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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oupjournals.org

Maximizing current treatment options: exploring psychological barriers to change

Ronald Murphy*

Dillard University, New Orleans, LA, USA

* Corresponding author. Tel: +1 504 816 4244; fax: +1 504 816 4185. E-mail address: maxco1{at}earthlink.net


   Introduction
Top
 Introduction
Addressing the problem
 Barriers and interventions for...
 Conclusions
 References
 
Atrial fibrillation (AF) is a common arrhythmia that represents a significant public health problem, affecting some 2.3 million people in the United States alone.1 The risk of stroke in AF patients is increased by approximately five-fold, resulting in a significant increase in the risk of mortality.2 As AF becomes more common with age—the risk doubling with every decade after the age of 55—an increasingly elderly population means that the burden of this condition will continue to grow.3,4 As detailed by Heinz Völler in the previous article in this supplement,5 there are ample data demonstrating that oral anticoagulation therapy with vitamin K antagonists, such as warfarin, significantly reduces the risk of stroke in patients with AF. In particular, warfarin has been shown to reduce the risk of stroke in AF patients by up to 62%.6 However, warfarin has several drawbacks, including a narrow therapeutic window leading to increased risk of bleeding and unpredictable anticoagulant activity that is subjected to numerous drug and food interactions, all of which necessitate regular coagulation monitoring.7–9 For optimal anticoagulation benefit in AF, the international normalized ratio (INR) needs to be maintained within a relatively narrow target range (2.0–3.0)10 and many patients treated with warfarin do not achieve this target INR.11 These potential problems have resulted in the underuse of warfarin, leading to considerable burden on both patients and healthcare systems.12–16

It has been suggested that warfarin use in AF can be maximized and its limitations minimized by implementing strategies such as improving INR control through greater use of anticoagulation clinics or patient self-management and greater adherence to relevant treatment guidelines.5 The problem is that, in practice, the simple dissemination of clinical guidelines is rarely sufficient to persuade practitioners to adopt optimal healthcare and treatment policies.17,18 Recent advances in behavioural science have resulted in the evolution of several theoretical models for addressing the problems of motivating individuals to change, and there is growing interest in applying such models to the development of strategies that encourage the adoption of best evidence into practice, including efforts to change behaviour.19–23 In this article, one such model is described—the stages of change in the transtheoretical model of Prochaska et al.—and suggest how it can be applied to alter warfarin prescriber behaviour.


   Addressing the problem
Top
 Introduction
 Addressing the problem
Barriers and interventions for...
 Conclusions
 References
 
Despite the evidence to support the utility of warfarin in reducing the risk of stroke in AF, physicians remain reluctant to increase the use of this agent. Prescriber attitudes need to be addressed to maximize the potential of warfarin while minimizing the risks. Clinical guidelines clearly detailing the benefits of warfarin use and providing algorithms for prescription and patient monitoring do exist. However, even when clear and consistent guidelines are available, the dissemination of these documents alone is not sufficient to induce changes in physician behaviour at a level that would impact overall healthcare practices.17 The problems associated with translating scientific evidence into clinical practice are not restricted to the field of AF. The gap between evidence and practice is a consistent finding in health services studies.24 Approximately 30–40% of patients are thought not to receive treatments of proven effectiveness and 20–25% of patients receive care that is unnecessary or even potentially harmful.18,25

Even when the scientific evidence has been widely disseminated and accepted and physicians are aware of the need to change their prescribing patterns, actual implementation of the necessary changes does not always follow. Why do prescribers not change when they know that they should? This lack of change in the face of evidence for change is a general issue and is an ongoing and critical concern in a number of fields of mental health, alcoholism, and other areas of public health, particularly smoking and diet.26–28 Seriously ill patients often do not follow treatment regimens that they know could cure them. In prescribing, a major problem is the over-prescription of antibiotics, which has led to the widespread dissemination of antibiotic resistance.

