Investigating Psychosocial Factors: Supporting Clinical Decisions for Outpatient Diabetes Care

Practitioners often make decisions to diverge from clinical targets specified in diabetes clinical practice guidelines (CPGs) based on each patient's unique situation, although reasons for this are poorly understood. Additionally, while practitioners understand that psychosocial factors may influence self-care behavior and subsequently health outcomes, little is known as to how psychosocial factors influence clinical decisions, including those that deviate from guidelines. Therefore, through a sequential exploratory mixed methods study involving physician interviews (n=17) and a survey of physicians, nurses and diabetes educators (n=229) I investigated practitioners' access to, and use of, psychosocial information as a basis for clinical decisions in outpatient diabetes care. This study revealed four major findings. First, that psychosocial information is not considered when patients have good glycemic control, but they do consider it when a patient: 1) has persistent, poor glycemic control, 2) is a new patient or has a new diabetes diagnosis, and 3) worsening of glycemic control. Second, access to psychosocial information is granted through dialogue in an ongoing, trusting relationship. Physicians use specific techniques to build trusting relationships, which include demonstrating caring and creating a safe environment characterized by patient autonomy and privacy. Third, awareness of psychosocial information may trigger decisions to personalize HbA1c targets, pursue less aggressive treatment plans or augment guideline-concordant treatment with actions to address barriers to care, such as referrals to prescription assistance. Fourth, EHR designs are not optimized for capturing and retrieving qualitative and situationally-dependent psychosocial information, which tends to come in a narrative form. Specifically, study findings offer new insight into circumstances in which practitioners' decisions may deviate from CPGs, and their rationales for doing so. Practitioners connecting patients to supplemental resources represent efforts to reduce negative impacts of psychosocial factors on diabetes-related self-care. If successful, these actions could ultimately improve diabetes outcomes. Findings regarding the importance of a trusting clinician-patient relationship also suggest the importance of care continuity to psychosocial information use. Moreover, results indicate that effective use of psychosocial information requires unique socio-technical supports that include clinician-patient relationship-building efforts and digital tools that are optimized for the capture and retrieval of information in narrative form.