Disclosures Consultant, Volcano Corporation Behaviorism and - - PowerPoint PPT Presentation

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Behaviorism and Compliance: Often Overlooked, Critically Important

UCSF Vascular Symposium 2016

Jonathan Labovitz, DPM

Medical Director, Foot & Ankle Center Associate Professor, College of Podiatric Medicine Western University of Health Sciences

Define the compliance and non-adherence Understand the role of behavioral health and non-adherence Appreciate the role and importance of behavioral health and non-adherence in the diabetic foot

Disclosures Objectives

Consultant, Volcano Corporation

Behavior impacts compliance Compliance impacts…

THE IMPACT OF BEHAVIORAL HEALTH

Why does behavior matter?

Providing Value

Population health Costs and utilization

Population health requires a “holistic” approach

Treat the patient not the limb

What is it like to live with a hole in your foot? …without a leg?

Understand social determinants of health

How do the changes affect your family and friends?

Based on the personal impact of the clinical outcomes, was the care received valuable?

THE IMPACT OF BEHAVIORAL HEALTH

Why does behavior matter?

Providing Value

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FUNCTIONAL LIMB SALVAGE We assess functional results as physical ability, mobility, and/or return of independence What about motivation, desire and willingness?

PROVIDING VALUE Behavioral Health

Compliance vs. Adherence

Compliance

• The extent a patient’s behavior coincides with

medical advice

• Cooperation or obedience

Adherence

• Relies on remaining constant
• The persistence in practice, steady observance or

maintenance

• Reflects patient’s tenacity to maintain behavioral

change over time

• Implies patient’s active choice

Compliance vs. Adherence

Unintentional Non-Adherence

• Limitations in capacity and the patient’s

resources (e.g., forgetfulness, dexterity, knowledge)

• Inadequate understanding of disease/condition

being treated

Intentional Non-Adherence

• Modify or completely reject the advice
• No attempt to undermine or discredit the Dr
• Conscious choice
• Based on the…
• Beliefs about disease severity, complications

risk, potential benefits of treatment

• Culture, circumstances, priorities,

preferences, experiences

Patient’s Psychological Perspective

Reaction to Diagnosis Reaction to Diagnosis Patient’s assessment of disease & risks Patient’s assessment of disease & risks Daily disease management Daily disease management Develop complications Develop complications Mood Personality Traits Habitual Behavior

Behaviors

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Weinger K. Abstract presented at the American Diabetes Association 75th Scientific Sessions, 2015

Reacting to the Doctor

RESPONDING TO COMPLICATIONS Emotional responses Behavioral responses Scared 50% Improve self-care 45% Sad 38% Not knowing what to do 15% Angry 31% Do nothing 13% Guilty 27% Want to give up 11% Hopeless 17% “Wake-up” call 46% Value of supporting the patients Feels supported “Wake-up” call 54% Improved self-care 58% Doesn’t feel supported “Wake-up” call 36% Improved self-care 27% Support = the Dr. Non-alarmist Answered ? Specific recommendations Non-punitive

The patient reaction to a provider discussion about a new onset complication

75% of patients > 1 microvascular complication 57% eye 40% nerve 29% renal

IMPACT OF DEPRESSION

Diabetes Mellitus and

PSYCHOSOCIAL MPACT OF DEPRESSION CLINICAL IMPACT OF DEPRESSION DEPRESSION AND TREATMENT ADHERENCE

Depression and Diabetes Mellitus

Depression = Treatment adherence

Decreased HRQoL Decreased foot self-care Increased number and severity of diabetes related complications

Social issues

Unhealthy diet Obesity, Exercise Sedentary lifestyle Tobacco use Societal burden

Depression can precede and/or follow

• nset diabetes complications

Depression Depression Increased risk DPN & PAD Increased risk DPN & PAD Increased risk DFU & Amputation Increased risk DFU & Amputation