In the past, explanations for why people do not do what they should do have tended to refer to trait labels such as denial, stubbornness, resistance, arrogance, and lack of readiness to change. More recently, behavioural scientists have developed a number of theoretical frameworks to explain how behavioural change is achieved. One of these is the transtheoretical model.29

The transtheoretical model
The transtheoretical model (including the stages of change) was initially conceived and validated in smoking cessation studies.30 The model has since been applied to a wide range of behaviours including weight loss, injury prevention, and overcoming alcohol and drug problems.31–38 This model proposes that modifiable beliefs about the need to change, rather than personality traits, denial, or negative attitude, underlie the behavioural change process. The idea is that behaviour change does not happen in one step. Rather, people tend to progress through different stages on their way to successful change. The stages of change are five stages associated with the states of belief about the need to change and the actions needed for change. These stages, which are further discussed subsequently, are the precontemplation stage, in which subjects are unaware of a need to change; the contemplation stage, in which subjects question their own need to change; the preparation stage, in which subjects question their ability to change; the action stage, where the change takes place; and the maintenance stage.

The key assumption of the model is that different interventions are needed at each stage of change to help individuals resolve questions about the need or ability to change that behaviour and move to the next stage. It is important to accept that there will be rational, understandable, stage-specific reasons why people do not do the things they should do. This approach could be used to change warfarin prescribing behaviours by applying multifactorial, stage-appropriate interventions targeting physician barriers to prescribing warfarin and tailored to each physician's readiness to change.


   Barriers and interventions for increased warfarin use
Top
 Introduction
 Addressing the problem
 Barriers and interventions for...
Conclusions
 References
 
The transtheoretical model has been successfully applied to numerous health and behaviour problems in a wide range of populations,31–38 but has not yet been applied to physician behaviour. I have conducted a stages of change analysis of warfarin prescriber behaviour and have identified potential interventions that could be used to initiate, implement, and maintain an increased use of warfarin in AF patients. The resultant stages of change analysis of warfarin prescriber behaviour is summarized in Table 1. The barriers to warfarin use that are presented in this model have been drawn from a review of the literature on warfarin prescriber behaviour. It is important that reasons for specific barriers are identified as vital to intervention planning and that any suggested interventions are specific to the barrier, the reason for the barrier and the stage of change.


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  		Table 1 Warfarin barriers and suggested interventions in a stages of change context
 
The precontemplation stage
In the precontemplation stage, the subject does not believe that there is any need to change his or her current behaviour. This may be due to a lack of knowledge or a lack of sensitivity concerning what the accepted norms are for a particular behaviour. Subjects may also be unaware of the risks or negative consequences that may result from their behaviour. With regard to warfarin, some physicians believe that there is inadequate evidence of benefit, while others are unaware of the high number of avoidable stroke events in AF patients. Physicians may also be unaware of their own loss-aversive decision biases; that is, they are highly averse to any kind of patient loss. Also, in this stage, we find physicians who are unaware of their decision bias resulting from a high regret over commission vs. a low regret of omission decisions.39 In other words, this group of physicians would rather do nothing and let something negative happen than do something and let something negative happen. Several interventions can be suggested to help physicians in this stage to move to the next stage. Convincing evidence regarding the risk of stroke in AF patients is needed. This evidence needs to be data-based and applicable to all provider contexts and all AF patient populations at risk of stroke. It is also important to provide evidence of the benefits of treatment using social/psychological techniques, social influence/persuasion techniques, and motivation-enhancement techniques. Also, physicians must be educated about their decision biases and the inconsistency of these biases with best practice. This should be supported by effectiveness data rather than efficacy data. Efficacy data are collected in controlled clinical trials, the design of which emphasizes internal validity over generalizability.40 The data from such trials may not be applicable to the more heterogeneous patients encountered in actual clinical practice, and cost estimates may be inaccurate because of protocol requirements. Effectiveness studies, in which treatments are studied under real-world conditions, will be more applicable to the prescribing physician. Clearly, a physician education programme requires that the accepted norms of treatment match the evidence that is being presented. This requires interventions in medical education at all levels, from the medical school up, and a functional accreditation and certification process.

