Patients with diabetes rank health concerns differently than their doctors

Patients and their doctors are significantly less likely to agree if the patient is in poor health

Ann Arbor, Mich.­­--   About one-third of doctors and their patients with diabetes do not see eye to eye on which of a patient's health conditions is most important, according to a survey led by the University of Michigan Medical School.

While both doctors and patients frequently ranked diabetes among their top concerns, 38 percent of doctors ranked hypertension as the most important condition that the patient faced, compared to only 18 percent of patients. Patients were also more likely to prioritize symptoms such as pain and depression.

The findings appear online today ahead of print in the Journal of General Internal Medicine and may shed light on why some patients have trouble managing their diabetes.

"If a patient and their doctor do not agree on which health problems should be prioritized, it will be more difficult for them to come up with an effective treatment plan together," says lead author Donna M. Zulman, M.D., a Robert Wood Johnson Foundation Clinical Scholar in the Department of Internal Medicine at the U-M Medical School and researcher at the VA Healthcare System in Ann Arbor.

When a diabetic patient visits the doctor, the doctor is often concerned about the patient's risk of long-term complications from high blood pressure or high blood sugar; problems that could lead to heart attack, stroke and kidney disease. The patient, however, might have more pressing issues, such as back pain or depression.

"Both sets of priorities are valid. We know from previous studies however that conditions like pain can interfere with a person's ability to manage his or her diabetes," says Zulman.  "So putting these types of symptomatic problems on the back-burner might lead to worse outcomes in diabetes and other chronic diseases."

On average adults with diabetes have at least three other chronic health conditions. It means that their doctors face the challenge of addressing multiple complex conditions in a brief office visit.

Researchers at the Ann Arbor VA Center for Clinical Management Research and U-M surveyed 92 primary care doctors and their nearly 1,200 patients who had diabetes and hypertension. Patients and their providers often agreed on the most important health conditions affecting patients. However, for 28 percent of the patient-provider pairs, the provider's list of top three priorities for the patient did not include the patient's top priority. Doctors and patients were significantly less likely to agree if a patient was in poor health.

"One possible explanation for this is that patients with poor health or competing demands may be more likely to face functional limitations, financial stress, and other barriers to care," Zulman says. "For these patients, symptomatic problems might be of utmost importance because they exacerbate their existing challenges."

The study reinforces the need for physicians to pay close attention to patients' symptomatic conditions, especially in this vulnerable population with multiple chronic diseases, Zulman says.

An estimated 18 million people in the U.S. have diabetes and another 5.7 million are undiagnosed. The number has nearly tripled since 1980 and people over age 65 account for 37 percent of all cases, according to the U.S. Centers for Disease Control and Prevention.

Diabetes and its complications raises health care costs and accounts for the sixth leading cause of death in the U.S.

Additional authors: Eve A. Kerr, M.D., MPH, professor in the U-M Department of Internal Medicine and director of the  Ann Arbor VA HSR&D Center of Excellence, Timothy P. Hofer, M.D., M.S., professor in the Department of Internal Medicine and research scientist at the VA Center for Practice Management and Outcomes Research, Michele Heisler, M.D., MPA, MPH, associate professor in the Department of Internal Medicine and assistant professor in the Department of Health Behavior and Health Education at the U-M School of Public Health, and Brian J. Zikmund-Fisher, Ph.D., assistant professor in the Department of Internal Medicine and assistant professor in the Department of Health Behavior and Health Education at the U-M School of Public Health.

Funding: Robert Wood Johnson Foundation Clinical Scholars Program and an associated VA Advanced Fellowship, as well as research grants from the U.S. Department of Veterans Affairs Health Services Research and Development Service and the Michigan Diabetes Research and Training Center Grant. Zikmund-Fisher is supported by a career development award from the American Cancer Society

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