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 Recall Recall of recommendations by the health care team and by patients in a diabetes clinic. Adapted from Page et al (1981). Provider Recall 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, 1967Johnson et al, 1982 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 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 goodpoor Compliance poor good Presumed Relationship Between Patient Behavior and Glycemic Control

The Relationship Between Patient Behavior and Glycemic Control in Childhood Diabetes

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

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 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 Mazze et al, 1984

Encouraging Patient Honesty: Do’s and Don’ts DON’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 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 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 Low High Anxiet y Performance 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 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