Huang, Elbert S., MD, MPH
Personalized decision support for older patients with diabetes
General Research Subject: Type 2 Diabetes
Focus: Clinical Therapeutics/New Technology, Diabetes Education, Health Care Delivery/Economics
Type of Grant: Clinical Translational Research
Project Start Date: January 1, 2009
Project End Date: December 31, 2011
Patients over 65 years of age represent a large and growing portion of the diabetes population that has traditionally been understudied. The challenge of caring for older patients is that they vary widely in their overall health condition and their ability to care for themselves and these differences require that doctors provide a highly personalized form of diabetes care. There is currently no established ways of personalizing diabetes care for older people. We propose to address this gap in clinical practice by developing and testing a computerized decision support tool, the Geriatric Diabetes Decision Aid (GDDA). The GDDA is an educational tool that may be used by patients in consultation with their doctor, before, during, or after clinical visits.
For patients, the GDDA will provide education on diabetes and its treatments while also providing personalized information about the impact of treatment choices. At the same time, the GDDA will provide important prognostic information to doctors to guide treatment decisions. During the development phase of this proposal, we will elicit patient and doctor feedback on the content and format of the GDDA. Following this, the GDDA will be pilot tested with 10 doctors and 75 older patients living with diabetes. This pilot test will help us to determine whether the GDDA can be easily incorporated into practice and if it can improve the individualization of diabetes care treatment decisions. Improving the individualization of diabetes treatment decisions may improve the quality of life of older patients and lead to more cost-effective care.
What area of diabetes research does your project cover?
This project concerns the quality of care of diabetes patients over 65 years of age. This group represents a large and growing portion of the diabetes population that is not often included in major clinical trials. Caring for older patients is challenging because individuals in this group vary widely in their overall health condition and their ability to care for themselves and this variation may change the risks and benefits of intensive diabetes care. In addition, older patients are oftentimes not actively involved in health care decision-making. As a result, care decisions are oftentimes made that are not compatible with the patient's lifestyle, values, or beliefs. The ADA and other clinical geriatric organizations have recently introduced new concepts from geriatrics regarding individualization of diabetes care into clinical guidelines. Many of these new concepts have never been formally developed or tested in practice and so doctors have no proven way of providing this form of diabetes care.
What role will this particular project play in preventing, treating and/or curing diabetes?
In this project, we will develop and test a web-based tool which is designed to help make diabetes care decisions in older patients easier. The tool will incorporate the latest developments in patient-doctor communication with a simulation model of diabetes complications. It will be designed for patients to use alongside their doctor. For patients, the tool will: provide diabetes-education about the disease and its treatments; provide personalized information about the impact of treatment choices; and encourage older patients to voice their preferences for treatment choices. At the same time, the tool will provide important prognostic information to doctors to guide treatment decisions. The completion of the project will help us to determine whether the decision support tool can be easily incorporated into clinical practice and if it can improve the personalization of diabetes treatment. We believe that providing individualized care may lead to a better quality of life for many older patients.
If a person with diabetes were to ask you how your project will help them in the future, how would you respond?
In general, a one-size-fits-all approach is currently used when developing diabetes treatment plans. The goals for your diabetes care such as the ideal targets for your glucose, blood pressure, or cholesterol are assumed to be the same for all patients. These targets are based on studies of middle-aged people with no other major medical concerns. The risks and benefits of achieving these targets may differ from person to person based on their medical history and age. We want to study whether or not acknowledging these differences in older patients can improve their diabetes care.
Our project and its findings will be relevant for any adult patient living with diabetes but will be particularly relevant if you are a diabetes patient over the age of 65. We are developing a computer-based tool that is being designed to ensure that your diabetes care is tailored to your medical history and to your treatment preferences. The tool will be an educational resource that you can use in visits with your doctor but also one that you can use in the comfort of your home. The tool will help you understand the impact of pursuing different risk factor targets and understand the various medication and lifestyle options available to achieve those targets. By using this tool, we believe that you will become much more involved in goal setting and treatment decisions. Ultimately, we think this will improve your diabetes care and your quality of life.
Why is it important for you, personally, to become involved in diabetes research? What role will this award play in your research efforts?
As a medical student, I vividly remember meeting older patients who varied widely in their medical condition in ways that transcended age. Some older patients had many medical problems and a laundry list of medications while others seemed relatively young with very few medical problems. These observations led to a long term interest in understanding how care for a condition like diabetes should vary from patient to patient. As a practicing general internist, I have always sought to provide care that acknowledges the overall context of patients' lives and that is sensitive to the everyday quality of their lives. Older patients that live with diabetes are very diverse and diabetes care is inherently complex, so geriatric diabetes is an important and natural area to study individualization of preventive care.
In my research, I have conducted studies that address a series of interconnected questions that cover diverse topics such as: older diabetes patients' self-report of health care goals, older patients' perceptions of the burden of life with medications, the assessment of quality of diabetes care in older patients, and the impact of comorbid illness and functional status on the expected benefits of intensive glucose control. These studies have been conducted with an eye towards developing new approaches to delivering diabetes care.
This Clinical Research Award provides critical support for the development and pilot testing of a new decision support tool for the care of older diabetes patients. The findings from this 3-year award will be used to develop a proposal for a larger randomized controlled trial to be carried out at clinics affiliated with an academic medical center, a network of community health centers, and a large integrated health system in the Chicago area.
In what direction do you see the future of diabetes research going?
Basic research in diabetes has enhanced our understanding of the molecular etiology of the disease and has increased the number of available therapies. It is important that we continue to support basic research that leads to new drug discovery.
At the same time, I believe that it is equally critical that we devote significant research efforts to understanding how these discoveries should be translated into the care of individual patients. In particular, it is important to understand how diabetes care should be tailored to individual patients based on differences in clinical health status. This is the motivation behind my own research. The larger hope is that we may one day be able to truly individualize diabetes care based, not only on clinical health status, but on the specific causes of an individual's diabetes.
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