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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