The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management

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Abstract

Patients' self-management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient-physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient-physician interaction styles on patients' diabetes self-management. This study assessed the influence of patients' evaluation of their physicians' participatory decision-making style, rating of physician communication, and reported understanding of diabetes self-care on their self-reported diabetes management. We surveyed 2,000 patients receiving diabetes care across 25 Veterans' Affairs facilities. We measured patients' evaluation of provider participatory decision making with a 4-item scale (Provider Participatory Decision-making Style [PDMstyle]; alpha = 0.96), rating of providers' communication with a 5-item scale (Provider Communication [PCOM]; alpha = 0.93), understanding of diabetes self-care with an 8-item scale (alpha = 0.90), and patients' completion of diabetes self-care activities (self-management) in 5 domains (alpha = 0.68). Using multivariable linear regression, we examined self-management with the independent associations of PDMstyle, PCOM, and Understanding. Sixty-six percent of the sample completed the surveys (N = 1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self-management assessments (P < .01 in all models). When modeled together, PCOM remained a significant independent predictor of self-management (standardized beta: 0.18; P < .001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self-management (standardized beta: 0.10; P =.004). Understanding was strongly and independently associated with self-management (standardized beta: 0.25; P < .001). For these patients, ratings of providers' communication effectiveness were more important than a participatory decision-making style in predicting diabetes self-management. Reported understanding of self-care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self-management, raising the possibility that both provider styles enhance self-management through increased patient understanding or self-confidence.

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Race, gender, and partnership in the patient-physician relationship.

Lisa Cooper-Patrick (1999)

Many studies have documented race and gender differences in health care received by patients. However, few studies have related differences in the quality of interpersonal care to patient and physician race and gender. To describe how the race/ethnicity and gender of patients and physicians are associated with physicians' participatory decision-making (PDM) styles. Telephone survey conducted between November 1996 and June 1998 of 1816 adults aged 18 to 65 years (mean age, 41 years) who had recently attended 1 of 32 primary care practices associated with a large mixed-model managed care organization in an urban setting. Sixty-six percent of patients surveyed were female, 43% were white, and 45% were African American. The physician sample (n = 64) was 63% male, with 56% white, and 25% African American. Patients' ratings of their physicians' PDM style on a 100-point scale. African American patients rated their visits as significantly less participatory than whites in models adjusting for patient age, gender, education, marital status, health status, and length of the patient-physician relationship (mean [SE] PDM score, 58.0 [1.2] vs 60.6 [3.3]; P = .03). Ratings of minority and white physicians did not differ with respect to PDM style (adjusted mean [SE] PDM score for African Americans, 59.2 [1.7] vs whites, 61.7 [3.1]; P = .13). Patients in race-concordant relationships with their physicians rated their visits as significantly more participatory than patients in race-discordant relationships (difference [SE], 2.6 [1.1]; P = .02). Patients of female physicians had more participatory visits (adjusted mean [SE] PDM score for female, 62.4 [1.3] vs male, 59.5 [3.1]; P = .03), but gender concordance between physicians and patients was not significantly related to PDM score (unadjusted mean [SE] PDM score, 76.0 [1.0] for concordant vs 74.5 [0.9] for discordant; P = .12). Patient satisfaction was highly associated with PDM score within all race/ethnicity groups. Our data suggest that African American patients rate their visits with physicians as less participatory than whites. However, patients seeing physicians of their own race rate their physicians' decision-making styles as more participatory. Improving cross-cultural communication between primary care physicians and patients and providing patients with access to a diverse group of physicians may lead to more patient involvement in care, higher levels of patient satisfaction, and better health outcomes.