SHARED DECISION-MAKING PROGRAM LED TO IMPROVED RATES OF BLOOD PRESSURE CONTROL IN FEDERALLY QUALIFIED HEALTH CENTERS: THE OFFICE-GUIDELINE APPLIED TO PRACTICE (OFFICE-GAP) PROGRAM

Purpose:  Shared decision making (SDM) implementation has been limited, in part, by lack of physician uptake. We tested an intervention that supplies a common missing ingredient in implementation: bilateral patient and physician education used with decision aids (DAs) and encounter prompts to structure communication.  

Method:  The Office-Guidelines Applied in Practice (Office-GAP) intervention included: 1) patient SDM training in one 90 min group visit 2) clinician SDM training in one 60-90 min session 3) patient decision aid & clinical encounter decision checklist.  Two site intervention/control design. Main outcome measure: change in blood pressure (BP) control by chart review.  Logistic regression analysis with propensity scoring to control for confounders was used to examine change over time in the rate of BP control in two clinical sites. 

Result: Participants were low-income patients with diabetes and coronary heart disease (CHD) in two Federally Qualified Healthcare Centers (FQHCs). 120 patients were in the intervention arm; 123 in the control arm. Medication use was not different statistically at baseline. Results show that program elements were consistently used with > 98% clinician attended training and the checklist present in the patient chart. Patient attendance at the group visit was > 80% in the intervention. After controlling for confounders, the model showed that the Office-GAP intervention significantly increased the probability of getting BP under control (p=0.0122, OR=2.36).  For diabetic patients, those with Medicaid insurance were more likely to have their BP under control compared to those without insurance (p=0.0590, OR=1.67). Patients whose BP was under control at baseline were more likely to have their BP controlled at 12 months (p<0.0001, OR=5.01).  Diabetic patients were less likely to have BP controlled compared to non-diabetic patients (p=0.0041, OR=0.312).

Conclusion: Use of the Office-GAP program to teach SDM and use of DAs in clinical practice was demonstrated to be feasible in FQHCs. This two group intervention showed that the Office-GAP intervention led to higher rates of BP control among underserved patients with CHD and diabetes.  The Office-GAP program combines previously developed interventions into a brief, efficient approach to improved communication and collaborative decision making in clinical practice.  Further research is needed to reproduce our results and describe the mechanism that appears to improve shared decision making.