August 2008
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Are Patients or Outcomes More Important?
We must address patients' behavioral and psychosocial concerns to achieve desired outcomes.
By Martha Mitchell Funnell, MS, RN, CDE; and Robert M. Anderson, EdD
In recent years, there has been a growing emphasis on outcomes as providers strive to achieve high scores on quality measures and to qualify for incentives through pay-for-performance programs. The Chronic Care Model1 has served as a guide for strategies to achieve these outcomes through practice redesign and information technology. Although these changes are laudable and effective, the focus on the informed, empowered patient working in concert with the practice team has received less attention than the other components of the model. The question then becomes, do patients matter when it comes to achieving outcomes?
It has long been recognized that patients with diabetes provide about 98% of their own care.2 A recent study, however, has shown that patient-related factors also contribute 98% of the effect on glycemic outcomes, while physician-related factors contribute the remaining 2%.3 Although some of these patient-related factors are not changeable (disease severity, age, race), 52% of the variance remains to be explored, and it may well be possible to enhance these factors through diabetes self-management education and psychosocial support.
The Diabetes Attitudes Wishes and Needs (DAWN) study4 provides further understanding of these issues. DAWN was one of the most comprehensive studies of diabetes self-management ever conducted on a global level. In this study, 85% of the more than 5,000 patients reported that they experienced feeling shocked, guilty, angry, anxious, depressed, or helpless at the time of diagnosis. Years after the diagnosis (mean = 15), problems of living with diabetes remained prevalent with 43.8% of the patients reporting that they were constantly afraid their diabetes was getting worse and one-third reporting that they feel that diabetes interferes with their daily lives, that they are stressed because of their diabetes, and they are worried about their ability to carry out their future family and other responsibilities. Among these same patients, less than 20% reported that they completely carried out all aspects of their treatment programs. In addition, they reported that psychosocial issues interfered with their self-management efforts and that they wanted more help from their providers to address these professionals. More than 80% of the 4,000-plus diabetes care providers who participated in this same study agreed that psychosocial issues were the major cause of diabetes self-management problems, yet both patients and providers indicated that these are rarely addressed in practice.
These studies make it clear that unless we address patients' behavioral and psychosocial concerns, they will not be able to achieve the outcomes that they and we need and want.
PATIENT-CENTERED PRACTICE STRATEGIES
A source of frustration for many providers is that there is more and more to do during an office visit that is steadily decreasing in length. Most providers want to address patient issues but feel constrained by the realities of the current practice environment. The following recommendations are based on three fundamental principles: (1) no one expects an individual provider to do it all; (2) there is no magic strategy that instantly fixes all of your patients; and (3) there are some simple steps that will not add to the length of the visit but will improve the quality of the patient-professional interaction.
Create a team. Team care among DAWN study patient participants was less than optimal, with most patients seeing fewer than two other providers, including a primary care provider or diabetes specialist physician, diabetes nurse, dietitian, eye doctor, foot doctor, or behavioral specialist.5 Patients who had a nurse available at their provider's office reported better self-management behaviors; team care can improve outcomes.6 This does not mean that you need to have a team in your office, however. You can create a team with other professionals in your area who have expertise in diabetes. Establishing effective communication between team members is critical for improving outcomes.7
Refer to a diabetes self-management education (DSME) program and/or a dietitian for education. Multiple meta-analyses8-13 have shown that DSME is effective for improving metabolic and psychosocial outcomes in diabetes care. Referral to DSME and nutrition counseling has also been shown to result in decreased hospitalizations and a significant cost savings.14 If these programs are not available in your area, consider who on your staff can fulfill this need. Making it part of someone's job will help ensure that it gets done and documented in a systematic way.
