Psychology and Illness: Patient Information, Satisfaction and Adherence

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Psychology and Illness Patient Information,
Satisfaction and Adherence
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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

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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

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Patient satisfaction

• An evaluation of a received service by a patient,
  contains cognitive and emotional reactions
• Why is it important?
• Draws attention to the patients experience of
  care
• Important as a measure of quality of care
• ? Concept has value in its own right

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What is patient satisfaction?

• Multi-dimensional (Cleary McNeil 1988)
• Technical quality
• Accessibility
• Convenience
• Finance
• Physical environment
• Availability
• Continuity
• Outcome
• The art of care

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What is the art of care?
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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

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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

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What influences patient satisfaction?

• Communication, communication, communication
• And
• Interpersonal skills

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What influences patient satisfaction?

• Roter (1989) most important influence was
  doctors information giving and interpersonal
  skills
• Effective information giving is bi-directional
  depends on identifying patients main concerns

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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

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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

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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

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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)

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Why is information important?

• Information important for decision-making 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 doctor-patient
  relationship

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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)

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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

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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 dont know what you dont know patients need
  to be supported in making their needs known

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Complexity of giving information

• Unvoiced concerns
• But if your hearts 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 dont take you into their confidence Either
  they think you are stupid or else not
  interested

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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

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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

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Compliance (adherence/concordance)

• Haynes the extent to which a persons behaviour
  (taking medications, following diets, or changing
  lifestyle) coincides with medical or health
  advice.
• Compliance following doctors orders
• Concordance negotiation over treatment regimes

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Rates of Non Adherence

• Reported medication non adherence varies between
  4-92
• In chronic illness 30-50 of patients are non
  adherent

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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

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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

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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)

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Understanding non adherence

• Patient characteristics
• Not associated with any major socio-demographic
  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

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• She wouldnt 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 youll 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 wouldnt allow any of the treatment I was
  just desperate, desperate and nobody else could
  give me any advice because Id tried everything
• Mother of 5 year old girl who had leukaemia

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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)

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Treatment characteristics

• Side-effects
• Complexity importance of how well treatment fits
  patients routine (Myers Branthwaite, 1992)

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Treatment characteristics
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Treatment characteristics

• Patient experience and efficacy of medications
• Are symptoms relieved?
• Asymptomatic conditions, delayed efficacy

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Information/ Knowledge
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Information/ Knowledge

• Basic awareness of how and when to take
  medication is essential for adherence
• Beyond this associations between knowledge and
  adherence are small

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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

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Understanding intentional non adherence

• Doctor-patient relationship and communication
• Patient satisfaction with doctor and with
  information/ explanation
• Dissatisfaction diminishes the motivation to
  adhere

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Intentional non adherence

• For the prescriber to reaffirm the views of
  medical science and to dismiss or ignore the
  patients beliefs is to fail to prescribe
  effectively
• Royal Pharmaceutical Society

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Intentional non adherence

• Patients 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

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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)
• Patients 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

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Patient Prof. Disease Treatment
Adherence

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Summary

• Importance of patient satisfaction
• Need for patient information
• Distinguish between intentional and unintentional
  non adherence
• Importance of d-p relationship and patients
  beliefs about medicines

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Steps to improve adherence

• Discuss the patients 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 1245 in
  room 208 C.