How Physicians Can Improve Patients' Participation ... - Europe PMC

0 downloads 0 Views 783KB Size Report
*_*s~.01ma. .ss . |rwwii| L W 1l ssis r" ... More effective intervention by physicians for selected self-care practices can ... (2) motivational characteristics; (3) physical, manual or eco- .... after a few direct questions, the best predictor of patient edu-.
346

| *_r* s w~.01maw. i i -.~f.f -_m

.

--a --pgh _

.ss | L W 1l ssis r~~"

* [ _ [[ [ [ - X_ %W_ [XX

tX

-sssW

wXwX w~~~~~~~~~~~~~V

How Physicians Can Improve Patients' Participation and Maintenance in Self-Care LAWRENCE W. GREEN, DrPH, Houston This feature will appear regularly in The Western Journal of Medicine. It is intended to cover recent developments in a broad range of issues that wifl have an impact-either directly or indirectly-on clinical practice. Occasionally the STEVEN A. SCHROEDER, MD seminars may include informed speculation about likely future developments. Series' Editor

A protocol for the stepped education and support ofpatients is derived from the cumulative experience of more than 200 clinical trials of patient education and behavioral change interventions. The recommended procedure entails assessing a patient's educational needs by asking a sequence of "diagnostic" questions to assure patient motivation, skill and resources and to reinforce adherence to the prescribed medical regimen or life-style modifications. The sequence of questions and interventions is also designed to minimize a physician's time commitment and to maximize the medical benefit to the patient. (Green LW: How physicians can improve patients' participation and maintenance in self-care. West J Med 1987 Sep; 147:346-349)

All too often physicians arrive at a correct diagnosis and devise appropriate management plans, only to be frustrated by unsatisfactory outcomes resulting from the patient's not understanding instructions or, in many instances, choosing to ignore them. What sustains an outpatient's adherence to a prescribed medical regimen between visits? The answer, apparently, is that not enough sustains their behavior. A physician sees countless indicators of instructions and admonitions gone astray. Patient adherence failure, often called noncompliance, is reflected most clearly in relapse rates ranging from 20 % to 80 %, not only in nonadherence to medications, but even more in ignoring advice on life-style modifications. ' We estimated from reviews of patient education studies and epidemiologic models that more effective physician interaction with a patient's teaching could reduce drug errors and improve clinical outcomes by as much as 40 % over conventional treatment.2

The Curve for Adherence Relapse The curve shown in Figure 1 is typical of the relapse pattern in a variety of practices recommended to patients, especially those practices relating to addiction, compulsive behavior, pleasures, comforts, unpleasant side effects, inconvenience, costs or even simple habits. Assuming that 100% of the patients who leave a physician's office are committed to adopting the prescribed practice, there is a characteristic drop of 40 % to 80 % in actual maintenance behavior during the first six weeks.3 Though the shape of the curve is highly predictable, the drop in percentage before it levels off is not. More effective

intervention by physicians for selected self-care practices can alter the curve's slope and plateau levels.4 For example, physicians can reduce a male patient's daily consumption of cigarettes by simply giving advice, as shown in a randomized clinical trial that also documented lower mortality in lung cancer compared with the control group.5 In our long-term follow-up of Johns Hopkins ambulatory patients in a randomized controlled trial using health education for hypertension, we found sustained improvement in blood pressure control and more than 50% fewer deaths in those who had received some combination of patient education than in the controls.6 In a family planning clinic, women smoked less when they were exposed to a combination of a physician's advice and waiting room media than when they were exposed only to waiting room media.7 A more positive way of interpreting the relapse curve is to note that as much as 40% to 60% of the population does maintain its self-care practices. This fact indicates that any global intervention program designed to prevent relapse may be unnecessary and probably wasteful for a large portion of patients entering health care programs. Furthermore, the interventions designed to prevent relapse range from simplistic, inexpensive methods effective for only a few patients to complex, obtrusive and costly methods effective for most but needed by few.

Characteristics of Patients Who Do Not Adhere to Self-Care Programs Given these descriptions of the problem, considerable study has been devoted to identifying the characteristics of

From the Center for Health Promotion Research and Development, The University of Texas Health Science Center at Houston. Reprint requests to Lawrence W. Green, DrPH, Center for Health Promotion Research and Development, The University of Texas Health Science Center at Houston, PO Box 20186, Houston, TX 77225-0186.

