Elders As Medical Consumers

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Elders as medical consumers

Running Head: ELDERS AS MEDICAL CONSUMERS

How consumer-oriented are our elderly?: A test of the medical consumer model.

By

Elayne Shapiro, Ph.D.

University of Portland

5000 N. Willamette Blvd

Portland, OR 97203

Joanna Kaakinen, Ph.D., R.N.

University of Portland

5000 N. Willamette Blvd

Portland, OR 97203

And

Barbara Mae Gayle, Ph. D

University of Portland

5000 N. Willamette Blvd

Portland, OR 97203

Presented at

APHA November 17, 2003

San Francisco, CA

Draft 3

How consumer-oriented are our elderly? A test of the medical consumer model

As the numbers in our elderly population grow, health care provider (HCP) communication with elderly patients increases in importance. Yet, the path to positive health outcomes is complex. Many different models have been proposed to optimize health care outcomes for the elderly (Cox, 1982, Pendleton, 1983, Williams, 1990). One issue germane to positive health outcomes is the extent of patient involvement in decision-making. Decision-making, characterized by physician dominance, is sometimes described as a paternalistic health care model in contrast to consumerist decision-making, in which the patient assumes a more active role. The movement from a paternalistic approach to more consumerist interaction has gained interest in the last thirty years (Ballard-Reisch, 1990; Beisecker, 1990; Beisecker & Beisecker, 1993; Haug & Lavin, 1981; Reeder, 1972; Roter, Stewart, Putnam, Lipkin, Stiles, & Inui, 1997; Strull & Lo, 1984)..

Research has demonstrated the value of participation by patients in HCP-patient encounters regardless of who steers the interaction (Greenfield, Kaplan & Ware, 1985; Greenfield, Kaplan, Ware, & Yano, 1988; Kaplan, Gandek, Greenfield, Rogers & Ware, 1995). A number of variables influence whether or not patients want to contribute to decision-making (Beisecker, 1990; Beisecker, 1996; Blanchard, Labrecque, Ruckdeschel, & Blanchard, 1988 ;Ende, Kazis, Ash, & Moskowitz, 1989; Thompson, Pitts, & Schwankovsky, 1993). In this essay, we compare the consumerist health care model to the paternalistic health care model to begin exploring the importance of patient participation in generating positive health outcomes. Specifically, we explore whether there are differences in the way various age groups of elderly clients enact a consumerist perspective. Finally, we present the results of research that surveyed boomers (55-64), young-old (65-74), old (75-84) and old-old (85 years and above) to compare their consumerist behaviors in terms of their internal motivation to participate in health care decision-making, their assertive behaviors in a health care interaction, and their propensity for making overall judgments about their health needs.

Consumerist versus Paternalistic Model

The medical consumerist model (Haug & Lavin, 1981; Reeder, 1972) maintains that patients assume an egalitarian power relationship with their health provider. In contrast to the paternalistic model, (where power resides with the health care professional), the patient in the consumerist model assumes an active decision-making role. Hibbard and Weeks (1987) explained that “A good patient is compliant, trusting and uncomplaining; a consumer, on the other hand, is questioning, willing to make independent judgments on whether to accept physician advice, and seeks out alternative sources of information “ (p. 1020). In its extreme, the paternalistic medical model views the patient as passively dependent receiving little information concerning treatment processes and outcomes (Reeder, 1972). Concomitantly, the extreme consumerist model “focuses on patient’s rights and physician’s obligations, rather than on physician rights (to direct) and patient obligations (to follow directions)” (Haug & Lavin, 1981, p. 213). In the consumerist paradigm, participation in decision-making and choice about treatment prevail.

Beisecker and Beisecker (1993) highlight the implications of the two metaphors, consumerism and paternalism. Paternalism focuses on obligations, beneficence of the HCP, trust of the HCP, and the principles of good medical care overriding individual treatment preferences. In contrast, consumerism focuses on rights of the patient, accountability of the HCP, and the importance of individual treatment preferences. When HCP and patient enter into the interaction with different metaphors, conflict may result (Beisecker & Beisecker, 1993). When patients do not participate in decision-making poorer health outcomes may result (Greenfield et al., 1985; Greenfield et al.,1988; Kaplan et al., 1995). Thus, the power of each participant varies according to the model enacted and the equality of the relationship is hindered by the selection of either stance which may affect the HCP/client interaction.

