Journal of General Internal Medicine

, Volume 18, Issue 11, pp 893–902 | Cite as

When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?

  • Michele Heisler
  • Sandeep Vijan
  • Robert M. Anderson
  • Peter A. Ubel
  • Steven J. Bernstein
  • Timothy P. Hofer
Original Articles


BACKGROUND: For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians.

OBJECTIVE: To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes.

DESIGN: One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management.

RESULTS: Overall, agreement on top treatment goals and strategies was low (all κ were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management.

CONCLUSION: Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.

Key words

chronic disease management diabetes patientdoctor communication self-management 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bandura A. Social Foundations of Thought and Action. A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.Google Scholar
  2. 2.
    Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21:1644–51.PubMedCrossRefGoogle Scholar
  3. 3.
    Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. How well do patients’ assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services? Diabetes Care. 2003;26:738–43.PubMedCrossRefGoogle Scholar
  4. 4.
    Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243–52.PubMedCrossRefGoogle Scholar
  5. 5.
    DiMatteo MR. Enhancing patient adherence to medical recommendations. JAMA. 1994;271:83.CrossRefGoogle Scholar
  6. 6.
    Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27:110S-127S.CrossRefGoogle Scholar
  7. 7.
    Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423–33.PubMedGoogle Scholar
  8. 8.
    Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med. 1992;15:447–68.PubMedCrossRefGoogle Scholar
  9. 9.
    Brownell KD, Cohen LR. Adherence to dietary regimens. 1. An overview of research. Behav Med. 1995;20:149–54.PubMedCrossRefGoogle Scholar
  10. 10.
    Marcus BH, Rakowski W, Rossi JS. Assessing motivational readiness and decision making for exercise. Health Psychol. 1992;11:257–61.PubMedCrossRefGoogle Scholar
  11. 11.
    Clark MM, Abrams DB, Niaura RS, Eaton CA, Rossi JS. Self-efficacy in weight management. J Consult Clin Psychol. 1991;59:739–44.PubMedCrossRefGoogle Scholar
  12. 12.
    Levetan CS, Dawn KR, Robbins DC, Ratner RE. Impact of computer-generated personalized goals on HbA (1c). Diabetes Care. 2002;25:2–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127(12):1097–102.Google Scholar
  14. 14.
    Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511–44.PubMedCrossRefGoogle Scholar
  15. 15.
    Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment. Results of a randomized controlled trial. Diabetes Care. 1995;18:943–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educ. 2000;26:597–604.PubMedGoogle Scholar
  17. 17.
    Glasgow RE, Anderson RM. In diabetes care, moving from compliance to adherence is not enough. Something entirely different is needed. Diabetes Care. 1999;22:2090–2.PubMedCrossRefGoogle Scholar
  18. 18.
    Bradley EH, Bogardus ST Jr, Tinetti ME, Inouye SK. Goal-setting in clinical medicine. Soc Sci Med. 1999;49:267–78.PubMedCrossRefGoogle Scholar
  19. 19.
    Wolpert HA, Anderson BJ. Management of diabetes: are doctors framing the benefits from the wrong perspective? BMJ. 2001;323:994–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Olivarius NF, Beck-Nielsen H, Andreasen AH, Horder M, Pedersen PA. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ. 2001;323:970–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Golin CE, DiMatteo MR, Gelberg L. The role of patient participation in the doctor visit. Implications for adherence to diabetes care. Diabetes Care. 1996;19:1153–64.PubMedCrossRefGoogle Scholar
  22. 22.
    Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med. 2002;24:80–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Senecal C, Nouwen A, White D. Motivation and dietary self-care in adults with diabetes: are self-efficacy and autonomous self-regulation complementary or competing constructs? Health Psychol. 2000;19:452–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Martin TL, Selby JV, Zhang D. Physician and patient prevention practices in NIDDM in a large urban managed-care organization. Diabetes Care. 1995;18:1124–32.PubMedCrossRefGoogle Scholar
  25. 25.
    Ashton C, Haldet P, Paterniti D, et al. Racial and ethnic disparities in the use of health services. J Gen Intern Med. 2003;18:1–7.CrossRefGoogle Scholar
  26. 26.
    Starfield B, Steinwachs D, Morris I, Bause G, Siebert S, Westin C. Patient-doctor agreement about problems needing follow-up visit. JAMA. 1979;242:344–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Starfield B, Wray C, Hess K, Gross R, Birk PS, D’Lugoff BC. The influence of patient-practitioner agreement on outcome of care. Am J Public Health. 1981;71:127–31.PubMedCrossRefGoogle Scholar
  28. 28.
    Freidin RB, Goldman L, Cecil RR. Patient-physician concordance in problem identification in the primary care setting. Ann Intern Med. 1980;93:490–3.PubMedGoogle Scholar
  29. 29.
    Helman CG. Communication in primary care: the role of patient and practitioner explanatory models. Soc Sci Med. 1985;20:923–31.PubMedCrossRefGoogle Scholar
  30. 30.
