574095 research-article2015
JAGXXX10.1177/0733464815574095Journal of Applied GerontologyBardach et al.
Article
Older Patients’ Recall of Lifestyle Discussions in Primary Care
Journal of Applied Gerontology 1–15 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464815574095 jag.sagepub.com
Shoshana H. Bardach1, Nancy E. Schoenberg2, and Britteny M. Howell2
Abstract Despite the known benefits of engaging in healthy diet and physical activity across the life span, suboptimal diet and physical inactivity are pervasive among older adults. While health care providers can promote patients’ engagement in health behaviors, patient recall of recommendations tends to be imperfect. This study sought to better understand older adults’ recall of dietary and physical activity discussions in primary care. One hundred and fifteen adults aged 65 and older were interviewed immediately following a routine primary care visit on whether and what they recalled discussing pertaining to diet and physical activity. Compared against transcripts, most patients accurately recalled their diet and physical activity discussions. The inclusion of a recommendation, and for diet discussions longer duration, increased the likelihood of patient recall for these health behavior discussions. These findings suggest that specific recommendations and an extra minute of discussion, at least for dietary discussions, increase the likelihood of accurate patient recall. Keywords health communication, lifestyle change, recall Manuscript received: October 22, 2014; final revision received: December 31, 2014; accepted: January 10, 2015. 1Lexington 2University
Veterans Affairs Medical Center, Lexington, KY, USA of Kentucky, Lexington, KY, USA
Corresponding Author: Shoshana H. Bardach, Lexington Veterans Affairs Medical Center, 1101 Veterans Drive, B408, Lexington, KY 40502-2236, USA. Email: [email protected]
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Journal of Applied Gerontology
Although modifiable lifestyle factors represent the largest category of factors influencing health, quality of life, and mortality (McGinnis, Williams-Russo, & Knickman, 2002), lifestyle behaviors such as healthy diet and physical activity remain suboptimal among older adults (Centers for Disease Control and Prevention, 1999, 2009). Health benefits are most significant if positive health behavior changes take place earlier in life; however, advantages still exist if people optimize their lifestyles later in life (Chernoff, 2001; Christmas & Andersen, 2000). For instance, Fiatarone and colleagues (1990) found that even among frail individuals in their nineties, an 8-week weight-training program can improve strength and gait speed. Strength-training programs with older adults may help delay individuals from declining below important functional thresholds, enabling them to remain independent longer (MalbutShennan & Young, 1999). Previous research also suggests that for adults aged 65 and older, even small improvements in diet, such as increasing fish consumption, may significantly lower the likelihood of stroke (Mozaffarian et al., 2005). Although the evidence regarding the effectiveness of primary care physician lifestyle counseling on influencing patient lifestyle behaviors remains inconclusive (Eden, Orleans, Mulrow, Pender, & Teutsch, 2002; Jacobson, Strohecker, Compton, & Katz, 2005), much existing research suggests that provider counseling has the potential to help patients with dietary and physical activity changes (Rippe, McInnis, & Melanson, 2001; Tyler et al., 2008). The health care system is evolving to provide more support for lifestyle counseling. The 2010 Patient Protection and Affordable Care Act provides for coverage of obesity, physical activity, and dietary counseling, not just in the context of disease management but also to prevent chronic disease (Bleyer, 2010; Koh & Sebelius, 2010). For older adults, Medicare will now reimburse providers for an annual wellness visit including discussion of patient prevention plans (DeVille & Novick, 2011; Tuma, 2012). Unfortunately, providers often view this counseling as futile and many feel they lack the time to incorporate this additional level of counseling when addressing complex patients’ existing chronic health concerns (Sherman & Hershman, 1993; Walsh, Swangard, Davis, & McPhee, 1999). The perception of counseling futility may develop from the complexity and difficulty of changing health behaviors as well as communication challenges in the patient–provider exchange. Communication is complex and imperfect regardless of age, but the challenges may be exacerbated in old age due to age-associated physiological changes. As individuals age, the likelihood of sensory and cognitive deficits increases; these changes can create difficulties with perception, comprehension, and memory of information (Adelman, Greene, & Ory, 2000; Kessels, 2003). Patients often leave visits
Downloaded from jag.sagepub.com by guest on November 14, 2015
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Bardach et al.
