IMPLEMENTATION OF A PATIENT DECISION AID ON TYPE 2 DIABETES: OPPORTUNITIES AND CHALLENGES FACED BY HEALTHCARE PROFESSIONALS IN MALAYSIA

Purpose: This study aimed to explore the challenges and opportunities faced by Malaysian healthcare professionals (HCPs) when implementing a patient decision aid (PDA) on insulin initiation in patients with type 2 diabetes.

Method: We conducted a qualitative study to capture the experiences of HCPs who have used the PDA in primary care consultations. In-depth interviews and focus group discussions were conducted after the consultations at university-based primary care clinics, public healthcare clinics and private general practices in 2012-2013. Participants included general practitioners (n=2), medical officers (n=7), diabetes nurses (n=3), and pharmacists (n=1). The interviews were audio-recorded, transcribed verbatim, checked and managed using Nvivo 9 software. A thematic analysis was used.

Result:

The challenges faced by HCPs include patient barriers (e.g. patient’s unwillingness to read the PDA, visual impairment); system barriers (e.g. lack of time to use the PDA in consultations, lack of reading space for patients); and potential medico-legal risks in using the PDA (e.g. negative health outcomes).

HCPs identified opportunities to use PDA at two levels: the health system and individual consultations. At the system level, HCPs suggested incorporating the PDA use into the existing patient care pathway and individualising the timing of introducing the PDA to patients (e.g. before, during or take home after consultations).When selecting patients to use the PDA, the HCPs considered patients’ literacy, the decision maker (patient or significant others), patient preparedness to decide, and knowledge of insulin.

At the individual consultation level, the use of the PDA by the HCPs was influenced by the following factors: being aware of different ways of using the PDA (e.g. cover to cover, focusing only on patient concerns, using the PDA over multiple consultations), being willing to modify their consultation style to use the PDA, giving more guidance to patients who had difficulty in understanding the PDA, and being able to use different language versions of the PDA. Some HCPs would avoid discussing the PDA at the initial consultation as they perceived that this might influence the patient’s decision to start insulin.

Conclusion: HCPs identified patient and system barriers in implementing the PDA.  The implementation of the PDA would depend on integrating the PDA into existing clinic pathway and being flexible when using the PDA with individual patients.