Counseling Patients in Primary PArte 1.pdf

coms. Counseling Patients in Primary Care: Evidence-Based Strategies Family physicians spend substantial time counseling patients with psychiatric conditions, unhealthy behaviors, and medical adherence issues. Maintaining efficiency while providing counseling is a major challenge. There are several...

coms. Counseling Patients in Primary Care: Evidence-Based Strategies Family physicians spend substantial time counseling patients with psychiatric conditions, unhealthy behaviors, and medical adherence issues. Maintaining efficiency while providing counseling is a major challenge. There are several effective, structured counseling strategies developed for use in primary care settings. The transtheoretical (stages of change) model assesses patients’ motivation for change so that the physician can select the optimal counseling approach. Structured sequential strategies such as the five A’s (ask, advise, assess, assist, arrange) and FRAMES (feedback, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) are effective for patients who are responsive to education about health risk behavior. For patients ambivalent about change, motivational interviewing is more likely to be successful. Capitalizing on a teachable moment may enhance the effectiveness of health behavior change counseling. The BATHE (background, affect, troubles, handling, and empathy) strategy is useful for patients with psychiatric conditions and psychosocial issues. Patients should be referred for subspecialty mental health or substance abuse treatment if they do not respond to these brief interventions. (Am Fam Physician. 2018;98(12):719-728. Copyright © 2018 American Academy of Family Physicians.) Counseling patients on lifestyle modification and psy- chosocial problems is a fundamental competency for family physicians.1-4 Approximately 40% of primary care office visits are for chronic illness5 in which psychosocial factors play a major role in etiology and disease progression.6 Counseling patients about health risk behaviors and health education is a core component of 18% of all primary care office visits.5 Although counseling regarding weight management, diet, smoking, and alcohol use is an important part of clinical practice, a survey found that only between 31% and 56% of primary care physicians rated themselves as having significant expertise in counseling about these issues.4 See related FPM articles at https://www.aafp.org/fpm/2011 /0500/p21.html and https://www.aafp.org/fpm/2016/0900/ p32.html. CME This clinical content conforms to AAFP criteria for continuing medical education. See CME Quiz on page 711. Author disclosure: No relevant financial affiliations. Illustration by Todd Buck H. Russell Searight, PhD, MPH, Lake Superior State University, Sault Sainte Marie, Michigan In the past decade, primary care counseling strategies have been refined,7-10 and some have been empirically evaluated.10-12 This article describes practical counseling strategies typically requiring no more than five to 10 minutes that can be integrated into a typical office visit1,3,9,13,14 (Table 13,15). Research and clinical guidelines suggest that smoking cessation can be effectively addressed in three WHAT IS NEW ON THIS TOPIC Counseling Strategies Research based on the transtheoretical (stages of change) model suggests that it is possible to change multiple health risk behaviors concurrently. Application of the FRAMES counseling protocol to French primary care patients found reductions in cannabis use among patients up to 18 years of age at the six-month follow-up, whereas use increased among adolescents receiving routine care. Downloaded from the American Physician Copyright © 2018 American Academy of Family Physicians. For the private, noncom◆ December 15, 2018 VolumeFamily 98, Number 12website at www.aafp.org/afp. www.aafp.org/afp American Family Physician 719 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. COUNSELING PATIENTS SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence rating References Comments The five A’s (ask, advise, assess, assist, arrange) technique has been associated with reduced smoking and alcohol use as well as modest weight loss. B 10, 25, 26 Multisite studies; recommended by the U.S. Preventive Services Task Force The FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) technique has been associated with reductions in alcohol-related risk behavior and reduced cannabis use. B 31, 32 Leads to harm reduction The use of motivational interviewing in primary care is associated with decreases in weight, blood pressure, and alcohol use. A 16, 33, 35 Meta-analyses and systematic reviews specific to the primary care setting The BATHE (background, affect, troubles, handling, empathy) technique is associated with increased patient satisfaction. B 11, 45 Two recent studies have found this pattern The transtheoretical (stages of change) model increases coaction of health behavior change for