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Understanding and Changing Clinician Behavior Epi 245 Ralph Gonzales, MD, MSPH Professor of Medicine; Epidemiology & Biostatistics 22 October 2009.

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Presentation on theme: "Understanding and Changing Clinician Behavior Epi 245 Ralph Gonzales, MD, MSPH Professor of Medicine; Epidemiology & Biostatistics 22 October 2009."— Presentation transcript:

1 Understanding and Changing Clinician Behavior Epi 245 Ralph Gonzales, MD, MSPH Professor of Medicine; Epidemiology & Biostatistics 22 October 2009

2 Seminar Outline: Stepwise Approach Clinician behavior in larger context Step 1: Use theory to understand clinician behavior Step 2: Use theory to create a model for changing clinician behavior Step 3: Integrate results from Steps 1 and 2 into an implementation strategy

3 Health Care Quality Donabedian A. JAMA 1988;260: StructureProcessOutcomes Community Characteristics Delivery System Characteristics Provider Characteristics Population Characteristics Health Care Providers -Technical Processes -Interpersonal Processes Public & Patients -Access -Acceptance -Adherence Health Status Functional Status Satisfaction Mortality Cost

4 Failed Attempts to Change Antibiotic Prescribing Behavior in the US Poses, 1995 (Univ Student Health, N=14 physicians) – Target: pharyngitis in college students – Strategy: Decision-making educational seminar – Results: pre/post non-equivalent control: no difference O’Connor, 1999 (Health Partners, MN, N=4 practices) – Target: URIs in adults – Strategy: dissemination of URI guideline – Results: pre/post, no control group: no difference in 21-day Rx rates Mainous, 2000 (Kentucky Medicaid, N=216 physicians). – Target: colds, URIs, bronchitis in children in – Strategy: Practice profiling and feedback – Results: pre/post randomized allocation: no difference

5 No Magic Bullets! Oxman AD, Thomson MA, Davis DA, Haynes B. No magic bullets: a systematic review of 102 trials of interventions to improve profession practice. Can Med Assoc J 1995;153:

6 Knowledge  Behavior ∆ Knowledge  ≠ ∆ Behavior “Knowledge is necessary, but usually insufficient, for behavior change” “Better implementation strategies must be created in order to effectively Translate Evidence into Practice.”

7 Rudimentary individual change theory KNOWLEDGE ATTITUDE / MOTIVATION BEHAVIOR

8 Eisenberg… Medical Care 1985;23:461–483. Understanding physician behavior “There are few iron-clad rules for practicing medicine and too much of it is an exercise in dealing with uncertainty.” As a result, there are a wide variety of factors that can influence what doctors do… Self-interest: Desire for income; Desire for a style of practice; Personal characteristics; Practice setting; Community standard of care Patient interest: Patient’s economic well-being; Clinical factors; Patient demand; Defensive medicine; Patient characteristics; Patient convenience Social good: Role in society; Sustaining medical profession

9 PATIENT FACTORS Symptoms & their meanings Expectations; Demands Health system experiences Health care coverage or ability to pay Cultural understandings [Dis]trust re advice SYSTEM FACTORS Cost of medicines & care Care setting factors (e.g. schedules, formularies) Health plan features Pharmaceutical promotions Pharmacy practices Availability of technology Regulatory environment Community factors Cultural context Media / health information CLINICIAN FACTORS Sociodemographics Specialty / training Knowledge and Awareness Judgment & heuristics Perceived patient expectations Communication style Self-Efficacy Medical Decision/Behavior Cross-sectional model of clinician behavior

