Understanding and Changing Clinician Behavior

Epi 245

Ralph Gonzales, MD, MSPHProfessor of Medicine; Epidemiology

& Biostatistics

22 October 2009

Seminar Outline: Stepwise Approach

• Clinician behavior in larger context• Step 1: Use theory to understand clinician

behavior• Step 2: Use theory to create a model for

changing clinician behavior• Step 3: Integrate results from Steps 1 and 2

into an implementation strategy

Health Care Quality• Donabedian A. JAMA 1988;260:1743-8

Structure Process Outcomes

Community Characteristics

Delivery System Characteristics

Provider Characteristics

Population Characteristics

Health Care Providers-Technical Processes-Interpersonal Processes

Public & Patients-Access-Acceptance-Adherence

Health Status

Functional Status

Satisfaction

Mortality

Cost

Failed Attempts to Change Antibiotic Prescribing Behavior in the US

Poses, 1995 (Univ Student Health, N=14 physicians)– Target: pharyngitis in college students– Strategy: Decision-making educational seminar– Results: pre/post non-equivalent control: no difference

O’Connor, 1999 (Health Partners, MN, N=4 practices)– Target: URIs in adults– Strategy: dissemination of URI guideline– Results: pre/post, no control group: no difference in 21-day Rx rates

Mainous, 2000 (Kentucky Medicaid, N=216 physicians). – Target: colds, URIs, bronchitis in children in 1997.– Strategy: Practice profiling and feedback

– Results: pre/post randomized allocation: no difference

No Magic Bullets!

Oxman AD, Thomson MA, Davis DA, Haynes B. No magic bullets: a systematic review of 102

trials of interventions to improve profession practice. Can Med Assoc J 1995;153:423-31.

Knowledge Behavior∆ Knowledge≠ ∆ Behavior

“Knowledge is necessary, but usually insufficient, for behavior change”

“Better implementation strategies must be created in order to effectively Translate Evidence into

Practice.”

Rudimentary individual change theory

KNOWLEDGEKNOWLEDGE ATTITUDE / ATTITUDE / MOTIVATIONMOTIVATION BEHAVIORBEHAVIOR

Eisenberg… Medical Care 1985;23:461–483. Understanding physician behavior“There are few iron-clad rules for practicing medicine and too

much of it is an exercise in dealing with uncertainty.”

As a result, there are a wide variety of factors that can influence what doctors do…

• Self-interest: Desire for income; Desire for a style of practice; Personal characteristics; Practice setting; Community standard of care

• Patient interest: Patient’s economic well-being; Clinical factors; Patient demand; Defensive medicine; Patient characteristics; Patient convenience

• Social good: Role in society; Sustaining medical profession

PATIENT FACTORSSymptoms & their meaningsExpectations; DemandsHealth system experiences Health care coverage or ability to payCultural understandings[Dis]trust re advice

SYSTEM FACTORSCost of medicines & careCare setting factors (e.g. schedules, formularies)Health plan featuresPharmaceutical promotionsPharmacy practicesAvailability of technologyRegulatory environment Community factors Cultural context Media / health informationCLINICIAN FACTORS

SociodemographicsSpecialty / trainingKnowledge and AwarenessJudgment & heuristicsPerceived patient expectationsCommunication styleSelf-Efficacy

Medical Decision/BehaviorMedical Decision/Behavior

Cross-sectional model of clinician behavior

PATIENT FACTORS SYSTEM FACTORS

CLINICIAN FACTORS

Clinical Decision/BehaviorClinical Decision/Behavior

Coronary Artery Stents

PATIENT FACTORS SYSTEM FACTORS

CLINICIAN FACTORS

Clinical Decision/BehaviorClinical Decision/Behavior

Antibiotic Treatment of Viral URIs

PATIENT FACTORS SYSTEM FACTORS

CLINICIAN FACTORS

Clinical Decision/BehaviorClinical Decision/Behavior

Contraceptive Method

Kravitz RL et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293:1995-2002.

