We developed and pilot tested Office-Guidelines Applied to Practice (Office-GAP) an innovative program that taught both physicians and patients to use shared decision making (SDM) and decision aids (DA) in one Federally Qualified Community Health Center (FQCHC). We report its impact on two SDM measures, patient satisfaction with physician communication (SWC) and confidence in decision (CID), and on medication adherence.
Method:
The program was implemented from January 2009 to December 2011, enrolling patients with coronary artery disease or diabetes mellitus, plus 2 doctors, a nurse-practitioner, and 8 staff. We collected process data at the 90-minute provider training session, 90-minute group visits with patients and on use of GAP tools during patients’ 2 follow-up office visits with their physicians. Both SWC and CID were measured by subscales of the Combined Outcome Measure for Risk Communication and Treatment Decision Making (COMRADE) survey with modified scoring procedures. Medication adherence was measured by use documented in patient charts. Multilevel regressions tested whether SWC and CID changed over time. Multilevel logistic regressions tested whether the probability of aspirin, ACEI, beta blocker, and statin use changed over time. Logistic regressions examined predictors of medication use at 12 months.
Result:
The feasibility of Office-GAP was clear: All providers and staff attended the training and the Office-GAP tool used at 98.7% of office visits. Of the 96 enrolled patients who attended the group visits, 80 (83.3%) completed the first Office-GAP provider visit and 75 (78.1%) completed the second visit. Both satisfaction and confidence increased over time. Scores at both visit 2 (SWC M = 42.9, p = < .001; CID M = 43.1, p = < .001) and visit 3 (SWC M = 44.3, p = < .001, and CID M = 43.8, p = < .001) exceeded baseline values (SWC M = 38.6; CID M = 38.9). Use of all medications also increased over time. Age and number of Office-GAP visits predicted aspirin use; having Medicaid/Medicare insurance predicted statin use at 12 months.
Conclusion:
Although the reach, effectiveness and cost-effectiveness of Office-GAP require further evaluation, using SDM and DA in real time appears feasible in a FQCHC setting. Office-GAP may benefit low-income patients with CAD and diabetes by improving satisfaction with physician communication, confidence in decisions, and medication adherence.