Importance of Participation for Health Outcomes

Participation in decision-making affects health outcomes. In a study of ulcer patients, Greenfield et al. (1985) found that increased involvement by patients resulted in fewer limitations imposed by the disease on patients’ functional ability. Greenfield et al. (1988), who studied diabetic patients that were coached for increased patient participation, found blood sugar control and patient functioning in every day life significantly improved over a control group that did not receive coaching and who participated less in their own health care decision-making. Kaplan et al. (1989) looked at patients with ulcer disease, hypertension, diabetes, and breast cancer and discovered that better health, measured physiologically, behaviorally, and subjectively resulted when patients are involved in health decision-making. The researchers noted that the nature of chronic disease involves substantial responsibility by the patient for implementing treatment and participative decision-making on issues that affect one’s life style may ensure follow-through. Overall, participation in health care decision-making appears to promote positive health outcomes.

In a review of twenty-one studies, Stewart (1995) found that communication elements were significantly related to positive health out comes. Sixteen studies were identified that relate to communication and: symptom resolution, role limitation, functional status, blood pressure, self-perceived health status, and pain. Stewart, Brown and Galajda (2000) discovered that physicians who ask questions about patients’ problems, concerns, expectations, and functional difficulties and show support and empathy have better client follow through. These authors also found patients engage in more positive health behaviors when they express feelings, opinions, and information, perceive that a full discussion of the problem occurred, feel they were encouraged to ask questions, and successfully obtain information either through their HCP or information packets. When the physician and patient agreed about the problem and the follow-up and the physician has given lots of information accompanied by emotional support, the patient is more likely to experience positive health outcomes (Stewart et al., 2000). Recognizing the variability in response to participative decision-making among the elderly is important in trying to achieve positive health outcomes (Stewart el al., 2000).

Taken together, the studies linking positive health outcomes to communicative interactions suggest that a consumerist or paternalistic stance may be in part negotiated between the health care provider and the patient. Clearly, though patient participation in discussion with the health care provider appears to be more beneficial in producing positive health outcomes than being told what to do by the health care provider.

Likelihood of the Elderly Enacting the Consumerist Model

In comparison studies of younger and older patients (Beisecker, 1988; Ende et al., 1989; Greene, Hoffman, Charon, & Adelman, 1987), most elderly patients were found to be less likely to engage in the consumerist model and were perhaps more interested in their providers’ ability to understand the ramifications of their health issues than dominating the decision-making process. These studies focused on provider dominance, patient satisfaction, age and age-related factors. Yet, no differentiation was made between various elderly age cohorts as most studies considered the elderly population to encompass individuals 60 to 65 years-old.

As early as 1979, Haug reported that the elderly (over 60) accepted authority more readily than younger patients. Beisecker (1988) observed that as age increased elders (over 60) preferred to put themselves in the hands of the doctor. Yet, Ende et al. (1989) emphasized that patients, regardless of age, desired information about a wide range of medical areas that pertained to their health even if they did not want to make decisions.

Other studies explored the authority relationship between patients and their health care provider and the influence of age-related factors. Ende et al. (1989) explored the idea of health status and found that as patients’ health declined so did their desire to make decisions. Street and Weimann (1987) noted that the relationship between dominance and satisfaction depended on how anxious a patient felt about her or his health. These authors discovered that the more anxious patients expressed more tolerance for dominance.

It appeared that those patients who were willing to take an active role in their health care decisions shared other characteristics besides age. Strull, Lo, and Charles (1984) found that patients who wished to help make decisions were more likely to be white, more highly educated, and had higher income levels. Indeed, Roter, Stewart and Putnam (1997) reported that the consumerist pattern was more often observed in the youngest healthiest group of patients. Some authors suggest that it is the patient’s behavior that influences their role in the health care provider/client dialogue. Kaplan et al. (1989) reported that elderly patients tend to use fewer conversational behaviors such as question-asking, interrupting, and asserting opinions, compared to other age groups. Strull et al. (1984) pointed out that while some patients may prefer/enact a more passive role, it may work against their ability to control the effects of their disease.

