Education and decision making at the time of triptan prescribing: patient expectations vs actual practice.

There are 3 general models for decision making regarding medical treatment: the paternalistic model, the informed model, and the shared model.1 The classic “paternalistic model” is one in which the physician makes medical decisions for the patient without substantial consideration of the patient's preferences. This model has been challenged over time with a push toward models that take the patient's preferences into account. The reasons for this shift in the approach to medical decision making include the rise of consumerism, the passage of legislation focusing on patients' rights, and an increased focus on the principle of autonomy. The “informed model” involves the physician communicating information to the patient regarding treatment options, risks, and benefits. After being provided sufficient information, the patient ultimately makes an informed treatment decision based on their preferences. The “shared model” involves the physician discussing treatment options and preferences with the patient and then both parties actively participate in making a shared medical decision.1 Optimizing patient satisfaction and adherence with treatment plans requires an understanding of patient preferences regarding their role in decision making. Furthermore, informed and shared decision making require that patients be educated about their treatment options. In order to maximize patients' abilities to participate in medical decision making, clinicians must be aware of the educational topics for which patients desire education and must understand how patients want their education to be delivered. Although triptans are effective migraine-specific acute medications,2 they are underutilized by the migraine population.3,4 There are likely numerous reasons for triptan underutilization, including patients not consulting a healthcare provider for migraine, patients not receiving a migraine diagnosis after they present to a healthcare provider, lack of health insurance, physicians not feeling that the patient's symptoms are sufficiently severe to warrant a triptan, and expense associated with filling the triptan prescription.3-5 In addition, there are high rates of non-adherence and discontinuation of triptans in those patients prescribed triptans, with at least one third discontinuing triptan use within 1 year.6 While several studies have investigated patient satisfaction with triptan treatment, barriers to treatment, and predictors of adherence,5,7-9 little is known about patient satisfaction with triptan education and with their role in decision making when a triptan is prescribed. Patient satisfaction with their triptan and adherence to triptan therapy are likely optimized when the patient's role in decision making matches their expectations, and when the education that is provided is consistent with the patient's educational desires. In clinical practice, the extent of patient participation in the decision to initiate treatment with a triptan, as well as the forms and extent of patient education are highly variable. In this observational study, migraine patients who had used triptans were asked about their expectations for education when a triptan is prescribed and their desire to be involved in the decision-making process regarding whether and which triptan is prescribed. In order to assess the congruence between patient expectations and actual practice, migraineurs were also asked about the actual education that they received and their actual role in the decision-making process when the triptan was prescribed.