Changing Physician Behavior to Improve Disease Prevention

doi:10.1006/pmed.1994.1040

Preventive Medicine

Volume 23, Issue 3, May 1994, Pages 284-291

https://doi.org/10.1006/pmed.1994.1040 Get rights and content

Abstract

Physicians often fail to provide nationally recommended preventive services for their patients. Addressing this, we have reviewed selected literature on changing physician behavior using the organizational construct of the |readiness for change| transtheoretical model. This model suggests that behavior evolves through stages from precontemplation, to contemplation, to preparation, to initiation, and to maintenance of change. Traditional continuing medical education may affect knowledge and beliefs, but rarely results in behavior change. However, motivational strategies such as practice feedback reports and influential peers can foster stage change. Successful interventions aimed at physicians preparing for change frequently use an office-system approach that targets not only physicians, but office staff and patients as well. Illustrating how the readiness to change model can guide the design and implementation of interventions, we describe strategies being used in a statewide randomized controlled trial to improve cancer prevention counseling and early detection by primary care physicians. The multistage interventions of Partners for Prevention include support from a medical liability carrier, a motivational videotape, a task-delineated office manual, chart flowsheets, patient activation forms, practice feedback reports, a designated prevention coordinator within each practice and regular telephone calls and office visits by project staff.

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Cited by (145)

