Transcript Health Psychology

Psychology and Illness: Patient
Information, Satisfaction and
Adherence
Important announcement about
the assessment
• Prose question will be on the material
covered in the 3rd theme in the module:
psychology of illness and treatment (i.e.
sessions 8-11)
• SAQ questions will cover the whole
module
Objectives
• Evaluate the importance of providing
information for patients
• Begin to recognise the importance of
patient satisfaction as an outcome of
care and treatment
• Examine the problem of non adherence
and the factors influencing adherence
Patient satisfaction
An evaluation of a received service by a patient,
contains cognitive and emotional reactions
Why is it important?
– Draws attention to the patient’s experience of care
– Important as a measure of quality of care
 Concept has value in its own right
What is patient satisfaction?
• Multi-dimensional (Cleary & McNeil 1988)
– Technical quality
– Accessibility
– Convenience
– Finance
– Physical environment
– Availability
– Continuity
– Outcome
– The “art of care”
What is the “art of care”?
What is the “art of care”?
• Health professionals’ interpersonal
skills
• Communication skills
• Sensitivity/empathy for patients’
concerns
• These valued as much as technical
skills by patients
Why is patient satisfaction important (again)?
• Adherence
• Re-attendance
• Change of health care provider
• Use of complementary therapies
• Health status and well being
–o
Cleary et al (1991) patients who reported
poor health reported 2x more problems with care
than those who rated their health as excellent
 Concept has value because of its association
with important outcomes
What influences patient satisfaction?
Communication, communication,
communication
And
Interpersonal skills
What influences patient satisfaction?
• Roter (1989): most important influence
was doctors’ information giving and
interpersonal skills
• Effective information giving is bidirectional: depends on identifying
patients’ main concerns
Information and Patient Satisfaction
Survey by Bruster 1994 of over 5000
patients attending 36 NHS hospitals
– Main source of dissatisfaction was
communication
– 16% reported receiving no explanation of
condition
– Not given important information about
hospital/routine and treatment
– Discharge planning and pain management
also gave rise to complaints
Patient information
French physician Samuel de Sorbiere (1672)
argued that telling patients the truth:
• Might seriously jeopardise medical practice
• Would not catch on!
• He was right
– Oken (1961) 90% of US surgeons would not
routinely discuss cancer diagnosis with their
patients
– Thomsen et al (1993) survey of European
gastroenterologists: 60% did not routinely tell
patients of their cancer diagnosis
Why is information important?
• (Most) patients want it and have a right to it
(informed consent)
– Meredith (1996) 96% of patients attending an
oncology clinic wanted to know if their illness was
cancer: 75% wanted as much information as
possible
– Ajaj (2001) 88% of older people (65-94 years)
wanted to be told if they had cancer: 62% wanted
as much information as possible
– Patients feel they have a right to information and
that they [the patient] should have a say in who
else is told
Why is information important?
• Reduced distress, analgesia, pain,
hospital stay
• Improved recovery, quicker resumption
of normal activities
• Improved physiological outcomes (e.g.
blood pressure, heart rate)
Why is information important?
• Information important for decisionmaking and patient self management
• Patients need to understand what is
happening to them so they can “make
sense” of their experiences
• Important for trust and the doctorpatient relationship
What do patients want to know?
•
•
•
•
•
•
•
•
•
A disease label or name
Causes
Prognosis
Symptoms
Diagnosis/ further tests
Treatment – sensory information
Treatment – procedural information
Treatment – efficacy/outcomes/risks
Other (practical/ emotional information/
needs)
Important issues in giving
information
• Individual differences in patients’ preferences
for information
– E.g. cultural differences linked to age, gender,
ethnicity, social class,
– Differences in coping strategies (monitorers v
blunters)
• Differences over time
• Complexity
Complexity of giving information
• Mismatch between patient needs and
doctor views
• Need to avoid harming vulnerable
patients (e.g. highly anxious, children)
• Time constraints
• You don’t know what you don’t know:
patients need to be supported in making
their needs known
Complexity of giving information
Unvoiced concerns
“But if your heart’s damaged does it
deteriorate more over the years or does it
remain at that level? Do you know what I
mean?
Is it terminal?”
Barriers
“Even my own doctor and the doctor before that
– they don’t take you into their confidence…
Either they think you are stupid… or else not
interested”
Complexity of giving information
• Despite its importance to patients,
information giving may be perceived as
“non technical” – delegated to
inexperienced staff
• Difficulty of finding out how much
information individual patients want –
need for continual assessment of
patients’ cues
Complexity of giving information
“If the breaking of bad news is done
badly, patients and their families may
never forgive us, but if it is done well
they will never forget us”
Robert Buckman (1996) Medical
oncologist
Compliance (adherence/concordance)
• Haynes ‘the extent to which a person’s
behaviour (taking medications, following
diets, or changing lifestyle) coincides
with medical or health advice.’
