Improving Health Literacy through Innovative Health Communication Tools

Transcription

1 Improving Health Literacy through Innovative Health Communication Tools David W. Baker, MD, MPH Chief, General Internal Medicine Institute for Healthcare Studies Feinberg School of Medicine, Northwestern University Health Communication in Today s Outpatient Medical Practice Physicians have little training in how to communicate effectively Thin margins, high patient volume Little time for patient education Studies show physicians provide little information about preventive services or new medications No standardization of the information Systems-Based Approach to Improve Health Communications Develop tools with patients Plain language Limit cognitive load Universal precautions: standard approach with all patients Use technology Check comprehension: Teach Back, Teach to Goal, Learning Mastery 1

2 A New Paradigm Health needs assessed before a visit Based on this, patients given materials to prepare them for the discussion. Print, multimedia, or both Standardized information Designed with patients to ensure clarity of words and concepts Office tools help providers communicate Patients sent home with summaries Automatic reminders sent to patients Before the Appointment Dear Mr. Lucky, Thank you for taking the time to complete your health check. This showed that you have never been screened for colon cancer. Screening for colon cancer can save your life. Please come to your visit 15 minutes early. The nurse will show you a short video and answer your questions. Dr. Quick will also discuss this with you when you see her. At the Start of the Visit Presentation of Colon Cancer Screening Patient Education Program Dr. Gregory Makoul PI Funded by American Cancer Society 2

3 The Visit Mr. Smith? Dr. Quick will see you now. Presentation of Colon Cancer Screening Office- BasedCounseling Tool Dr. Gregory Makoul PI Funded by National Cancer Institute After the Appointment Automated Reminders to Reinforce Understanding and Adherence Dear Mr. Lucky, I wanted to tell you again how important it is to be screened for colon cancer. Don t t wait! Be sure to schedule your colonoscopy as soon as possible. Remember, this test could save your life. Sincerely, Dr. Quick 3

