Transcript Enhancing Patient-Provider Communication

Enhancing Patient-Provider
Communication
Suzanne Bennett Johnson
Florida State University College of Medicine
Management Of Diabetes In Youth
Biannual Conference of the Barbara Davis Center for Childhood Diabetes
Keystone Colorado, July 14, 2008
Defining Compliance
“the extent to which a person’ behavior
(in terms of medications, following diets, or
executing lifestyle changes)
coincides with medical or health advice”
Haynes et al, 1979
Helping People Manage Diabetes
1. Clear communication of medical/health advice
Patient-Provider Miscommunication
Provider
Recall
Patient
Recall
Recall of recommendations by the health care team and by
patients in a diabetes clinic. Adapted from Page et al (1981).
Clear Communication: Do’s and Don’ts
DON’T…...
• use medical jargon
• use vague prescriptions
• provide too many
recommendations
• assume the patient
understands
• expect patients to recall
your medical advice
DO…...
• use simple explanations
• be specific
• prioritize, give a few critical
recommendations
• ask the patient to describe
the treatment plan
• give your patient written
recommendations
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
Skill Deficits in Diabetes Management
50%
40%
30%
20%
10%
0%
Insulin-Adults
Watkins et al, 1967
Insulin-Kids
Johnson et al, 1982
Hypoglycemia-Teens
Johnson et al, 1998
Knowledge/Skill Assessment and
Instruction: Do’s and Don’ts
DON’T…...
• Assume knowledge/skill
• Teach too much at one
time
• Assume one-session
learning
• Assume skills will remain
accurate over time
DO…...
• Observe behavior
• Prioritize, teach one skill
at a time
• Repeat instruction
• Make skill assessment
and instruction part of
standard care
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
What is the Best Way to Assess
Patient Behavior?
• Glycosylated hemoglobin:
most popular method but provides limited
and often misleading information
Presumed Relationship Between
Patient Behavior and Glycemic Control
Glycosylated Hemoglobin
good
poor
The Relationship Between Patient Behavior
and Glycemic Control in Childhood Diabetes
Glycemic Control
Compliance
Good
Poor
HA1C < 7.6%
HA1C > 10.1%
Good
30%
18%
Poor
24%
28%
N=103
Adapted from Johnson (1994)
The Relationship Between Compliance with Medication and
Subsequent Blood Pressure in Hypertensive Steelworkers
Blood Pressure
Good
Poor
Compliance
< 90 mm Hg
> 90 mm Hg
23%
34%
12%
31%
Good
 80% meds
Poor
< 80% meds
N=134
Adapted from Taylor et al (1978)
Glycosylated hemoglobin
• Is a poor measure of patient behavior because
– patient behavior and GHb are only weakly related
– GHb provides no specific information about what
patient behaviors need to be changed
– it can lead to
• “patient blaming”
• missed opportunities to correct problem behavior
What is the Best Way to Assess
Patient Behavior?
• Glycosylated hemoglobin:
most popular method but provides limited
and often misleading information
• Pill counts and glucose testing meters:
useful but provide limited information
• Physician/investigator ratings:
most unreliable of all methods
Diabetes Regimen Compliance
100%
80%
60%
40%
20%
0%
Medication
BG Testing
Diet
Exercise
Patients do not have “compliant” or
“noncompliant” personalities
They do exhibit both compliant and
noncompliant behaviors
Behavior with one component of the
diabetes regimen does not predict
behavior with any other component
What is the Best Way to Assess
Patient Behavior?
• Observational methods are now available for
– insulin injection
– blood glucose testing
• Provide useful information for some behaviors
• Can be adapted to assess other behaviors
What is the Best Way to Assess
Patient Behavior?
• Patient self-reports: underutilized and
viewed with skepticism
• Available methods permit good quality
self-report data to be obtained when the
patient describes time limited intervals (24
hr) of recent occurrence (yesterday) in
temporal sequence (waking to retiring)
• The only method to provide detailed,
reliable information about actual behavior
Conducting a 24-hr Recall Interview
• Patient describes yesterday’s events from
waking until retiring
• Interviewer prompts for missing information
• Interviewer is always nonjudgmental
• Family member may be interviewed separately
about the patient’s behavior
• Several interviews (about both weekend and
weekdays) provide more information
Assessing Behavior as Part of
Standard Care: Do’s and Don’ts
DON’T…...
• Use GHb to assess behavior
• Ask what the patient
“usually” does
• Ask if the patient “knows”
how to do a regimen task
• Describe a patient as
“noncompliant”
DO.…..
• Assess behavior directly
• Ask what the patient did
yesterday
• Observe the patient carry
out the task
• Specify which behaviors
are problematic
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
Log Book vs Memory Meter Data
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
>10% Lower Mean BG
High BGs Omitted
Mazze et al, 1984
Low BGs Added
Encouraging Patient Honesty:
Do’s and Don’ts
DON’T…….
• Be judgmental
DO……
• Accept less than perfect
behavior
• Criticize and threaten
• Expect too much
• Ignore good behavior
• Do problem solve
• Set realistic goals
• Praise even small positive
behavior change
Helping People Change
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
5. Build consensus about disease management
Patients do what they can do
Patients do what they want to do
BG Goals: Parents vs Pediatricians
80%
Mothers
70%
Fathers
Pediatricians
60%
50%
40%
30%
20%
10%
0%
Normoglycemic
Slightly
Hyperglycemic
Moderately
Hyperglycemic
Glycemic Profile Selected as Ideal
(Marteau et al, 1987)
Terminology: Does it matter?
• Compliance
• Adherence
• Self-Care
Consensus Building: Do’s and Don’ts
DON’T
• Make arbitrary
recommendations
• Assume patient
understands rationale
• Assume patient accepts
your rationale
• Force patient acceptance
DO
• Discuss options with patient
• Provide a clear explanation
• Discuss patient attitudes
and beliefs
• Negotiate a mutually
agreeable plan
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
5. Build consensus about disease management
6. Attend to patient feelings, worries, concerns
The Anxiety/Performance Curve
High
Low
Low
Anxiet
y
High
Common Patient Concerns
•
•
•
•
•
•
•
Insulin (or other medication) effects
Pain (associated with injections, glucose testing)
Hypoglycemia
Weight gain (associated with intensive therapy)
Expense, insurance access, employment
Interpersonal (family, social) disruptions
Complications
Helping People Manage Diabetes
1. Clear communication of medical/health advice
2. Teach knowledge and skills necessary for good
disease management
3. Make assessing behavior part of standard care
4. Encourage patient honesty
5. Build consensus about disease management
6. Attend to patient feelings, worries, concerns