1: Physicians' shared decision-making behaviors in depression care.Young HN, Bell RA, Epstein RM, Feldman MD, Kravitz RL.Arch Intern Med. 2008 Jul 14;168(13):1404-8.2: Let's not talk about it: suicide inquiry in primary care.Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL.Ann Fam Med. 2007 Sep-Oct;5(5):412-8.3: Exploring and validating patient concerns: relation to prescribing for depression.Epstein RM, Shields CG, Franks P, Meldrum SC, Feldman M, Kravitz RL.Ann Fam Med. 2007 Jan-Feb;5(1):21-8.4: Do patient requests for antidepressants enhance or hinder physicians' evaluation of depression? A randomized controlled trial.Feldman MD, Franks P, Epstein RM, Franz CE, Kravitz RL.Med Care. 2006 Dec;44(12):1107-13.5: Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients.Franz CE, Epstein R, Miller KN, Brown A, Song J, Feldman M, Franks P, Kelly-Reif S, Kravitz RL.Health Serv Res. 2006 Dec;41(6):2290-302.6: Types of information physicians provide when prescribing antidepressants.Young HN, Bell RA, Epstein RM, Feldman MD, Kravitz RL.J Gen Intern Med. 2006 Nov;21(11):1172-7.7:What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms.Kravitz RL, Franks P, Feldman M, Meredith LS, Hinton L, Franz C, Duberstein P, Epstein RM.J Gen Intern Med. 2006 Jun;21(6):584-9.

What 1 Good Audio-Taped Study Can Do For You

System Factors: Aiken Study

• Measure Quality and Quality Gap– Variation in nurse-patient ratios

• Link Quality Gap to Outcome Gap– Lives saved per change in nurse-patient ratio

Seminar Outline: Stepwise Approach

• Clinician behavior in larger context• Step 1: Use theory to understand clinician

behavior– Why do they do what they do?– What types of studies does one employ?

• Step 2: Use theory to create a model for changing clinician behavior

• Step 3: Integrate results from Steps 1 and 2 into an implementation strategy

Step 1: Understanding Behavior

A. Study the knowledge, attitudes, beliefs and behaviors that are associated with a specific target behavior…. Understand your target group using interviews, surveys & observation.

B. Study the environmental and ecological factors associated with the specific target behavior…. such as geography, practice setting, patient population characteristics

Case Study:Why do physicians prescribe (unnecessary)

antibiotics for viral URIs?

• Clinician Studies– Clinician Factors– Patient Factors

• Patient Studies• Public Studies

Physician Practice AnalysisAbx Rate Purulence Factors Present

0

20

40

60

80

100

0 1 2 3 to 5

No. Factors Present

An

tib

ioti

c R

x R

ate

(%)

n=148

n=106

n=46

n=22

Purulence Factors: Hx green nasal discharge; Hx green phlegm; PEx green nasal discharge; PEx tonsillar exudate; tobacco use

Physician Practice Analysis + Survey

Antibiotic Treatment of Acute Respiratory Infections

0

20

40

60

80

100

Perceived Patient Expectations

Ant

ibio

tic P

resc

ript

ion

Rat

e

YesNoUnsure

Hamm, J Fam Pract 1996;43:56-62

How do URI patients influence their doctors?-Scott, J Fam Pract 2001;50:853-8.

Frequency Abx RxExplicit request 15 93%Chief complaint presentation -Candidate diagnosis 66 62%

-Portraying severity of illness 119 80%Appeals to circumstances

-life-world 16 88%-previous positive experience 39 97%

*Used field-notes from direct observation of 298 encounters (18 practices; 50 FP physicians)

Is Antibiotic Treatment Necessary forPatient Satisfaction?

• Hamm, 1996– patient satisfaction not related to antibiotic prescription

• Mangione-Smith, 1999– parent satisfaction not related to antibiotic prescription

• Gonzales, 2000– patient satisfaction not related to antibiotic prescription

even after antibiotic prescribing had been reduced

Identify “Targets” for Improving Antibiotic Use

Patient Expectations/Demands for Abx– Clinical Features: Purulence = antibiotics– Previous Antibiotic Treatment– Illness Label

Clinician Beliefs about Abx Rx– Acute Bronchitis: Diagnosis = Antibiotic– URIs: Purulence = Antibiotic

System Factors: facilitators/barriers…– Visit Duration– Telephone advice nurse

Examples of how we incorporated into Guidelines and Education

Seminar Outline: Stepwise Approach

• Clinician behavior in larger context• Step 1: Use theory to understand clinician

behavior• Step 2: Use theory to create a model for

changing clinician behavior– How do we help change happen?

