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Archive - Meet the Researcher
Victor Montori, MD, MSc - Knowledge and Encounter Research Unit, Mayo ClinicVictor Montori, MD, MSc, was the recipient of an ADA-Novo Nordisk Clinical Research Award to help determine the best way to help people with type 2 diabetes make decisions about diabetes medications, including insulin. This was a competitive grant awarded and administered by the ADA , with funding support from Novo Nordisk, Inc. Dr. Montori explains, “Patients with type 2 diabetes whose pills only achieve limited blood sugar control often delay starting insulin therapy. This delay may increase complications and impair the quality of their lives. Delays may occur because of knowledge gaps, fears, beliefs, and other barriers that disqualify insulin as a valid treatment choice.”
To encourage conversation about medication options, including insulin, between patient and physician, Dr. Montori and his colleagues developed a tool to present unbiased information about different treatment choices, their benefits and drawbacks. In treating type 2 diabetes five of the most commonly prescribed drugs, or classes of drugs, are metformin, sulfonylureas (glipizide, glyburide, glimepiride), thiazolidinediones (brand name Actos or Avandia), exenatide (brand name Byetta), and insulin. To help patients become a part of the medication decision process, Dr. Montori, a group of patients with diabetes from the community, clinicians, and designer Maggie Breslin worked together to develop a decision tool made up of six cards, each detailing an important outcome of using one of the five medications described:
To test the effectiveness of the six “Diabetes Medication Cards,” Dr. Montori’s study team, led by study coordinator Rebecca Mullan, recruited 40 physicians who had patients eligible for the trial. Eligible patients included those who were willing to give informed consent to participate in the trial, had type 2 diabetes for at least one year, had an A1C level between 7-9.5 percent within the last six months, were not on insulin, and were using less than four oral medications to treat high blood glucose associated with their diabetes.
In the experimental group, the physician presented all six cards to the patient at a regular office visit and asked which of the six issues was most important to them personally in deciding which medications to take; this started a conversation that continued with patients reviewing as many cards as they needed to arrive at a decision with their clinician. Dr. Montori and his colleagues then surveyed both groups of patients and physicians after each office visit, and found that, “There was a trend that patients who received the decision aid were more likely to feel that their physician involved them in the decision making process. Most noticeably, 96 percent of patients who received the decision aid strongly agreed or agreed with the statement, ‘My provider identified blood sugar control as a choice that I could participate in,’ compared to 84 percent of patients in the control group.” Dr. Montori reports that weight change was one of the most common concerns among patients in the experimental group, with the weight change card being the card most likely to be chosen first among medication concerns (39 percent), and the second most commonly viewed card (56 percent). The patients who received the decision tool also were more likely to implement a follow-up plan for their next office visit if their A1C did not improve. Finally, insulin as a medication option was discussed in all of the visits in the experimental group. Almost all patients using the cards (96 percent) considered clinicians knew their concerns and preferences regarding diabetes medications compared to 71 percent of patients in the usual care arm. Overall, physicians felt the tool was beneficial. Eighty-four percent of the 21 physicians who used the tool felt that it was helpful in fostering a discussion about medications with their patient, and 90 percent said they would use the cards again. The result of the study was that both the patients and physicians found the cards helpful. According to Dr. Montori, “Compared to usual visits, patients and clinicians using the decision aid were more likely to discuss and consider issues that mattered to patients (such as the effect of medications on their weight). Consequently, patients using the decision aid felt they had greater participation in this decision and that their clinician considered their preferences in making recommendations.” Over the next few months, Dr. Montori and his colleagues will be completing follow-up analysis of their study to determine if patients adhered to their medication decisions and how these cards affected diabetes control. At this time, Dr. Montori and his team have developed instructional videos on how to use the cards (http://mayoresearch.mayo.edu/mayo/research/ker_unit/decision-aids.cfm), a pamphlet of the decision tool for patients, and a prototype of an on-line version of the tool. He hopes to test the tool in larger, more diverse populations, as well as implement another, similar tool (the Statin Choice decision aid) for Spanish-speaking patients. Also, cards focusing on costs and on lifestyle interventions are in the works. Use our searchable Research Database to familiarize yourself with other currently funded ADA researchers. |
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Physicians were randomly assigned to use the “Diabetes Medication Cards” decision tool when discussing medication options (experimental group), or to have their usual discussion on medication options without using the tool (control group). Twenty-one physicians and 48 of their patients participated in the experimental group, and 19 physicians and 37 patients participated in the control group. | Información en español | About Us | Donate Now | Join ADA | Volunteer | Message Boards | Sign up for Enewsletters |
