Partnering with the Patient for Effective Eye Care Delivery

This year marks the tenth year of the global initiative, VISION 2020: The Right to Sight, striving to eliminate avoidable blindness. Looking back at the last ten years, there has been tremendous progress in creating awareness as well as alignment of the global eye care community to the broad mandate of VISION 2020 The Right to Sight. We also have models of service delivery in place, to provide eye care for all the priority eye diseases under this global initiative.

However, we have not achieved a good mechanism to ensure each patient seeks, utilizes and follows the treatment mandated to him. The challenge lies in aligning eye care delivery to the patients. The most common frustrations of eye care providers around the world are:

• low utilisation of eye care services or facilities by the community
• even among those patients who access eye care services, the compliance to medical advice or the treatment protocols, such as medication or surgery or regular follow up, is very poor

For example, an eye hospital in Bangladesh had the mechanism to reach and identify a substantial number of cataract patients. However, only 30% of those who needed it actually underwent the surgery. With such low compliance rates, this is a lost opportunity both to the patients and for the provider.

Cataract Surgeries	Year I	Year II
Surgeries Advised	4,495	3,110
Surgeries performed	1,092 (24%)	1,210 (39%)
Not treated	3,403 (76%)	1,900 (61%)

In conditions such as glaucoma, effective treatment demands regular follow-up visits to monitor intra-ocular pressure in order to prescribe medication accordingly. An analysis of the follow up rate of glaucoma patients after surgery (at Aravind Eye Hospital-Madurai), revealed a steep decrease in a span of four years from 82% to 32%. While efforts have been spent in reaching, diagnosing and treating the patient, the effectiveness of the treatment suffers when he does not come for the essential follow up visits.

How can patients help to improve health outcomes?

In an ideal world, we would expect that our patients, and the community we serve, exhibit favourable behaviour – where each individual:

• knows how to lead a healthy lifestyle and strives to do so

• is able to recognise when his vision is impaired

• knows where appropriate eye care can be accessed

• acts to learn more about his condition and options for its management

• is able to judge what the appropriate treatment option is

• ensures that he receives quality care

• follows the treatment regimen decided upon and arrives for necessary follow up visits

• makes health care a priority while making financial or temporal decisions

• actively promotes a healthy lifestyle to his family, neighbours and community

• actively motivates others to seek treatment when required

We, as service providers, can do much to produce this effect, by empowering our patients and the community to take better control of their health. While it may require time and effort the direct benefits include increased demand generation, better utilisation of resources, improved service quality and ultimately increased effectiveness of the treatment provided.

For the community too, timely intervention helps in promoting continued economic productivity, better prognosis and reduced treatment costs and better quality of life.

Patients as ‘partners’ in healing:

Today, our patients find themselves with no option than to listen to the advice of the doctor – he will either follow it implicitly or disregard it – either way the outcomes are considered the patient’s responsibility. By making the patient a ‘partner’, we make him an active participant in the treatment process where he takes responsibility to understand his condition, where he is able to evaluate his options and make health decisions appropriate to his priorities and adhere to the treatment decided upon.

Patient empowerment, with its multi-dimensional approach, enables individuals or communities to take control of their health. To achieve this stage of pro-activity, the community requires the appropriate knowledge, access to service, ability to evaluate and make a decision based on its priorities.

Angelmar and Berman, in their report titled, ‘Patient Empowerment and Efficient Health Outcomes’, classify the conditions required for patients to assume greater responsibility for healthcare activities under:

Role understanding: Clarify to the patients, what activities are expected of them to ensure better health outcomes

Knowledge: Ensure the patient has the knowledge he requires, to effectively carry out his role and make appropriate decisions – this includes knowledge about:

• his disease

• his options: the different service providers, different treatment options, different payment modes etc

• his own personal health status

• his preferences

Skills: Patients require certain basic skills in order to take better control over their health:

• Self-efficacy: The patient should believe he has the capacity to carry out the activities required for him to take better control of his health

• Health Literacy: The patient should be able to obtain, process and understand basic health information in order to make appropriate decisions pertaining to his health

A facilitating environment: Even though patients may have the required knowledge and skills they may not be allowed to exercise them:

• Right to choose: ensure that patients are allowed to the right to freely choose from among different treatment procedures and choose from different service providers

• Access to information: ensure that they have access to unbiased information which will allow them to take health decisions based on their values and preferences

• Decision aids: provide decision aids to help patients make appropriate choices

• Congruent physician role: this demands that the doctor’s role too should be changed to be congruent to the required patient’s role – the doctor should also endorse patient empowerment in order not to impede the patient’s exercise of his power

• Ensure equity to all patients: Empowerment should ensure that everyone is capable of taking control of their health – today, people of the well-educated or higher income group may have the required skill and knowledge required; so, it is essential that efforts are taken to improve the health literacy of others as well.

It works!

In her study titled, ‘Does physician–patient communication that aims at empowering patients improve clinical outcome?’ Dr. Trummer studied effects of improved communication and better patient systems, in the in-patient care in the cardiac section of a university hospital in Austria.

The intervention included communication skills training for care-givers along with a reorganisation of patient information schemes in a way that allowed clear understanding of what was expected of the patient, while creating a supportive and participatory relationship between patient and care-giver.

The results showed a reduction of length of hospital stay by more than a day and reduction in the incidence of post surgery tachyarrhythmia by 15%. It also showed a tremendous improvement in patient satisfaction in several dimensions including how they perceived the attitude and involvement of the care-givers.

Creating Positive Behaviour Change:

Patient empowerment requires the patient to take on a proactive role in the treatment process. Getting patients to comply with treatment decisions and getting people in the community to proactively seek eye care is not achieved without creating a fundamental change in awareness levels, attitudes and behaviour.

MART, a rural marketing agency successfully demonstrated how such positive change in behaviour can be brought about by facilitating the change. In a situation, where most rural Indian households use fire wood for cooking – causing excessive deforestation as well as being a health hazard due to the exposure to smoke (A WHO study revealed that such women tend to inhale as much carcinogen benzopyrene as if they were to smoke 20 cigarettes a day) – MART’s award winning strategy of setting up community kitchens helped to bring about awareness, acceptance and finally behaviour change towards the use of LPG for cooking.

Patient Empowerment in Eye Care:

Providers of eye care services can improve demand for their services and improve the effectiveness of the treatment they provide by enhancing the patient’s role in the treatment process. This cannot be

expected by today’s patient or in the traditional set up of a hospital where the patient plays a passive role.

By consciously increasing health literacy and awareness about eye care, more patients will proactively seek our services and an enlightened community will educate its members about the different eye conditions and the symptoms to respond to.

The services themselves have to be designed in a way so as to be convenient, accessible and affordable to the patient. The services should be user-friendly and should encourage the patient to take an active part in his treatment and enable him to adhere to the protocol decided upon. This will require the management and the leadership of any institution to endorse that the service should be designed with the patient at the centre. Most importantly, the ophthalmologist should recognise the advantage of empowering the patient.

First Steps:

Each hospital will have to take the first step by changing mindsets and way of working in a few broad areas:

• The organization should build the culture of viewing its services from the patient’s perspective

• To create awareness – the focus should be on the community as a whole

• Effectiveness of one’s services should not be measured just by the volume of patients covered but by how many of them have truly received the best possible visual outcome in the long term.

This can be developed only in incremental iterations and is never a onetime process – it calls for constant reevaluation with incremental and continuous improvement.