervention as set out in our current protocol is not feasible without significant modification to improve recruitment and follow-up of participants. The study also provides insights into the feasibility and challenges of conducting complex intervention trials in everyday clinical practice.

TRIAL REGISTRATION

ISRCTN75070242.

Impact of an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes on decisional conflict--study protocol for a randomized controlled trial

BACKGROUND

Competing health concerns present real obstacles to people living with diabetes and other chronic diseases as well as to their primary care providers. Guideline implementation interventions rarely acknowledge this, leaving both patients and providers feeling overwhelmed by the volume of recommended actions. Interprofessional (IP) shared decision-making (SDM) with the use of decision aids may help to set treatment priorities. We developed an evidence-based SDM intervention for patients with diabetes and other conditions that was framed by the IP-SDM model and followed a user-centered approach. Our objective in the present study is to pilot an IP-SDM and goal-setting toolkit following the Knowledge-to-Action Framework to assess (1) intervention fidelity and the feasibility of conducting a larger trial and (2) impact on decisional conflict, diabetes distress, health-related quality of life and patient assessment of chronic illness care.

METHODS/DESIGN

A two-step, parallel-group, clustered randomized controlled trial (RCT) will be conducted, with the primary goal being to assess intervention fidelity and the feasibility of conducting a larger RCT. The first step is a provider-directed implementation only; the second (after a 6-month delay) involves both provider- and patient-directed implementation. Half of the clusters will be assigned to receive the IP-SDM toolkit, and the other will be assigned to be mailed a diabetes guidelines summary. Individual interviews with patients, their family members and health care providers will be conducted upon trial completion to explore toolkit use. A secondary purpose of this trial is to gather estimates of the toolkit's impact on decisional conflict. Secondary outcomes include diabetes distress, quality of life and chronic illness care, which will be assessed on the basis of patient-completed questionnaires of validated scales at baseline and at 6 and 12 months. Multilevel hierarchical regression models will be used to account for the clustered nature of the data.

DISCUSSION

An individualized approach to patients with multiple chronic conditions using SDM and goal setting is a desirable strategy for achieving guideline-concordant treatment in a patient-centered fashion. Our pilot trial will provide insights regarding strategies for the routine implementation of such interventions in clinical practice, and it will offer an assessment of the impact of this approach.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.

The diabetes app challenge: user-led development and piloting of internet applications enabling young people with diabetes to set the focus for their diabetes consultations

Background

Traditionally, some teenagers and young adults with diabetes have not engaged well at diabetes appointments, giving rise to concerns about long-term health risks. We considered that apps might help this group of patients to improve preparation for, and therefore engagement at their appointments. Although there are already many apps for young people with type 1 diabetes (YPD), we thought that by supporting YPD themselves to develop apps, the resulting products would have greater “authenticity” and relevance.

Objective

To test the feasibility of an online competition to (1) recruit and support YPD to develop apps (mobile or Internet based) to help prepare for clinic appointments, and (2) for these apps to be tested and rated by YPD.

Methods

The “Diabetes App Challenge” was a United Kingdom (UK) national competition, run between June and October 2012 for teams including at least one YPD (aged 16-25) to pilot the design and development of apps for use by other YPD prior to clinic appointments. The competition was advertised by social media, email, AdWords and postings on the Diabetes UK website. Registrants for the competition were supported via email and discussion forum. After app development, other YPD were invited (November 2012-February 2013) to trial the apps, choose and use one prior to a clinic appointment, and review their experiences.

Results

Of 56 people (including 28 YPD) who expressed interest in the competition, 6 teams (14 people) developed and submitted an app. Two apps aimed to facilitate agenda setting in clinic consultations, 2 enabled data logging and 2 helped insulin dose calculation. Of 135 YPD who registered to trial the apps, 83 (61.5%) took part (mean age 18.98, 37/83 male). Agenda setting apps were considered most useful for preparing for and setting the focus of clinic appointments (P=.02). Just over half (46/83, 55%) said they would use their chosen app again and 4/5 (67/83, 81%) would recommend it to a friend.

Conclusions

This competition to engage YPD in developing and reviewing apps proved successful. App designers and testers saw a need for a range of functions. However, this may, in part, reflect a lack of detailed knowledge of all existing apps and be limited by the technical skills of YPD. App competitions appear worth applying to other patient groups, but future competitions should include a review stage and perhaps focus on ideas for app design for subsequent professional implementation.