with incomplete or inaccurate understanding of recently discussed information, sometimes due to overly technical or medical terminology/jargon or differing interpretations of everyday language (Ali, Khan, Akunjee, & Ahfat, 2006; Hume, Kennedy, & Asbury, 1994). Older patients themselves are often cognizant of communication limitations (Hickman et al., 2009). For example, Hastings and colleagues (2011) found that older adults within 3 days of discharge from the emergency department indicate significant comprehension limitations: They report not understanding self-care instructions (16%), discharge information about diagnosis (21%), return precautions (56%), and expected course of illness (63%). Physicians tend to overestimate (by nearly threefold) the amount of information they can effectively convey during a 15-min discharge interaction (Ackermann et al., 2012). Given these challenges, recall of health behavior discussions and advice is relatively low. Even in a relatively young sample, Flocke and Stange (2004) documented that patients correctly recall the occurrence of discussions of exercise and diet only 43% and 44% of the time, respectively.
Purpose Given this prior research indicating poor recall of dietary and physical activity advice among adults, and the likelihood of additional communication challenges among older adults, this study seeks to better understand older adult patients’ recall of diet and physical activity discussions. This is the first study of which we are aware that specifically examines older adult recall of health behavior discussions in comparison with recorded clinical visits. We use the term discussion to include any conversation between the patient and provider, regardless of length or the inclusion of recommendations for behavior change. Exploring patient recall is an important first step toward understanding how lifestyle discussions may ultimately facilitate behavior change and improve quality of life for older adults.
Method This study was approved by the Institutional Review Board of the University of Kentucky. All provider and patient participants completed an informed consent prior to their participation. Providers were eligible if they saw older patients in either of the two participating clinics; providers consented to have their patient visits audio-recorded and did not engage in any activities beyond their normal care provision. Patients aged 65 and older of consenting providers were recruited from Internal Medicine and Family and Community Medicine clinics within an academic medical center. We recruited patients
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Journal of Applied Gerontology
from the waiting areas immediately prior to being seen by their provider. Patients were excluded if they were unable to participate in an interview due to being too hard of hearing, not English speaking, unable to speak at length, or cognitively impaired. Patients were excluded if the visit was for an acute or emergent concern rather than for a routine check-up or regularly scheduled disease follow-up. To create a diverse sample, we approached men and nonWhite participants first in instances where multiple eligible patients were present simultaneously. We approached a total of 171 patients, 40 refused, 16 were excluded according to the criteria above, and 115 participated. The 115 older adult primary care patients who agreed to have their routine medical visits audio-recorded were interviewed immediately following those visits. Interview questions included sociodemographic information, selfreported patient recall of the appointment, as well as recall of diet and physical activity discussions that had just taken place. Participants were asked if they had discussed diet and/or physical activity during that visit, and if so, we asked about the nature of those discussions. The semi-structured interview questions were guided by “self-determination theory” to include questions pertaining to patient autonomy, competence, and relatedness with providers (Creswell, 2003; Ryan & Deci, 2000). Analysis was limited to 104 of the 115 patients; reasons for exclusion from this analysis included incomplete visit recordings (2), incomplete interviews (2), non-routine visits (4), and severe patient comprehension difficulties prohibiting meaningful participation in the interview (3). Analysis of patient recall involved (a) identification in the visit transcripts of all the discussion of diet and physical activity, (b) responses during patient interviews about whether or not diet and/or physical activity were discussed, and (c) comparisons between patients’ reported descriptions of these discussions and the audiotapes. To better understand factors influencing recall, patient recollection was examined in light of the duration of the diet or physical discussion (measured by cumulative time content was covered in the visit) and the inclusion of dietary or physical activity recommendations within the discussion. Furthermore, for those individuals who did not recall discussions that had taken place, we conducted a critical review of the visit transcript and the interview field notes to identify possible explanations for the lack of recall. This thorough understanding of context enhances credibility and authenticity (Beer, 1997). Patient visit and interview recordings were transcribed by the lead author. We used qualitative content analysis to code the visits. Initial categories and response options were provided, but additional items and options were included as needed through multiple iterations of coding. The visit transcripts were coded by the lead author and 10% were coded by a co-coder, an older
Downloaded from jag.sagepub.com by guest on November 14, 2015
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Bardach et al.
adult trained to become familiar with the coding scheme. Inter-rater reliability reached 88% for this aspect of the coding (Weber, 1990). Patient recall was determined by response to survey questions asking whether or not diet and/or physical activity were discussed in the visit that had just taken place. Accuracy of this recall was determined by comparing patient responses to the coded visit transcripts. Duration of discussion was calculated, using the audio-recording time indicators, by totaling each instance in the visit where diet and physical activity were discussed.
