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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