10 PATIENT FACTORS SYSTEM FACTORS CLINICIAN FACTORS Clinical Decision/Behavior Coronary Artery Stents

11 PATIENT FACTORS SYSTEM FACTORS CLINICIAN FACTORS Clinical Decision/Behavior Antibiotic Treatment of Viral URIs

12 PATIENT FACTORS SYSTEM FACTORS CLINICIAN FACTORS Clinical Decision/Behavior Contraceptive Method

13 Kravitz RL et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293:

14 1: Physicians' shared decision-making behaviors in depression care.Physicians' shared decision-making behaviors in depression care. Young HN, Bell RA, Epstein RM, Feldman MD, Kravitz RL. Arch Intern Med Jul 14;168(13): : Let's not talk about it: suicide inquiry in primary care.Let's not talk about it: suicide inquiry in primary care. Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Ann Fam Med Sep-Oct;5(5): : Exploring and validating patient concerns: relation to prescribing for depression.Exploring and validating patient concerns: relation to prescribing for depression. Epstein RM, Shields CG, Franks P, Meldrum SC, Feldman M, Kravitz RL. Ann Fam Med Jan-Feb;5(1): : Do patient requests for antidepressants enhance or hinder physicians' evaluation of depression? A randomized controlled trial.Do patient requests for antidepressants enhance or hinder physicians' evaluation of depression? A randomized controlled trial. Feldman MD, Franks P, Epstein RM, Franz CE, Kravitz RL. Med Care Dec;44(12): : Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients.Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients. Franz CE, Epstein R, Miller KN, Brown A, Song J, Feldman M, Franks P, Kelly-Reif S, Kravitz RL. Health Serv Res Dec;41(6): : Types of information physicians provide when prescribing antidepressants.Types of information physicians provide when prescribing antidepressants. Young HN, Bell RA, Epstein RM, Feldman MD, Kravitz RL. J Gen Intern Med Nov;21(11): :What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms.What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms. Kravitz RL, Franks P, Feldman M, Meredith LS, Hinton L, Franz C, Duberstein P, Epstein RM. J Gen Intern Med Jun;21(6): What 1 Good Audio-Taped Study Can Do For You

15 System Factors: Aiken Study Measure Quality and Quality Gap – Variation in nurse-patient ratios Link Quality Gap to Outcome Gap – Lives saved per change in nurse-patient ratio

16 Seminar Outline: Stepwise Approach Clinician behavior in larger context Step 1: Use theory to understand clinician behavior – Why do they do what they do? – What types of studies does one employ? Step 2: Use theory to create a model for changing clinician behavior Step 3: Integrate results from Steps 1 and 2 into an implementation strategy

17 Step 1: Understanding Behavior A.Study the knowledge, attitudes, beliefs and behaviors that are associated with a specific target behavior…. Understand your target group using interviews, surveys & observation. B.Study the environmental and ecological factors associated with the specific target behavior…. such as geography, practice setting, patient population characteristics

18 Case Study: Why do physicians prescribe (unnecessary) antibiotics for viral URIs? Clinician Studies – Clinician Factors – Patient Factors Patient Studies Public Studies

19 Physician Practice Analysis Abx Rate  Purulence Factors Present n=148 n=106 n=46 n=22 Purulence Factors: Hx green nasal discharge; Hx green phlegm; PEx green nasal discharge; PEx tonsillar exudate; tobacco use

20 Physician Practice Analysis + Survey Hamm, J Fam Pract 1996;43:56-62

21 How do URI patients influence their doctors? -Scott, J Fam Pract 2001;50: FrequencyAbx Rx Explicit request 15 93% Chief complaint presentation -Candidate diagnosis 66 62% -Portraying severity of illness % Appeals to circumstances -life-world 16 88% -previous positive experience 39 97% *Used field-notes from direct observation of 298 encounters (18 practices; 50 FP physicians)

22 Is Antibiotic Treatment Necessary for Patient Satisfaction? Hamm, 1996 – patient satisfaction not related to antibiotic prescription Mangione-Smith, 1999 – parent satisfaction not related to antibiotic prescription Gonzales, 2000 – patient satisfaction not related to antibiotic prescription even after antibiotic prescribing had been reduced

23 Identify “Targets” for Improving Antibiotic Use Patient Expectations/Demands for Abx – Clinical Features: Purulence = antibiotics – Previous Antibiotic Treatment – Illness Label Clinician Beliefs about Abx Rx – Acute Bronchitis: Diagnosis = Antibiotic – URIs: Purulence = Antibiotic System Factors: facilitators/barriers… – Visit Duration – Telephone advice nurse