Findings Sample Characteristics The analysis involved 104 patient participants who were on average 73 years old, ranging in age from 65 to 95. There were slightly more female (54%) than male participants (46%). The majority (59%) were married. Participants reported relatively high levels of education, with 69% achieving some postsecondary education. The majority (58%) of the participants perceived they had more than enough to get by financially, with just over a third (38%) indicating household incomes above US $50,000 a year. The majority (82%) of the sample was White, non-Hispanic (see Table 1).
Patient Recall of Diet and Physical Activity Discussions The majority of patient visits included some discussion of physical activity (72.1%) and diet (67.3%). Additional details about the content of the visits, as well as the context for diet and physical activity discussions and the content of behavioral recommendations, are published elsewhere (Bardach & Schoenberg, 2014). On average, patients perceived that they could recall an extensive amount of visit content. When asked to rate their recall of their visit on a 10-point scale (with 1 = very poor recall and 10 = excellent recall), patients ranked themselves an average of 8.7 (SD = 1.7, range = 3-10). This self-assessment is consistent with patients’ perceived high ability to accurately recall whether or not discussions of diet or physical activity had taken place (see Table 2). Recall of physical activity discussions was fairly high. The majority (82%) of patients had accurate recall of whether or not discussions had taken place. Among just those patients for whom physical activity discussions had taken place, ability to accurately recall that the discussion had occurred was 79%; the remaining 21% of individuals whose visits had included some discussion of physical activity did not recall the discussion. There were also three individuals
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Journal of Applied Gerontology
Table 1. Sample Sociodemographic Characteristics (N = 104). Characteristics
Age, M (SD, range) Sex, n (%) Male Female Marital status, n (%) Married/partnered Separated/divorced Widowed Single, never married Education, n (%)
JAGXXX10.1177/0733464815574095Journal of Applied GerontologyBardach et al.
Article
Older Patients’ Recall of Lifestyle Discussions in Primary Care
Journal of Applied Gerontology 1–15 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464815574095 jag.sagepub.com
Shoshana H. Bardach1, Nancy E. Schoenberg2, and Britteny M. Howell2
Abstract Despite the known benefits of engaging in healthy diet and physical activity across the life span, suboptimal diet and physical inactivity are pervasive among older adults. While health care providers can promote patients’ engagement in health behaviors, patient recall of recommendations tends to be imperfect. This study sought to better understand older adults’ recall of dietary and physical activity discussions in primary care. One hundred and fifteen adults aged 65 and older were interviewed immediately following a routine primary care visit on whether and what they recalled discussing pertaining to diet and physical activity. Compared against transcripts, most patients accurately recalled their diet and physical activity discussions. The inclusion of a recommendation, and for diet discussions longer duration, increased the likelihood of patient recall for these health behavior discussions. These findings suggest that specific recommendations and an extra minute of discussion, at least for dietary discussions, increase the likelihood of accurate patient recall. Keywords health communication, lifestyle change, recall Manuscript received: October 22, 2014; final revision received: December 31, 2014; accepted: January 10, 2015. 1Lexington 2University
Veterans Affairs Medical Center, Lexington, KY, USA of Kentucky, Lexington, KY, USA
Corresponding Author: Shoshana H. Bardach, Lexington Veterans Affairs Medical Center, 1101 Veterans Drive, B408, Lexington, KY 40502-2236, USA. Email: [email protected]
Downloaded from jag.sagepub.com by guest on November 14, 2015
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Journal of Applied Gerontology
