Diabetes mellitus (DM) is an epidemic in the U.S. More than 30 million people (9.4% of the total population) have DM; type 2 DM (T2SM) accounts for 95% of these cases.1 The estimated prevalence of DM among individuals aged > 65 years is about 3 times higher at 26%. The prevalence among veterans enrolled in the VA is higher than in the general population; about 25% of VA users have been diagnosed with DM.2 As a result, DM is the leading cause of blindness, end stage renal disease, amputations, and a significant contributor to myocardial infarction and stroke. Older adults with DM have an increased risk of mortality compared with individuals without DM.3 In 2012, DM was estimated to cost $176 billion in direct and indirect medical costs.4 These health and cost implications make effective management of DM a priority for health care providers (HCPs), policy makers, and patients nationwide.
The 2017 VA/DoD Clinical Practice Guideline (CPG) for the Management of T2DM in Primary Care provides the primary care team an evidence-based and individualized approach to holistic care of the patient with T2DM.5 Key recommendations were developed based on methods established by the VA/DoD Evidence-Based Practice Working Group (EBPWG) and are aligned with standards for trustworthy guidelines by using the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of the evidence base and assign a grade for the strength for each recommendation.6,7 The EBPWG included a multidisciplinary panel of practicing clinician stakeholders, including primary care physicians, endocrinologists, medical nutritionists, pharmacists, diabetes educators, and nurse practitioners. The CPG development process also included a patient focus group. Important themes from the focus group were shared with the EBPWG to help address the needs and perspectives of patients receiving treatment for DM in the VA and DoD.
In this article, the authors briefly review several of the most pertinent CPG updates for the busy clinician.
Shared Decision Making
Shared decision making (SDM) is a central component of the approach to patients with DM. Shared decision making involves the patient and care providers together making important decisions about the treatment plan and goals of care, using communication tools and exploring patient preferences.8
Using an empathetic and nonjudgmental approach facilitates discussions about a patient’s specific health care needs and goals for care. Shared decision making also can provide culturally appropriate treatment and care information to meet the needs of those with limited literacy or numeracy skills, or other learning barriers, such as physical, sensory, or learning disabilities. Family involvement is an important component of SDM when desired by the patient.9
The goals of successful SDM include a decrease in patient anxiety and an increase in trust in the health care team, ideally leading to improvement in adherence and patient outcomes.8,10-12 Improved patient-clinician communication conveys openness to discuss any future concerns. Furthermore, SDM does not need to take a significant amount of a clinician’s time to create an environment of consideration and goal formation. Training in communication skills may be helpful for those unfamiliar with SDM techniques. Patients are most likely to participate in the SDM process when they are comfortable speaking with clinicians and have some knowledge about their specific disease process.13
The clinical team can review all prior treatment attempts with the patient to understand the patient's perspective on these interventions. Lastly, patients are involved in prioritizing problems to be addressed and in setting specific goals. A 5-step SDM process prompted by the SHARE acronym can be used:
- Seek your patient’s participation;
- Help your patient explore and compare treatment options;
- Assess your patient’s values and preferences;
- Reach a decision with your patient; and
- Evaluate your patient’s decision (Figure).8
The VA/DoD CPG noted that there is high-quality evidence supporting SDM for improving patients’ knowledge, satisfaction, and engagement with their treatment plan.14-16 Specific methodologic approaches to SDM are not well defined for individual patient groups, which represents a significant research gap. Patients diagnosed with T2DM might respond differently to SDM depending on personal goals, life experiences, and coping strategies.14-16 Shared decision making should be used at every decision point in the treatment process, from the diagnosis of pre-diabetes to the patient with advanced complications. This includes— at a minimum—at initial diagnosis, when experiencing difficulties in management, and at times of transition or development of complications.16
A shared understanding is critical to the SDM process. Diabetes self-management education and diabetes self-management support provide a framework that involves a collaborative, ongoing, interactive process to help patients gain knowledge, modify behavior, and successfully manage the disease. The goal of DM education in SDM is to ensure that the patient has sufficient knowledge and skills to achieve the treatment goals they set with their health care team. Assessment of patient understanding in the clinic could include use of the “teach-back method.”17 Health coaching and motivational interviewing strategies also may help clinicians understand patients’ perceptions, values, and beliefs regarding their condition, treatment, and self-management options, particularly when patients seem to be reluctant to fully participate in decisions and care.
A challenge for HCPs is to help patients understand how they can successfully manage DM and partner with health care teams to express their goals and preferences to aid in individualized health care decisions. Using SDM tools and ensuring that clinicians can use patient-centered communication skills increase patients’ willingness to share in decision making and engage in the treatment plan.