You have probably heard the term, “evidence-based medicine.” But do you really know what the term means and why it is such a big deal? Evidence-based medicine refers to any healthcare and self-care practice that seeks to apply valid evidence, accrued from the traditional scientific method to improve health outcomes for real people.

A Deeper Look at Evidence-Based Approaches
One way to understand the importance of evidence-based medicine is to look at a couple of examples of what happened when we jumped-the-gun and did not incorporate an evidence basis for a clinical treatment, a self-care recommendation or a community or educational intervention.

Example 1: Several years ago we jumped-the-gun and a medical device manufacturer promoted and sold the Garron Gastric Bubble as a treatment for obesity and weight loss. The small balloon was inserted into a patient’s stomach, then inflated, and the result was the presence of the balloon would give the patient the feeling of satiety, or fullness, causing them to eat smaller portions and to eat fewer calories overall. Because the device was not adequately tested prior to widespread marketing and use, what was not initially understood was over time the balloon would often (too often!) break and cause dangerous, often fatal, gastric blockage. The bubble was taken off the market. If only we had had the evidence to guide better healthcare treatment decisions sooner… (1)

Example 2: You probably remember the DARE Program because it was a part of the health/safety/drug prevention curriculum in almost every school system in the US in the very recent past. The purpose of DARE was to reduce adolescents’ chances of getting involved in illegal drugs and alcohol by giving them skills to resist the temptations associated with use. The DARE strategy used a mix of messages, a friendly policeman in the classroom teaching elementary-age children how to resist drugs and alcohol ~ and ~ at the same time, warning them about the serious punishments that awaited those that did not resist. Recently, we learn from scientifically designed evaluations of numerous drug/alcohol prevention programs, that children exposed to the DARE Program are actually more likely to get involved with alcohol and illegal drugs as adolescents – as compared to children who did not participate in a DARE Program. If only we had had the evidence to guide our educational curriculum choices sooner… (2)

Example 3: Many, if not most, people believe taking a daily vitamin supplement is a good, safe and relatively inexpensive self-care practice to maintain optimum health. Grocery stores and pharmacies have rows and rows of shelf space filled with dozens of daily dietary supplements. For the consumer, never quite sure if they are getting “enough” or “all” of what they need from their food intake, it makes good intuitive sense to insure better health by simply swallowing a vitamin supplement each morning with breakfast. The cost seems low in comparison to the perceived benefit of improving a diet that may is surely lacking in this-or-that. But now, the scientific evidence does not support such practice. After exhausting analysis of study-upon-study, the collective results show there is simply no real benefit to taking vitamin supplements – unless there is a well established medical necessity (pregnancy, menopause, etc.). Sadly, there is not a quick and easy “magic bullet” to remedy a poor diet. If only we had had the evidence to guide us to better consumer choices sooner… (3)

So now that you understand what happens when we practice healthcare and self-care without solid scientific evidence, you have probably a better understanding of the benefits of having an adequate evidence basis a priori (before) the adoption of any treatment, practice, or community intervention – however well intentioned.

Coaching for Activation™ and Evidence Basis
Coaching for Activation™ (CFA) is unlike many health-coaching strategies because it actually has a huge and expanding evidence base to support each and every key principle, recommendation, resource, and expected outcome. The study of activation, and research on the Patient Activation Measure™ (PAM™) actually preceded the development of the CFA approach – and the CFA technique is subject to testing for effectiveness, using rigorous scientific designs, to determine short and long-term outcomes on real people like you and the folks you coach.

The CFA approach guides individuals to evidence based, best practice behavior by customizing the interaction for each level of activation. Individuals who are lower in activation will not step up to best-practice care simply because they’re told its important. Key skills, knowledge and confidence must be developed to move an individual toward best-practice or evidence-based care. For most individuals, achieving best-practice self care does not occur until Level 3 or 4.

For example, a Level 1 person with Type 2 Diabetes might be encouraged to simply pay attention to the amount of care, or lack of care they give to their feet. At Level 2, they might be encouraged to learn why proper diabetic foot care is so important – and the health coach would lead the individual to activation-level appropriate resources to fill in the existing knowledge gaps. At Level 3, individuals are supported as they move to engage in proper and routine foot care. And at Level 4, the focus in on maintaining, through thick and thin, the correct foot care practices previously established.

As we uncover new “learnings,” or evidence, from both science and practice, they are incorporated into the CFA approach., Our science-based findings are openly disclosed with the larger world of healthcare and health policy researchers through peer-reviewed research journals.

We welcome your thoughts, opinions, concerns, and questions on this blog. Thanks for reading and for sharing!

1 E Mathus-Vliegen: Intragastric Balloon Treatment for Obesity: What Does It Really Offer? Dig Dis 2008;26:40-44
2 General Accounting Office: Youth Illicit Drug Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify Effective Programs. GAO-2003-172R
3 Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, and C Gluud: Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases (Review). The Cochrane Collaboration 2008, Issue 2

Health care providers have been largely blind to individual differences in self-management competencies. Yet, as health care has grown more complex, and the patient’s role in the care process is enlarged, this one-size-fits all approach adversely affects patient outcomes and adds to wasteful spending. It is clearly inefficient when patients are unable to follow through on treatment regimens or when they experience avoidable health crises. Yet, we continue to operate with the implicit assumption that patients can manage even the most onerous tasks and life-style changes if they are simply exhorted to do so. Only when patients are “drowning” in the deep end of the pool, is a more substantive life -line thrown to them, in the form of care management or disease management. The lifeline may be sufficient to keep them from drowning, but it may not build the capacity that enables the individual to “swim” on their own.

The “Patient Activation Measure™ Method” takes a unique approach in addressing the above deficiencies.

First, by starting with PAM™ measurement, it is possible to gain an understanding of the degree to which the individual is goal oriented about their health. Activation level also gives insight into whether the individual feels overwhelmed with the process of managing their health. It further sheds light on the specific behaviors that are realistic for individuals to tackle. Finally, measurement gives the clinician or coach feedback on whether and how much progress is being made. Accurate insights about patient competencies for self-management and reliable measurement for tracking progress are essential for effective patient support and have been absent from the care process. One could argue that a patient’s level of activation is another “vital sign” that should be known and tracked just like blood pressure.

Second, based on the insights gained from measuring activation, it is possible and desirable to tailor support for the individual. For example, we know that those who are low in activation feel overwhelmed with the task of managing their health. Because there is so much they know they should be doing, and they know they can’t manage to do it all, they ‘freeze up’ and do nothing. For these individuals, the primary goal is to help them reduce the feelings of being overwhelmed and help them focus on something they can achieve. Giving the low activated “permission” to not deal with their long list of tasks, but to focus on only one thing for right now, often “unfreezes” them and helps them to start taking action. For individuals who have started taking action, for example at activation level 3, helping them to set realistic goals and to problem solve on how to overcome barriers will help these individuals move forward in taking control of their health. Starting where the individual is, is the key. Pushing a low activated person to do more than they are ready for, just keeps them in their “frozen” position.

Third, the goal of the PAM method is not to simply increase compliance or to change a “risk behavior”, but to build capacity in the individual to manage their health and health care. Our research shows that when people start to feel more activated, they change several behaviors not just one. This indicates that taking a developmental approach (starting where the individual is and encouraging them forward), one that focuses on increases activation, will yield greater results than simply trying to achieve compliance. That is to say, the goal of both wellness programs and chronic illness care should be to build self-management capacity within the individual. unhealthfulness

By changing the focus from compliance to capacity building, organizations using the PAM method, are revolutionizing health care.