Monday, July 4, 2011

A Primer on Motivational Interviewing: The Definition and a Review of the Supporting Science for Disease Management

First, I'll express empathy....
The Disease Management Care Blog typically doesn't don the peer-review swimmies for a jump into the pool of nursing journals, but the title "Motivational Interviewing: A Useful Approach to Improving Cardiovascular Health" was too much to resist.  While "motivational interviewing" is one of those widely quoted catch-phrases that sound good in care management marketing collaterals, what's the science behind the concept and does it really work?

Your handy DMCB investigates by summarizing the article for its thousands of readers.

According to the authors, motivational interviewing (MI) can be defined as "a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence."  Four underling principles of MI are 1) expressing empathy, 2) developing discrepancies between current and desired behaviors, 3) 'rolling' with any client resistance by finding a different way to respond and 4) supporting self-efficacy by building on the client's choosing and carrying out ways of changing. 

It turns out there have been 29 randomized trials that compare MI to usual care, many of which involve substance as well as tobacco abuse, HIV risk behaviors, healthy eating and exercise.  They generally show a positive effect, a dose-response relationship and some evidence that it works even during brief encounters.  That being said, in the area of cardiovascular risk management, the science is still limited by only 6 studies with small sample sizes, varied outcomes, bias, confounding and limited generalizability. 

What's more, we still don't know which elements of MI are essential, which patients are most likely to respond, how it can be made more culturally appropriate, how long it takes to train a health professional (for example, is a one day workshop enough?), how well it addresses underlying patient misconceptions and the best fit in high-volume or fast-paced clinical settings.  It also turns out that there are times when simple advice and nothing more is all that is needed, so MI is not the answer to every patient counseling need.

This was a very helpful review and will be tucked away in the DMCB intelligence files.  It also stands as a good reminder that this corner of disease and population-based care management is still in its infancy and more work needs to be done in better understanding the role of MI.  As population health management continues to evolve, look to the industry to perform additional studies to gain additional insights on how it can be used to drive quality and reduce unnecessary costs. 

Last but not least, the DMCB points out that, based on its reading, MI remains very much a nurse-led intervention: few physicians have the skills or the interest to provide this particular kind of counseling.

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