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