Goal Setting
Patient-reported use of collaborative goal setting and glycemic control among patients with diabetes

https://doi.org/10.1016/j.pec.2013.01.016Get rights and content

Abstract

Objective

Little is known about how patient–clinician communication leads to better outcomes. Among patients with diabetes, we describe patient-reported use of collaborative goal setting and evaluate whether perceived competency and physician trust mediate the association between collaborative goal setting and glycemic control.

Methods

Data from a patient survey administered in 2008 to a cohort of insured patients aged 18+ years with diabetes who initiated oral mono-therapy between 2000 and 2005 were joined with pharmaceutical claims data for the prior 12 months and laboratory data for the prior and subsequent 12 months (N = 1065). A structural equation model (SEM) was used to test mediation models controlling for baseline HbA1c.

Results

The hypothesized mediation model was supported. Patient-reported use of more collaborative goal setting was associated with greater perceived self-management competency and increased level of trust in the physician (p < 0.05). In turn, both greater perceived competence and increased trust were associated with increased control (p < 0.05).

Conclusions

Findings indicate that engaging patients in collaborative goal setting during clinical encounters has potential to foster a trusting patient–clinician relationship as well as enhance patient perceived competence, thereby improving clinical control.

Practice implications

Fostering collaborative goal setting may yield payoffs in improved clinical outcomes among patients with diabetes.

Introduction

Despite the availability of effective pharmacological and other treatments, clinical control, measured by hemoglobin (Hb) A1c, is often not achieved among patients with diabetes [1], [2]. Recently, interest has centered on how the features of patient–clinician communication may affect health outcomes [3]. Of particular interest is the role of active patient participation during clinical encounters [4].

Previous observational [5], [6], [7], [8] and interventional studies [9] have highlighted the benefits of active patient participation in medical encounters, although findings in the context of diabetes care are mixed [10]. One key component of active patient participation is collaborative goal setting [11]. Collaboratively setting a goal has been shown to lead to increased levels of goal commitment [4], [12], [13], [14], [15], [16], [17]. Furthermore, collaboratively helping patients set and follow up on goals may be an effective way to help patients improve their self-efficacy, an important predecessor to effective self-management, and thus glycemic control and other patient-centered outcomes [11], [18]. Furthermore, the act of collaboratively setting goals may be beneficial to patient–clinician rapport, improving factors, such as patient trust, which have been shown to improve patient adherence to recommended treatment [19]. As such, the American Diabetes Association's clinical practice guidelines acknowledge the importance of collaborative goal setting in diabetes care management [20].

Among patients with diabetes, patients’ perceptions of collaborative care (including collaborative goal setting) have been shown to be associated with patients’ reported self-management [7] and, indirectly, with hypertension control [5]. However, the relationship between collaborative goal setting and clinical control among patients with diabetes remains poorly understood. Using a patient survey joined with laboratory data on HbA1c control among a sample of insured, primary care patients with diabetes, we describe patient-reported use of collaborative goal setting when receiving medical care for their diabetes, and evaluate the associations between patient reports of collaborative goal setting and subsequent glycemic control (as measured by HbA1c). As advocated by Street and colleagues [3], we do so by evaluating plausible pathways through which communication may contribute to healing. Specifically, we evaluate whether patient perceived self-management competence and physician trust mediate the relationship between patient-reported use of collaborative goal setting when receiving medical care for their diabetes and subsequent glycemic control.

Section snippets

Patient selection

Survey-eligible patients were selected from a previously established cohort of insured patients aged 18 years and over who initiated oral mono-therapy between 2000 and 2005 [21]. This cohort included all insured patients receiving diabetes care between 2000 and 2005 from a salaried, multi-specialty group practice in southeast Michigan. The medical group, which staffs 27 ambulatory clinics in Detroit and its surrounding suburbs, is owned by an integrated health system which maintains a large

Sample characteristics

Among the N = 1580 patients contacted for survey administration, N = 190 were ineligible (N = 17 were deceased, 5 did not speak English, 27 reported not having diabetes and 104 reported currently using insulin and N = 37 did not have valid contact information). One thousand and sixty-five (N = 1065) eligible respondents completed the survey (N = 951 via mail and N = 114 via telephone) resulting in an overall response rate of 77% (i.e., 1065/(1580  190)). Those who reported not seeing a primary care physician

Discussion

Findings here illustrate that, controlling for patient characteristics including the patient's prior HbA1c control, the more patients with diabetes report engaging in collaborative goal setting when receiving medical care for their diabetes, the more likely they are to report both increased trust in their physician and high perceived competence, which in turn are associated with better glycemic control. As such, these findings indicate that engaging patients with diabetes in collaborative goal

Funding

The database used was developed under a contract from Sanofi-Aventis.

Acknowledgments

J.E.L, E.D., and H.L.M. worked on the concept and design. J.E.L. and E.D. collected the data. J.E.L., H.L.M., and L.D. analyzed the data. J.E.L., H.L.M., E.D., M.H., R.W., and L.D. interpreted the data, reviewed/edited the manuscript, and gave final approval. The study was funded by Sanofi-Aventis. Representatives from the funding agency did not play any role in the study design, data collection, analyses or interpretation. The Institutional Review Board of the participating medical group

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