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Psychology and Illness: Patient Information, Satisfaction and Adherence Important announcement about the assessment • Prose question will be on the material covered in the 3rd theme in the module: psychology of illness and treatment (i.e. sessions 8-11) • SAQ questions will cover the whole module Objectives • Evaluate the importance of providing information for patients • Begin to recognise the importance of patient satisfaction as an outcome of care and treatment • Examine the problem of non adherence and the factors influencing adherence Patient satisfaction An evaluation of a received service by a patient, contains cognitive and emotional reactions Why is it important? – Draws attention to the patient’s experience of care – Important as a measure of quality of care Concept has value in its own right What is patient satisfaction? • Multi-dimensional (Cleary & McNeil 1988) – Technical quality – Accessibility – Convenience – Finance – Physical environment – Availability – Continuity – Outcome – The “art of care” What is the “art of care”? What is the “art of care”? • Health professionals’ interpersonal skills • Communication skills • Sensitivity/empathy for patients’ concerns • These valued as much as technical skills by patients Why is patient satisfaction important (again)? • Adherence • Re-attendance • Change of health care provider • Use of complementary therapies • Health status and well being –o Cleary et al (1991) patients who reported poor health reported 2x more problems with care than those who rated their health as excellent Concept has value because of its association with important outcomes What influences patient satisfaction? Communication, communication, communication And Interpersonal skills What influences patient satisfaction? • Roter (1989): most important influence was doctors’ information giving and interpersonal skills • Effective information giving is bidirectional: depends on identifying patients’ main concerns Information and Patient Satisfaction Survey by Bruster 1994 of over 5000 patients attending 36 NHS hospitals – Main source of dissatisfaction was communication – 16% reported receiving no explanation of condition – Not given important information about hospital/routine and treatment – Discharge planning and pain management also gave rise to complaints Patient information French physician Samuel de Sorbiere (1672) argued that telling patients the truth: • Might seriously jeopardise medical practice • Would not catch on! • He was right – Oken (1961) 90% of US surgeons would not routinely discuss cancer diagnosis with their patients – Thomsen et al (1993) survey of European gastroenterologists: 60% did not routinely tell patients of their cancer diagnosis Why is information important? • (Most) patients want it and have a right to it (informed consent) – Meredith (1996) 96% of patients attending an oncology clinic wanted to know if their illness was cancer: 75% wanted as much information as possible – Ajaj (2001) 88% of older people (65-94 years) wanted to be told if they had cancer: 62% wanted as much information as possible – Patients feel they have a right to information and that they [the patient] should have a say in who else is told Why is information important? • Reduced distress, analgesia, pain, hospital stay • Improved recovery, quicker resumption of normal activities • Improved physiological outcomes (e.g. blood pressure, heart rate) Why is information important? • Information important for decisionmaking and patient self management • Patients need to understand what is happening to them so they can “make sense” of their experiences • Important for trust and the doctorpatient relationship What do patients want to know? • • • • • • • • • A disease label or name Causes Prognosis Symptoms Diagnosis/ further tests Treatment – sensory information Treatment – procedural information Treatment – efficacy/outcomes/risks Other (practical/ emotional information/ needs) Important issues in giving information • Individual differences in patients’ preferences for information – E.g. cultural differences linked to age, gender, ethnicity, social class, – Differences in coping strategies (monitorers v blunters) • Differences over time • Complexity Complexity of giving information • Mismatch between patient needs and doctor views • Need to avoid harming vulnerable patients (e.g. highly anxious, children) • Time constraints • You don’t know what you don’t know: patients need to be supported in making their needs known Complexity of giving information Unvoiced concerns “But if your heart’s damaged does it deteriorate more over the years or does it remain at that level? Do you know what I mean? Is it terminal?” Barriers “Even my own doctor and the doctor before that – they don’t take you into their confidence… Either they think you are stupid… or else not interested” Complexity of giving information • Despite its importance to patients, information giving may be perceived as “non technical” – delegated to inexperienced staff • Difficulty of finding out how much information individual patients want – need for continual assessment of patients’ cues Complexity of giving information “If the breaking of bad news is done badly, patients and their families may never forgive us, but if it is done well they will never forget us” Robert Buckman (1996) Medical oncologist Compliance (adherence/concordance) • Haynes ‘the extent to which a person’s behaviour (taking medications, following diets, or changing lifestyle) coincides with medical or health advice.’ • Compliance = following doctors orders • Concordance = negotiation over treatment regimes Rates of Non Adherence • Reported medication non adherence varies between 4-92% • In chronic illness 30-50% of patients are non adherent Measuring adherence: Indirect • Patient self report – Pros: easy, inexpensive – Cons: prone to disadvantages • Second hand reports (doctors, relatives) – Pros and cons: similar to self reports – Depends on familiarity with patient – Health profs. over estimate adherence • Pill counts – Pros: more objective – Cons: prone to inaccuracies and bias Measuring adherence: Indirect • Mechanical or electronic to record dose dispensed – Pros: objective, most accurate indirect method – Cons: does not measure whether medication has been taken Measuring adherence: Direct • Blood or urine tests – Pros: direct information on consumption/adherence to advice – Cons: • Expensive and invasive = limits use • Affected by metabolism • Non adherence may be masked • Observation (of consumption of medication) Understanding non adherence • Patient characteristics – Not associated with any major sociodemographic variables (Haynes et al 1979) except age: • Adherence lower in preschool children, adolescents, older infirm patients on complex drug regimes – Adherence varies in individuals over time and between different aspects of treatment regime “She wouldn’t allow any of the treatment … I sat down with her one day and I said “You do know that unless you let the doctors give you your treatment you’ll die.” She sat quietly and she sat there and she thought about it and from then on she changed … I was getting frustrated because she wouldn’t allow any of the treatment … I was just desperate, desperate and nobody else could give me any advice because I’d tried everything” Mother of 5 year old girl who had leukaemia Reasons for non adherence • Illness severity and adherence – Non adherence is common even in severe illness – Greenstein & Siegal (1998) 22% of adult renal patients were non adherent – Rovelli (1989) 91% of renal patients who fail to take their medication experience organ rejection or death (18% of adherent patients) Treatment characteristics • Side-effects • Complexity: importance of how well treatment fits patient’s routine (Myers & Branthwaite, 1992) Treatment characteristics Treatment characteristics • Patient experience and efficacy of medications – Are symptoms relieved? – Asymptomatic conditions, delayed efficacy Information/ Knowledge Information/ Knowledge • Basic awareness of how and when to take medication is essential for adherence • Beyond this associations between knowledge and adherence are small Memory • Remembering that you have medicine to take • Remembering when and how to do it • Information and memory are necessary but not sufficient for adherence • Non-adherence may be intentional Understanding intentional non adherence • Doctor-patient relationship and communication – Patient satisfaction with doctor and with information/ explanation – Dissatisfaction diminishes the motivation to adhere Intentional non adherence “For the prescriber to reaffirm the views of medical science and to dismiss or ignore [the patient’s] beliefs is to fail to prescribe effectively” Royal Pharmaceutical Society Intentional non adherence • Patient’s beliefs and cognitions (Horne 1997) • Specific – Necessity: beliefs about efficacy of medication • Specific – Concerns: beliefs about the potential for harm • General – Harm: beliefs about intrinsic properties of medicines • General – Overuse: beliefs about whether medicines are over used Intentional non adherence • Discrepancies between doctor and patient beliefs (e.g. about risk of not taking medication) • Misunderstandings in prescribing because of lack of patient participation in the consultation (Britten et al 2000) • Patient’s beliefs about medicines go unvoiced (i.e. their expectations and preferences) • Doctors need to check whether their understandings about patients are correct • Ask patients what they think of taking their medicines Patient + Prof.+ Disease + Treatment = Adherence Summary • Importance of patient satisfaction • Need for patient information • Distinguish between intentional and unintentional non adherence • Importance of d-p relationship and patient’s beliefs about medicines Steps to improve adherence • Discuss the patient’s beliefs • Simplify the treatment/tailor to the patient • Make sure the patient is satisfied • Check patient understanding and your communication • Provide written information • Consider involving significant others • Regular follow-up - ask about problems with treatment • Consider using reminder devices Reminder: research project on prioritising health care, with Katherine. This lunchtime at 12:45 in room 208 C.