4 Improving Patient Safety: Adverse Event Detection Amiodarone example Medline plus information nt/druginfo/medmaster/a html IMPORTANT WARNING: Amiodarone may cause lung disease that can be serious or life-threatening.tell your doctor if if you have or have ever had any type of lung disease. If you experience any of the following symptoms, call your doctor immediately: fever, shortness of breath, wheezing, cough, coughing up blood, and any other breathing problems. Amiodarone also may cause liver disease. Tell your doctor if if you have or have ever had liver disease. If your experience any of the following symptoms, call your doctor immediately: upset stomach, vomiting, dark colored urine, excessive tiredness, yellowing of the skin or eyes, itching, or pain in the upper right part of the stomach.amiodarone may cause your irregular heart rhythm (arrhythmia) to worsen or may cause you to develop new arrhythmias. Tell your doctor if if you have ever been dizzy or lightheaded or have fainted because your heartbeat was too slow and if if you have or have ever had low levels of potassium in your blood; heart or thyroid disease; or any problems with your heart rhythm other than the irregular heartbeat being treated. Tell your doctor and pharmacist if if you are taking any of the following medications: antifungals such as fluconazole (Diflucan), ketoconazole (Nizoral), and itraconazole (Sporanox); azithromycin (Zithromax); beta blockers such as atenolol (Tenormin), labetalol (Normodyne), metoprolol (Lopressor, Toprol XL), nadolol (Corgard), and propranolol (Inderal); calcium channel blockers such as amlodipine (Norvasc), diltiazem (Cardizem, Dilacor, Tiazac, others), felodipine (Plendil), isradipine (DynaCirc), nicardipine (Cardene), nifedipine (Adalat, Procardia), nimodipine (Nimotop), nisoldipine (Sular), and verapamil (Calan, Covera, Isoptin, Verelan); cisapride (Propulsid); clarithromycin (Biaxin); diuretics ('water pills'); dofetilide (Tikosyn); erythromycin (E.E.S., E-Mycin, Erythrocin); fluoroquinolone antibiotics such as ciprofloxacin (Cipro), gatifloxacin (Tequin), levofloxacin (Levaquin), lomefloxacin (Maxaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), and sparfloxacin (Zagam); other medications for irregular heartbeat such as digoxin (Lanoxin), disopyramide (Norpace), flecainide (Tambocor), phenytoin (Dilantin), procainamide (Procanbid, Pronestyl), quinidine (Quinidex) and sotalol (Betapace); and thioridazine (Mellaril). If you have any of the following symptoms, call your doctor immediately: lightheadedness; fainting; fast, slow, or pounding heartbeat; or feeling that your heart has skipped a beat.you will probably be hospitalized for one week or longer when you begin your treatment with amiodarone. Your doctor will monitor you carefully during this time and for as long as you continue to take amiodarone. Your doctor will probably start you on a high dose of amiodarone and gradually decrease your dose as the medication begins to work. Your doctor may decrease your dose during your treatment if if you develop side effects. Follow your doctor's directions carefully.keep all appointments with your doctor and the laboratory. Your doctor will order certain tests, such as blood tests, X-rays, and electrocardiograms (EKGs, tests that record the electrical activity of the heart) before and during your treatment to be sure that it is safe for you to take amiodarone and to check your body's response to the medication.your doctor or pharmacist will give you the manufacturer s patient information sheet (Medication Guide) when you begin treatment with amiodarone and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if if you have any questions. RxList Cordarone is intended for use only in patients with the indicated life-threatening arrhythmias because its use is accompanied by substantial toxicity. Cordarone has several potentially fatal toxicities, the most important of which is pulmonary toxicity (hypersensitivity pneumonitis or interstitial/alveolar pneumonitis) ) that has resulted in clinically manifest disease at rates as high as 10 to 17% in some series of patients with ventricular arrhythmias given doses around 400 mg/day, and as abnormal diffusion capacity without symptoms in a much higher percentage of patients. Pulmonary toxicity has been fatal about 10% of the time. Liver injury is common with Cordarone,, but is usually mild and evidenced only by abnormal liver enzymes. Overt liver disease can occur, however, and has been fatal in a few cases. Like other antiarrhythmics, Cordarone can exacerbate the arrhythmia, e.g., by making the arrhythmia less well tolerated or more difficult to reverse. This has occurred in 2 to 5% of patients in various series, and significant heart block or sinus bradycardia has been seen in 2 to 5%. All of these events should be manageable in the proper clinical setting in most cases. Although the frequency of such proarrhythmic events does not appear greater with Cordarone than with many other agents used in this population, the effects are prolonged when they occur. Even in patients at high risk of arrhythmic death, in whom the toxicity of Cordarone is an acceptable risk, Cordarone poses major management problems that could be life-threatening in a population at risk of sudden death, so that every effort should be made to utilize alternative agents first. The difficulty of using Cordarone effectively and safely itself poses a significant risk to patients. Patients with the indicated arrhythmias must be hospitalized while the loading dose of Cordarone is given, and a response generally requires at least one week, usually two or more. Because absorption and elimination are variable, maintenance-dose selection is difficult, and it is not unusual to require dosage decrease or discontinuation of treatment. In a retrospective survey of 192 patients with ventricular tachyarrhythmias,, 84 required dose reduction and 18 required at least temporary discontinuation because of adverse a effects, and several series have reported 15 to 20% overall frequencies of discontinuation due to adverse reactions. The time at which a previously controlled life-threatening arrhythmia will recur after discontinuation or dose adjustment is unpredictable, ranging from weeks to months. The patient is obviously at great risk during this time and may need prolonged hospitalization. Attempts to substitute other antiarrhythmic agents when Cordarone must be stopped will be made difficult by the gradually, but unpredictably, changing amiodarone body burden. A similar problem exists when Cordarone is not effective; it still poses the risk of an interaction with whatever subsequent treatment is tried. 4

5 Define Learning Goals: Less is More What information is essential? Define learning goals; focus on them How do we increase long-term recall? ADEs may occur well into the future. Graphics? Interactivity? Reinforcement? Should patients be required to show they understand prior to prescribing? We Can Do Better Multidisciplinary teams Patient-friendly tools Innovative use of technology Check for comprehension Supportive policies 5