PowerPoint PresentationChanging Patient Behavior is Easier Said Than Done Betty Rabinowitz, MD FACP CMO NextGen Healthcare Rochester, NY
Presenter reports no conflicts of interest at time of presentation. 
• Describe the principles of self-determination theory
• Identify how to apply Self-Determination Theory to  health care encounters and complex patient  situations 
Learning Objectives
2020 Causes of Death
Hypertension Smoking High Cholesterol
Yusuf et al., INTERHEART Lancet 2004;364:953-962
• Overall lifetime risk for CVD was 60.3%  for men and 55.6% for women.  This is the biggest single risk we all face in our  lives.
• Tobacco use, high cholesterol and blood pressure account for  the majority of this risk.
The Impact of Healthy Lifestyle Factors on Life Expectancies
Circulation 2018 Jul 24;138(4):345-355.
Yanping Li et al., Circulation 2018: 137
Factor Impact
BMI – 18.5 to 25 Gain 2-4 years
Moderate Alcohol Intake Gain 2 years
High Quality Diet Gain 4 years
150 minutes Physical Activity per week Gain 4-6 years
All Cause Mortality for 0 risk vs. 5 risk factors  - 0.26 (CI 0.22-0.31)
Cancer Mortality  - 0.35 (CI 0.27-0.45)
Cardiovascular Mortality  - 0.18 (CI 0.12-0.26)
Adopting 5 at age 50 Life expectancy >14 years longer for women
Life Expectancy >12 years longer for men
The Impact of Low-Risk Factors
• The projected life expectancy at age 50 years was on  average 14.0 years longer among female Americans  with 5 low-risk factors compared with those with  zero low-risk factors 
• For men, the difference was 12.2 years longer
Adopting a healthy lifestyle could substantially reduce premature mortality and prolong life expectancy in US adults.
- 10 -©2021 MGMA. All rights reserved.
Not Many Patients Adhere to Our Recommendations•    
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338986/
change for > 1year 
smoking with best  of treatments
20-30% of medication  prescriptions are  never filled
Approximately 50% of  medications for 
chronic disease are  not taken as  prescribed
A third of kidney  transplant patients don’t  take their anti-rejection 
medications
cardiovascular disease and  its major risk factors have 
poor adherence to  prescribed medications
Statin Persistence for 1 Year After Initiation
Patients High Adherence (80% days covered)
Number analyzed
No DM & No MI  37% 2,200,000
• Fear • Cost • Misunderstanding • Too complicated drug regimens • Lack of symptoms • Mistrust
Extrinsic Versus Intrinsic Motivation
• Extrinsic motivation: completing a task or exhibiting a  behavior to avoid punishment or receive a reward
• Intrinsic motivation: doing an activity for its inherent  satisfaction rather than for a separable consequence
Human Psychological Needs
integrity and well being  
When satisfied,  evidence of thriving
Basic psychological  needs: essential for  psychological growth,  integrity and wellness
Natural rather than  acquired
Psychological Needs: Supporting Optimal Motivation
Deci & Ryan, 1991, 2000
• The need to feel choiceful and volitional in  one’s behavior
• The need to feel optimally challenged and  capable of achieving outcomes
Autonomy
• The need to feel connected to and  understood by important others
Competence
Relatedness
Self-Determination Theory Versus Behavioral Theories
• Behavioral approaches typically involve rewards or  penalties or try to lower barriers
• Applying self determination theory principles increases  human energy to overcome barriers by working to  support and satisfy our psychological needs.
The Undermining Effect: Deactivation of Bilateral Striatum as a Function of Rewards in Subsequent Performance
Intrinsic Motivation Can Be Facilitated
The Clinician’s Role in Autonomy Support
Elicit and  acknowledge  the patient’s  perspectives  and feelings
01
Explore the  patient’s values  and how they  relate to the  behavior being  addressed
02
03
Provide  alternate  options for  change and  acknowledge  the option of  NOT changing
04
05
The Clinician’s Role in Competence Support
Be Positive the  patient can  succeed
01
02
04
Develop a plan  that is  appropriate for  the patient’s  abilities
05
06
The Clinician’s Role in Relatedness Support
01 02
Remain non- judgmental and  provide  unconditional  positive regard 
01 02 03 06
US Preventive Services Task Force 5A’s
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/tools-and-resources-for-better-preventive-care
Arrange follow-up