Physicians' participatory decision-making and quality of diabetes care processes and outcomes: Results from the triad study

Objectives: In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians' diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive. Methods: 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n = 4198) in 10 US health plans across the country and their physicians (n = 1217). We characterized physicians diabetes care PDM preferences and practices as no patient involvement, physician-dominant, shared, or patient-dominant and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patientssatisfaction with physician communication; and (3) whether patients A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control. Results: Most physicians preferred shared PDM (58%) rather than no patient involvement (9%), physiciandominant (28%) or patient dominant PDM (5%). However, most reported practicing physician-dominant PDM (43%) with most of their patients, rather than no patient involvement (13%), shared (37%) or patient-dominant PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred shared PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03-3.07] and patients of physicians who preferred patient-dominant treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04-2.39] than those of providers who preferred no patient involvement in treatment decision-making. There were no differences in patients satisfaction with their doctors communication or control of A1c, SBP or LDL depending on their physicians PDM preferences. Physicians self-reported PDM practices were not associated with any of the examined aspects of diabetes care in multivariate analyses. Conclusions: Patients whose physicians prefer more patient involvement in decision-making are more likely than patients whose physicians prefer more physician-directed styles to receive some recommended risk factor screening tests, an important first step toward improved diabetes outcomes. Involving patients in treatment decision-making alone, however, appears not to be sufficient to improve biomedical outcomes.