THE WESTERN JOURNAL OF MEDICINE OF

MEDICINE

*

SEPTEMBER 1987

SEPTEMBER

-

147 * 3 *

1987147

patients or participants in medical care and health programs who typically drop out or fail to sustain the recommended behavioral changes. Comparative and prospective studies have identified four sets of correlates that predict adherence or relapse: (1) demographic and socioeconomic characteristics; (2) motivational characteristics; (3) physical, manual or economic facilitators and barriers, and (4) circumstantial rewards and penalties associated with the behavior, especially in the social environment. The first of the four sets of factors-demographic and socioeconomic characteristics-cannot be easily changed, especially in the clinical setting; the other three sets of factors can. The second is easier to change than the third, and the third easier than the fourth. This hierarchy of factors influencing adherence and relapse suggests a logical order of intervention that should maximize the impact on a patient while conserving the energy and time of the physician. The logic, as in that applied in stepped care, would dictate the concentration of educational resources on patients according to which of the three changeable characteristics they possess. 8 It would further dictate that if a patient possesses more than one of the changeable characteristics predicting relapse, a combination of interventions designed to change the characteristics should be applied.9 A Hierarchy of Adherence Factors One additional fact about the three sets of changeable characteristics predicting adherence or relapse is that they reflect a natural hierarchy of action from wanting to do, being able to do and being rewarded for doing. This hierarchy produces a logical flow of intervention from strengthening motivation to enabling to reinforcing the self-care behavior. A patient's need to conserve resources, however, dictates skipping those interventions not required if a patient is already motivated, enabled or reinforced. The skip pattern can be guided by a minimum of questions designed to detect the motivational state, the barriers and the potential rewards and side effects for the patient. The skip pattern can also include assessments, decision nodes and recursive loops in an algorithm for patient education, diagnosis and intervention as suggested in Figure 2. Phase 1: The Initial Triage of Patients According to Motivation The first question a physician or other clinical staff needs to answer is whether a patient even cares enough about the problem to bother with the prescribed regimen. This can be answered on three levels, according to the health belief model. 10 * First, does the patient believe that he or she is susceptible to continuing problems if the recommended behavior is not adopted? * Second, does the patient believe that the problems associated with failure to comply with the recommended behavior are severe? * Third, does the patient perceive the benefits of adopting the recommended behavior to be greater than the perceived risks, costs, side effects, barriers and hassles? If the answer to all three questions is yes, the patient is likely to be willing to try the recommended behavior. The physician need not lecture this patient. If a patient is already willing, considerable time and en-

347

347

3

ergy otherwise spent on persuasion can be conserved for training or support. If a patient is not motivated according to these three criteria, then it would be premature to train the patient in skills or to counsel the patient to overcome barriers in the home environment. The time and resources of the physician should be spent first on educating the patient on the importance and benefits of the recommended practice. The purpose of this initial education is to strengthen the three beliefs in the patient. In this situation written materials are no substitute for face-to-face two-way communication. In a systematic assessment of 102 controlled studies of patient education related to prescription drugs, the factors that predicted the magnitude of change in patient knowledge or beliefs, as well as in drug errors and clinical effects, were not the media or channels of communication, but rather the individual attention, relevance and feedback provided in the communication. "I 100 70

, C

-

,x.') 60 50

>ia *Co5 (DO u ,

C" a) 0

a,

40

mL o

30 0

12 18 24 30 36 52 Weeks Following Initiation of Self-Care Figure 1.-Typical relapse pattern for patients following long-term self-management regimens. 0

6

Yes

Congratuotaions Increase self-monitoring Continue self-care

and spocing of

oppointment intervoals

Figure 2.-A protocol is shown for stepped-care approach to counseling patients in managing their medical regimen. The flow chart was prepared for a National Heart, Lung, and Blood Institute working group and benefitted from comments by Donald Fedder, DrPH, David Levine, MD, William McClelland, MD, Patricia Mullen, DrPH, Edward Roccella, PhD, and Scott Simonds, DrPH. O = decision node; O- = recommended intervention

DELIVEAY SEMINARS IN HEALTH CARE DELIVERY~~~~~~~~~~~~

348

If a patient's level of prior motivation cannot be assessed after a few direct questions, the best predictor of patient education and counseling at this first level is the years of school completed by the patient. Less formal education means a greater need for patient education.12 This might seem too obvious to warrant mention, but an irony of medical practice is that physicians tend to talk more to patients who ask more questions-typically those of higher educational achievement-than to those who ask fewer questions but probably need more answers. 3 Regardless of the level of education, a physician can easily probe for a patient's level of understanding by asking the patient to repeat the instructions he or she is to follow.

