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Physician tips: Motivating Behavioral Change for Liver Health

As a physician you know that for most of your patients at risk of liver disease, the one best thing they can do is to lose weight, and the hardest thing to do is to motivate them to do so.

According to the Patient Protection and Affordable Care Act, patient engagement and activation is no longer an academic question. Pay for performance and quality of care policies are increasing responsibility for patient outcomes on clinicians. Figuring out what works, however, is an inexact science.

Patient activation is defined as having the knowledge, confidence, and skills to take care of one’s health and healthcare. In short, patient education is often not enough to get people to change. Getting them to take steps toward improving their health is key.

Research has shown that getting patients to participate in a program is more successful in achieving behavioral and lifestyle change. A 2012 Italian study showed that patients with NAFLD participating in a cognitive behavioral program significantly improved their general and liver parameters and sustained the beneficial effects at 2-year follow-up.[i]

The study was carried out within a tertiary referral center and many such medical centers offer a range of programs for health improvement. Connecting with the healthy living director at your institution can help with incorporating wellness programs into your practice.

If you are not affiliated with such a center or your institution doesn’t offer such programs for your liver patients, there is still so much you can do to move patients from contemplation to activation.

In a 2016 study in the Annals of Family Medicine[ii] conducted by Fairview Health Services an Accountable Care Organization (ACO) in Minnesota, researchers identified 7,144 patients who had shown both positive and negative activation measured by two PAM (patient activation measure) scores.

They then matched patients scores with 54 clinicians who had 40 or more patients with serial PAM scores and analyzed them. They then ranked the top 15 clinicians based on median positive change scores and 15 clinicians with median negative change scores or bottom performers.

Using a standardized 30-minute interview guide to explore how the clinicians handled situations when patients did not make recommended behavior change, they found 5 key strategies for successfully motivating patients to activation:

  • Focus on patient ownership of their own health. Establishing a coaching relationship that clearly places the responsibility of improving health on patients.
  • Partnering with patients to co-create goals and strategies to positive change and to solve problems
  • Identification of small steps toward change and helping patients identify those steps that allow patients to succeed in accomplishing those steps and gain confidence in their ability to change.
  • Frequent follow-ups are key to the coaching relationship. Such follow-ups need not be face-to-face, successful clinicians also made effective use of the patient portals of their EHRs to communicate with patients.
  • Acting with care and concern establishes the strength of connection needed to convince patients the effort matters not just to the clinician but to their loved ones.

By contrast the warning strategy was most commonly used by the bottom performers, i.e. listing the consequences of bad behavior. Not surprisingly, top performers were optimistic about their patients while less successful clinicians were more pessimistic, which tended to result in “giving up patients.”

Interestingly both groups of clinicians had arrived at their strategies through trial and error, adjusting their approaches to support behavior change, which speaks to training and the lack of research in the area of patient behavior and patient activation.

To address that deficiency the researchers are conducting a follow-up study with a larger provider sample. If that study validates the strategies identified in this study, the researchers plan to develop training to help clinicians to apply them.

Fibronostics is a healthcare technology company providing algorithm-based solutions in a variety of diagnostic tests to support clinician decision-making. LiverFAStTM is the premier non-invasive liver disease screen for early detection of steatosis, NASH and fibrosis. It is simple, less expensive and offers greater confidence in determining a patient’s level of liver injury and stage of liver disease. Its easy-to-read graphical report makes it ideal for starting the lifestyle conversation with patients.

HealthFACTR is an algorithm-based, broad spectrum health assessment tool targeting & visualizing several of the most critical risks to a person’s health and longevity. It is a scientifically based test addressing key focus areas adversely affecting human health. It has robust clinical support using state-of-the-art gold standard testing methods and backed up by hundreds of clinical support papers. Heart disease, Diabetes, Stroke, Liver disease, Obstructive Sleep Apnea, Cholesterol, Triglyceride, Blood Pressure, HDL, LDL, Diet Assessment, Fitness Assessment, Fitness Goals, Body Fat Analysis - are measured, individual risk assessed, and actions recommended to reduce disease progression. HealthFACTR provides detailed visualization into a person’s metabolic health risks and fitness.

Contact us via email, or by phone at 1-888-552-1603 today to learn more about our LiverFASt™ family of diagnostic tests and HealthFACTR services. 


[i] Moscatiello, Luzio, et al. Cognitive-Behavioral Treatment of Nonalcoholic Fatty Liver Disease: A Propensity Score-Adjusted Observational Study. Obesity, Sep. 6, 2012

[ii] Greene, Hibbard, et al; Supporting Patient Behavior Chante: Approaches Used by Primary Care Clinicians Whose Patients have an Increase in Activiation Levels. Annals of Family Medicine, Vol. 14, No. 2, March/April 2016

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