12. Patient-centred Care
12.1 General Aspects
The importance of multifactorial risk assessment and lifestyle management, including diet and exercise, in the prevention and treatment of DM and CVD has been emphasized in earlier sections. However, supporting patients in achieving and maintaining lifestyle changes on an individualized basis, using defined therapeutic goals and strategies, continues to be a substantial challenge. The intensive approach used successfully in clinical trials to prevent and treat DM and CVD is difficult to replicate in practice. Once intensive intervention stops, positive changes in lifestyle and risk factors may end, although ongoing booster sessions at intervals can maintain the effects.
Effective strategies for supporting patients in achieving positive lifestyle changes and improving self-management can be recommended. Patient-centred care is an approach that facilitates shared control and decision-making between patient and provider; it emphasizes a focus on the whole person and their experiences of illness within social contexts, rather than a single disease or organ system, and it develops a therapeutic alliance between patient and provider. Patient-centred care fosters a multifactorial approach, working within the context of patient priorities and goals, and allows for lifestyle changes and treatments to be adapted and implemented within cultural beliefs and behaviours. Providers should take into account age, ethnic and gender differences in DM and CVD, including lifestyle, disease prevalence and presentation, response to treatment and outcomes.
Understanding the patient's perspective and priorities enables providers and patients to jointly develop realistic and acceptable goals and programmes for behavioural change and self-management. A Cochrane Collaboration systematic review of 11 clinical trials (n = 1532) concluded that group-based (≥6 participants), patient-centred education resulted in clinically relevant, significant improvements in glycaemic control, DM knowledge, triglyceride concentrations, blood pressure, medication reduction and self-management for 12–14 months. Benefits for 2–4 years, including decreased DM-related retinopathy, were apparent when group classes were provided on an annual basis. Cognitive behavioural strategies, including problem-solving, goal-setting, self-monitoring, ongoing support and feedback/positive reinforcement in individual or group-based sessions are effective in facilitating behavioural change, especially when multiple strategies are used.[536–538] However, a systematic review of studies on increasing physical activity found the positive effect of these strategies to be short-term (six months) and to decline thereafter; this may simply indicate the need for subsequent booster sessions beginning around six months. Similar patient-centred cognitive educational strategies, along with simplification of dosing regimens and increasing convenience, can be effective in improving medication adherence.[539–541] Research is still needed regarding the most effective strategy combinations and the duration, intensity and timing of sessions.
For patients with greater reluctance or resistance towards making behavioural changes, motivational interviewing is patient-centred counselling with the purpose of working through ambivalence and fostering a patient-driven agenda. Motivational interviewing has been effective in helping patients to decrease body mass index and systolic blood pressure and increase physical activity and fruit and vegetable consumption. Motivational interviewing techniques are often adapted and incorporated within prevention programmes.
Multifaceted strategies are most effectively delivered through multidisciplinary teams. The International Diabetes Federation, Diabetes Roundtable and Global Partnership for Effective Diabetes Management are advocates for multidisciplinary team care in DM, and such teams are essential components of successful disease-management programmes for CVD. Nurse-led multidisciplinary programmes, including nurse case-management, have been effective in improving multiple cardiovascular risk factors and adherence in patients with CVD and DM within primary and secondary care.[536,537,545,546]
Patient-centred care emphasizes the person, their experiences, priorities and goals in managing various conditions, and the partnership between providers and patients. When this approach is used by a multidisciplinary team with skills in cognitive behavioural strategies, there will be increased success in supporting patients in achieving lifestyle changes and effectively self-managing their conditions. It is also important to recognise that single or limited interventions or sessions on behavioural change are not sufficient to maintain lifestyle changes and that ongoing support and booster sessions will be necessary for sustained change.
12.2 Gaps in Knowledge
Effects of patient-centred interventions on outcome measures, including micro- and macrovascular complications, are not known.
