I’m presenting a CEU with a colleague and the director of the residency program tomorrow on balance and falls. Part of my portion is on adherence to fall risk recommendations – I can’t go in depth in this CEU as I have at other times (when the topic was specifically adherence), and it has been a while since I’ve really dug into the literature on adherence in general other than monitoring it via PubMed’s weekly update email. One of the adherence models used is the Transtheoretical Model (stages of change), which uses Motivational Interviewing, or MI. In refreshing my memory, I found two good videos on this that I’ll post here. Watching them reminded me how I found the TTM and MI intriguing, and that I’d like to take a class on it to get better.
Category Archives: adherence
Have you ever been a patient (for any provider, not just PT) and had a really great or a really bad experience? What was the key to that experience for you? For me, it was the interaction with the provider. I’ve contemplated switching providers because of an interaction where I felt like a number, that my concerns were minimized and derided, and that his time was much more valuable than mine.
I received the most recent PTJ yesterday. A few articles grabbed my attention, including “What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” (O’Keeffee M, Cullinane P, Hurley J, et al; Phys Ther 2016; 96: 609-622). It reminds me a lot of the PTJ article by Hush and colleagues from 2011 entitled “Patient Satisfaction with Musculoskeletal Physical Therapy Care: a Systematic Review” which is one I have my students read.
The authors identified four themes in their review: PT interpersonal and communication skills (active listening, empathy, friendliness, encouragement, confidence but not overconfidence, and non-verbal communication), PT practice skills (patient education – a big one for patients, and PT expertise and training), individualized patient centered care (individualized, and taking patient opinion and preference into consideration) and organization and environmental factors (time, flexibility).
The results aren’t all that surprising, but they bear repeating to ourselves as providers; I would argue while both articles examine this in light of musculoskeletal PT, it very likely applies across all specialties and settings. Do positive interactions enhance adherence and give better outcomes? No evidence on this yet, but it would make sense especially for self-efficacy. I think I do pretty well in my interactions, but I think I’ll focus on my listening and patient education. What can you work on to improve patient satisfaction and possibly their adherence and outcomes?
Thanks to a recent blog post on PT Think Tank by Kyle Ridgeway, I became aware of Better: A Surgeon’s Notes on Performance by Atul Gawande, MD, MPH. I checked it out from the library and read it in just a few days, but am going back and digesting it more. While he is a surgeon writing about the practice of medicine, I believe there is much in here we can apply as physical therapists.
In the book he writes that the practice of medicine is more than diagnosis, technical skills, or empathy, but you also have to wrestle with “systems, resources, people and ourselves.” Still, we “must advance… refine… improve.” How much does that describe PT? We may do differential diagnosis, be masters at manual therapy, stroke recovery, etc, and really connect with our patients, but we work within a system. Most of us are within a corporation or organization, but we are all within a larger system as we face rules, regulations, and reimbursement issues. Next, we may have difficult families, or coworkers having bad days. And finally there is us – our virtues and our vices, the things that warm our hearts or set us off. Our professional life is so much more than the basics of Netter to the mastery of motor control or manual therapy.
Why should we care about being better? “Betterment is a perpetual labor. The world is chaotic, disorganized and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one’s life is bound up in others and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question, then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.” Substitute the word “medicine” with “physical therapy” and it may need a few tweaks but overall I think it describes well why we should work at betterment.
He believes there are three core requirements in any endeavor that involves risks and responsibility – the first of these is diligence. He defines diligence as the “necessity of giving sufficient attention to detail to avoid error and prevail against obstacles” and believes it is “central to performance and fiendishly hard.” He then goes on to tell three stories to demonstrate this: hand washing, eradication of polio, and the story of decreasing combat mortality.
