Enhancing Patient-Provider Communication

Suzanne Bennett JohnsonFlorida State University College of Medicine

Management Of Diabetes In YouthBiannual 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

PatientRecall

Recall of recommendations by the health care team and by patients in a diabetes clinic. Adapted from Page et al (1981).

ProviderRecall

Patient-Provider Miscommunication

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 DiabetesHelping People

1. Clear communication of medical/health advice

2. Teach knowledge and skills necessary for good disease management

Skill Deficits in Diabetes Management

Watkins et al, 1967 Johnson et al, 1982 Johnson et al, 1998

Knowledge/Skill Assessment and Instruction: Do’s and Don’tsDON’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 DiabetesHelping People

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

Glycosylated Hemoglobin

good poorC

omp

lia n

c e

poor

good

Presumed Relationship BetweenPatient Behavior and Glycemic Control

The Relationship Between Patient Behavior and Glycemic Control in Childhood Diabetes

Glycemic Control

Compliance GoodHA1C < 7.6%

PoorHA1C > 10.1%

Good 30% 18%

Poor 24% 28%N=103Adapted from Johnson (1994)

The Relationship Between Compliance with Medication and Subsequent Blood Pressure in Hypertensive Steelworkers

Blood Pressure

Compliance Good< 90 mm Hg

Poor> 90 mm Hg

Good 80% meds 23% 34%Poor< 80% meds 12% 31%

N=134Adapted 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

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 Diabetes1. Clear communication of medical/health

advice2. Teach knowledge and skills necessary

for good disease management3. Make assessing behavior part of

standard care4. Encourage patient honesty

Log Book vs Memory Meter Data

Mazze et al, 1984

Encouraging Patient Honesty: Do’s and Don’tsDON’T…….• Be judgmental

• Criticize and threaten

• Expect too much• Ignore good

behavior

DO……• Accept less than

perfect 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 honesty5. Build consensus about disease management

Patients do what they can do

Patients do what they want to do

BG Goals: Parents vs Pediatricians

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 Diabetes1. Clear communication of medical/health advice2. Teach knowledge and skills necessary for good

disease management3. Make assessing behavior part of standard care4. Encourage patient honesty5. Build consensus about disease management6. Attend to patient feelings, worries, concerns

The Anxiety/Performance Curve

Low HighAnxiety

Perf

orm

ance

Low

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 Diabetes1. Clear communication of medical/health

advice2. Teach knowledge and skills necessary for

good disease management3. Make assessing behavior part of standard

care4. Encourage patient honesty5. Build consensus about disease management6. Attend to patient feelings, worries, concerns