24 Examples of how we incorporated into Guidelines and Education

25 Seminar Outline: Stepwise Approach Clinician behavior in larger context Step 1: Use theory to understand clinician behavior Step 2: Use theory to create a model for changing clinician behavior – How do we help change happen? Step 3: Integrate results from Steps 1 and 2 into an implementation strategy

26 Drilling Down Deeper… Understanding Behavior Change Theory of Planned Behavior; Transtheoretical Model

27 Step 2: Create Model for Behavior Change A.Organize and predict how various factors inter-relate; what role they play as facilitators and barriers B.Explain change process and pathway – Draw causal inferences between intervention and results C.Guide evaluation and iterative process

28 Theory of Planned Behavior Behavior Attitude Behavior Intention Subjective Norms Perceived Behavioral Control Behavioral Beliefs Outcome Expectancy Normative Beliefs Motivation to Comply Control Beliefs Perceived Power External Factors -Practice Guidelines -Patient Requests -Environment/Resources Ceccato et al, J Cont Educ Health Prof 2007

29 Cabana MD, et al. Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement. JAMA 1999;282: Differential Diagnosis Lack of Awareness Lack of Familiarity Lack of Agreement Lack of Self-Efficacy Lack of Outcome Expectancy Inertia of Previous Practice; Heuristics Delivery System/Practice Barriers; Environmental Guideline Related Barriers; Uptake vs. Eliminate Patient Preferences

30 Rubinson L, et al. Why is it that internists do not follow guidelines for preventing intravascular catheter infections? Infect Control Hosp Epidemiol Jun;26(6): NOT ASSOCIATED with adherence Clinician experience and subspecialty Awareness of CDC guidelines STRONGLY ASSOCIATED with adherence High outcome expectancy for the use of large sterile drapes (OR, 5.3; CI 95, ). Availability influenced use of specific antiseptic agents CONCLUSIONS: Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

31

32 Copyright © 2008 The Royal College of Psychiatrists CHILVERS, R. et al. Br J Psychiatry 2002;181:99-101

33 Prochaska-Driven Intervention Design Pre-Contemplation Preparation Contemplation Action Maintenance CME; Report Cards, etcSkill-Building, P4P, Laws, etc. Intervention Strategies Education; FeedbackCQI; Incentives; DetailingRegulatory; CQI

34 “Stages of Change” / TTM Very appealing! – Brief – High face validity – Easy to explain – Readily applicable for understanding & interventions – Useful for distinguishing between motivation phase & volition phase – Stages of change interventions appear in the short term at least to be somewhat more effective than non-stage matched interventions

35 Limitations of TTM The bad news: Rather weak evidence, mostly from cross-sectional studies Stages of change may be unstable over time Few studies about using TTM in changing providers’ behavior Need for prospective studies -- longitudinal, experimental designs Sutton S. Interpreting cross-sectional data on stages of change. Psychol Health. 2000;15:163–171. Adams JWM. Why don't stage-based activity promotion interventions work? Health Educ Res. 2004;20:237–243.

36 From TPB (content) Patient Factors/Demands: origins of expectations – Clinical Features: Purulence = antibiotics – Previous Antibiotic Treatment – Illness Label Physician Factors: origins of Abx Rx – Beliefs Acute Bronchitis: Diagnosis = Antibiotic URIs: Purulence = Antibiotic System Factors: facilitators/barriers… – Visit/Pharmacy co-pay – Visit Duration – Telephone advice nurse From TTM (mechanism) For contemplation stage physicians Need convincing Need stronger motivation Preparation stage Attenuate strong patient factors Need to make it normative/impt. Action stage Need to make it easy Need to reassure they can do it Communication skills Practice Guidelines How TPB and TTM informed Abx Intervention Designs