In the chapter on hand washing, several things jumped out at me. It is the approach to others with the lack of performance or knowledge that matters. Don’t ask “why don’t you wash your hands” but “why can’t you wash your hands” – you will get two different responses and answers. Here is where he presents the idea of positive deviance that Kyle mentions in his blog post (“the idea of building on capabilities people already had than telling them how they had to change”) – have others identify the ideal, then have them visit the ideal to see exactly what they are doing. They involved everyone in this – from food service staff to MD’s to patients, having them identify ways of solving the problem. In the groups, even if it was the 30th time they had heard the suggestion the facilitators treated them like group #1 “because it was the first time those people had been heard, the first time they had a chance to innovate for themselves.” What a great way to solve a system problem. In this case it impacted infection rates (as PT’s, how are we at washing hands?), but can we use the idea of positive deviance to help others follow clinical guidelines, or patients be more adherent or participate more fully?
The story of the work on the eradication of polio is inspiring. One quote stuck out – “if the eradication of polio is our monument, it is a monument to the perfection of performance – to showing what can be achieved by diligent attention to detail coupled with great ambition.” As PT’s we won’t have that type of public health impact. But what can we achieve in our profession or in the systems we work in if we have diligence and great ambition?
The last story for diligence is about how military surgeons have dramatically reduced mortality rates in the wars in Iraq and Afghanistan. By being observant and keeping statistics, 90% of those wounded in battle are saved. Simple things like requiring the wearing of Kevlar vests and changing where and how the wounded are treated have made a great impact. “Military doctors continued to transform their strategies for the treatment of war casualties. They did so through a commitment to making a science of performance, rather than waiting for new discoveries.” (the science of performance – “to investigate and improve how well they use the knowledge and technologies they already have on hand.” Do you track data on your patients, taking into account who treated them, comorbidities, activities performed, codes and units used during the plan of care, etc? Do you use everything at your disposal in your clinic, maybe being creative and changing how you do something to improve your patient outcomes?
Next up: Components of being “Better” – “Do Right”
Every PT has experienced it. The patient who isn’t improving between sessions (or even losing the gains made during your previous session). “Are you doing the exercises I gave you?” “Oh, no. I forgot where I put the sheet” (or insert any other reason you have heard). Or your patient calls and cancels multiple times in a row, or just doesn’t show up at all.
I’m reading through older journals, trying to clean out my office and learn at the same time. There is an article in the October 2013 issue of PTJ about shared decision making (SDM) which I found interesting, especially after some great CSM programming in Las Vegas this past February. SDM is “a model that reduces the unbalanced power between health professionals and patients… and has 5 characteristics:
- at least 2 participants have to be involved
- both parties have to take steps to participate in the process of treatment decision making
- Information sharing is a prerequisite to shared decision making
- Deliberation has to take place by discussing the treatment preference of both parties
- A treatment decision has to be made and both participants have to agree upon the decision.”
SDM has been shown to improve “patient satisfaction, treatment adherence, and health outcomes.” In this study they observed the interaction between PT’s and patients in Belgium (in an outpatient self-employed setting). Interestingly, rarely was shared decision making applied or attempted by the therapists. You can read more about the study here, but there are 12 items in the instrument looking at SDM and I found them interesting and challenging in my own practice. You can read about the OPTION instrument and the items here. How often do we do these items even to a baseline skill level? Can we use the items from the OPTION instrument in improving our relationship with our patient, and thus improve the patient’s “satisfaction, treatment adherence, and health outcomes”?
We finally got our condo on the market – hopefully it will sell before we need to move to Minnesota (I should be licensed by June 10th, and residency starts September 1st!). Now that the hectic time has passed, I’ve had time to read and share.
- Hip fracture recovery: Kristensen M. Factors affecting functional prognosis of patients with hip fracture. Eur J Phys Rehabil Med. 2011 Jun;47(2):257-64. (free text). I have wondered why some patients do really really well after a hip fracture and others have not done as well. This paper is a good overview of the answer to that question, and maybe a few ideas for treatment (dovetails well with the recent Cochrane review about hip fractures and rehab).
- More on hip fracture recovery: The lead author on this is also an author on the recent Cochrane review, but this is free text (yeah for open access!). Sherrington C, Tiedemann A, Cameron I. Physical exercise after hip fracture: an evidence overview. Eur J Phys Rehabil Med. 2011 Jun;47(2):297-307. Epub 2011 May 10.
