Cystic fibrosis: an example of research and practice
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1 Cystic fibrosis: an example of research and practice Dr Gary Latchford 2015
2 Plan Questions from earlier presentation Cystic Fibrosis Our work in CF: Clinical practice, research, and a focus on adherence
3 Questions?
4 Cystic Fibrosis (CF) Inherited (Autosomal recessive) Commonest inherited life limiting condition in Caucasians (1/2500 affected births) Typically presents in childhood
5 Mutation Mutation in cystic fibrosis transmembrane regulator (CFTR) Chloride blocked mucus builds up (e.g. in lungs) Multisystemic consequences
6 Consequences Lungs prone to infection & damage Diabetes Poor weight gain Infertility Nb segregation
7 Consequences Prognosis improving Before 1939, 85% died by age 2 Predicted survival 40 yrs for 1990 birth cohort But heavy disease burden And intrusive adherence regimen Physiotherapy to keep lungs clear Tablets with every meal Antibiotics to keep lungs sterile And more!
8 One Day s Treatment!
9 Adherence A study of nebuliser use (for anti-biotics) in CF: < 40% adherence. No one taking all medications as prescribed. Latchford, G., Duff, A., Quinn, J., Conway, S. & Conner, M. (2009). Adherence to nebulised antibiotics in cystic fibrosis. Patient Education and Counselling, 75:
10 CF in Norway Approx. 280 patients with CF in Norway About 60% over 18
11 What we do in Leeds Clinical services Research Our work on adherence
12 Clinical services Adult regional unit Paediatric regional unit Brownlee brothers in Triathlon!
13 Clinical Services 2 psychologists in paediatric unit (1.5 wte) 2 psychologists in adult unit (1.2 wte) Reasons for referral? Paediatric: adherence, procedural distress (e.g. needles), parental anx/dep, pre-school behaviour problems (esp. feeding), child/adolescent anx/dep Adult: Psychological support (& trauma), anx/dep, OCD, adherence
14 Clinical Services Recent survey on anxiety and depression (TIDES study) Higher rates in parents Rates for adults with CF? No higher than general population in Leeds (Latchford & Duff, 2013) Because already receiving psychological support? Individuals do become distressed; related to decline in health & serious consequences..
15 Clinical Services Currently screening patients and parents using depression and anxiety measures Also using routine, sessional measurement of outcome and therapeutic alliance
16 Research Adult regional unit Clinical Psychology Training Programme Paediatric regional unit
17 Research Recent Clinical Psychology Trainee doctoral research in CF Adherence beliefs of children and their parents Experience of education and employment Experience of young mothers with CF Beliefs about new drug treatments Decision making about risk of infection
18 Our work on adherence
19 Tackling adherence Individual referrals But too many patients: team needs to change practice How can we help the team change? Duff AJA; Latchford G. Adherence in cystic fibrosis; care teams need to change first. The Lancet Respiratory Medicine. 2014; 2 (9):
20 Training CF teams in Motivational Interviewing (MI) 1. Provide training in adherence: Potential reasons for non-adherence (e.g. Rob Horne s necessity/concerns framework) Behaviour change techniques 2. Provide training in MI 3. Help team think about support and organisational change
21 Society Social/ cultural Influence Beliefs about treatment Family & Friends Context & resources Patient Aspects of treatment The Treatment Health Professional Team Emotion Knowledge Self-belief/ confidence Values Organisation & Planning
22 The Necessity-Concerns Framework (Horne, 1997, 2003, 2006) NECESSITY Do I need the medication? Will it work? CONCERNS Will I get any adverse effects?
23 The change process Beliefs, behaviours, etc. The Team Support Change in clinics etc The Decision Motivational Interviewing Behaviour Change Techniques The context of the team
24 What is MI?
25 Motivational Interviewing: origins It began with alcohol, where the traditional treatment was Confront the patient until they accept their illness Assumption: unless the patient admitted they were an alcoholic, they would not get better What happened? Patients denied the problem Conclusion? Put down to poor willpower
26 Motivational Interviewing: the idea An alternative view from Bill Miller: Motivation is not fixed it goes up and down! Motivation is a product of the situation So confronting someone makes them more stubborn Instead, motivational interviewing is designed to enhance motivation to change Worked with Steve Rollnick: MI applied to many behaviours, including physical health
27 A definition of Motivational Interviewing A directive, client-centered counseling style for eliciting behaviour change by helping clients explore and resolve ambivalence Rollnick and Miller, 1995
28 Key ingredients Avoid confrontation Don t impose change on patients Instead, help them to talk about their ambivalence and resolve it by choosing to change Readiness to change is not a trait, but a fluctuating product of interpersonal interaction Aim for a partnership, not expert/recipient
29 Key skills & principles Expressing empathy Reflective listening Respect client autonomy
30 The spirit of MI (Rollnick and Miller, 1995) But also: Motivational Interviewing is not a series of techniques for doing therapy but instead is a way of being with patients Bill Miller
31 What s it like? Jones, Latchford & Tober: client experiences of MI, an Interpersonal Process Recall study
32 What s it like? Jones, Latchford & Tober: client experiences of MI She s driving the conversation, very very subtly, that s the trick She s allowing me to take the reigns of the conversation, but she s steering it very gently, allowing me to get out what I need to.
33 She s made us think about stuff I didn t even know I was thinking.
34 Does MI work? Extensive research base (> 100 trials) E.g. some of the largest psychotherapy RCTs (Project MATCH, UKATT ) 6 Meta analyses, most recent: Lundahl et al (2013) 48 RCTs in health
35 Does MI work? Group of comparison Weak (Waiting list, treatment as usual, written materials ) Strong (12-step program or cognitive behavioral therapy) Bigger effect when compared with a non-psychological intervention Effect size (1=standard deviation) CI < As effective, no better as expected BUT quicker (3 or 4 sessions) p
36 Are teams using MI already? No Moran, Latchford and Bekker (2008): analysis of routine consultations in a diabetes clinic Minimal to no use of MI style Patient centred style: higher patient satisfaction & greater expression of views So if MI is to be used by teams, they need to be trained
37 Training health professionals in MI Difficult! No time Professionals sometimes think they are doing MI but are not Therapist drift after training (Miller & Mount, 2001)
38 Training CF teams in MI Established training package: 2 sessions, three months apart Trained CF teams together in UK & Ireland Feedback from questionnaire & telephone interview
39 Training CF teams in MI Positive feedback: teams like MI; believe it improves practice Barriers and facilitators: Support after training Changing team culture Duff AJ; Latchford GJ. Motivational interviewing for adherence problems in cystic fibrosis; evaluation of training healthcare professionals. J Clin Med Res. 2013; 5 (6):
40 Embedding MI in CF care Teams are very important in CF MI in context of support from team: Training for staff Supervision and peer support Embed MI in clinic structure Current work: training adherence advocates/champions as resources for the team
41 Takk! Noen Spørsmål?
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