Although modifiable lifestyle factors represent the largest category of factors influencing health, quality of life, and mortality (McGinnis, Williams-Russo, & Knickman, 2002), lifestyle behaviors such as healthy diet and physical activity remain suboptimal among older adults (Centers for Disease Control and Prevention, 1999, 2009). Health benefits are most significant if positive health behavior changes take place earlier in life; however, advantages still exist if people optimize their lifestyles later in life (Chernoff, 2001; Christmas & Andersen, 2000). For instance, Fiatarone and colleagues (1990) found that even among frail individuals in their nineties, an 8-week weight-training program can improve strength and gait speed. Strength-training programs with older adults may help delay individuals from declining below important functional thresholds, enabling them to remain independent longer (MalbutShennan & Young, 1999). Previous research also suggests that for adults aged 65 and older, even small improvements in diet, such as increasing fish consumption, may significantly lower the likelihood of stroke (Mozaffarian et al., 2005). Although the evidence regarding the effectiveness of primary care physician lifestyle counseling on influencing patient lifestyle behaviors remains inconclusive (Eden, Orleans, Mulrow, Pender, & Teutsch, 2002; Jacobson, Strohecker, Compton, & Katz, 2005), much existing research suggests that provider counseling has the potential to help patients with dietary and physical activity changes (Rippe, McInnis, & Melanson, 2001; Tyler et al., 2008). The health care system is evolving to provide more support for lifestyle counseling. The 2010 Patient Protection and Affordable Care Act provides for coverage of obesity, physical activity, and dietary counseling, not just in the context of disease management but also to prevent chronic disease (Bleyer, 2010; Koh & Sebelius, 2010). For older adults, Medicare will now reimburse providers for an annual wellness visit including discussion of patient prevention plans (DeVille & Novick, 2011; Tuma, 2012). Unfortunately, providers often view this counseling as futile and many feel they lack the time to incorporate this additional level of counseling when addressing complex patients’ existing chronic health concerns (Sherman & Hershman, 1993; Walsh, Swangard, Davis, & McPhee, 1999). The perception of counseling futility may develop from the complexity and difficulty of changing health behaviors as well as communication challenges in the patient–provider exchange. Communication is complex and imperfect regardless of age, but the challenges may be exacerbated in old age due to age-associated physiological changes. As individuals age, the likelihood of sensory and cognitive deficits increases; these changes can create difficulties with perception, comprehension, and memory of information (Adelman, Greene, & Ory, 2000; Kessels, 2003). Patients often leave visits
Downloaded from jag.sagepub.com by guest on November 14, 2015
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Bardach et al.
with incomplete or inaccurate understanding of recently discussed information, sometimes due to overly technical or medical terminology/jargon or differing interpretations of everyday language (Ali, Khan, Akunjee, & Ahfat, 2006; Hume, Kennedy, & Asbury, 1994). Older patients themselves are often cognizant of communication limitations (Hickman et al., 2009). For example, Hastings and colleagues (2011) found that older adults within 3 days of discharge from the emergency department indicate significant comprehension limitations: They report not understanding self-care instructions (16%), discharge information about diagnosis (21%), return precautions (56%), and expected course of illness (63%). Physicians tend to overestimate (by nearly threefold) the amount of information they can effectively convey during a 15-min discharge interaction (Ackermann et al., 2012). Given these challenges, recall of health behavior discussions and advice is relatively low. Even in a relatively young sample, Flocke and Stange (2004) documented that patients correctly recall the occurrence of discussions of exercise and diet only 43% and 44% of the time, respectively.
Purpose Given this prior research indicating poor recall of dietary and physical activity advice among adults, and the likelihood of additional communication challenges among older adults, this study seeks to better understand older adult patients’ recall of diet and physical activity discussions. This is the first study of which we are aware that specifically examines older adult recall of health behavior discussions in comparison with recorded clinical visits. We use the term discussion to include any conversation between the patient and provider, regardless of length or the inclusion of recommendations for behavior change. Exploring patient recall is an important first step toward understanding how lifestyle discussions may ultimately facilitate behavior change and improve quality of life for older adults.
