Transcript Jamie Hayes presentation

Jamie Hayes
Clinical Trial Patient ?
Real Patient ?
Prescribing decisions
Patient
Knowledge,
attitudes,
habits,
experiences
Prescriber
making
decisions
Patient
Other parties
actively
passively
influencing
In the black box
Knowledge
Drug outcomes, guidelines, what
others believe & do
Values
Relative importance of above
Attitudes
Role of drugs, risk-taking,
doctor-patient relationship,
professionalism
Experience
Patients, drugs, personal
Habits &
strategies
Consultation management,
information seeking, making
prescribing decision
Patient
Prescriber
Prescription
Parties influencing black box
Patient
• Government
• Health insurers
• Pharmaceutical industries
• Academia, C(ME)
Prescriber
• Professional organisations
• Colleagues
• Other professionals
• Patient (organisations)
Prescription
Targeting ‘contents’ of black box
Knowledge
Values
Attitudes
Education
Approach: how people learn, use their knowledge,
motivation for learning
Information
Selection, retrieval and interpretation
Persuasion/Marketing
(Academic) detailing, opinion leaders, media
Decision aids
Experience
Protocols, decision rules, computer programmes
Habits &
Strategies
Feedback/reminders
Pro-active & re-active correction
Steps in black box
Definition of problem
Patient/disease characteristics
Possible set of
treatment opinions
Prescribe drug or not
Personal set of prescriber
Final choice for
individual patient
Decision strategy followed
Decisions underlying prescribing
• Decision to adopt (new) drug in personal set
• Decision to prescribe or not
• Decision what to prescribe for individual
-
which drug substance
brand/generic
administration form
dosage
duration
Overview
• There is more to prescribing than
knowing all about drugs and diseases
• Prescribing is result of an interaction
between external and internal factors
• To alter prescribing focussing on only
one aspect in the black box is usually
not enough
Theory of Planned Behaviour
Attitudes
Subjective
Norms
Perceived
Behavioural
Control
Behavioural
Intentions
Behaviour
To predict whether a person intends to do something,
we need to know:
• Whether the person is in favour of doing it
(‘attitude’)
• How much the person feels social pressure to do it
(‘subjective norm’)
• Whether the person feels in control of the action in
question (‘perceived behavioural control’)
By changing these three ‘predictors’, we can increase
the chance that the person will intend to do a desired
action and thus increase the chance of the person
actually doing it.
A patient with atrial fibrillation
presents to their GP for an annual
review.
The patient is not currently being
treated with warfarin.
Will the GP prescribe warfarin?
The answer to this depends on whether
the GP intends to do so.
It is not an automatic, habitual or thoughtless
action. The intention, in turn, depends on:• Whether, overall, the GP has a positive or negative attitude to
prescribing warfarin for patients with AF
• To what extent the GP perceives that they experience social
pressure to prescribe or not, including whether the GP thinks
that:
the patient wants warfarin
professional colleagues would approve of prescribing;
the health care system encourages prescribing
and how important these various people’s opinions are to the
GP
• Whether the GP finds it difficult to prescribe i.e. how difficult
it is to enact the behaviour in the given context.
Principles of Academic Detailing
1. Conducting interviews to investigate baseline knowledge and
motivations for current prescribing patterns.
2. Focusing programmes on specific categories of physicians as well
as on their opinion leaders.
3. Defining clear educational and behavioural objectives.
4. Establishing credibility through a respected organisational
identity, referencing authoritative and unbiased sources of
information, and presenting both sides of controversial issues.
5. Stimulating active physician participation in educational
interactions.
6. Using concise graphic educational materials.
7. Highlighting and repeating the essential messages.
8. Providing positive reinforcement to improved practices in followup visits.
Much of this has been recognised in
previous reports
See also: Cochrane Effective Practice and Organisation of Care (EPoC)
Group Reviews http://epoc.cochrane.org/epoc-reviews
• How do we introduce ourselves?
• How are we introduced?
– Does it matter?
Research suggests that
nurses who wear
stethoscopes, an
emblem symbolising a
physician’s expertise,
are viewed as more
authoritative than those
who do not
How are we doing?
• Good teams in place
• Much resource spent on improving
diagnosis and therapeutic decision
• Systems in place to decide on which
medicines are clinically and cost
effective
• ...
• But there’s much more to it
How can the science of persuasion help?
Summary
• The many reports make a lot of sense
• We still tend (naturally) to concentrate on
the therapeutics/knowledge
• Perhaps we should take a closer look at human
behaviour
– patients
– prescribers
• How do our teams go about their business...
• Role of health psychologists?