- Adherence to exercise: I had the opportunity to hear Dr. Resnick present at ExPAAC last summer – she is a great speaker and I got a lot of great ideas that I would love for my employer to implement to improve physical function in older adults in assisted living and LTC. I haven’t had a chance to read the study itself yet (requesting a copy of the study), but according to the abstract “self-efficacy and negative outcome expectations are directly related to exercise behavior.” We as PT’s need to be encouraging our patients’ self-efficacy and addressing outcome expectations (I love the topic of adherence – if/when I go back for a PhD, that will most likely be my focus somehow) Resnick B, D’Adamo C. Factors associated with exercise among older adults in a continuing care retirement community. Rehabil Nurs. 2011 Mar-Apr;36(2):47-53, 82.
- Land vs. aquatic therapy for hip or knee OA: We have a pool onsite, so when I saw the title I wanted to read further. They found no differences between the two for outcomes, and unfortunately the variability of the programs and the quality of the designs were not great, and they reported that the components of the programs were not described (this could be due to space limitations of the paper – word limits can hamper what you want to say which is good in that you are concise but bad because you might not be able to be as thorough). If you ever write a case report or conduct a study, see if you can include this type of information in an appendix. Batterham SI, Heywood S, Keating JL. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. BMC Musculoskeletal Disorders 2011, 12:123doi:10.1186/1471-2474-12-123
- BWST vs. HEP. For those that missed it, part of the LEAPS trial has been published with the report that there is no difference between early gait training with BWS and a progressive HEP – so don’t feel bad if you don’t have a BWS system (we don’t either). Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, Dobkin BH, Rose DK, Tilson JK, Cen S, Hayden SK; LEAPS Investigative Team. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med. 2011 May 26;364(21):2026-36.
- Urban elderly, fall reduction, and adherence: For the residency I’ll be at Augustana in downtown Minneapolis 4 days a week. One of the things that drew me to the program is that it is urban and there is more variety in the patient population. When I read the title of this article I wanted to read more. It is interesting that over half attended all the onsite sessions but only one person reported exercising at home all 12 weeks (I would be interested to see what was the overall percentage of adherence to both), and even more interesting is that if they lived alone they were more likely to attend, but if they were depressed they were less likely to attend all the classes (I’ve requested this article, haven’t received it yet). Stineman MG, Strumpf N, Kurichi JE, Charles J, Grisso JA, Jayadevappa R. Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program.Gerontologist. 2011 Jun;51 Suppl 1:S59-72.
We have some changes going on at work, and I hope to have some good research and posts out of them soon – stay tuned!
Thanks to Monique Serpas PT, I read an interesting article about insurance covering exercise programs. I think this should be covered or at least supplemented. Here is why, and the possible problems:
Why: more cost-effective for everyone (providing the insured does the program), better for the health of the insured (versus medications and side-effects, especially with polypharmacy), reduced disease burden not only for the country/ community, but also for the individual and their family as they age.
Problems: Adherence (how many of us join a gym but don’t make good use of it?); motivation – ties into adherence, but unless there is either a tangible reward or punishment (better health/ function, or money) I suspect there is less likelihood of participation; insurance company buy-in – because they know the stats on adherence to exercise (why pay for something most won’t keep doing?); lack of education – like Monique said in the comments, there is a lack of education and knowledge on how to lose weight or be more active safely.
Group Health (an HMO in Seattle) does this – they underwrite a good portion of EnhanceFitness for their participants, with good (published) results. I’d like to see other insurance companies do similar structured pilot programs and see what happens.
Hundreds of studies have shown self-efficacy is important in performing an action or activity (exercise, taking medication, doing a HEP, quitting smoking, etc). Here is another from an Open Access journal about how SE, social support, and physical exercise is important in functional health:
Lachman ME, Agrigoroaei S (2010) Promoting Functional Health in Midlife and Old Age: Long-Term Protective Effects of Control Beliefs, Social Support, and Physical Exercise. PLoS ONE 5(10): e13297. doi:10.1371/journal.pone.0013297
How do you promote your patient’s self-efficacy?