Catherine Yu*, St. Michael's Hospital, University of Toronto, Toronto, Canada Dawn Stacey, University of Ottawa, Ottawa, Canada Susan Hall, St. Michael's Hospital, University of Toronto, Toronto, Canada Noah Ivers, University of Toronto, Toronto, Canada Jeremy Rezmovitz , University of Toronto, Toronto, Canada Fok-Han Leung, St. Michael's Hospital, University of Toronto, Toronto, Canada Joanna Sale, St. Michael's Hospital, University of Toronto, Toronto, Canada Michael Coons, University of Toronto, Toronto, Canada Harold Yuen, Southlake Regional Health Centre, Newmarket, Canada David M Kaplan, University of Toronto, Toronto, Canada Sharon E Straus, St. Michael's Hospital, University of Toronto, Toronto, Canada Paul Cantarutti, Southlake Regional Health Centre, Newmarket, Canada Track: Research Presentation Topic: Consumer empowerment, patient-physician relationship, and sociotechnical issues Presentation Type: Poster presentation Submission Type: Single Presentation Last modified: 2014-05-24

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Background: Care of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and priority-setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. These strategies have not been taken up extensively in clinical practice.
Objectives: To explore the feasibility of an electronic interprofessional SDM and goal-setting toolkit for patient with diabetes and other chronic diseases for use in clinical care
Methods: Individual semi-structured interviews with healthcare providers and patients were used to explore their experiences with shared decision-making and priority-setting, including facilitators and barriers, and the relevance of a decision aid and toolkit for priority-setting in clinical care. Family physicians, nurses, dietitians, pharmacists, and patients with diabetes and two other comorbidities were recruited through 5 family health teams in the academic and community settings. Audiotapes were transcribed to create a verbatim transcript, which were coded independently by 2 team members for emergent categories and themes within and across interviews.
Results: Preliminary results from 10 interviews (6 physicians, 2 nurses, 1 dietitian, 1 pharmacist) are presented here. We identified 6 themes: 1) Approach to decision-making was closely tied into one’s professional identity, spanning the spectrum from provision of information to making of the decision, though this was tailored to the specific clinical situation. 2) Barriers to priority-setting included tension between the patient’s “be” goals and “do” goals, between health professional’s and the patient’s agenda, competing health and life concerns and lack of time. 3) Facilitators to priority-setting included understanding patient barriers, putting the patient’s goal in context of the health professional’s goal, involving the team and use of flowsheets and case studies. 4) Barriers to SDM mirrored those for priority-setting. 5) Facilitators to SDM included patient education, a holistic patient approach, electronic medical record-based flowsheets, and intra-team communication. 6) The use of SDM tools generated mixed feelings: while some thought that they would result in greater efficiencies in time and a positive impact on the relationship, others thought that lack of time, tool complexity and lack of interaction with the patient would be barriers to their use.
Conclusion: Interprofessional SDM regarding priority-setting with the use of an electronic decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Our preliminary findings confirm previous knowledge regarding competing issues in the care of the complex patient, but also identify new information regarding facilitators of priority-setting and SDM, namely use of flowsheets in the electronic medical record. Adhering to principles of user-centered design, we will develop and refine a toolkit, by addressing identified barriers and leveraging identified facilitators.