In these primary care practices, agreement between patients with diabetes and their PCPs on diabetes treatment goals and strategies in general was quite low. Recent randomized clinical trials have found that multifaceted programs that promote patient involvement in defining diabetes treatment goals and strategies improve clinical outcomes.20,51
Nevertheless, collaborative goal setting is not a standard part of chronic disease management in many primary care practices. Thus, one likely explanation for the low rates of agreement is that providers are not explicitly discussing treatment goals or strategies and seeking to reach agreement with their patients on priority areas to target.52,53
In light of the importance of blood pressure and lipid control for clinical outcomes in diabetes,54
the especially low agreement on goals and strategies targeting lipid and blood pressure control is concerning, and raises the possibility that doctors have more effectively conveyed to patients the importance of glycemic control than lipid and blood pressure control.
Although agreement in general was low, there was significant variation in levels of agreement across patient-provider pairs, and more agreement was indeed associated with higher patient self-efficacy and more positive assessment of their diabetes self-management. Those patients who shared responsibility with their physicians for making treatment decisions more often agreed on priority treatment strategies with their providers. Moreover, provider reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. A supportive style by itself, however, was not enough in the absence of discussion on what patients need to know to be able to prioritize treatment goals and strategies. In fact, those patients who evaluated their providers overall as being more patient centered, after adjustment for potential confounders, were not more likely to agree with them on treatment goals or strategies. What appeared to predict agreement was sharing in treatment decision making and having discussed the relevant content areas.
In our sample, patients who might be more likely to share their providers' views—those with more confidence in the efficacy of their medical treatment regimens and those with more formal education—were indeed more likely to agree with their providers on treatment goals and strategies. These results coincide with prior research finding that patient adherence is more likely if patients and their doctors share disease models and agree on which medical problems are important and how to evaluate therapeutic success.38,55–57
Greater patient self-efficacy and more positive assessments of diabetes self-management are beneficial outcomes and have been associated with improved clinical outcomes such as glycemic control.2,3,58
Our findings support the hypothesis that greater concordance between patients and their providers on goals and strategies may be a mechanism by which better patient-provider communication and collaboration contribute to improved patient outcomes, as postulated in . Accordingly, we need to understand better factors, such as those highlighted in this study, that contribute to or impede agreement between patients and providers on treatment goals and strategies.
There are a number of ways effective goal setting between patients and providers might enhance processes and outcomes of diabetes and other chronic illness care. Besides encouraging patients and providers to articulate their goals and thus provide opportunities to negotiate potential conflicts in priorities,31,32
recommended plans of care can be linked to desired outcomes, clarifying for patients the purpose of various recommendations.18
While it is possible that differing goals might expand the number of issues addressed, poor agreement on treatment goals and strategies suggests that patients and providers may be failing to work together as a team—or even may be working at cross-purposes to each other.31
These data from a small sample of patient-provider pairs in only two health systems represent exploratory findings on this little investigated dimension of patient-provider relations. Several limitations must be noted. First, we elicited patient and provider goals and strategies only once. Of note, however, all participating patients had seen their provider at least once before, and 86% of the patients had seen this same PCP 6 months or longer. Thus, patients and providers had had several visits in which to discuss and establish mutual goals and strategies. Second, several features of our study design may have led to overestimating concordance. The patients had ranked their top goals and priorities before they saw their provider, which may have primed them to discuss these at their visit before their provider completed the after-visit questionnaire. Moreover, while respondents had the option of writing in other choices, we largely focused on biomedical outcomes and strategies in the list from which participants chose. While our aim was to assess whether there would be agreement within this more limited range of goals most closely associated with patients' clinical outcomes, our method likely did not capture the full universe of patients' valued treatment goals and strategies.
Third, our sample size was too small to enable us to explore significant differences among PCPs. Certain PCPs might have better agreement with their patients. For example, women providers may be more likely to adopt collaborative styles with their patients, ask more questions, and have better communication,59
and race-concordant pairs may have more participatory decision-making styles.45
Similarly, we had insufficient numbers of ethnic minorities to assess possible ethnic differences in degree of concordance with providers. This study needs to be replicated in a larger, diverse sample and with a longitudinal design to track whether and how agreement on treatment goals and strategies varies and to assess the consequences of different levels of agreement for self-management and clinical outcomes over time.
In conclusion, while many patients and providers in standard primary care practices have poor agreement on diabetes treatment goals and strategies, better agreement on both of these is associated with improved self-efficacy and self-management. Increased patient-provider discussion of treatment goals and specific strategies to meet these goals may increase agreement on these and lead to improved patient outcomes. We need to explore how best to operationalize appropriate goal setting in clinical settings and evaluate the effects of encouraging patients and providers to jointly define and pursue shared diabetes treatment goals and strategies.