Phase 2: Steps in Triage of Patients According to Enabling Factors Once a physician is satisfied that a patient is motivated, the next diagnostic step is to assure that the patient is able to carry out the prescribed behavior. Problems that need to be investigated are the skills, resources and barriers in the home or work environment that the patient needs help to develop or overcome. If the patient is highly motivated and willing to try the regimen prescribed by the physician, but faces inability, lack of needed resources or barriers that cannot be overcome alone, the patient will be frustrated and ultimately discouraged. Skill deficiencies are most common in young children, arthritic patients who cannot open certain containers, illiterate or non-English-speaking patients who cannot read or understand directions, old patients whose eyesight or mobility makes adherence to certain regimens impossible and other disabled or poor patients who cannot obtain or afford the necessary resources to follow the physician's recommendations. If any of these enabling factors are found to be deficient in a patient, the physician recommending the unattainable regimen has some obligation to help the patient find ways to overcome the deficiency. Some training of the patient in the necessary skills or modification of the regimen to fit the patient's circumstances are minimal interventions expected of the physician. At the very least, the physician owes it to the patient to provide systematic referral to other agencies or resources in the community to help deal with these enabling factors. Phase 3: Assessing Reinforcing Factors Necessary to Patients' Adherence Even with the predisposing and enabling factors in place, there remains one more level of possible breakdown in a patient's "compliance" with a prescribed regimen. If the recommended behavior is met with side effects, inconvenience, derision by family or friends, criticism by employer or teacher or other sources of discouragement, the patient is likely to discontinue the practice prescribed or recommended by the physician. The opposite of these discouraging factors are reinforcing factors. The physician can help build reinforcement of patient compliance in two ways. First, the physician can provide reinforcement by assuring that the patient's expectations are realistic so that what happens during the course of the treatment is expected rather than coming as a rude shock. Side effects should be anticipated. Counseling can help prevent the relapse typically associated with the first signs of side effects.'4 Difficulties in following a diet or in stopping smoking should be described in

CARE

advance, coupled with encouragement for the patient to expect and cope with them rather than to give up at the first discouraging experience or event. If a patient has unrealistic expectations about the smooth course of recovery, weight loss, abstention or adoption of a new health practice, the physician needs to correct these misperceptions before they become an excuse for giving up. The second way in which a physician can help reinforce the adoption of a complex regimen requiring behavioral change at home or at work is to communicate directly or indirectly with family members or others in a patient's immediate circle of daily contacts. Family members can be invited to accompany the patient in discussing the prescribed regimen with the physician. Often family members are left sitting in the waiting room when they could be participating in the discussion of home strategies to support the patient in adapting the prescribed regimen to daily routines. If the important parties cannot be influenced in the physician's office, a written message to them from the physician, carried by the patient or mailed to them with the patient's permission, could carry as much weight. The power of involving family members in reinforcing support of patients has been well estab-

lished. 15.16 Phase 4: Self-monitoring Once a physician has been assured of a patient's motivation, has addressed the enabling and reinforcing factors and has provided the counseling, referrals and support necessary to make the patient's self-care possible, return appointments can be spaced with increasing intervals. With each subsequent visit, some of what the physician examines as signs, symptoms, risk factors or problems can be made the responsibility of the patient to self-monitor. Transferring increasing responsibility for self-care to the patient should be accompanied by the patient's increasing self-monitoring skills. Physicians miss a powerful educational tool when they hoard patients' data and the methods of observation that would make patients capable of obtaining their own feedback on progress and success in self-management. By transferring these skills and tools-such as self-monitoring blood pressure devices-to patients, physicians enable the patients to obtain more immediate feedback on adjustments they are making in their life-style or in a dietary or medication regimen. II Feedback from self-monitoring can over time become the most powerful source of reinforcement for positive behavior. If a patient continues to depend on the physician for this reinforcement, the patient can fail to make the conversion to self-reliance that is so essential to long-term maintenance and control coincident with chronic or compulsive disorders.

Conclusion Sufficient knowledge has now accumulated to enable physicians to approach the problem of patient compliance with greater confidence, effectiveness and efficiency. Greater confidence should come from the accumulated evidence achieved by physicians' teaching and counseling their patients on selfmedication and more complex life-style changes. Greater effectiveness should come from the increased awareness among physicians that basic principles of learning have been instrumental in transferring knowledge, skills and responsibility to patients. Greater efficiency should come from the steppedcare approach to patient education and counseling outlined in this article. By concentrating their time and effort at that level

THE WESTERN JOURNAL OF MEDICINE

o

SEPTEMBER 1987 * 147 * 3

of help needed by each patient, physicians can bypass needless motivational appeals and skill development for some patients and can target their counseling for other patients who most need these levels of help. A physician's final maneuver in consigning greater responsibility to patients for their own care and health maintenance is to transfer self-monitoring skills and tools to them. These become both the enabling and the reinforcing factors in patients' long-term maintenance of behaviors conducive to health. REFERENCES

1. Haynes RB. Taylor DW. Sackett DL (Eds): Compliance in Health Care. Baltimore. Johns Hopkins University Press. 1979 2. Green LW. Mullen PD. Friedman R: An epidemiological approach to targeting drug information. Pat Educ Couns 1986: 8:255-268 3. Marlatt GA. Gordon JR (Eds): Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York. Guilford Press, 1985 4. Brunton SA: Physicians as patient teachers. In Personal health maintenance [Special Issue]. WestJ Med 1984 Dec; 141:855-860 5. Rose G. Hamilton PJ. Colwell L. et al: A randomised controlled trial ot' anti-smoking advice: 10-year results. J Epidemiol Community Health 1982;

36:102-108 6. Morisky DE. Levine DM, Green LW. et al: Five-year blood pressure control and mortality following health education for hypertensive patients. Am J Public Health 1983; 73:153-162

349

349

7. Li VC. Coates TJ, Spielberg LA. et al: Smoking cessation with young women in public family planning clinics: The impact of physician messages and waiting Prev Med 1984; 13:477-489 8. Cantor JC. Morisky DE. Green LW. et al: Cost-effectiveness of educational interventions to improve patient outcomes in blood pressure control. Prev Med 1985; 14:782-800 9. Bartlett EE: Eight principles from patient education research. Prev Med 1985; 14:667-669 10. Janz NK. Becker MH: The health belief niodel: A decade later. Health Educ Q1984: 11:1-47 11. Mullen PD. Green LW. Persinger G: Clinical trials of patient education for chronic conditions: A comparative meta-analysis of intervention types. Prev Med 1985; 14:753-781 12. Hatcher ME. Green LW. Levine DM. et al: Validation of a decision model for triaging hypertensive patients to alternate health education interventions. Soc Sci Med 1986; 22:813-819 13. Roter DL: Patient participation in the patient-provider interaction: The effects of patient question asking on the quality of interaction. satisfaction and compliance. Health Educ Monogr 1977; 5:281-315 14. Jacobs C. Ross R. Walker IM, et al: Behavior of cancer patients: A randomized study of the effects of education and peer support groups. Am J Cl in Oncol 1983; 6:347-350 15. Morisky DE. DeMuth NM. Field-Fass M, et al: Evaluation of family health education to build social support for long-term control of high blood pressure. Health EducQ 1985; 12:35-50 16. Earp JL. Ory MG, Strogatz DS: The effects of family involvement and practitioner home visits on the control of hypertension. Amn J Public Health 1982: 72:1146-1154 room media.

Causes for Delay in Diagnosing Breast Cancer THE NUMBER ONE CAUSE for delays in diagnosing breast cancer is not knowing the limits of mammography. Physicians and patients accept a normal mammogram as evidence that cancer is not present when there is a palpable mass. About 20 % of cancers will not show on a manrnogram with a palpable mass. Whenever I order a mammogram, I tell the patient "This is a screening test. If it's positive, it helps me; if it's negative, we have to go beyond that, and we'll discuss those choices when we get the mammogram." The next risk is not doing a biopsy when they find something on a mammogram and cannot find a mass. Next is not doing a needle or aspiration biopsy. With a needle and syringe, I can diagnose any cyst in the breast in two minutes. And I have an absolute diagnosis; it is not just a picture. I have fluid in a syringe. If I do not have fluid in a syringe, I do either a needle biopsy or an open biopsy. If a patient has nipple discharge and it is bloody, there is a 50 % chance the patient has cancer. So you must do an occult blood test on nipple

discharge. -HOLGER RASMUSSEN. MD Extracted from Auidio-Digest FaimilY Practice, Vol. 35. No. 17, in the Audio-Digest Foundation's series of tape-recorded programs. For subscription information: 1577 E Chevy Chase Dr. Glendale, CA 91206