37 Summary Steps 1 & 2 We understand some of the key factors that contribute to the behavior of interest We have a model for understanding how these factors influence behavior We have a hunch about where our physicians lie in their readiness to change…

38 Seminar Outline: Stepwise Approach Clinician behavior in larger context Step 1: Use theory to understand clinician behavior Step 2: Use theory to create a model for changing clinician behavior Step 3: Integrate results from Steps 1 and 2 into an implementation strategy

39 Step 3: Design & Implement Intervention A.Visit the Toolbox B.Probe your Target Audience C.PRECEDE-PROCEED

40 Changing Clinician Behavior The Tool Box Education [adult learning theory] – Best if real-time, leadership-endorsed, repeated/sustained over time Feedback [social cognitive theory] Participation [management theory] Administrative changes [misanthropy] Incentives Penalties Eisenberg… Medical Care 1985;23:461–483.

41 Physician-Centered Strategies Education – Textbooks; medical journals – Medical school/residency curricula; CME Feedback – Reminders; Profiling Opinion Leaders Participatory CQI Financial Incentives and Penalties Administrative – Creating and/or Removing Barriers – Laws, Regulations, Institutional Policies Academic Detailing Weaker Stronger

42 Physician Survey: To what extent will different interventions facilitate a reduction in excess antibiotic use?

43 Quality of life Phase 1 Social assessment Health Educational strategies Policy regulation organization Health Program Phase 4a Phase 5 Implementation Phase 6 Process evaluation Phase 7 Impact & Outcome evaluation Predisposing Reinforcing Enabling Phase 3 Educational & ecological assessment Behavior Environment Phase 4b Phase 2 Epidemiological Assessment Genetics PRECEDE-PROCEED Administrative & policy assessment Intervention Alignment Green & Kreuter, Health Program Planning, 4 th ed., NY, London: McGraw-Hill, Predisposing, Reinforcing, & Enabling Constructs in Educational/Ecological Diagnosis & Evaluation Policy, Regulatory & Organizational Constructs in Educational & Environmental Development

44 Intervention Study (RWJF, 200k): An Office-Based Intervention to Improve Abx Rx Kaiser Permanente of Colorado Gonzales et al. Decreasing antibiotic use in ambulatory practice: Impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA, 1999;281:

45 Intervention Study: Impact of Office-Based Acute Bronchitis Intervention baselineyear 1year 2 Gonzales et al. JAMA 1999;

46 Denver Health Urgent Care Clinic (CDC, 75k) Intervention Design Considerations Public/Patient Population low literacy skills large Hispanic/Latino segment Clinician and Practice Setting MDs, NPs; variable schedules long waiting periods

47 Denver Health Urgent Care Clinic Intervention Components A. JABERWALKI Computer Module (Predisposing) B. Clinician Educational Session (Predisposing; Reinforcing) C. Examination Room Posters (Predisposing; Enabling)

48 Denver Health Urgent Care Clinic

49 Intervention Study (VA/AHRQ, 2M): Cluster-randomized ED Trial: IMPAACT Project Predisposing: CPGs; A/F Enabling: Posters  skills; Kiosks  Pt Educ’n Reinforcing: opinion leaders; A/F; endorsements

50 IMPAACT Results

51 ENVIRONMENT Behavioral Intention ActionMaintenance Theory of Planned Behavior Contemplation Preparation Pre- Contemplation PREDISPOSINGENABLINGREINFORCING Self - Efficacy Beliefs Attitudes Social Norms Motivation and Persuasion

52 SUMMARY (Homework Exercise) 1. Identify a clinician (eg, physician, nurse, pharmacist) behavior that is, or contributes to, the principle behavior that you are attempting to improve with your intervention. 2. Using the trans-theoretical model, stage your target clinician group with regard to the behavior that you are attempting to improve with your intervention. 3. Using the Theory of Planned Behavior, identify some potential factors that contribute to your clinician behavior of interest. Support with references if possible. 4. Describe a plan for learning more about the factors that contribute to the target clinician behavior of interest that will serve to inform your final intervention design.


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