Nguyen AL et al. J Diabetes Complications 2015; Simon GE, et al. Gen Hosp Psychiatry 2005; Egede LE, et al. Gen Hosp Psychiatry 2009; Kivimaki M, et al. Diabetes Med 2007

33% higher risk of incident major amputation 12% higher risk of any amputation No significant increased risk of minor amputations Major depression = 2-fold increased risk of incident ulcers 2-fold increased risk of non-healing foot ulcer 5-fold increased risk of ulcer recurrence

Depression and Foot Complication Risk

Diabetic Foot Ulcers Lower Extremity Amputations

Williams LH, et al. Am J Med, 2010 Williams LHC, et al. J Diabetes Complications, 2011 Monami M, et al. J Am Pod Med Assoc, 2008

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NON-ADHERENCE

It may not be the patient’s fault… It could be our ours!

Cognitive Ability and Diabetes Mellitus

Non-Adherence Cognition

Cognition = Treatment adherence

The diabetic foot is a complex systemic condition including cognitive deterioration

Natovich R. Abstract at ADA 75th Scientific Sessions, 2015

The patient may lack the cognitive ability to adhere to treatment plans

• Is the patient able to process, understand, or remember them?
• Is the patient able to focus, organize thoughts to implement them?

IMPACT: PATIENT EDUCATION AND INSTRUCTIONS

Impaired global cognition

50% age > 65

Lower extremity amputation

Global cognition impaired (OR = 3.59) Episodic memory deficit (OR = 4.13)

Microvascular disease & episodic memory deficit (OR = 9.68)

COGNITIVE ABILITY & DM FOOT DISEASE

Cognitive impairment after lower limb amputation is common and under-diagnosed Increased odds of cognitive deficits in microvascular disease

CONCLUSIONS

Cognition and Diabetes Mellitus

0% 25% 50% 75%

63% 54% 60% 53% 52% 32%

Cognitive Impairment

Marseglia A, Xu W, Rizzuto D, et al. J Diabetes Complications, 2014

Low mental health function

• Increase DFU odds > 4x

Independent risk factor for Major LEA

• Mobility
• Independence S/P LEA
• Falls

Global cognition impaired Cognitive domains impacted

• Memory
• Reaction time
• Attention
• Executive functioning
• Psychomotor skill

DIABETES & COGNITIVE DYSFUNCTION IMPACT OF COGNITIVE DYSFUNCTION

Cognition and Diabetes Mellitus

Natovich R. Abstract at ADA 75th Scientific Sessions, 2015 Tseng C, et al. Gen Hosp Psychiatry, 2007

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772 T2DM patients at high-risk for foot complications at 8 VAMC

• Adherence to foot self-care recommendations = 32.2%
• Depression history = 33.2% but no significant effect on adherence to

foot self-care

• No alcohol/drug dependence added to predictability of patient

performing self-care

ALCOHOL AND ADHERENCE TO SELF-CARE

Alcohol consumption a coping mechanism but makes neuropathy worse and possible synergistic effects with hyperglycemia

ALCOHOL CONSUMPTION

Alcohol Dependence and Diabetes Mellitus

Altenburg N, Joraschky P, Barthel A, et al. Diab Med 2011 Johnston MV, Pogach L, Rajan M, et al. JRRD 2006; 43(2): 227-238

CRITICALLY IMPORTANT

Behaviorism and Compliance

PROVIDING VALUE: CRITICALLY IMPORTANT

Minor LEA > DFU DFU = Major LEA

Diabetes and Decreased HRQoL

Diabetic Foot Ulcers No T2DM > DM > many other chronic illnesses Complications the most important variable

DIABETES MELLITUS

Ribu L, et al. J Diabetes Complications, 2008; Siersma V, et al. J Foot Ankle Surg, 2014

