Health Education for Patients with Chronic Conditions

For chronic conditions, patient health education can reduce mortality and morbidly, in part due to self-managing tasks and understanding of proper medication use. Previous studies have indicated that health professionals sometimes fail to provide adequate health education, leading to ineffective therapies, return visits, and iatrogenic illnesses.

Some noted barriers to health education include failure of insurance companies to provide reimbursement for education services, lack of time for the physician to spend counseling the patient, and lack of confidence of skill set in counseling among healthcare providers.

A recent study examined how health education provision by physicians, physician assistants (PAs), and nurse practitioners/certified midwives (NPs) may differ [Centers for Disease Control and Prevention. 2014; DOI:dx.doi.org/10.5888/pcd11.130175]. The researchers analyzed data from 5 years of data—2005 to 2009—from the outpatient department subset of the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NHAMCS is administered annually by the National Center for Health Statistics at the Centers for Disease Control and Prevention and is designed to collect data on the use and provision of ambulatory care in hospital emergency and outpatient departments.

The following data is collected for each patient on the patient record form:

            · Demographic characteristics

            · Symptoms

            · Diagnosis of chronic conditions

            · Vital signs

            · Diagnostic and screening services provided

            · Health education provided

            · Treatments implemented

            · Provider type

A final sample of 136,432 adult patients were included with the following chronic conditions:

            · Asthma

            · Chronic obstructive pulmonary disease (COPD)

            · Depression

            · Diabetes

            · Hyperlipidemia

            · Hypertension

            · Ischemic heart disease

            · Obesity

Patients were excluded from the study if they made a visit for a new, undiagnosed condition, made a presurgery or a postsurgery visit, were <18 years of age, or the visit included care by >1 provider type (any combination of physician, PA, and NP).

A list of health education needs for each chronic condition was developed using national and international treatment guidelines (See Table below). Providers were credited for delivering health education if they documented it in the patient record. 

The researchers determined the number of patient visits for each type of provider—physician, PA, NP—and computed the percentage of patients who received health education from each.

The researchers found that health education was not routinely provided to patients with chronic conditions. The percentage of visits where health education was provided did not reach 50% for any combination of health education and provider type listed in the Table below.

Health education ranged from 13% for patients with COPD or asthma who were counseled on tobacco use and exposure by NPs to 42.2% for patients with diabetes or obesity who were provided counseling on exercise by PAs. NPs were more likely to provide counseling on diet or nutrition (odds ratio [OR], 1.6; P<.01) and stress management (OR, 2.68; P<.001) than physicians or PAs. PAs and NPs were more likely to provide counseling on tobacco use and exposure (OR, 3.42; P<.001; OR, 1.72; P=.03, respectively) and weight reduction (OR, 2.5; P=.002; OR, 1.96; P=.007, respectively) than physicians. Overall, health education rates were higher among PAs and NPs than among physicians.

The researchers reported limitations of the study, including that only health education elements documented by providers could be assessed, not what was actually provided during the visit, and although the NHAMCS data collection is representative of primary care delivered in hospital-based clinics throughout the United States, the survey is not representative of primary care as a whole in the country. NHAMCS data does not provide details on the health education provided, so the researchers were not able to describe the amount or quality of health education provided, track the health outcomes of patients who did receive health education, or assess whether the education provided was delivered in a culturally-competent manner or provided to the patient in the language they would understand.

The researchers reported potential reasons for the difference in health education per provider, including different training, differing roles within a clinic, or increased clinical demands on physicians. They suggested more research is needed to understand the causes for differences in health education and potential opportunities to increase the delivery of specific education to patients.