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Sharpening the Focus on Therapeutic Patient Education and Self-management

Disclosure: Owner, ES Heartworks, LLC, an online educational company
Pub Date: Monday, June 19, 2017
Author: Elaine E. Steinke, PhD, RN, CNS-BC, FAHA, FAAN
Affiliation: Wichita State University, School of Nursing, Wichita, Kansas

Citation

Barnason S, White-Williams C, Rossi LP, Centeno M, Crabbe DL, Lee KS, McCabe N, Nauser J, Schulz P, Stamp K, Wood K; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; and Stroke Council. Evidence for therapeutic patient education interventions to promote cardiovascular patient self-management: a scientific statement for healthcare professionals from the American Heart Association [published online ahead of print June 19, 2017]. Circ Cardiovasc Qual Outcomes, doi: 10.1161/HCQ.0000000000000025.

Article Text

Patient education has been a prime focus of clinicians for many years, yet patients may not follow the advice provided. Implementing lifestyle changes and following the recommended plan of care is particularly important given the 92 million people living with cardiovascular disease (CVD).1 The American Heart Association’s Life’s Simple 7 emphasizes CVD prevention and cardiovascular health, including patient education in supporting lifestyle changes.1  In some respects, however, health care professionals have been a barrier to effective patient education. Patients may be blamed for not following through with the plan of care and labeled as non-compliant or non-adherent, despite patients receiving only minimal patient education. In recent years, there has been greater emphasis on patient self-management, including providing the tools for patients to be more effective in managing their health. A search for articles on patient self-management in one database alone resulted in over 1,200 results, with most focused on self-management related to a particular disease process.

The AHA scientific statement, Evidence for Therapeutic Patient Education (TPE) Interventions to Promote Cardiovascular Patient Self-Management, introduces therapeutic patient education as an important component of patient self-management.2 Therapeutic patient education builds upon patient and family strengths, and lays the foundation for utilization of interventions shown to be most effective. The variety of interventions and outcomes evaluated can inform future interventions by clinicians. It is clear that patient education alone does not work and that multiple strategies, tailored to the individual patient, are essential for self-management to be successful

There are challenges in reframing our approach from provider of information to helping patients integrate lifestyle changes. With a focus on patient self-management, shared decision-making becomes a key process. This means that clinicians, patients, and families together must dialogue to determine the best approach in meeting disease management and health promotion goals, within the context of what will actually work for the patient. Without active involvement of the patient/family and tailored information related to the plan of care, efforts to meet management goals and outcomes often fail. An underlying premise is that clinicians seek opportunities to be better informed on approaches to facilitate patient self-management, therapeutic patient education, and shared decision-making. These approaches are most successful when using a team approach with clearly defined roles of team members and with the primary focus of helping patients understand their health situation and choices.3 Additionally, interventions must be culturally relevant;2 thus, clinicians may need further education on cultural norms and patient expectations to be effective in self-management efforts. Determining health literacy and assessing for cognitive impairment are important considerations for effective patient education and self-management.2 In these instances, self-management becomes more complex, and shared decision-making and tailored self-management strategies are of even greater importance. Thus, implementing health literacy and cognitive screening lays the groundwork for effective therapeutic patient education.

Therapeutic patient education as part of patient self-management is not a one-time event. In the past, clinicians expected that once they had provided education, such as discharge instructions, and their duty fulfilled, the patient would follow through on recommendations. Studies have illustrated that for many patients, a greater focus upon and tailoring of education and counseling are needed to improve outcomes.4 Thus, therapeutic patient education should occur on multiple occasions and across settings, relying less on one clinician to provide information. Strategies recommended by Barnason et al. include face-to-face education, use of teach-back techniques, telehealth methods such telephone follow-up or video conferencing, and increased referral to cardiac rehabilitation.2 There are barriers to implementing self-management interventions across settings. Time is the most frequently cited barrier, as most clinicians do not have an hour or more to devote to therapeutic patient education. Thus, new and creative strategies must be designed that are both time efficient and effective.

Measuring outcomes related to patient self-management is challenging. In one analysis, 64% of studies of therapeutic patient education demonstrated improved outcomes, while 30% showed no effect and 6% a worsening effect.5 In studies cited in the Barnason scientific statement,2 outcome measurement ranged from two weeks to two years; long term measurement may not be feasible in most clinical settings. The specific outcome may determine the most reasonable timing for follow-up. For example, if one is measuring knowledge, gains may be short-term. This has implications both in determining when to measure the outcome, but also what enhancements are needed to maintain knowledge. Teach-back techniques have been effective in improving patient knowledge in some populations, such as heart failure.6

It is unclear which outcomes are most important to measure. Consensus has not been reached on the best methods to evaluate therapeutic patient education, and individually tailoring information with multiple approaches makes evaluation of therapeutic patient education complex.7 Barnason et al. cited a variety of outcomes by diagnosis,2 and while variation in outcomes may be appropriate, it would be helpful to identify important common outcomes across cardiac populations to evaluate the impact of therapeutic patient education. Additionally, outcome measurement must keep the patient/family at the center of focus and be clinically relevant across a variety of settings. Improvement of therapeutic patient education practices occurs through formative evaluation of interventions, as well as research comparing different aspects of an intervention.7

A “structured protocol for delivery of therapeutic patient education”2 is an important recommendation from this scientific statement. Leadership in developing protocols and tools to facilitate therapeutic patient education efforts across settings are clearly needed, and organizations such as the American Heart Association can play a key role. This could include recommendations for outcome measurement, both short-term and longer-term outcomes. Further study must identify the best approaches for therapeutic patient education and patient self-management across settings; however, the recommendations from the scientific statement can guide clinicians and researchers now with assessment and implementation strategies. Ultimately, the increased focus on therapeutic patient education provides positive direction to support patients in self-management.

References

  1. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth LD, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D,  Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond W, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu J, Alger HM, Wong SS, Muntner P. Heart disease and stroke statistics - 2017 update. Circulation. 2017;135:e146-e603. Doi: 10.1161/CIR.0000000000000485
  2. Barnason S, White-Williams C, Rossi L, Centeno M, Crabbe DL, Lee KS, McCabe N, Nauser J, Schulz P, Stamp K, Wood K; on behalf of the American Heart Association Council of Cardiovascular and Stroke Nursing, Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, and Stroke Council.  Evidence for therapeutic patient education (TPE) interventions to promote cardiovascular patient self-management: a scientific statement for healthcare professionals from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2017:10:e000025. Doi: 10.1161/HCQ.0000000000000025.
  3. Col N, Bozzuto L, Kirkegaard P, Koelewijn-van Loon M, Majeed H, Ng CJ, Pacheco-Huergo V. Interprofessional education about shared decision making for patients in primary care settings. J Interprof Care 2011; 25(6):409-415.
  4. Jacobs AD, Ammerman AS, Ennett ST, Campbell MK, Tawney KW, Aytur SA, Marshall SW, Will JC, Rosamond WD. Effects of tailored follow-up intervention on health behaviors, beliefs, and attitudes. J Womens Health 2004; 13(5):557-568.
  5. Lagger G, Pataky Z, Golay A. Efficacy of therapeutic patient education in chronic diseases and obesity. Patient Educ Couns 2010; 79(3):283-286.
  6. White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is “Teach-Back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs 2013; 28(2):137-146.

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --