Inability to motivate diabetics with poor control to overcome barriers inhibiting healthier lifestyles frustrates physicians

Diabetes affects approximately 8 percent of the people in the United States and adults with diabetes have heart disease death rates two to four times higher than adults without diabetes, according to the American Diabetes Association. A new study shows that primary care physicians believe the barriers that put patients with uncontrolled diabetes at risk for cardiovascular disease as being patient-related or system-related. Published online today by the Journal of the American Board of Family Medicine by researchers at UMDNJ-Robert Wood Johnson Medical School and colleagues at the University of Hawaii and University of Michigan, the research also reports that the physician participants commonly reported a high level of frustration at being unable to motivate patients with poor control or help patients to overcome the barriers that inhibit healthier lifestyles.

"Physicians inherently want to help their patients get better, but diabetes is a chronic disorder that becomes more difficult to manage over time, even when treated properly," said lead study author Jesse Crosson, PhD, assistant professor of family medicine and director of the New Jersey Primary Care Research Network at UMDNJ-Robert Wood Johnson Medical School. "Our study is the first step in identifying ways to help primary care providers assist their patients in overcoming obstacles and developing strategies to help relieve the frustration felt by providers."

The exploratory study interviewed 34 primary care physicians in diverse practices in California, Indiana, Michigan and New Jersey who provided outpatient care to adult diabetic patients. Many of the physicians responded that patient-related socioeconomic concerns proved to be a significant barrier to maintaining good diabetic health. This included financial struggles by patients that kept them from maintaining the challenging lifestyle and diet that diabetes requires, such as buying healthy - often more expensive - food. Family-related concerns, such as a lack of support or caring for other family members before themselves, also proved a significant barrier for patients. The study also found that other medical conditions, such as pain or depression competed with patients' efforts to control cardiovascular risk factors.

System-related barriers fell into two categories: the physician's ability to deliver care and the patient's ability to access care. Physicians identified the cost of transportation to get to appointments, and the high cost of medication to treat diabetes as significant barriers for their patients. The health system presented other barriers such as difficulties obtaining referrals and making convenient appointments.

System-related barriers preventing physicians from delivering care included the failure to utilize technology to make a patient's health record readily accessible at the point of care. Poor coordination of care among health care providers also was noted as a significant barrier. "Ideally, a multidisciplinary team of nurses, diabetes educators, pharmacists and endocrinologists would greatly improve a primary care doctor's ability to assist patients who face significant barriers to controlling diabetes and its complications," said Dr. Crosson.

Physicians' perceptions that they were unable to help patients overcome these barriers resulted in high levels of frustration. According to the study, this response was consistent among physicians in all four areas of the country included in the study. The frustration arose from a perceived inability to address patients' motivation for maintaining good health, patients' resistance to treatment recommendations and a belief that the barriers faced by patients are outside of physicians' control.

Specifically, the study noted that none of the physician participants identified their own action or inaction in providing care as barriers to good control, but instead often felt that "nothing I do will change anything." As a result, the study recommends training physicians and other health care providers in effective strategies that will allow them to work collaboratively with patients to address the barriers. At the system-level, the study recommends that more team-based strategies be developed, with health plan partners included in those teams to address payment reform for physicians. Physicians noted that spending more time with diabetes patients is not cost-effective and that there is a lack of reimbursement from health insurers for time spent counseling patients.

The research included physician participants who provide care to adult diabetic patients at translational research centers participating in the Translating Research into Action for Diabetes (TRIAD) study. TRIAD is a ten-year project funded by the Centers for Disease Control and Prevention (CDC) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to understand and influence the quality of care for patients with diabetes in managed care settings.

The study can be found online at: http://www.jabfm.org/cgi/content/abstract/23/2/171.

Source UMDNJ-Robert Wood Johnson Medical School