Masud S. Khawaja Postdoctoral Fellow Department of Family Medicine University of Manitoba. Annual CAHSPR Conference Montreal, 31 May 2012

Transcription

1 The Mediating Role of Positive and Negative Emotional Attractors between Psychosocial Correlates of Doctor-Patient Relationship and Treatment Adherence in Type 2 Diabetes Masud S. Khawaja Postdoctoral Fellow Department of Family Medicine University of Manitoba Annual CAHSPR Conference Montreal, 31 May 2012

2 Overview What? Association between doctor-patient relationship variables, emotional states and treatment adherence Why? In order to identify if emotional states mediate the relationship between psychosocial variables of doctor-patient relationship and treatment adherence So that : We may have a better understanding of how healthcare providers can interact with patients in a manner which would help promote treatment adherence 2

3 Problem Statement Non-adherence - negative health and financial implications 125,000 deaths/yr in the United States (Peterson, Takiya & Finley, 2003) 10% of hospitalizations and 25% of nursing home admissions (Voils, Steffens, Flint & Bosworth, 2005) Estimated cost of non-adherence each year in the US is $ 100 billion dollars (Vermeire, Hearnshaw, Royen, & Denekens, 2001) Non-adherence for chronic illnesses such as Diabetes Mellitus is between 30% to 60% (Christensen, 2004) 3

4 Research on Adherence Adherence : the extent to which a person's behavior coincides with medical or health advice (Haynes, 1979). Connotes a collaborative relationship as opposed to compliance. Studies over the past three decades suggest that adherence to medical recommendations has been shown to be related to over 200 variables, though most of them inconsistently (Cameron, 1996). 4

5 Summary of variables commonly associated with adherence based on reviews Variable Haynes, Taylor & Sackett ( 76, 79) Vermiere, Hearnshaw, Royen & Donekens ( 01) Lehane & McCarthy ( 06) Jin, Sklar, Oh & Li ( 08) Julius, Novitsky & Dubin ( 09) Features of the Disease Diagnosis Yes Yes Yes nr nr Disease severity No nr nr Mixed nr Symptoms Yes nr nr Yes nr Concurrent illness No nr nr nr nr Family history of the Yes nr nr nr nr disease Dosage frequency Yes Yes Yes nr Yes Complexity Yes Yes Yes Yes nr Duration Yes Yes Yes Yes nr Cost Yes nr Yes Yes nr Clinical setting No No nr nr nr Appointment reminder nr No nr nr nr Side effects No Yes Yes nr Yes Features of the patient Age No No No Mixed Mixed Gender No No No No Mixed Race No nr No No Mixed Education No Yes No Mixed Socioeconomic status No Yes No nr nr Occupational status No nr nr nr nr Religion No nr nr nr nr Forgetfulness nr nr No Yes nr Depression nr nr nr Yes Yes Degree of disability Yes Yes nr nr nr Social Support Yes Yes Yes Yes Yes Features of the provider Attitude nr Yes Mixed nr nr Respect for patient nr Yes nr Yes nr Features of patient provider interaction Patient-provider Yes Yes Yes Yes Yes communication Number of visits nr nr Yes nr nr Satisfaction Yes nr nr nr nr Relationship nr Yes nr Yes Yes Knowledge of disease Yes Yes Yes Yes Yes Yes=relationship present, No=relationship absent, Mixed=both presence and absence of relationship almost equally reported, nr=not reported 5

6 The Gap After three decades of research on compliance studies we are now aware of a number predictors of treatment compliance, but little is known about the mechanism which links them (Scherman & Lowhagen, 2004). I have used Intentional Change Theory (Boyatzis, 2006) and the concept of Positive & negative emotional attractors (PEA/NEA) to propose one such possible mechanism to bring about behavioral change and increase treatment adherence in Diabetes Type 2 patients. 6

7 Two Emotional Attractors Positive Emotional Attractor Negative Emotional Attractor Strengths Focus on Future Hope Possibilities Optimism Learning Agenda & Goals Gaps/Weaknesses Focus on past Fear Problems Pessimism Performance Improvement Plan Richard E. Boyatzis,