weight management. B 3, 49 Three studies combined for analysis Clinical recommendation A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp. org/afpsort. TABLE 1 Summary of Primary Care Counseling Strategies Counseling strategy Problem type Major features Transtheoretical (stages of change) model Specific health behavior and adherence Assumes that patients have varying levels of motivation for change; assesses patients’ pros and cons for changing behavior Five A’s (ask, advise, assess, assist, arrange) Substance use; lifestyle modification; lack of adherence to medication, medical testing, or a procedure Assumes that patients lack complete knowledge of the impact of health risk behavior, nonadherence, etc.; patients will respond to direct advice FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) Substance use; lifestyle modification; lack of adherence to medication, medical testing, or a procedure Provides new information; encourages patients to select personalized treatment or lifestyle modifications from a menu to increase likelihood of a behavior change Motivational interviewing Substance use; health behavior and adherence Recognizes and directly acknowledges patients’ ambivalence about change; systematic approach to increasing patients’ motivation; relates health behavior to patients’ core values BATHE (background, affect, troubles, handling, empathy) Psychosocial problems and their social, emotional, and cognitive dimensions Specific statements and questions that quickly develop rapport with patients; focuses on a specific dimension of a problem; encourages improved coping Information from references 3 and 15. minutes, problem alcohol use in five minutes, and dietary fat consumption and lipid levels in eight minutes.13 These strategies may also be adapted to multiple patient contacts. For example, the U.S. Preventive Services Task Force guidelines16 and a recent Cochrane review 17 for addressing alcohol misuse suggest that several 10- to 15-minute 720 American Family Physician counseling appointments are most effective for reducing alcohol consumption. Transtheoretical (Stages of Change) Model The stages of change model (Table 23,15,18-20), originally developed from studying successful smoking cessation www.aafp.org/afp Volume 98, Number 12 ◆ December 15, 2018 COUNSELING PATIENTS TABLE 2 Transtheoretical (Stages of Change) Model for Addressing Health Risk Behavior Stage Description Counseling statements Goals Precontemplation Patient has no plans to change health-related behavior; may not be interested or may oppose change “Is it okay if I talk to you about your smoking?” Increases patient awareness of the health-related issue; emphasizes patient choice to continue the behavior “What are your thoughts about your weight?” “Has your drinking been a problem to you or anyone else in your life?” “What would be the first sign that would tell you that it might be time to cut down on your use of marijuana?” “How long do you think you will keep smoking two packs of cigarettes per day?” Contemplation Preparation Patient considering behavior change in the next six months; likely ambivalent about behavior change; has not taken specific action “What do you see as the pros and cons of continuing to smoke?” Definitely planning on making behavior change in the next 30 days; notifies others in social network “How can I help you be successful in quitting smoking?“ Making environmental changes (e.g., removing ashtrays and lighters from home; considering possible challenges to behavior change Action Maintenance “What do you think the hardest thing would be about reducing your drinking?” “What do you like about smoking marijuana?” Helps the patient articulate ambivalence about health behavior change; increases pros and decreases cons of behavior change “What would be the biggest challenge you would face if you decided to change your diet?” “What would be the best day in the next month to stop smoking?” “Once you quit smoking, what do you see as the major challenges?” “What could happen that might make you start drinking again?” Engaging in new behavior for a continuous period of six months; has successfully negotiated unanticipated challenges to behavior change “You’ve done really well in cutting down your drinking.” New behavior has been in place for more than six months; the patient has likely had several lapses “Some lapses are normal when you change a long-standing habit. After you smoked those 10 cigarettes, how did you regain control?” “What have been the major challenges in staying away from cigarettes?” “Have there been any situations in which you were tempted to overeat? How did you handle the situation?” “It sounds like there were some new situations that could trigger heavy drinking that you had not anticipated. That is entirely understandable. The important thing is that after that night of heavy drinking, you went back to having only one drink per day.” Elicits specific commitment to change; encourages collaboration