• Step 3: Integrate results from Steps 1 and 2 into an implementation strategy

Drilling Down Deeper…

Understanding Behavior Change

Theory of Planned Behavior; Transtheoretical Model

Step 2: Create Model for Behavior Change

A. Organize and predict how various factors inter-relate; what role they play as facilitators and barriers

B. Explain change process and pathway– Draw causal inferences between intervention

and results

C. Guide evaluation and iterative process

Theory of Planned Behavior

Behavior

Attitude

BehaviorIntention

Subjective Norms

Perceived Behavioral

Control

Behavioral Beliefs

Outcome Expectancy

Normative Beliefs

Motivation to Comply

Control Beliefs

Perceived Power

External Factors-Practice Guidelines-Patient Requests-Environment/Resources

Ceccato et al, J Cont Educ Health Prof 2007

Cabana MD, et al. Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement. JAMA 1999;282:1458-65

Differential Diagnosis• Lack of Awareness• Lack of Familiarity• Lack of Agreement• Lack of Self-Efficacy• Lack of Outcome Expectancy• Inertia of Previous Practice; Heuristics• Delivery System/Practice Barriers; Environmental• Guideline Related Barriers; Uptake vs. Eliminate• Patient Preferences

Rubinson L, et al. Why is it that internists do not follow guidelines for preventing intravascular catheter infections? Infect Control Hosp Epidemiol. 2005 Jun;26(6):525-33.

NOT ASSOCIATED with adherence• Clinician experience and subspecialty• Awareness of CDC guidelinesSTRONGLY ASSOCIATED with adherence

• High outcome expectancy for the use of large sterile drapes (OR, 5.3; CI 95, 2.2-12.6).

• Availability influenced use of specific antiseptic agents

CONCLUSIONS:Because improved adherence to these practices will require increased outcome

expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

http://www.engenderhealth.org/res/onc/hiv/preventing/hiv6p3.html

Copyright © 2008 The Royal College of PsychiatristsCHILVERS, R. et al. Br J Psychiatry 2002;181:99-101

Prochaska-Driven Intervention Design

Pre-Contemplation

Preparation

Contemplation

Action

Maintenance

CME; Report Cards, etc Skill-Building, P4P, Laws, etc.

Intervention Strategies

Education; Feedback CQI; Incentives; Detailing Regulatory; CQI

“Stages of Change” / TTM

• Very appealing! – Brief– High face validity – Easy to explain – Readily applicable for understanding & interventions– Useful for distinguishing between motivation phase &

volition phase– Stages of change interventions appear in the short term at

least to be somewhat more effective than non-stage matched interventions

Limitations of TTMThe bad news: • Rather weak evidence, mostly from cross-sectional

studies • Stages of change may be unstable over time• Few studies about using TTM in changing providers’

behavior• Need for prospective studies -- longitudinal,

experimental designs

Sutton S. Interpreting cross-sectional data on stages of change. Psychol Health. 2000;15:163–171.Adams JWM. Why don't stage-based activity promotion interventions work? Health Educ Res. 2004;20:237–243.

From TPB (content)Patient Factors/Demands: origins of

expectations– Clinical Features: Purulence =

antibiotics– Previous Antibiotic Treatment– Illness Label

Physician Factors: origins of Abx Rx – Beliefs

• Acute Bronchitis: Diagnosis = Antibiotic

• URIs: Purulence = AntibioticSystem Factors: facilitators/barriers…

– Visit/Pharmacy co-pay– Visit Duration– Telephone advice nurse

From TTM (mechanism)For contemplation stage physicians

Need convincingNeed stronger motivation

Preparation stageAttenuate strong patient factors Need to make it normative/impt.

Action stageNeed to make it easyNeed to reassure they can do it

Communication skillsPractice Guidelines

How TPB and TTM informed Abx Intervention Designs

Summary Steps 1 & 2

• We understand some of the key factors that contribute to the behavior of interest

• We have a model for understanding how these factors influence behavior

• We have a hunch about where our physicians lie in their readiness to change…

Seminar Outline:Stepwise Approach

• Clinician behavior in larger context• Step 1: Use theory to understand clinician

behavior• Step 2: Use theory to create a model for

changing clinician behavior• Step 3: Integrate results from Steps 1 and 2

into an implementation strategy

Step 3: Design & Implement Intervention

A. Visit the Toolbox

B. Probe your Target Audience

C. PRECEDE-PROCEED

Changing Clinician BehaviorThe Tool Box

• Education [adult learning theory]– Best if real-time, leadership-endorsed,

repeated/sustained over time

• Feedback [social cognitive theory]• Participation [management theory]• Administrative changes [misanthropy]• Incentives• PenaltiesEisenberg… Medical Care 1985;23:461–483.

