Endocrinology: Patient Noncompliance vs. Provider Bias: A Clinical Revelation Pamela Combs, MSN, BC-ANP, CDE 1
Case Study: Bobbi This is a case regarding a patient who presented to the Cleveland Clinic in October of 2015 with recurring Diabetic Ketoacidosis (DKA) She has a known history of Diabetes Mellitus Type 1 She developed DKA over the preceding weekend, after having received the flu shot. 2
Objectives Review patient centered interview techniques Goals of the interview: Determining the nature the problem. To establish a relationship with the patient. To provide feedback and formulate a treatment plan. Discuss how to build rapport Discuss use of open ended questions Discuss listening and feedback Explore what is meant by non-compliance vs. adherence 3
The Patient Centered Interview Interview is a method of patient assessment during patient care. It includes Rapport Questions Listening Feedback 4
Patient Centered Definition: defined as care that is respectful of and responsive to individual patient, preferences, needs, and values and ensuring that patient values guide all clinical decisions 5
Rapport Introduce yourself Greet the patient by name Arrange for a private comfortable setting Appropriately tell the purpose of the interview Put the patient at ease Be supportive, attentive, non judgmental and encouraging. 6
Case Study: Bobbi You have read through Bobbi s chart and noted that she has been labeled by many providers as non-compliant due to recurring episodes of DKA. How might you approach her in order to: A. build rapport? B. put her at ease? C. assure her you will not judge her? 7
Case Study: Bobbi You notice that Bobbi is somewhat anxious. She denies missing ANY insulin doses. You KNOW that it is very unlikely that any patient would develop DKA when taking their insulin as prescribed. 8
Probing Asking questions during the interview to elicit information from patient. The idea is to probe the patient to find out if They have unanswered questions. They have misunderstandings. They have any fears or concerns Patients may not reveal information to you unless you initiate a dialogue. What are some pertinent probing questions you might have for Bobbi? 9
Questions that Elicit Feedback How do you take the insulin? Please show me how you draw up insulin? How do you inject it? What concerns or fears do you have about taking insulin? 10
Case Study: Bobbi According to Bobbi glucose levels are always high, 300-500 s mg/dl, with an occasional glucose in the 200 range. She endorsed polyuria, polydipsia, and 80-100 lbs weight loss since diagnosis. Bobbi appears to be very frustrated and anxious. 11
Noncompliance and Non-adherence: What it really means Every Life Deserves World Class Care 12
Medication Non-Compliance As dangerous and costly as many illnesses Increases the cost of healthcare as a result of adverse outcomes 4 (i.e. hospitalizations, development of additional illnesses/complications, exacerbation of the disease or disease progression, premature disability, or death) 13
Definition: Compliance Compliance, is simply defined as an agreement. With regard to medicine, compliance means agreeing to take medicine(s) as directed, and then following through with that agreement..accepting the responsibility of taking medicine(s) as agreed 8 14
Definition: Adherence Adherence is defined as the extent to which a patient s health behavior coincides with their physician s recommendations, whether taking medications or following advice for some type of behavioral change 15
Adherence vs. Compliance Adherence is a more accurate term than compliance Compliance suggests a process in which dutiful patients passively follow the advice of their physicians Adherence, in contrast, better fits how most patients actively participate in their care and decide for themselves when and whether to follow their doctor s advice 16
Case Study: Bobbi Do you feel that Bobbi is correctly labeled as Noncompliant? Non Adherent? Why or why not? 17
Case Study: Bobbi Based upon this definition of patient centered care care that is respectful of and responsive to individual patient, preferences, needs, and values and ensuring that patient values guide all clinical decisions What is the next most important question you might ask Bobbi? 18
Case Conclusion: Bobbi When I asked Bobbi what was the one thing she wanted to do about her Diabetes Care she said All I want to do is put my weight back on. 19
Case Conclusion: Bobbi In light of her recalcitrant hyperglycemia and recurring episodes of DKA, we wondered if in fact the patient, who had been deemed noncompliant was really compliant but had antibodies to Lantus/Humalog insulin? What if it were not the patient, but the insulin? 20
Case Conclusion: Bobbi It was decided that we would attempt to manage with Human Recombinant Insulin. We decided to do this based upon a hunch, even without results of antibody testing 21
Case Conclusion: Bobbi Converted to NPH and R 10/2015, one year later: Conclusion: At 1 year follow up Weight 10/15/15 = 119 lbs Weight 10/18/16 = 163 lbs HgA1c = 12.1 9/2014 HgA1c=13.2 3/2015 HgA1c=14.6 8/2015 HgA1c=9.7 10/2016 She has no further admissions for DKA! 22
References 1. Interventions to Enhance Patient Adherence to Medication Prescriptions ; Clinician s Corner 2. Up-To-Date: Adherence to Pharmacologic Therapy 3. Adherence to Pharmacologic Therapy in Patients with Type 2 Diabetes Mellitus ; American Journal of Medicine; Vol. 118, May 2005 4. Zuger, Abigail. The Other Drug Problem: Forgetting to Take Them, The New York Times, June 2:Section F, Page 1, Column 2, 1998 5. Santella, T., Wertheimer, A.. Medication Compliance Research: Still So Far to Go, The Journal of Applied Research; Vol. 33, 2001 6. Berger, Bruce. Improving Treatment Adherence: A Motivational Interviewing Approach, Walgreens.com, 2002 7. Claxton et al., A Systematic Review of the Associations between Dose Regimens and Medication Compliance, Clinical Therapeutics, 23 (8): 1296-1310, August 2001. 8. http://www.innoviant.com/members/mempub/whatiscompliance.pdf 23
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