with the patient in developing a concrete plan Helps patient recognize and prepare for challenges with smoking, alcohol, and cannabis abstinence Reinforces patient success; highlights patient self-efficacy; encourages patient to consider unanticipated challenges to abstinence Reinforces patient success; normalizes lapses as part of the change process; highlights patient success in preventing lapses from becoming relapses; emphasizes that the new behavior is the result of the patient’s efforts and is under his or her control Information from references 3, 15, and 18 through 20. techniques,18,19 recognizes that many patients are currently unmotivated or ambivalent about habit change. The stages of change model provides a framework for assessing the patient’s degree of commitment to change, and can guide physicians in choosing from counseling strategies such as the five A’s, FRAMES, or motivational interviewing. December 15, 2018 ◆ Volume 98, Number 12 By asking questions assessing the patient’s motivation, and determining his or her specific stage in the change process (i.e., precontemplation, contemplation, preparation, action, maintenance), physicians can move the patient toward initiating action or support ongoing health behavior change.15,18,19 www.aafp.org/afp American Family Physician 721 COUNSELING PATIENTS Patients in the precontemplative stage pose a particular protocol for primary care physicians to efficiently assess and challenge. If a patient appears unconcerned about health counsel patients about smoking cessation,3,10,15,26 alcohol risks, the physician may be tempted to emphasize the conse- intake,3,19 and weight loss.24,25 Whenever possible, advising quences of a behavior such as continued smoking or excess and assessing should link the patient’s presenting problem alcohol use. However, aggressive education may increase (e.g., gastrointestinal distress, knee pain with a body mass resistance and has the unintended effect of reducing patient index above 30 kg per m2) to objective, factual standards openness to physician input.3,15,16,18,19,21 (e.g., safe vs. unsafe levels of alcohol use, recommended In precontemplation, the cons of changing outweigh daily caloric intake). Patients are likely to respond more any perceived benefits.18 Therefore, counseling at this stage favorably to “I” statements (“I recommend…”) rather than should emphasize the benefits of change. Achieving “deci- “You” statements (“You should…”).3 sional balance” involves eliciting the patient’s stated pros and In one study, using some of the five A’s in a brief emercons for changing his or her behaviors. To move the patient gency department intervention required a median of seven from contemplation to action, the physician should address minutes that included screening, describing the relationobstacles to change. Studies of multiple health behaviors ship between alcohol and the patient’s presenting probconclude that moving through these stages involves a cross- lem, enhancing patient motivation, and goal setting. This over, with an increase in the pros and a decrease in the cons physician-delivered intervention, when assessed during a of changing behaviors.18 In the action and maintenance TABLE 3 stages, patients contend with possible lapse and relapse. When a lapse occurs, Five A’s for Addressing Health Risk Behavior patients are more likely to relapse to Technique Physician intervention their former habit when they attribute the lapse to internal causes such as perAsk “How many alcoholic drinks have you had in the past week?” sonality, genetics, or lack of willpower. “How long does a pack of cigarettes last for you?” Patients attributing their lapse to “When was the last time that you exercised for half an hour straight?” external factors such as peer pressure (May also use structured surveys such as the CAGE questionnaire or or work-related stress are less likely Fagerstrom Scale) to relapse.20 Physicians should frame Advise Describe, in factual terms, the patient-relevant health risks of conlapses and relapses as learning experitinuing the current behavior. ences and help patients recognize forProvide written patient education information as appropriate. merly unanticipated challenges as well “As your doctor, I recommend that you stop smoking (reduce alcohol as develop a plan for preventing future use or begin exercising for 30 minutes at least five times per week).” episodes. When appropriate, link the presenting problems to the recommenAlthough the stages accurately dation (e.g., “Cutting back on alcohol use has been found to reduce predict health-related behaviors, the blood pressure,” “Patients using marijuana as much as you describe effects of specific stage-matched interoften do have chronic cough.”) ventions are unclear.22,23 For examAssess “What do you know about how drinking/smoking/lack of exercise ple, the stages of change are useful in affects health?” approaching smoking cessation coun“What do you know about