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Joslin’s Diabetes Deskbook, A Guide for Primary Care Providers, Updated 2nd Ed., Excerpt 1: What Are the Five Steps to Patient Adherence?

By Richard S. Beaser, M.D. and Richard Jackson, MD

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The Approach to Diagnosis and Treatment: Collaboration is Key to Adherence

The gap in meeting clinical targets is in large part due to the gap that presently exists between actual and optimal treatment goals and strategies for patients and physicians.

Even when patients have an ongoing relationship with their primary physician, they often fall short of the recommended treatment goals due to gaps between actual and ideal treatment strategies. Collaboration is the key to closing this gap. Your patients are the most underused resource in your clinical practice. If you and your patients are able to jointly establish aligned goals, they will improve their health, and you will improve the efficiency of your practice and outcomes that you can achieve.

First Step 

When your patient comes in, start with a simple open-ended question:

"What brings you in today?" 

"Where would you like to start?" 

On average, providers interrupt or redirect patients’ responses within 23 seconds. If allowed to complete their initial thoughts or questions, the average length of time that it takes patients to complete their concerns is only 32 seconds. Sit back, relax, and let them guide you in the beginning. Be sure to include statements like "Tell me more" or "Anything else?" Patients will listen to you later if they feel comfortable knowing that you are listening to them now. 

Second Step 

Help the patient to focus on their risk factors, and to appreciate their clinical importance. These factors include their blood pressure, lipids, A1C, microalbumin, and the results of an eye exam. One of the difficulties patients with diabetes face is the overwhelming number of actions they are told to take — eat this, don’t eat that, exercise more, lose 20 pounds, take this pill, take that pill, get blood from your finger to test your glucose, do that more often…. This unfocused shotgun approach often leads to inaction, or to the wrong action. 

Take advantage of the knowledge gained through all of the clinical trials done in patients with diabetes and guide your patient in focusing on their risk factors. Instead of telling your patients to do everything, focus on the one or two areas where they will gain the most advantage. For one patient it might be improving glycemic control, but for more, it will be improving blood pressure. However, it isn’t sufficient for the physician to choose an appropriate goal. If this chosen goal isn’t one of the patient’s goals, and doesn’t become one of the patient’s goals, the chance for long-term success is low. This is where skillful listening is essential, as you try to match your goal preferences to your patients’ goal preferences. Remember here that the patients’ goals always trump yours, since they are the ones living with and treating their health on a daily basis. Your job is to provide accurate information, in a personalized way, that will help them make the best choices. Once you have explained the relation of the patient’s numbers to their health risk, and they understand and appreciate this relationship, the next steps become easier. This is one of the most important components of improving results for diabetes-related complications. When patients realize that one of the keys to reaching their long-range goal of "living a long and healthy life" is to move or keep their numbers on target, they have aligned their intermediate goals with yours.

Third Step 

If you have succeeded in reaching an agreement about a general goal such as improving blood pressure, then ask the patient where they would like their target, and how would they like to get there. Remember that there are different paths to achieving the same result, with different combinations of lifestyle changes and medications. If their strategy doesn’t seem optimal, you can then suggest: "I have some information on what strategies have worked for other patients similar to you. Would you like to hear some of these possibilities?"

Your patient may choose an approach that you don’t think will work. For example, their LDL may be 132 and you and the patient have agreed upon a goal of under 100, and they have already received education in the useful lifestyle changes that could improve their LDL. At this point, you judge that a statin should be given, but the patient tells you that they don’t want to take a pill, that they are concerned about some of the side effects that they have heard about. If it is the case that you and the patient are aligned on the LDL goal of under 100, your position should become much more positive. Ask "What would you like to try in order to improve your LDL?" They will likely say something like, "I just need to start eating better and exercise a little more." Accept this as a reasonable approach, but go the extra step of asking, "How long do you want to wait to see if your eating and exercise changes will make a difference?" After they have chosen the timeframe, ask them to pick an LDL result that they would term successful. For example, they might choose a one month timeframe, and an interval LDL goal of 110. Once this has occurred, you are set. They will either achieve their goal through lifestyle changes alone, or they will fail, and will then be ready to make another choice, which will probably be the statin. The message you are giving them is not that they should be taking a pill, but that they should be achieving a target, whether A1C, BP, or cholesterol, that will improve their overall health. You don’t care how they get there, you just want them to stay healthy. This type of collaboration results in alignment of goals, and increases the chance of good outcomes.

Fourth Step 

Having chosen a goal and a treatment strategy, it is important not to lose momentum. Decide, with the patient, on a timeframe to reassess the (BP, LDL or A1C). This may include some home monitoring by the patient, in the case of A1C, BP or physical activity. Emphasize that it is the result that is important, more than the process. If they are having trouble implementing the agreed-upon strategy, make sure that they let you know right away, so that you can advise them on making another choice. If the patient feels that the physician’s goal was for them to take an ACE inhibitor, and they then stop it because it made them cough, you will have both lost momentum. On the other hand, if they know that your goal, and theirs, is to lower their blood pressure, they will call you for advice about another treatment choice.

Fifth Step — Keep Cycling 

The hardest work involves the first four steps described above, but providers and patients often fall short of reaching their goals because they lose momentum; they don’t check their progress, reassess their options, and step-up or change the treatment strategy if they aren’t on target. This is especially important for maintaining self-efficacy for the patient. If the planned treatment isn’t effective, and isn’t modified, the patient will lose confidence in their ability to reach their goal. An important consideration here lies in choosing the starting dose of medication, and considering whether to start with just one, or with a combination of medications. This is particularly important if the starting BP, LDL, or A1C is high. You and your patient need to keep "cycling" back through the treatment regimen choices, and keep advancing or changing the treatment until their goal is met. 

Summary 

This is a great time to be treating people with diabetes, and those without diabetes who are at risk for cardiovascular disease. Clinical results are improving dramatically; and while clinical gaps continue to exist, they are responsive to a number of different approaches. This provides an opportunity for the physician, but an opportunity that is best addressed through collaboration with your patient. The physician’s role is to evaluate the patient’s disease state, listen carefully to their concerns, and then provide the needed information that will help to inform and form the patient’s choices. The patient controls their disease, whether they want to or not. You need to be the best guide possible in their journey toward health.

Copyright © 2010 by Joslin Diabetes Center. All rights reserved. Reprinted with permission. Neither this book nor any part thereof may be reproduced or distributed in any form or by any means without permission in writing from Joslin. Note: Joslin does not endorse products or services.

For Excerpt #2 from the Joslin Diabetes Deskbook, 2nd, in this series, just click here.

You can purchase the updated 2nd Edition of JOSLIN’S DIABETES DESKBOOK at:

https://www.joslin.org/jstore/books_for_healthcare_professionals.html

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Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.

Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.

This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.