8 Conceptual Model Patient s knowledge about diabetes Patient perception of Information Exchange Social Support available to the patient Co - morbid depression Patient perception of Shared decision- - making Patient perception of Doctor-Patient Rapport PEA / NEA of the patient Treatment Adherence Patient perception of Trust Patient perception of Empathy PEA / NEA of the physician Clinical Outcome 8

9 Study Design Nested model 15 patients nested in 25 physicians; 375 patients and patients companions Survey based study Setting Outpatient diabetic facilities in seven hospitals and clinics Inclusion criteria for patients - Adults - Diabetes Mellitus Type 2 patient - Follow-up visit (<10) - Accompanying adult living in same household 9

10 Nested Model Pa tie nt Patie nt Patie nt Doctor Doctor Doctor 10

11 2-1-1 Model Upper Level Independent variable Lower level Independent variables Mediator Outcome variable 11

12 Completely Mediated Model for Empathy and Treatment Adherence Patient PNEA.618**.087* Empathy.145 Treatment adherence P**<.01, P*<.05 12

13 Partially Mediated Model for Information Exchange and Treatment Adherence Patient PNEA.709*.087* Information Exchange.336** Treatment adherence P**<.01, P*<.05 13

14 No Relationship Shared Decision-making Co-morbid Depression Social Support 14

15 Indirect mediation paths with all variables in the model Patient s knowledge about diabetes Social Support available to the patient Co-morbid depression Patient perception of Information Exchange.182* Patient perception of Shared decisionmaking.709*.086 PEA/NEA of the patient.087* Treatment Adherence Patient.430** perception of Doctor-Patient Rapport Patient perception of Trust.214* Patient perception of Empathy.618**.033** PEA/NEA of the physician 15

16 Summary of Hypotheses and Results Hypothesis Result H1a Empathy increases Treatment adherence Supported H1b Patient PNEA mediates the relationship between Empathy and Treatment adherence Completely mediated H2a Trust increases Treatment adherence Supported H2b Patient PNEA mediates the relationship between Trust and Treatment adherence Completely mediated H3a Information exchange increases Treatment adherence Supported H3b Patient PNEA mediates the relationship between Information exchange and Treatment adherence Partially mediated H4a Rapport increases Treatment adherence Supported H4b Patient PNEA mediates the relationship between Rapport and Treatment adherence Completely mediated H5a Shared decision-making increases Treatment adherence Not Supported H5b H6 Patient PNEA mediates the relationship between Shared decision-making and Treatment adherence Patient PNEA mediates the relationship between Physician PNEA and Treatment adherence Not mediated Partially mediated H7a Co-morbid depression decreases Treatment adherence Not Supported H7b Patient PNEA mediates the relationship between Co-morbid depression and Treatment adherence Not mediated H8a Social Support increases Treatment adherence Not Supported H8b Patient PNEA mediates the relationship between Social Support and Treatment adherence Not mediated H9a Diabetes knowledge increases Treatment adherence Supported H9b Patient PNEA mediates the relationship between Diabetes knowledge and Treatment adherence Completely mediated 16

17 TreatAdh Doctor Relationship between Patient PNEA and Treatment Adherence per Doctor Pt. PNEA High scores on PNEA scale indicate positive emotional state Increase levels of Positive Emotional Attractor result increased Treatment adherence PEA makes a person more willing to change, thus a diabetic person is more amenable to change in life-style when the PEA is high 17

18 Implications for Research & Practice Diabetes Patient Education Improve effectiveness of intervention programs, by concentrating on arousal of positive emotions in the patient. Appropriately focus on elements that enhance treatment adherence, thereby reducing cost of the programs Medical Education Study demonstrates benefits of establishing an overall positive emotional tone Training of medical students and doctors to evoke positive emotions in medical encounters 18

19 Future Studies Assessment of treatment adherence on direct physiological measures, as evidence of clinical outcome, such as blood sugar levels in diabetic patients Since diabetes is a chronic illness assessment of treatment adherence over time in longitudinal studies would be helpful 19

20 "We prescribing clinicians continue to struggle with the most basic of problems: how to get our patients to take the pills that we think that they need, in the way that we think that they should. As efficacious as medications are in research reports and clinical studies, they cannot be effective without moving from the prescription vial to the patient s body James Ellison, M.D. (as cited in Shea, 2006, p.3). Have we moved closer to a solution? 20