A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients' sexual risk behavior
2022, Journal of Substance Abuse Treatment
High risk sex—such as sex with multiple partners, condomless sex, or transactional or commercial sex—is a risk factor in individuals with substance use disorders (SUDs). SUD treatment can reduce sexual risk behavior, but interventions to reduce such behavior in this context have not been consistently effective. This study sought to determine if the impact of treatment on sexual risk behavior can be increased.
In a nested 2 × 2 factorial repeated measures design, we examined outcomes of two interventions: training for counselors in talking to patients about sexual risk; and availability to both counselors and patients of a personalized feedback report based on patient self-report of sexual behavior. Counselors received either a brief, information-based, Basic Training, or a multi-session, skills-based Enhanced Training. Their patients completed an audio-assisted computerized assessment of sexual behavior and received either No Feedback or a Personalized Feedback Report (PFR). Four hundred seventy six patients participated. Patient follow-up occurred 3- and 6-months postbaseline. Primary patient outcome measures were Number of Unsafe Sex Occasions (USO) and whether patients reported talking about sex in counseling sessions (Discussed Sex), both in the past 90 days. Secondary outcomes included Number of Sexual Partners, Sex Under the Influence of Substances, and Perceived Condom Barriers.
Patients of Enhanced-condition counselors compared to those of Basic-condition counselors were more likely to report talking about sex with their counselor at 6-month follow-up. Personalized feedback also increased the likelihood of reporting counselor discussions at 6-month follow-up. Neither the training nor the feedback condition affected USO, Number of Partners, or Sex Under the Influence.
We discuss why these two interventions apparently altered counselor-patient communication about sexual risk behavior without affecting the behavior itself.
Increasing substance use disorder counselors’ self-efficacy and skills in talking to patients about sex and HIV risk: A randomized training trial
2019, Drug and Alcohol Dependence
Citation Excerpt :
Prior clinician training studies have achieved initial skill improvements but have demonstrated difficulty in maintaining skill gains. This included both medical provider training on discussing sex with patients (Bradley-Springer et al., 2006; Dodge et al., 2001) and SUD counselor training in skills such as Motivational Interviewing (Baer et al., 2009; Carroll et al., 2000; Cohen et al., 1994 Gerbert et al., 2003; Miller et al., 2004). Yet, some studies of training medical providers reported sustained (12-month) effects (Kelly et al., 2000; Patel et al., 2012; Thrun et al., 2009).
People with substance use disorder (SUD) experience increased risk for HIV, Hepatitis C, and sexually transmitted illnesses via risky sex. This high-risk population would benefit from sexual risk reduction interventions integrated into SUD treatment. However, many SUD counselors report lack of skill or confidence in addressing sexual risk with patients.
This study was part of a larger nested 2 × 2 factorial repeated measures design, which compared two levels of counselor training (Basic-2 h versus Enhanced-10 h plus ongoing coaching). We determined whether counselors receiving Enhanced training addressing their motivation, confidence and skills (a) increased knowledge about sexual issues; (b) increased self-efficacy to discuss sex with patients; and (c) improved skills in discussing sex as part of SUD treatment, compared with those receiving shorter information-based training. Counselors providing individual therapy at two opioid treatment programs (OTP) and two psychosocial outpatient programs in the United States were eligible. Randomization occurred after Basic training. Measures included self-report (self-efficacy and knowledge) and blinded coding of standardized patient interviews (skill).
Counselors receiving Enhanced training (n = 28) showed significant improvements compared to their Basic training counterparts (n = 32) in self-efficacy, use of reflections, and use of decision-making and communication strategies with standardized patients. These improvements were maintained from post-training to 3-month follow-up. No adverse effects of study participation were reported.
Results suggest that counselors can improve their knowledge, self-efficacy and skill related to sexual risk conversations with patients based on modest skills-based training.
Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City
2016, Patient Education and Counseling
Colorectal cancer could be prevented through regular screening. Individuals age 50 and older are recommended to get screened via colonoscopy. Because physician referral is a major predictor of colonoscopy completion, two low-cost, evidence-based interventions were tested to increase referrals by activating patients to self-advocate.
This study compared the impact of a pre-visit educational handout that prompts patients to discuss colonoscopy with their physician with the handout plus brief counseling through exit interviews and chart reviews. The main outcome was physician referral.
Medical charts were reviewed for eligibility: 130 control patients (Arm 1), 45 patients who received the educational handout and health counseling (Arm 2), and 50 patients who received only the handout (Arm 3). Colonoscopy referral rates increased from 24.6% in Arm 1 to 44.4% and 52.0% in Arms 2 and 3, respectively (p = 0.001). The proportion of exit interview participants who discussed colonoscopy with their doctor increased from 68.8% in Arm 1 to 76.5% and 88.9% in Arms 2 and 3, respectively.
Results indicate that both interventions are effective at increasing colonoscopy referrals.
: Results suggest that an educational handout alone is sufficient in prompting patient-initiated discussions about colonoscopy.
Attitudes, Beliefs, and Behavior
2015, Psychology and Geriatrics: Integrated Care for an Aging Population
This chapter reviews decades of empirical evidence and theory linking attitudes, beliefs and behavior, with special focus on medical and geriatric populations. The clinical relevance of patient self-efficacy and stereotyping is emphasized. The discussion covers patient, caregiver and physician attitudes, beliefs and behavior and how they can influence patient outcomes, including adherence and chronic disease self-management.
Improving clinician self-efficacy does not increase asthma guideline use by primary care clinicians
2012, Academic Pediatrics
Citation Excerpt :
The gap between asthma guidelines and their implementation in primary care practice settings is considerable. The reasons for this gap are multifactorial and include patient, payer,25 and provider-related issues.11 We implemented a set of interventions designed to increase clinician self-efficacy and examined the effectiveness of these interventions at changing behavior as measured by enrollment of children in a disease management program, creation of a written asthma treatment plan, and use of anti-inflammatory therapy.
The purpose of this study was to show the association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing).
A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy.
At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (relative rate [RR], 1.34; 95% confidence interval [CI], 1.04–1.72; P = .04) but not treatment plan development (RR, 0.63; 95% CI, 0.29–1.35; P = .23) or anti-inflammatory use (RR, 1.76; 95% CI, 0.92–3.35; P = .09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (P = .01) and more clinicians were in an action stage of change (P = .001) but these changes were not associated with changes in primary or secondary outcomes.
Self-efficacy scores correlated with program use at baseline and increased in the intervention arm, but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change.
Telephone counseling and attendance in a national mammography-screening program: A randomized controlled trial
2011, American Journal of Preventive Medicine
In Germany, a mammography-screening program (MSP) was implemented on a national level. It complies with all criteria of the European guidelines for quality assurance in screening mammography; however, the attendance rate is 54%, falling short of the target attendance rate of 70%. The aim of this study was to investigate whether additional telephone counseling improves attendance among nonresponders and the level of satisfaction with telephone counseling.
In a prospective RCT, women identified as nonresponders in the MSP were randomized to a control group that received written reminders or to an intervention group that additionally received telephone counseling. In a follow-up, a subset of the intervention group was contacted by telephone regarding their satisfaction with telephone counseling.
In 2008, a total of 5477 women aged 50–69 years who were eligible for the German MSP but had not participated up to 6 weeks after the first invitation were included in the study.
Individual telephone counseling consisted of scripted calls from a trained counselor who provided information on MSP and answered the woman's questions.
Report of mammography use provided by the screening unit 3 months after the reminder was sent.
Analysis was conducted in 2009. Comparison of screening attendance revealed a significantly higher attendance rate in the intervention group compared with controls (29.7% vs 26.1%, p=0.0035). When only women for whom telephone numbers were available were analyzed, attendance was even better (35.5% vs 29.7%, p=0.0004). In the follow-up, 278 of 404 women were actually surveyed. Of those, 33% stated that telephone counseling had influenced their decision, 56% stated that they had undergone screening mammography, and 77% agreed that personal telephone counseling should be used routinely to encourage nonresponders to go for screening.
Individual telephone counseling for nonresponders to a national program for breast cancer screening was well accepted by participants and effective.
This study is registered at the Australian New Zealand Clinical Trials Registry ACTRN12611000645954.

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Changing Physician Behavior to Improve Disease Prevention