ESC Guidelines on Diabetes, Pre-diabetes, and Cardiovascular Diseases Developed in Collaboration With the EASD

The Task Force on Diabetes, Pre-Diabetes, and Cardiovascular Diseases of the European Society of Cardiology (ESC) and Developed in Collaboration With the European Association for the Study of Diabetes (EASD)

Lars Rydén (ESC Chairperson) (Sweden); Peter J. Grant (EASD Chairperson) (UK); Stefan D. Anker (Germany); Christian Berne (Sweden); Francesco Cosentino (Italy); Nicolas Danchin (France); Christi Deaton (UK); Javier Escaned (Spain); Hans-Peter Hammes (Germany); Heikki Huikuri (Finland); Michel Marre (France); Nikolaus Marx (Germany); Linda Mellbin (Sweden); Jan Ostergren (Sweden); Carlo Patrono (Italy); Petar Seferovic (Serbia); Miguel Sousa Uva (Portugal); Marja-Riita Taskinen (Finland); Michal Tendera (Poland); Jaakko Tuomilehto (Finland); Paul Valensi (France); Jose Luis Zamorano (Spain); Jose Luis Zamorano (Chairperson) (Spain); Stephan Achenbach (Germany); Helmut Baumgartner (Germany); Jeroen J. Bax (Netherlands); Héctor Bueno (Spain); Veronica Dean (France); Christi Deaton (UK); Çetin Erol (Turkey); Robert Fagard (Belgium); Roberto Ferrari (Italy); David Hasdai (Israel); ArnoW. Hoes (Netherlands); Paulus Kirchhof (Germany UK); Juhani Knuuti (Finland); Philippe Kolh (Belgium); Patrizio Lancellotti (Belgium); Ales Linhart (Czech Republic); Petros Nihoyannopoulos (UK); Massimo F. Piepoli (Italy); Piotr Ponikowski (Poland); Per Anton Sirnes (Norway); Juan Luis Tamargo (Spain); Michal Tendera (Poland); Adam Torbicki (Poland); William Wijns (Belgium); Stephan Windecker (Switzerland); Guy De Backer (Review Coordinator) (Belgium); Per Anton Sirnes (CPG Review Coordinator) (Norway); Eduardo Alegria Ezquerra (Spain); Angelo Avogaro (Italy); Lina Badimon (Spain); Elena Baranova (Russia); Helmut Baumgartner (Germany); John Betteridge (UK); Antonio Ceriello (Spain); Robert Fagard (Belgium); Christian Funck-Brentano (France); Dietrich C. Gulba (Germany); David Hasdai (Israel); Arno W. Hoes (Netherlands); John K. Kjekshus (Norway); Juhani Knuuti (Finland); Philippe Kolh (Belgium); Eli Lev (Israel); Christian Mueller (Switzerland); Ludwig Neyses (Luxembourg); Peter M. Nilsson (Sweden); Joep Perk (Sweden); Piotr Ponikowski (Poland); Zeljko Reiner (Croatia); Naveed Sattar (UK); Volker Schächinger (Germany); André Scheen (Belgium);

Disclosures

Eur Heart J. 2013;34(39):3035-3087. 

In This Article

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.[65]

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.[534] 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.[535] 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;[538] 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.[542] Motivational interviewing techniques are often adapted and incorporated within prevention programmes.[537]

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,[543] and such teams are essential components of successful disease-management programmes for CVD.[544] 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

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