Physician-Centered Strategies• Education

– Textbooks; medical journals– Medical school/residency curricula; CME

• Feedback– Reminders; Profiling

• Opinion Leaders• Participatory CQI• Financial Incentives and Penalties• Administrative

– Creating and/or Removing Barriers– Laws, Regulations, Institutional Policies

• Academic Detailing

Weaker

Stronger

Physician Survey:To what extent will different interventions facilitate

a reduction in excess antibiotic use?

0

10

20

30

40

50

60

70

% r

espo

ndin

g "A

Gre

at D

eal"

new rapid tests

patient education

advice nurse &self-care manuals

practiceguidelines

new antibiotics

Quality of life

Phase 1 Socialassessment

Health

Educational strategies

Policyregulation

organization

HealthProgram

Phase 4a

Phase 5Implementation

Phase 6Process evaluation

Phase 7Impact & Outcome evaluation

Predisposing

Reinforcing

Enabling

Phase 3Educational &

ecologicalassessment

Behavior

Environment

Phase 4b

Phase 2

Epidemiological Assessment

Genetics

PRECEDE-PROCEED

Administrative &policy assessment

InterventionAlignment

Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.

• Predisposing,• Reinforcing, &• Enabling• Constructs in• Educational/Ecological• Diagnosis &• Evaluation

• Policy,• Regulatory &• Organizational• Constructs in• Educational &• Environmental• Development

Intervention Study (RWJF, 200k):An Office-Based Intervention to Improve Abx Rx

C on trolS ite

O ff iceE ducation

O ff ice In terven tionS ite

preven tionself -care

w hen to seek carew hat to expect

H ouseholdE ducation

du ration of illnesslack of A bx benef it

an tibiotic res is tance

O ff iceE ducation

opin ion leaderfeedback"detailing"

C lin ic ianE ducation

F u ll In terven tionS ite

Kaiser Permanente of Colorado

Gonzales et al. Decreasing antibiotic use in ambulatory practice: Impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA, 1999;281:1512-1519.

Intervention Study:Impact of Office-Based Acute Bronchitis Intervention

0

20

40

60

80

100

11 12 1 2 // 11 12 1 2 // 11 12 1 2

% in

cide

nt v

isit

s pr

escr

ibed

Abx

ControlLimitedFull

baseline year 1 year 2

Gonzales et al. JAMA 1999;

Denver Health Urgent Care Denver Health Urgent Care Clinic (CDC, 75k)Clinic (CDC, 75k)Intervention Design Intervention Design

ConsiderationsConsiderationsPublic/Patient Population• low literacy skills• large Hispanic/Latino segment

Clinician and Practice Setting• MDs, NPs; variable schedules• long waiting periods

Denver Health Urgent Care Denver Health Urgent Care ClinicClinic

Intervention ComponentsIntervention Components

A. JABERWALKI Computer Module (Predisposing)

B. Clinician Educational Session (Predisposing; Reinforcing)

C. Examination Room Posters (Predisposing; Enabling)

Intervention Impact

0

20

40

60

80

100

bronchitis pharyngitis sinusitis URI/viral

Ant

ibio

tic

Rat

e, %

baselinecomputerno computer

Denver Health Urgent Denver Health Urgent Care ClinicCare Clinic

Intervention Study (VA/AHRQ, 2M):Cluster-randomized ED Trial: IMPAACT Project

• Predisposing: CPGs; A/F• Enabling: Posters skills; Kiosks Pt Educ’n• Reinforcing: opinion leaders; A/F;

endorsements

IMPAACT Results

ENVIRONMENT

Behavioral Intention Action Maintenance

Theory of Planned Behavior

Contemplation

Preparation

Pre- Contemplation

PREDISPOSING ENABLING REINFORCING

Self -Efficacy

Beliefs Attitudes

Social Norms

Motivation and Persuasion

SUMMARY (Homework Exercise)1. Identify a clinician (eg, physician, nurse, pharmacist) behavior that is, or

contributes to, the principle behavior that you are attempting to improve with your intervention.

2. Using the trans-theoretical model, stage your target clinician group with

regard to the behavior that you are attempting to improve with your intervention.

3. Using the Theory of Planned Behavior, identify some potential factors that

contribute to your clinician behavior of interest. Support with references if possible.

4. Describe a plan for learning more about the factors that contribute to the

target clinician behavior of interest that will serve to inform your final intervention design.