Communicate effectively. The DAWN study further demonstrated that patients who identified they had a good relationship with their providers reported better outcomes, better self-management behaviors and less diabetes distress.4 Specific strategies include:15
- Establish the patient's agenda at the beginning of the visit. Begin with an assessment of patients' concerns, questions, and progress toward metabolic and behavioral goals. Some providers ask patients to complete a short open-ended form in the waiting room to ascertain any questions or concerns they would like addressed during the visit (Table 1).16-17 Others simply begin the visit by asking, "What questions or concerns would you like addressed today?
- Use the ALE (ask, listen, empathize) method of communication: (1) Ask "What issue or concern would you like addressed at today's visit?" (2) Listen to the patient's response without offering opinions, judgments, or advice. (3) Empathize and encourage discussion by asking for clarification of the issue and the patient's thoughts and feelings about the issue.
- Solicit patients' opinions about home blood glucose-monitoring results and other laboratory and outcome measures before offering your opinion.
- Take advantage of teachable moments during the visit. Remember that patients are much more interested in their own diabetes than in a general discussion of diabetes.
- Provide ongoing information about the costs and benefits of therapeutic options. Involve the patient in the decision-making process. They are more likely to take a medication that they helped choose rather than one they do not feel that they need.
- Close the loop at the end of the visit by asking patients to tell you what they would say to a family member who asks about what happened during the visit. This strategy lessens the likelihood that patients will think that you are testing them.
- End the visit by jointly jotting down a brief list of the decisions made during the visit.
Motivational interviewing (MI) is a communication strategy that has been shown to be effective.18,19 MI is a directive counseling style for helping patients explore and resolve ambivalence about their behavior.20 MI may be particularly relevant for patients who demonstrate a low readiness to make behavioral changes. Readinesss is defined as the patients' perception of the importance of the change and confidence in their ability to make the change.20 MI is nonjudgmental, empathetic, and encouraging, and there is no attempt to convince, persuade, or advise the patient.21 Training is generally required to use this method effectively.
Collaborate effectively. Creating a partnership with patients who have diabetes is fundamental to creating an informed, empowered patient. The partnership acknowledges the expertise and the importance of the roles of both the patient and the health care professional.15 Specific strategies include:
- Stress the importance of the patients' roles in self-management and daily decision making. Describe the health professional's role as a partner in the care process. Acknowledge the patients' rights and responsibilities to make self-care choices and to be the primary decision-makers about the daily self-management of their diabetes. This is important to address from the time of diagnosis so that patients understand their responsibility in terms of decision making and outcomes.
- Review and revise diabetes care plans as needed based on patients' and providers' assessments of its effectiveness.
- Assist patients in solving problems and overcoming barriers to self-management.
- Support and facilitate patients in their roles as self-management decision makers.
- Create a patient-centered environment that incorporates self-management support from all practice personnel and is integrated into the flow of the visit.
Goal setting is a strategy that is particularly helpful in creating a collaborative relationship and is effective for supporting behavior change.15,20 Assist patients to select one area of self-management on which to concentrate that can be reinforced by all team members. The process can be formal as outlined in Table 2 or more informal in which the provider simply asks the patient to identify one thing he or she will do between now and the next visit to care for his or her diabetes. If a more formal process is used, staff members other than the physician can learn to work with patients on these issues. A goal-setting strategy is to set SMART goals: specific, measurable, achievable, realistic, and timely.
Empowerment is defined helping patients discover their own innate ability to obtain mastery over their diabetes. Supporting patients in this process is a critical step in obtaining desired outcomes in diabetes care.
Martha Mitchell Funnell, MS, RN, CDE; and Robert M. Anderson EdD are from the Michigan Diabetes Research and Training Center and Department of Medical Education, University of Michigan Medical School, Ann Arbor, Mich. Ms. Funnell may be reached at mfunnell@umich.edu; phone: 734-936-9237; or fax: 734-936-8967. Dr. Anderson may be reached at boba@umich.edu.
This research is supported in part by grant number NIH5P60 DK20572 and 1 R18 0K062323-01 from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.
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