Higher HRQoL Lower HRQoL

QoL all physical & psychosocial domains

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500 patients

• T2DM > 1 yr
• Age > 25 y.o.
• Outpatient

FOOT CARE NON-ADHERENCE & HRQoL

T2DM, Low HRQoL, & Non-Adherence

Saleh F, Mumu SJ, Ara F, et al. BMC Public Health 2014; 14: 431-438

Overall HRQoL

Mobility Self-care Usual activities Pain/Discom fort Anxiety/Dep ression

✔ ✔ ✔ Exception? 75% of patients w/anxiety showed self foot-care adherence

0% 20% 40% 60%

Blood glucose monitoring Foot care Diet Exercise Smoking

37.0% 43.2% 44.8% 33.2% 37.2%

Adherence Rate

READMISSIONS IN PATIENTS W/ DIABETES MELLITUS BY PROCEDURE

Critically Important: Readmissions

Source: HCUP Statistical Briefs #153 & #154, 2010

READMISSIONS IN PATIENTS W/ DIABETES, 2010

1.8 8.5 97.8 20.3 20 40 60 80 100 Readmit/1,000 % readmit w/out complications with complications

READMISSIONS IN DM PATIENTS BY ADMITTING DX

Diagnosis of Gangrene

2nd highest readmission rate

31.6 21.3 20.3 17.2 11.2 8.5 5 10 15 20 25 30 35 Percentage readmitted

Highest readmission rate (30 most common procedures)

Lower extremity amputation

22.8 20.7 19.1 17 18 19 20 21 22 23 24 Amputation of lower extremity LE vascular bypass Debridement wound, infection, or burn

% Readmitted

Critically Important: Depression Cost & Utilization

5.6% increased cost LOS 31.2% longer

Unpublished data - CA OSHPD Public Discharge Files 2010-2013

Inpatient foot complications ± depression

11.1% 6.4% 0.0% 10.0% 20.0% Foot complication No foot complication

Depression prevalence in diabetic inpatient care in CA, 2010 - 2013

More services, Higher Costs, Less effective care

Behavioral Health, Cost & Utilization

Unpublished data

The Impact of Behavioral Health Conditions on Length of Stay and Acute Care Costs in T2DM with Lower Extremity Complications

6.1 6.8 5.5 7.0 8.1 7.5 6.9 7.5 8.6 $18.48 $20.92 $16.58 $19.70 $19.66 $20.71 $19.62 $22.05 $22.35

5 10 15 20 25

Length of Stay / Cost in USD) Behavioral Health Condition

LOS Cost (x1,000)

* * * * *

* p < 0.0001 ^ p < 0.05

* ^ * ^ * * * *

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THE CHALLENGE

Desire, willingness, and ability to adhere Other providers do not emphasize foot care

Patient effort on tx course associated w/ later LEA LEA incidence higher poor life circumstances (HR 2.97) PCP assessment of patient motivation of DM mgmt. Associated w/ higher DFU prevalence (OR 6.11)

PCP ASSESSMENT & DFU PCP ASSESSMENT & AMPUTATION

Patient self-assessment of effort = no significant association w/ DFU prevalence or amputation rate PCP assessments of patient motivation, effort, life circumstances in DM control and treatment related to DFU occurrence & amputations

IMPACT: PATIENT EDUCATION AND INSTRUCTIONS

Motivation, Effort, & Life Circumstances

Bruun C, Guassora AD, Nielsen ABS, et al. Diabetic Med 2014

Education alone won’t change adherence behavior We need interventions to

Initiate and maintain change Change suboptimal adherence behaviors once habitual patterns develop

“Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”

Haynes RB, McDonald H, Garg AX, et al. The Cochrane Library 2002

The Solution ?

POPULATION HEALTH

Diabetic Foot Risk: Three Ring Circus?

Infection Ischemia Infection + Ischemia Infection + Ischemia Ischemia Infection Behavioral Health

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Instead of making the patient fit the treatment, maybe we should make the treatment fit the patient

Price PE. Diab Met Res Rev 2008;24: 101-105.

Collaborative, Integrated Care

THE SOLUTION ?