    Kwoh CK, O’Connor GT, Regan-Smith MG, et al. Concordance between clinician and patient assessment of physical and mental health status. J Rheumatol. 1992;19:1031–7.PubMedGoogle Scholar
  31. 31.
    Bogardus ST, Bradley EH, Williams CS, Maciejewski PK, van Doorn C, Inouye SK. Goals for the care of frail older adults: do caregivers and clinicians agree? Am J Med. 2001;110:97–102.PubMedCrossRefGoogle Scholar
  32. 32.
    Hunt LM, Pugh J, Valenzuela M. How patients adapt diabetes self-care recommendations in everyday life. J Family Pract. 1998;46:207–15.Google Scholar
  33. 33.
    Boyer BA, Lerman C, Shipley TE Jr, McBrearty J, Quint A, Goren E. Discordance between physician and patient perceptions in the treatment of diabetes mellitus: a pilot study of the relationship to adherence and glycemic control. Diabetes Educ. 1996;22:493–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Cohen MZ, Reimer TT, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: patient practitioner variation. Soc Sci Med. 1994;38:59–66.PubMedCrossRefGoogle Scholar
  35. 35.
    Gillespie CR, Bradley C. Causal attributions of doctor and patients in a diabetes clinic. Br J Clin Psychol. 1988;27:67–76.PubMedGoogle Scholar
  36. 36.
    Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37:5–14.PubMedCrossRefGoogle Scholar
  37. 37.
    Wagner EH. Meeting the needs of chronically ill people. BMJ. 2001;323:945–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Hunt LM, Arar NH, Larme AC. Contrasting patient and practitioner perspectives in type 2 diabetes management. West J Nurs Res. 1998;20:656–76.PubMedCrossRefGoogle Scholar
  39. 39.
    Williams GC, Grow VM, Freedman ZR, Ryan RM, Deci EL. Motivational predictors of weight loss and weight-loss maintenance. J Pers Soc Psychol. 1996;70:115–26.PubMedCrossRefGoogle Scholar
  40. 40.
    Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med. 1996;156:1414–20.PubMedCrossRefGoogle Scholar
  41. 41.
    Beisecker AE, Beisecker TD. Patient information-seeking behaviors when communicating with doctors. Med Care. 1990;28:19–28.PubMedCrossRefGoogle Scholar
  42. 42.
    Strull WM, Lo B, Charles G. Do patients want to participate in medical decision making? JAMA. 1984;252:2990–4.PubMedCrossRefGoogle Scholar
  43. 43.
    Ruggiero L, Glasgow R, Dryfoos JM, et al. Diabetes self-management. Self-reported recommendations and patterns in a large population. Diabetes Care. 1997;20:568–76.PubMedCrossRefGoogle Scholar
  44. 44.
    Stewart AL, Napoles-Springer A, Perez-Stable EJ. Interpersonal processes of care in diverse populations. Milbank Q. 1999;77:274.CrossRefGoogle Scholar
  45. 45.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care. 2000;23:943–50.PubMedCrossRefGoogle Scholar
  47. 47.
    Goodall TA, Halford WK. Self-management of diabetes mellitus: a critical review. Health Psychol. 1991;10:1–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Fleiss JL. Statistical Methods for Rates and Proportions. New York: Wiley and Sons; 1981.Google Scholar
  49. 49.
    Huber P. The behavior of maximum likelihood estimates under nonstandard conditions. Proc Fifth Berkeley Symp Mathemat Statistics Probability. 1967;1:221–3.Google Scholar
  50. 50.
    White H. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica. 1980;40:817–30.CrossRefGoogle Scholar
  51. 51.
    Berger M, Muhlhauser I. Diabetes care and patient-oriented outcomes. JAMA. 1999;281:1676–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Glasgow RE, Boles SM, Calder D, Dreyer L, Bagdade J. Diabetes care practices in primary care: results from two samples and three measurement sets. Diabetes Educ. 1999;25:755–63.PubMedGoogle Scholar
  53. 53.
    Glasgow RE, Strycker LA. Preventive care practices for diabetes management in two primary care samples. Am J Prev Med. 2000;19:9–14.PubMedCrossRefGoogle Scholar
  54. 54.
    Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med. 2003;138:593–602.PubMedGoogle Scholar
  55. 55.
    Daltroy LH. Doctor-patient communication in rheumatological disorders. Baillieres Clin Rheumatol. 1993;7:221–39.PubMedCrossRefGoogle Scholar
  56. 56.
    Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care. 1998;21:1391–6. 0149–5992.PubMedCrossRefGoogle Scholar
  57. 57.
    Peyrot M, McMurry JF, Hedges R. Living with diabetes: the role of personal and professional knowledge in symptom and regimen management. Res Sociol Health. 1987;6:107–46.Google Scholar
  58. 58.
    Harris MA, Wysocki T, Sadler M, et al. Validation of a structured interview for the assessment of diabetes self-management. Diabetes Care. 2000;23:1301–4.PubMedCrossRefGoogle Scholar
  59. 59.
    Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002;288:756–64.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Michele Heisler
    • 1
    • 2
    • 3
  • Sandeep Vijan
    • 1
    • 2
    • 3
  • Robert M. Anderson
    • 3
    • 4
  • Peter A. Ubel
    • 1
    • 2
  • Steven J. Bernstein
    • 1
    • 2
  • Timothy P. Hofer
    • 1
    • 2
  1. 1.Veterans Affairs Center for Practice Management and Outcomes ResearchVA Ann Arbor Healthcare SystemAnn Arbor
  2. 2.Department of Internal MedicineUniversity of Michigan School of MedicineAnn Arbor
  3. 3.Michigan Diabetes Research and Training CenterUniversity of Michigan School of MedicineAnn Arbor
  4. 4.Department of Medical EducationUniversity of Michigan School of MedicineAnn Arbor

Personalised recommendations