Part of Cox’s (1985) research focused on the importance of a patient’s internal motivation and their willingness to actively participate in exchanges about health outcomes. Cox viewed motivation as an important antecedent variable and correlate of the client’s cognitive and affective responses to health concerns, the type of health care intervention and interaction expected by the client, and the client’s health outcomes subsequent to the intervention. To measure intrinsic motivation, she developed and tested the Health Self-Determinism Index which separates the contributing roles of judgment, behavior, sense of competency, and responsiveness to internal or external cues (Cox, 1985). Cox and Wachs (1985) discovered that an individual's total health self-determinism score was best predicted by age, sex, and education. In all cases, as respondents' age increased, their scores decreased, indicating that older people were less intrinsically motivated overall to actively participate in their health decision-making, specifically with respect to judgment, behavior and internal/external cue responsiveness. It is possible that older people attribute higher status to members of the health care professions or feel that it is the responsibility of providers to know what is best for their clients' health. Thus, understanding the intrinsic motivation of an age cohort might provide explanation for the desire to, or not to, participate in health care decision-making.

In sum, it appears that adults who are younger, in better health, wealthy, intrinsically motivated, and educated are most likely to embrace the consumerist model. Elders in poor health, less educated, less intrinsically motivated, and less wealthy are more susceptible to the paternalistic health care model. Yet, research suggests that participation can improve health outcomes. Thus, it seems reasonable to explore how various aged senior citizens use a consumeristic approach to their health.

Study Questions and Procedures

Questionnaires were constructed to measure seven aspects of the consumerist behavior. The elderly sample was gathered using a variety of methods articulated below.

Procedures

The elderly sample for this study was obtained from members in a senior center and elders who live independently or in assisted living facilities. Researchers contacted the managers of the senior center, assisted living facilities or independent retirement communities to seek permission to survey residents. In all cases, researchers personally contacted or approached seniors and asked them if they would be willing to participate in a study that was looking at seniors’ communication with their health care providers (HCP). At the time of the survey, the elderly subjects were provided a human subject’s agreement and informed that they could withdraw from the study at any time by calling the researcher identified on the human subject agreement form and providing their survey number. No subjects withdrew from the study. Names were not used and there was no master list of participants. Seniors were given the option to complete the survey without the researcher helping them to read the questions or having the researcher read the questions with them. Both options were used by the elders.

The Baby Boomer sample was collected using both snowball and convenience sample technique. For two thirds of the Boomer sample, nursing students were asked to give the survey to their parents if they were over 55 years of age. Each survey was accompanied by a human subjects’ agreement, including the option to withdraw from the study at any time by calling the researcher and providing the number at the top of their agreement form. No subjects withdrew from the study. Subjects were not identified in any way in the study. An addressed and stamped envelop was provided so the survey could be mailed back to the researcher. For the other third of the Boomer sample a snowball technique was used.

This study included 62 women and 30 men. Table 1 illustrates the distribution of the participants by age groups.

Table 1: Age Distribution of Participants

Age / Frequency / Percent
Boomers / 52-64 / 31 / 26.5
Young-Old / 65-74 / 19 / 16.2
Old / 75-85 / 24 / 20.5
Old-Old / Above 85 / 18 / 15.4

Scales from both Haug (1979) and Cox (1985) were used to construct a questionnaire that assessed the efficacy of six hypotheses posed to test the various age cohorts of elderly patients’ affective, cognitive, and behavioral response to the consumerist model of health care decision-making. Each of the hypotheses and the way they were measured is articulated below.

Based on previous research by Beisecker (1988), Ende et al., (1989) and Greene et al. (1987), suggesting that different age groups put more decision-making power in the hands of the health care provider, we predicted that “there is a significant difference between various aged elderly groups and their overall consumer behaviors.” (Hypothesis One). To test the elderly’s overall consumeristic tendencies, respondents were asked one forced choice question based in part on the Haug (1979) and Haug and Lavin (1981) studies. Respondents determined 1) whether they “wanted their medical provider to give them their diagnosis and tell them what to do,2) ” whether they “wanted to hear all the information about their diagnosis and be asked what they wanted to do,” or 3) whether they “wanted to hear all the information, hear the medical provider’s advice, and make their own decision “