• Compliance = following doctors orders
• Concordance = negotiation over
treatment regimes
Rates of Non Adherence
• Reported medication non adherence
varies between 4-92%
• In chronic illness 30-50% of patients are
non adherent
Measuring adherence: Indirect
• Patient self report
– Pros: easy, inexpensive
– Cons: prone to disadvantages
• Second hand reports (doctors, relatives)
– Pros and cons: similar to self reports
– Depends on familiarity with patient
– Health profs. over estimate adherence
• Pill counts
– Pros: more objective
– Cons: prone to inaccuracies and bias
Measuring adherence: Indirect
• Mechanical or electronic to record dose
dispensed
– Pros: objective, most accurate indirect
method
– Cons: does not measure whether
medication has been taken
Measuring adherence: Direct
• Blood or urine tests
– Pros: direct information on
consumption/adherence to advice
– Cons:
• Expensive and invasive = limits use
• Affected by metabolism
• Non adherence may be masked
• Observation (of consumption of medication)
Understanding non adherence
• Patient characteristics
– Not associated with any major sociodemographic variables (Haynes et al 1979)
except age:
• Adherence lower in preschool children,
adolescents, older infirm patients on complex
drug regimes
– Adherence varies in individuals over time
and between different aspects of treatment
regime
“She wouldn’t allow any of the treatment … I sat
down with her one day and I said “You do
know that unless you let the doctors give you
your treatment you’ll die.” She sat quietly and
she sat there and she thought about it and
from then on she changed … I was getting
frustrated because she wouldn’t allow any of
the treatment … I was just desperate,
desperate and nobody else could give me
any advice because I’d tried everything”
Mother of 5 year old girl who had leukaemia
Reasons for non adherence
• Illness severity and adherence
– Non adherence is common even in severe
illness
– Greenstein & Siegal (1998) 22% of adult
renal patients were non adherent
– Rovelli (1989) 91% of renal patients who
fail to take their medication experience
organ rejection or death (18% of adherent
patients)
Treatment characteristics
• Side-effects
• Complexity: importance of how well
treatment fits patient’s routine (Myers &
Branthwaite, 1992)
Treatment characteristics
Treatment characteristics
• Patient experience and efficacy of
medications
– Are symptoms relieved?
– Asymptomatic conditions, delayed efficacy
Information/ Knowledge
Information/ Knowledge
• Basic awareness of how and when to
take medication is essential for
adherence
• Beyond this associations between
knowledge and adherence are small
Memory
• Remembering that you have medicine
to take
• Remembering when and how to do it
• Information and memory are necessary
but not sufficient for adherence
• Non-adherence may be intentional
Understanding intentional non
adherence
• Doctor-patient relationship and
communication
– Patient satisfaction with doctor and with
information/ explanation
– Dissatisfaction diminishes the motivation to
adhere
Intentional non adherence
“For the prescriber to reaffirm the views of
medical science and to dismiss or
ignore [the patient’s] beliefs is to fail to
prescribe effectively”
Royal Pharmaceutical Society
Intentional non adherence
• Patient’s beliefs and cognitions (Horne 1997)
• Specific – Necessity: beliefs about
efficacy of medication
• Specific – Concerns: beliefs about the
potential for harm
• General – Harm: beliefs about intrinsic
properties of medicines
• General – Overuse: beliefs about
whether medicines are over used
Intentional non adherence
• Discrepancies between doctor and patient beliefs
(e.g. about risk of not taking medication)
• Misunderstandings in prescribing because of lack of
patient participation in the consultation (Britten et al
2000)
• Patient’s beliefs about medicines go unvoiced (i.e.
their expectations and preferences)
• Doctors need to check whether their understandings
about patients are correct
• Ask patients what they think of taking their medicines
Patient + Prof.+ Disease + Treatment
= Adherence
Summary
• Importance of patient satisfaction
• Need for patient information
• Distinguish between intentional and
unintentional non adherence
• Importance of d-p relationship and
patient’s beliefs about medicines
Steps to improve adherence
• Discuss the patient’s beliefs
• Simplify the treatment/tailor to the patient
• Make sure the patient is satisfied
• Check patient understanding and your communication
• Provide written information
• Consider involving significant others
• Regular follow-up - ask about problems with treatment
• Consider using reminder devices
Reminder: research project on prioritising health care,
with Katherine. This lunchtime at 12:45 in room 208 C.