Tuesday, October 15, 2013

Patient Advocacy: Engaging Patients to ImproveTreatment Outcomes

Engaging Patients to ImproveTreatment Outcomes
Dr Dhivya Ramasamy
Positive health outcomes depend not just on the clinical but also on the non-clinical aspects of a patient’s treatment plan
Over the years, thanks to rapid advances made in understanding the causes of various diseases and developing newer methods of managing them, healthcare providers have been successful in bringing about wide scale improvement in patient care. Today, we have effective clinical solutions in place to treat most diseases. However, even those diseases that can be treated through well-established, standard treatment protocols, such as cataracts or refractive error, remain poorly addressed –cataract continues to be the number one cause of blindness in the world, mainly because of non-clinical, patient-related factors that impact positive clinical outcomes (Source: Donatella Pascolini, Silvio Paolo Mariotti; Global estimates of visual impairment: 2010; Br J Ophthalmol 2012; 96:614-618).
Aravind Eye Hospitals in Tamil Nadu has been grappling with this challenge for years and has striven to address this issue through active patient engagement. This article explores the potential of engaging patients in their treatment to achieve better treatment outcomes.
When can the treatment protocol be deemed to be effective?
How do we measure the effectiveness of a treatment plan? That’s a tricky question. At any healthcare establishment, the metric used is the number of patients seen or the number of surgeries performed. Let’s examine how this metric would apply to an eye care facility.
Given our progressive national eye care programme and the wide spread use of community-based outreach camps, a significant number of patients get examined and identified for cataract surgery, every year. However only a fraction of those advised surgery, actually undergo it. The acceptance of cataract surgery is reported to be around only 14% in the community and 45% in hospital-based settings. Knowing that surgery is the only solution for treating cataract, how do we ensure that those with cataract seek care and undergo the surgery?
Similarly, children with uncorrected refractive error have a significant disadvantage and tend to do poorly in studies and sports. This can adversely affect the future career prospects of the child. While spectacles provide a simple and cost-effective solution, it has been reported that compliance with spectacle wear among school children remains as low as 30%.How do we ensure that the needs of children with refractive error are effectively addressed?
As a third example, patients with glaucoma (a chronic ocular condition) are required to be on continuous medication and must come for essential annual review visits. Patients with poor adherence show progressive worsening of the disease. Yet, adherence to medication is poor. Also, the adherence to the essential follow visits drops to less than a third by the fourth year. How do we enable glaucoma patients to have their disease effectively controlled?
The inference from these examples is that for any treatment to be truly effective, it’s important that each and every patient successfully completes his treatment journey:

Figure 1: The Patient Journey
While we advocate this treatment pathway to all our patients, in reality we see patients drop off at different points along their journey, eventually rendering the treatment ineffective.
Over the years, we have experimented with the following strategies to reduce this drop-off rate:
Patient engagement
Given that much of the treatment depends on the behaviour of the patient, our strategy has been to nudge him in the right direction. Actively engaging patients in their treatment plan can help in positively influencing their role in seeking care; adhering to the treatment advised; following instructions for self-care ; and returning for review visits.
Helping patients seek timely care
Awareness creation through well-designed health education programmes targeted at the appropriate audience can help patients identify symptoms and seek timely care. Squint or strabismus is considered to bring good luck, hence parents in India often do not attempt to
correct these conditions. It is important to break such misconceptions. Parents should be made aware that strabismus can lead to severe visual impairment, so they must act fast.
Low birth weight children are at risk for Retinopathy of Prematurity, leading to degeneration of the retina. This can be controlled if managed within three weeks of birth. Thus it’s essential to make pregnant mothers aware of this condition so they can seek timely care for their premature babies.
Partnering with opinion leaders in the community
For conditions that are widespread in the population (such as cataract and diabetes), it’s important to rope in youth volunteer groups, NGOs, Rotary Clubs, etc to assist in information dissemination.
Helping patients make the right decision
At Aravind, counselors are an integral part of our clinical team. They ensure that patients have the opportunity to voice their concerns and clarify their doubts. Today, the cataract surgery acceptance rate is about 75% in our hospital, and about 85% in the outreach camps, thanks to the presence of these counselors.
Aravind’s counselors are recruited when they pass out from high school and are intensively trained for two years in : the basics of how the eye works; its diseases; treatment options; and counseling techniques. Regular monitoring and performance feedback help them perfect their counseling skills on an ongoing basis.
Patient Motivators
We’ve discovered that where patients face emotional and psychological barriers to following medical advice, peer counseling is very effective. In the early 1990s when cataract surgical acceptance was poor, Aravind found the use of aphakic motivators was the most effective means to convince patients to undergo cataract surgery. These were patients who had undergone the surgery themselves and were able to share their experience with those being counseled.
All said and done, patients have different information needs. Their concerns and questions are unique to the stage they find themselves in (Figure 2). Patient engagement strategies must be customized to address these specific needs and the individual’s treatment goals.

Figure 2: Information Needs of the Patient
(Source: The Informed Patient: Study Report, March 2003; D.E. Detmer, et al; Judge Institute of Management, UK)
In the final analysis, the hospital must take full ownership of patient disengagement and find innovative ways of engaging patients to help them reclaim control over their lost health.
they will direct you to another clinician who can. Nurses typically work on 12-hour shifts (i.e. from 6 a.m. to 6 p.m.) so find out when the shift change is and try to wait until the nurse on duty has the information she needs to answer your questions.

                Get to know the hospital’s discharge planner or case manager. It is their job to help with discharging your loved one and ensuring that you have all the information you need before leaving the hospital. She can provide you information about local resources, referrals to other medical professionals, when to follow up, etc. 

The above is an extract from Dr.Aniruddha Malpani's book : Patient Advocacy - Giving Voice to Patients
The book launch will take place on Saturday, 16 November 2013 at Hall of Harmony, Nehru Center, Worl, Mumbai - 400018 during the 4th Annual Putting Patients First Conference.

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