12.3 Recommendations for Patient-centred Care in Diabetes
Abbreviations and acronyms
2hPG, 2-hour post-load plasma glucose; ABI, ankle–brachial index; ACCOMPLISH, Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension; ACCORD, Action toControlCardiovascular Risk inDiabetes; ACE-I, angiotensin converting enzyme inhibitor; ACS, acute coronary syndrome; ACTIVE, Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events; ACTIVE A, Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events Aspirin; ACTIVEW, Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular EventsWarfarin; ADA, American Diabetes Association; ADDITION, Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care; ADP, adenosine diphosphate; ADVANCE, Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; AF, atrial fibrillation; AGEs, advanced glycation end-products; AIM-HIGH, Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes; ALTITUDE, Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints; Apo, apolipoprotein; ARB, angiotensin receptor blocker; ARIC, Atherosclerosis Risk In Communities; ARISTOTLE, Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; ASCOT, Anglo-Scandinavian Cardiac Outcomes Trial; ATLAS, Assessment of Treatment with Lisinopril And Survival; AVERROES, Apixaban VERsus acetylsalicylic acid to pRevent strOkES; AWESOME, AnginaWith Extremely Serious Operative Mortality Evaluation; BARI 2D, Bypass Angioplasty Revascularization Investigation 2 Diabetes; BEST, BEta blocker STroke trial; BMS, bare-metal stent; BP, blood pressure; CABG, coronary artery bypass graft surgery; CAC, coronary artery calcium; CAD, coronary artery disease; CAN, cardiac autonomic neuropathy; CAPRIE, Clopidogrel vs. Aspirin in Patients at Risk of Ischaemic Events; CARDia, Coronary Artery Revascularization in Diabetes; CARDS, Collaborative Atorvastatin Diabetes Study; CETP, cholesterylester transfer protein; CHA2DS2-VASc, cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74 and sex category (female); CHADS2, cardiac failure, hypertension, age, diabetes, stroke (doubled); CHARISMA, Clopidogrel for High Atherothrombotic Risk and Ischaemic Stabilization, Management and Avoidance; CHARM, Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity; CI, confidence interval; CIBIS, Cardiac Insufficiency Bisoprolol Study; CLI, critical limb ischaemia; COMET, Carvedilol Or Metoprolol European Trial; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival; COX-1 and 2, cyclo-oxygenase 1 and 2; CTT, Cholesterol Treatment Trialists; CVD, cardiovascular disease; DCCT, Diabetes Control and Complications Trial; DECODE, Diabetes Epidemiology:COllaborative analysis of Diagnostic criteria in Europe; DES, drug-eluting stent; DETECT-2, The Evaluation of Screening and Early DetectionStrategies for T2DM and IGT; DIABHYCAR, Hypertension, Microalbuminuria or Proteinuria, Cardiovascular Events and Ramipril; DIAMOND, Danish Investigations and Arrhythmia ON Dofetilide DIG Digitalis Investigation Group; DIGAMI, Diabetes and Insulin–Glucose Infusion in Acute Myocardial Infarction; DIRECT, DIabetic REtinopathy Candesartan Trials; DM, diabetes mellitus; DPP-4, dipeptidylpeptidase-4; ECG, electrocardiogram; EDIC, Epidemiology of Diabetes Interventions and Complications; eNOS, endothelial nitric oxide synthase; EPC, endothelial progenitor cells; ERFC, Emerging Risk Factor Collaboration; EUROASPIRE, European Action on Secondary Prevention through Intervention to Reduce Events; EUROPA, EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease; FDA, Food and Drug Administration; FFA, free fatty acid; FIELD, Fenofibrate Intervention and Event Lowering in Diabetes; FINDRISC, FINnish Diabetes RIsk SCore; FPG, fasting plasma glucose; FREEDOM, Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease; GFR, glomerular filtration rate; GIK, glucose-insulin-potassium; GLP-1, glucagon-like peptide-1; GLUT-4, glucose transporter 4; HAS-BLED, Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (.65), Drugs/alcohol concomitantly (1 point each); HbA1c glycated haemoglobin A1C; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; HI-5, Hyperglycaemia: Intensive Insulin Infusion in Infarction; HOMA-IR, Homeostasis Model Assessment of Insulin Resistance; HOPE, Heart Outcomes Prevention Evaluation; HOT, Hypertension Optimal Treatment; HPS, Heart Protection Study; HPS-2-THRIVE, Heart Protection Study 2 Treatment