the level of alcohol use that is considseling, with precontemplative patients ered safe for men?” responding best to a brief motivational Assist “Do you feel you are ready to quit smoking in the next month?” intervention accompanied by written “Strategies that have helped many patients stop smoking include information.23 Patients in the preparamedication and educational support groups. Would you like to hear tion or action stage benefit most from a more about these?” combination of focused advice, written guidance, and prescription medication Arrange “I would like to see you again in about two weeks. At that time, we can see how your exercise program is going and if there is any help when indicated.23 The Five A’s The five A’s (ask, advise, assess, assist, arrange; Table 33,10,15,24,25), is a stepwise 722 American Family Physician you need with it. We can also discuss diet and whether speaking with a nutritionist might help.” Information from references 3, 10, 15, 24, and 25. www.aafp.org/afp Volume 98, Number 12 ◆ December 15, 2018 COUNSELING PATIENTS six-month follow-up visit, was associated with an average of 3.3 fewer binge episodes in the previous 28 days compared with 1.5 fewer episodes for patients receiving standard care.27 Some evidence suggests that depending on the clinical context and problem, the impact of the specific A’s may vary.24,25 For example, when the five A’s impact on dietary change was assessed at the three-month follow-up, weight loss of 3.3 lb (1.5 kg) occurred only when the intervention included the “arrange” step, whereas small, statistically significant self-reported changes in fat and fiber intake occurred with the first four A’s alone.25 FRAMES FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, selfefficacy enhancement) is a precursor to motivational interviewing, and was originally developed to address alcohol misuse. However, it has been applied to other health issues such as reducing stroke risk 28 (Table 4 3,15,27,28). To facilitate collaboration, the physician obtains the patient’s permission before providing information. By granting permission, patients maintain control, implicitly demonstrate interest, and are less likely to experience a threat to their independence. 3,15,21,29,30 How open the patient is to change will usually be evident by his or her answer to the responsibility statement that emphasizes the patient’s autonomous choice to address health risk behavior. Specific, individualized feedback is presented in a factual, nonjudgmental manner. For some patients, seeing numerical data, such as blood pressure readings or body weight, in the context of normal values, may be adequate for eliciting motivation to change. 3,15,27 The FRAMES strategy incorporates elements of motivational interviewing21 and patient-centered care’s emphasis TABLE 4 FRAMES for Addressing Health Risk Behavior Technique Physician intervention Feedback about personal risk Provide information in a factual manner; for example, use a CAGE questionnaire or laboratory test results to explain alcohol use. Make the connection, “Do you see any connection between drinking and your blood pressure, your history of falling and breaking bones, your stomach pain and indigestion?” If yes, briefly elaborate again using facts. “There is a pretty clear association between unintentional injuries and the amount of alcohol people drink.” If no, provide information and then ask, “What do you think of that?” Responsibility of patient “Making a change in your alcohol use is a choice that only you can make.” Advice to change Advice should be conveyed neutrally, but based on objective indicators such as the National Institute on Alcohol Abuse and Alcoholism standards for moderate drinking (one drink per day for women and two for men27). “Although stopping marijuana altogether would probably be the best thing that you can do, cutting down would benefit you.” Menu of options “Different strategies work better for different patients based on their lifestyle. Here are some strategies that have been successful for stopping smoking.” Options may include medication and/or educational groups for smoking cessation or following written guidelines or attending self-help groups for dietary changes. Empathy “You sound like you have a lot of stressors in your life. It is hard to make a major change when you’re feeling all these demands.” “It sounds like you are at a point where you want to make a change and are really motivated to quit smoking and at the same time are a bit nervous about going through nicotine withdrawal.” Self-efficacy enhancement “Two years ago, you were able to quit smoking for six months. You succeeded despite the worst part for many patients—nicotine withdrawal. That tells me that you have a lot of strength and follow-through. I genuinely believe you can be successful this time.” Information from references 3, 15, 27, and 28. December 15, 2018 ◆ Volume 98, Number 12 www.aafp.org/afp American Family Physician 723