The contemplation stage
Once subjects have accepted that there is a problem, the next question that they need to consider is, ‘Do I need to change?’ People may get stuck in this stage because, in their mind, the disadvantages of change outweigh the advantages. Again, lack of knowledge and insensitivity concerning the consequences or risks of their behaviour may contribute to keeping subjects at this stage. This is a key stage for the problem of warfarin underuse; many physicians believe that the risk of adverse events outweighs the benefit in terms of stroke reduction and that optimal INRs are only rarely achieved. In this case, the perceived risk is more important to these individuals than the evidence base found in the guidelines to support warfarin use. In addition, a prescriber in the contemplation stage may think that the treatment guidelines do not address the complexities of decision making for an individual patient. What interventions would help a physician in this stage to deal with these issues? Firstly, it is important to be very clear about all the advantages and disadvantages of warfarin use, including those that the physicians may not have thought of, in order to help them work through the evidence themselves. There is also a need to educate prescribers about the risk of stroke in AF and realistic estimates of intracerebral haemorrhage (ICH) risk with warfarin (prescriber estimation of ICH risk is actually 10 times higher than research estimates and clinical reports)39,41 and to provide data-based information about the significant stroke prevention benefit and low bleeding risk when the INR is maintained in the optimal range. Algorithms for successful warfarin prescription need to be provided for a range of clinical settings that will be relevant to individual prescribers.

The preparation stage
Having contemplated the evidence and having become convinced of a need to change, the subject enters the next stage of the process—the preparation stage. Here, the subject wonders about his or her ability to change. This is a very important step that many psychologists miss by assuming that once someone is convinced of the need to change, they know how to change. However, for many people who do not really know how to change, this stage is an essential bridge between contemplation and action. Physicians may feel that they need to be doing more in terms of warfarin prescription, but they have a number of rational and reasonable reasons for not actually proceeding to change. In general, subjects' reasons for doubting their ability to change may be related to a perceived low self-efficacy regarding problem solving; that is, they are not confident that they can overcome all the difficulties that might be involved in the change. They may also have a low expectancy of a positive outcome resulting from the change. This low expectancy may be reinforced, if the subject has not seen any of his or her peers successfully carrying out this change in behaviour.

With regard to warfarin, physicians may feel that they cannot manage the extra time, effort, and patient interaction involved in INR monitoring. They may not be confident about addressing patients' concerns or fears about their ability to ensure INR-related compliance issues such as diet and testing schedules. Many physicians may not have seen any of their peers successfully prescribing warfarin in a similar setting to their own and may feel that warfarin prescription is not possible in a busy practice or in an environment with limited resources.

Key opinion leaders could play a crucial role in helping to prepare physicians to move on to the action stage. Education efforts need to empathize with physician concerns, prescribing barriers, and setting specific difficulties. Physicians need to know that their concerns are acknowledged and understood and that any solutions proposed will be relevant to their situation. Physicians could be armed with motivation-enhancement strategies to address patient compliance and health belief issues and to help change the behaviour of patients over short periods of time. Collection and dissemination of effectiveness data from a wide range of settings will help physicians to accept that the specific barriers that they face can be overcome in clinical practice.

The action and maintenance stages
Having been convinced of their ability to change, individuals now need to actually make the change. Generally, subjects get stuck in this stage because of lack of skills or lack of environmental re-inforcement or support. So, physicians need strategies and skills to manage the extra time, effort, and patient interaction involved in INR monitoring. It is often difficult in busy practice to really address patient concerns in a timely manner, especially when the patient is not being co-operative or compliant. Physicians also need skills for helping to enhance patient engagement and compliance concerning diet and regular INR testing. Appropriate interventions at this stage would include providing the physician with setting-specific strategies for changing prescribing practices, addressing barriers, motivating patient compliance, and addressing patient fears and health beliefs. Physicians at this stage could benefit enormously from realistic vignettes and situations that address their particular needs. Having successfully implemented a change in prescribing behaviour, a practitioner will need continued support to maintain this behaviour. Ongoing education, monitoring and feedback systems, and continuing contact with other successful warfarin prescribers will all help to prevent the practitioner from reverting to his or her previous behavioural patterns.


   Conclusions
Top
 Introduction
 Addressing the problem
 Barriers and interventions for...
 Conclusions
References
 
Evidence showing that warfarin is effective at reducing the risk of stroke in AF patients has been available for several years,6 but warfarin is still underused and the burden of morbidity and mortality associated with AF remains high.42 The simple dissemination of treatment guidelines is insufficient to bring about meaningful changes in practitioner behaviour and is unlikely to increase warfarin use significantly. Analysis of stages of change of warfarin prescriber behaviour may be one approach to address specific barriers and to identify strategies for changing physician behaviour in terms of prescribing warfarin. It will, however, be of vital importance to target specific sub-groups or particularly reluctant prescribers who will vary according to the types of barrier that they present and the stage of change that they have achieved.


   References
Top
 Introduction
 Addressing the problem
 Barriers and interventions for...
 Conclusions
 References
 

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