21 References Boyatzis, R.E. (2006). An overview of intentional change from a complexity perspective, Journal of Management Development, 25, 7, Cameron, C. (1996). Patient compliance: recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. Journal of Advanced Nursing, 24, Christensen, A.J., (2004). Patient adherence to medical regimes: bridging the gap between behavioral science and biomedicine. London: Yale University Press. Ekas, N.V (2009). Adaptation to stress among mothers of children with autism spectrum disorder: the role of positive affect and personality. University of Notre Dame, IA Gianola, F. (2007). Who is responsible for the patient s adherence to treatment? JAAPA : Journal of the American Academy of Physician Assistants, 20(4), Haynes, R. B. (1979). Determinants of compliance and non-compliance. In R. B. Haynes, D. W. Taylor, & D. L. Sackett (Eds.), Compliance in health care (pp ). Baltimore: Johns Hopkins University Press. Jin, J., Sklar, G.E., Min, Oh V.M. & Li S.C. (2008). Factors affecting therapeutic compliance: A review from the patientʼs perspective. Therapeutics and Clinical Risk Management, 4, Julius, R.J., Novitsky, M.A. & Dubin, W.R. (2009). Medication adherence: A review of the literature and implications for clinical practice. Journal of Psychiatric Practice, 15(1) 21

22 References (contd.) Lehane, E. & McCarthy, G. (2007). Intentional and unintentional medication non-adherence: A comprehensive framework for clinical research and practice? A discussion paper. International Journal of Nursing Studies, 44(8), 1468 Kenny, D. A., Kashy, D. A., & Bolger, N. (1998). Data analysis in social psychology. In D. T. Gilbert, S. T. Fiske, & G. Lindzey (Eds.), The handbook of social psychology. (Vol. 1, 4th ed., pp ). New York: McGraw- Hill. Scherman, H. & Lowhagen, M. (2004). Drug compliance and identity: reasons for non-compliance. Experiences of medication from persons with asthma/allergy. Patient Education and Counseling, 54, 3 9. Vermeire, E., Hearnshaw, H., Van Royen, P., & Denekens, J. (2001). Patient adherence to treatment: three decades of research: a comprehensive review. Journal of Clinical Pharmacy and Therapeutics, 26, Voils, C.I., Steffens,D.C., Flint, E.P. & Bosworth H.B. (2005). Social support and locus of control as predictors of adherence to antidepressant medication in an elderly population. American Journal of Geriatric Psychiatry, 13:

23 Thank You 23

24 6/8/

25 Method: Barron & Kenny Modified Mediation Model (1998) Stage 1: If a significant relationships exist between the Independent variable (X) and the Mediator (M); and also between the Mediator (M) and the Dependent variable (Y), then this would imply that a relationship exists between the Independent variable (X) and the Dependent variable (Y) (Kenny, Kashy & Bolger, 1998). Stage 2: If stage 1 is met, then one could proceed to assess if this relationship is partially or totally mediated. According to Kenny, Kashy & Bolger (1998, p. 260). Partial mediation would occur if the Independent variable (X) relates to the Dependent variable (Y), indirectly through the Mediator (M), such that the relationship is significant (Kenny, Kashy & Bolger, 1998; Ekas, 2009). However, complete mediation would occur if the Independent variable (X) relates to the Dependent variable (Y), indirectly through the Mediator (M), such that the relationship is insignificant (Kenny, Kashy & Bolger, 1998). Mediator (M) a b Independent Dependent Variable (X) c variable (Y) Baron and Kenny: Modified Mediation model 25

26 Boyatzis Intentional Change Theory (1970, 1999, 2000, 2006) First Discovery The Ideal Self Second Discovery Practicing new behaviors Fourth Discovery Experimenting with new behaviors Fifth Discovery Relationships that help, support, and encourage each step in the process The Real Self Strengths: where my Ideal Self and Real Self overlap Third Discovery My Learning Agenda: building on strengths while reducing gaps Gaps: where my Ideal Self and Real Self differ Richard E. Boyatzis,