We know that intensive blood glucose control in diabetes prevents microvascular complications, and we also know that it is difficult to obtain and maintain an acceptable degree of control. In general, the needs of patients with a chronic illness are complex. And diabetes is a chronic problem whose management poses considerable difficulties given the nature of the disease--often asymptomatic--its inexorable progression, fluctuations in metabolic control, etc. Treatment involves effort and sacrifice with no apparent, immediate benefit for the patient. Persons with diabetes encounter barriers that make compliance with treatment difficult--barriers related with lifestyle, education, psychological and environmental factors.
To facilitate daily living with diabetes, medical knowledge in itself is not enough; also needed are continuity and availability of care, and good communication tools.
Implementation of any effective treatment plan involves fluent communication. But patients' and care providers' differing perspectives and expectations affect the potential for effective communication. Doctor-patient contacts are often superficial and frequently center on metabolic control. Care providers concentrate on controlling numbers (blood glucose, glycosylated hemoglobin, weight, blood pressure, etc.) and on technical aspects of diabetes management, and often make decisions based on their own knowledge, without taking patients' beliefs and expectations into account. Patients, on the other hand, are mainly concerned with how to integrate the control of diabetes into their daily life so as to enjoy as good a quality of life as possible (Table 1). It is not often that they receive the information they expect or need, and they do not usually participate in decision-making about their illness. Only treatments viewed as logical, feasible and acceptable can be integrated into the patient's daily life. Setting goals for disease management without considering individual goals or sharing the decision-making is what leads to failure and frustration.
This article provides information of great interest regarding these considerations--information obtained in a qualitative study based on open-ended interviews carried out in the Spanish primary care setting. The authors investigate the perceptions of patients with type 2 diabetes regarding their disease and their relationships with primary health care providers. Bolaños and Sarría-Santamera emphasize that most interviewees received little information about the progression of their disease. In the relationship with care providers, the features valued most highly were clear information adapted to the patient's needs, within a setting of empathy, warmth and respect, and with support for the change and consideration for the patient's individual perspectives and circumstances. In their conclusion, the authors note the need to incorporate patients' expectations into diabetes care and management.
Decisions affecting the care of patients with diabetes should be based on collaboration between patients and health care providers, and on the use of agreed-upon objectives. Care providers need to be aware of the patient's perspective to take it into account in decision-making. An appropriate assessment of existing barriers will make it easier to reduce obstacles to appropriate control, and will favor compliance with treatment and follow-up.
Evaluating users' needs and expectations is also a key aspect in planning care for patients with diabetes, as this makes it possible to obtain information of use in establishing lines of action aimed at responding to users' demands within a strategy of continuing quality improvement.
Earlier studies have been published on diabetes care planning in Europe (United Kingdom) and in Spain (Andalusia). These studies, based on qualitative research methods (focus groups, interviews) to explore patients' perspectives and expectations for the health care system, have identified the following needs:
1. More information and emotional support.
2. Facilitated access to medication and materials necessary for treatment.
3. Coordination so that different needs can be covered in the course of a single appointment.
4. Access on demand to health care providers with the right areas of expertise and authority.
5. Coordination between all care providers to guarantee continuity of care.
The quality of care can be evaluated in different ways, one of which is to obtain information based on patients' and care providers' opinions, particularly about their perception of the services received.
It is important to develop lines of research that will make it possible to confirm the hypothesis regarding the efficacy of effective communication and agreed-upon objectives in preventing the complications of diabetes. Additional goals are to and enhance the quality of life of patients with this disease, and to improve the health outcomes once patients' expectations have been incorporated into health policies for diabetes care.
General bibliography
Clark M, Hapson SE. Comparison of patients' and healthcare professionals' beliefs about and attitudes towards type 2 diabetes. Diabetic Med 2003;20:152-4.
Fernández Fernández I, Aguilar Diosdado M, Amaya Baro ML, Barrigüete Andreu MI, Benito López P, Cornejo Castillo M, et al. Diabetes mellitus tipo 2: Proceso Asistencial Integrado. Sevilla: Consejería de Salud de la Junta de Andalucía, 2002. Disponible en: http://www.juntadeandalucia.es/salud/contenidos/profesionales/procesos/ diabetes/Mellitus_2.pdf
Freeman J, Loewe R. Barriers to communication about diabetes mellitus. Patients' and physicians' different view of the disease. Fam Pract 2000;6:507-12.
Hiscock J, Legard R, Snape D. Listening to diabetes service users: qualitative findings for the Diabetes National Service Framework. UK 2001. En: http://www.doh.gov.uk/nsf/diabetes/nsf.pdf (consultado el 30-6-2003).
Snoek FJ. Breaking the barriers to optimal glycemic control -- what physicians need to know from patients' perspectives. Int J Clin Pract Suppl 2002;129:80-4.
Wolpert HA, Anderson BJ. Management of diabetes: are doctors framing the benefits from the wrong perspective? BMJ 2001;323:994-6.
