Decision Aid May Increase Lifestyle Changes for Prediabetes

Troy Brown, RN

June 23, 2020

Patients with prediabetes may experience less decisional conflict about treatment options and be more likely to participate in intensive lifestyle intervention (ILI), including physical activity and weight loss, after reviewing a decision aid, researchers report.

"We found that 30% of patients in our pilot study either enrolled in an intensive lifestyle intervention or received a metformin prescription. This rate of treatment adoption is manyfold higher than that observed with usual care," lead author Matthew J. O’Brien, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, told Medscape Medical News.

"Our findings suggest that providing patient-centered information about how to prevent diabetes leads to improved treatment adoption," added O'Brien, who is an associate professor of internal medicine and preventive medicine. The study was published online June 15 in Journal of General Internal Medicine.

The researchers conducted a single-arm, pretest-posttest trial in which they collected data immediately before and after patients in a community health center reviewed the novel prediabetes decision aid. The study included patients who were at least 18 years old, had prediabetes, and were overweight or obese. Patients were excluded if they had dementia or had already adopted ILI or were taking metformin.

A medical assistant (MA) or study staff member reviewed the one-page pamphlet with patients. In that review, the patient's needs and the next steps in management were explored. The decision aid "uses three icon arrays to display the absolute risk of developing T2D [type 2 diabetes] when participating in ILI, taking metformin, and without treatment. Each icon array includes a picture of 100 people, with the number likely to develop T2D shaded. Brief text describing each treatment condition is included below the corresponding icon array," the authors explain.

On the back of the decision aid are open-ended questions about the patient's needs regarding T2D prevention. The aid also outlines the next steps for managing the patient's prediabetes.

The decision aid fulfils the National Quality Forum's criteria for tools that help patients make treatment decisions. The MA and study staff underwent a half day of training before the study began.

Validated questionnaires were used to assess outcomes and to measure patient uncertainty with respect to medical decision making, the intention to practice ILI, and initiation of metformin treatment.

During the study, healthcare professionals spent approximately 6.8 minutes reviewing the decision aid with each of 40 patients. Participants reported significantly less decisional conflict after using the aid than they experienced before using it, as assessed with the total scale (31.0 pretest vs 20.9 posttest; P < .001) and for each subscale (P < .01 for all). Moreover, on the posttest questionnaire, 35 participants (88%) said they intended to adopt ILI, whereas on the pretest questionnaire, 28 did so (70%) (P = .02).

However, participants' intention to take metformin did not change significantly (P = .66) after use of the decision aid. Outcomes did not differ substantively with respect to whether study staff reviewed the decision aid or MAs did so.

"While we did not study clinicians reviewing the decision aid with patients, this may be particularly important for discussing metformin. Future research with prediabetes decision aids should employ randomized designs to examine long-term changes in patient-centered outcomes, prediabetes treatment adoption, and metabolic endpoints," the authors explain.

Diabetes Education Critical for Those With Prediabetes, Experts Say

"Seven national health organizations, including the AAFP [American Academy of Family Physicians], recently collaborated on the Diabetes Self-management Education and Support (DSMES) Consensus Report, since the heart of diabetes management is what the patient does outside of our office," Beulette Y. Hooks, MD, FAAFP, a family physician at the Family Medical Home at Martin Army Community Hospital on Fort Benning in Georgia, told Medscape Medical News.

"This report is about getting diabetes educators involved as soon as possible with diabetes, but they can also help with the education of the prediabetic patient," Hooks added.

"By the time most patients present to their primary care physician, they already have type 2 diabetes. Using a diabetes educator to help with the management needs to be more widely used by primary care," Hooks explained. "A referral to a diabetes educator can also help with patients who are prediabetic with education about diet, exercise, and medication that can help decrease the chance of developing type 2 diabetes," she explained.

The fact that one third of US adults have prediabetes "makes it a major public health problem," O'Brien told Medscape Medical News. "There are two evidence-based treatments to prevent diabetes — intensive lifestyle intervention and metformin — yet these are used by less than 10% of adults with prediabetes. Decision aids are widely used to help promote adherence to evidence-based care, but there are few examples focused on diabetes prevention," O'Brien explained.

"There is a Web-based decision aid that has been studied as part of a shared decision making intervention led by primary care pharmacists. A study of this intervention demonstrated an even higher rate of treatment adoption," O'Brien told Medscape Medical News.

However, that intervention takes about 40 minutes to complete and may be hard to implement in "busy primary care settings," in which a pharmacist may not be immediately available, he continued. "Our tool can be delivered by anyone in the primary care practice who does health education (eg, nurses, medical assistants, health educators, etc), and it took only 6 minutes to deliver in our study."

"If this study is validated, it could help to improve prediabetes management and help reduce the number of patients developing type 2 diabetes, thereby decreasing the healthcare costs for treating the complications of diabetes," Hooks said.

The authors and Hooks have disclosed no relevant financial relationships.

J Gen Intern Med. Published online June 15, 2020. Abstract

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