of HDL to Reduce the Incidence of Vascular Events; HR, hazard ratio; HSP, hexosamine pathway; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; IMMEDIATE, Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care; IMPROVE-IT, IMProved Reduction of Outcomes: Vytorin Efficacy International Trial; INR, international normalized ratio; IR, insulin resistance; IRS-1, insulin receptor substrate-1; ISAR-REACT, Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment; ITA, internal thoracic artery; LDL, low-density lipoprotein; LDL-C, low-density lipoprotein cholesterol; LEAD, lower extremity artery disease; Lp a, lipoprotein a; LV, left ventricular; LVEF, left ventricular ejection fraction; MACCE, major adverse cardiac and cerebrovascular events; MAIN COMPARE, Revascularization for unprotected leftmain coronary artery stenosis: comparison of percutaneous; MERIT-HF, Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure; MetS, metabolic syndrome; MI, myocardial infarction; MRA, mineralocorticoid receptor antagonists; N-ER, niacin; NAPDH, nicotinamide adenine dinucleotide phosphate hydrogen; NDR, National Diabetes Register; NHANES, NationalHealth andNutritionExamination Survey; NICE, National Institute for Health and Clinical Excellence (UK); NNT, number needed to treat; NO, nitric oxide; NOAC, new oral anticoagulants; NYHA, New York Heart Association; OAT, Occluded Artery Trial; OGTT, oral glucose tolerance test; OMT, optimal medical treatment; ONTARGET, ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial; OR, odds ratio; ORIGIN, OutcomeReduction with an Initial Glargine Intervention trial; PAD, peripheral artery disease; PAI-1, plasminogen activator inhibitor-1; PCI, percutaneous coronary intervention; PG, plasma glucose; PI3K, phosphatidylinositol 3-kinases; PKC, protein kinase C; PLATO, PLATelet inhibition and patient Outcomes trial; PPARα, peroxisome proliferator-activated receptor alpha; PPARγ, peroxisome proliferator-activated receptor gamma; PREDIMED, Primary Prevention of Cardiovascular Disease with a Mediterranean Diet; PROActive, PROspective pioglitAzone Clinical Trial In macroVascular Events; PROCAM, Prospective Cardiovascular Münster; RAAS, renin-angiotensin-aldosterone system; RAGE, receptor for advanced glycation end products; RCT, randomized controlled trial; RE-LY, Randomized Evaluation of the Long-term anticoagulant therapy with dabigatran etexilate; REGICOR, Myocardial Infarction Population Registry of Girona; RESOLVE, Safety and Efficacy of Ranibizumab in Diabetic Macular Edema Study; RESTORE, Ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema; RIDE, Ranibizumab Injection in SubjectsWith Clinically Significant Macular Edema (ME)With Center Involvement Secondary to Diabetes Mellitus; RISE, Ranibizumab Injection in SubjectsWith Clinically Significant Macular Edema (ME)With Center Involvement Secondary to Diabetes Mellitus; ROCKET, Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition, compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; ROS, reactive oxygen species; RRR, relative risk reduction; SCORE®, The European Systematic Coronary Risk Evaluation; SGLT2, sodium–glucose co-transporter-2; SHARP, Study of Heart and Renal Protection; SMI, silent myocardial ischaemia; SR-B, scavenger receptor B; SOLVD, Studies Of Left Ventricular Dysfunction; STEMI, ST-elFevation myocardial infarction; SYNTAX, SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; TACTICS-TIMI 18, Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction; TG, triglyceride; TIA, transient ischaemic attack; tPA, tissue plasminogen activator; TRL, triglyceride-rich lipoprotein; UKPDS, United Kingdom Prospective Diabetes Study; VADT, Veterans Administration Diabetes Trial; VEGF, vascular endothelial growth factor; VKA, vitamin K antagonist; VLDL, very low-density lipoprotein; WHO, World Health Organization
Other ESC entities having participated in the development of this document:
Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA)
Coronary Pathophysiology and Microcirculation, Thrombosis, Cardiovascular Surgery
Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Cardiovascular Imaging
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
Eur Heart J. 2013;34(39):3035-3087. © 2013 Oxford University Press
Copyright 2007 European Society of Cardiology. Published by Oxford University Press. All rights reserved.