Method This study was approved by the Institutional Review Board of the University of Kentucky. All provider and patient participants completed an informed consent prior to their participation. Providers were eligible if they saw older patients in either of the two participating clinics; providers consented to have their patient visits audio-recorded and did not engage in any activities beyond their normal care provision. Patients aged 65 and older of consenting providers were recruited from Internal Medicine and Family and Community Medicine clinics within an academic medical center. We recruited patients
Downloaded from jag.sagepub.com by guest on November 14, 2015
4
Journal of Applied Gerontology
from the waiting areas immediately prior to being seen by their provider. Patients were excluded if they were unable to participate in an interview due to being too hard of hearing, not English speaking, unable to speak at length, or cognitively impaired. Patients were excluded if the visit was for an acute or emergent concern rather than for a routine check-up or regularly scheduled disease follow-up. To create a diverse sample, we approached men and nonWhite participants first in instances where multiple eligible patients were present simultaneously. We approached a total of 171 patients, 40 refused, 16 were excluded according to the criteria above, and 115 participated. The 115 older adult primary care patients who agreed to have their routine medical visits audio-recorded were interviewed immediately following those visits. Interview questions included sociodemographic information, selfreported patient recall of the appointment, as well as recall of diet and physical activity discussions that had just taken place. Participants were asked if they had discussed diet and/or physical activity during that visit, and if so, we asked about the nature of those discussions. The semi-structured interview questions were guided by “self-determination theory” to include questions pertaining to patient autonomy, competence, and relatedness with providers (Creswell, 2003; Ryan & Deci, 2000). Analysis was limited to 104 of the 115 patients; reasons for exclusion from this analysis included incomplete visit recordings (2), incomplete interviews (2), non-routine visits (4), and severe patient comprehension difficulties prohibiting meaningful participation in the interview (3). Analysis of patient recall involved (a) identification in the visit transcripts of all the discussion of diet and physical activity, (b) responses during patient interviews about whether or not diet and/or physical activity were discussed, and (c) comparisons between patients’ reported descriptions of these discussions and the audiotapes. To better understand factors influencing recall, patient recollection was examined in light of the duration of the diet or physical discussion (measured by cumulative time content was covered in the visit) and the inclusion of dietary or physical activity recommendations within the discussion. Furthermore, for those individuals who did not recall discussions that had taken place, we conducted a critical review of the visit transcript and the interview field notes to identify possible explanations for the lack of recall. This thorough understanding of context enhances credibility and authenticity (Beer, 1997). Patient visit and interview recordings were transcribed by the lead author. We used qualitative content analysis to code the visits. Initial categories and response options were provided, but additional items and options were included as needed through multiple iterations of coding. The visit transcripts were coded by the lead author and 10% were coded by a co-coder, an older
Downloaded from jag.sagepub.com by guest on November 14, 2015
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Bardach et al.
adult trained to become familiar with the coding scheme. Inter-rater reliability reached 88% for this aspect of the coding (Weber, 1990). Patient recall was determined by response to survey questions asking whether or not diet and/or physical activity were discussed in the visit that had just taken place. Accuracy of this recall was determined by comparing patient responses to the coded visit transcripts. Duration of discussion was calculated, using the audio-recording time indicators, by totaling each instance in the visit where diet and physical activity were discussed.
Findings Sample Characteristics The analysis involved 104 patient participants who were on average 73 years old, ranging in age from 65 to 95. There were slightly more female (54%) than male participants (46%). The majority (59%) were married. Participants reported relatively high levels of education, with 69% achieving some postsecondary education. The majority (58%) of the participants perceived they had more than enough to get by financially, with just over a third (38%) indicating household incomes above US $50,000 a year. The majority (82%) of the sample was White, non-Hispanic (see Table 1).
Patient Recall of Diet and Physical Activity Discussions The majority of patient visits included some discussion of physical activity (72.1%) and diet (67.3%). Additional details about the content of the visits, as well as the context for diet and physical activity discussions and the content of behavioral recommendations, are published elsewhere (Bardach & Schoenberg, 2014). On average, patients perceived that they could recall an extensive amount of visit content. When asked to rate their recall of their visit on a 10-point scale (with 1 = very poor recall and 10 = excellent recall), patients ranked themselves an average of 8.7 (SD = 1.7, range = 3-10). This self-assessment is consistent with patients’ perceived high ability to accurately recall whether or not discussions of diet or physical activity had taken place (see Table 2). Recall of physical activity discussions was fairly high. The majority (82%) of patients had accurate recall of whether or not discussions had taken place. Among just those patients for whom physical activity discussions had taken place, ability to accurately recall that the discussion had occurred was 79%; the remaining 21% of individuals whose visits had included some discussion of physical activity did not recall the discussion. There were also three individuals
Downloaded from jag.sagepub.com by guest on November 14, 2015
6
Journal of Applied Gerontology
Table 1. Sample Sociodemographic Characteristics (N = 104). Characteristics
Age, M (SD, range) Sex, n (%) Male Female Marital status, n (%) Married/partnered Separated/divorced Widowed Single, never married Education, n (%)
