Making Sense of Motivational Interviewing, Part 2: Clinical, Economic, and Other Evidence

This article is the second of a 2-part series. In part 1, we (1) briefly described motivational interviewing (MI), (2) provided an example of how it works, (3) explained our conceptual approach to MI, and (4) explained why it is so effective in helping patients engage in healthy behaviors (taking their medications, losing weight, quitting smoking, etc). In this article, we describe the clinical and economic effectiveness of MI compared with traditional counseling methods used by health care professionals (HCPs).

Because MI training for HCPs varies considerably in terms of quantity and quality, any review of the efficacy of MI must factor in the type and the extent of training involved. The literature consistently shows that when MI training is of sufficient length and appropriate quality, MI is highly effective at promoting health behavior change and better clinical outcomes. The effectiveness of MI has been especially well established in the substance abuse literature.¹ As an intervention, MI has the lowest sustained relapse rates for substance abuse. Given the overwhelming success of MI in treating substance abuse, it seemed reasonable that MI might also be useful for facilitating constructive behavior related to chronic disease management. Therefore, the studies reported here focus on health care and HCPs who received training of sufficient length and quality. Sufficient training requires a minimum of 8 hours focused on mastering MI strategies to engage patient sense-making in a nonthreatening way.

Clinical and Economic Evidence of the Efficacy of MI in Health Care

Numerous studies have supported the use of MI in health care to reduce cholesterol level, blood pressure, blood alcohol level, weight, etc.^2-9 For example, Simpson et al demonstrated statistically significant decreases in weight and body mass index (BMI) in a randomized clinical trial in which the treatment group received MI interventions.¹⁰ Other studies have shown the effect of MI on various cognitive and emotional variables underlying patient sense-making and decision making. More specifically, Linden et al used MI-based health coaching for 160 chronically ill patients and compared the results with 230 chronically ill patients who did not receive this coaching over the same period of time. Patients coached with MI improved their scores for self-efficacy (P = .01), patient activation (P = .02), lifestyle change score (P = .01), and perceived health status (P = .03) versus patients not coached with MI. Fewer participants increased their stages-of-change risk (eg, moved from Preparation back to Contemplation or Precontemplation) over time, than nonparticipants (P <.01). In addition, more participants decreased their stages-of-change risk over time (eg, moved from Precontemplation to Contemplation or Preparation) than nonparticipants (P = .03).¹¹

Various reviews of research have confirmed the overall effectiveness of MI in increasing patient and provider satisfaction and in producing better health outcomes. For example, Rubak et al¹² concluded the following:

• MI “…outperforms traditional advice-giving in approximately 80% of the studies. No studies have reported motivational interviewing to be harmful or to have any kind of adverse effect.”
• MI was clinically and statistically significantly effective in reducing BMI, total cholesterol level, systolic blood pressure, and blood alcohol content.
• Motivational interventions did not need to take longer than 15 minutes, and just 1 intervention with a patient can increase the likelihood of a positive outcome.

As recently reported by Pharmacy Times, pharmacist-conducted MI improved adherence 17% using 15- to 20-minute interventions during a 3-month follow-up and 6-month follow-ups. Continuity of care, between patient discharge from the hospital and patients visiting community pharmacies, was an important element of this study.¹³ A similar study reported an increase in adherence of 14%.¹³

As a result, health care systems are increasingly looking to MI for the reduction of treatment nonadherence and the adoption of healthier behaviors by patients. This focus on MI will grow as performance-based compensation strategies increasingly focus on outcomes achieved (as measured by star ratings, readmission rates, etc) rather than on services performed. The potentially massive economic impact of MI is starkly delineated in one study, conducted in 2005 for Biogen Idec, concerning the specialty drug Avonex for multiple sclerosis.¹⁴ In a randomized controlled clinical trial, patients in the MI intervention group had a statistically and clinically significantly lower proportion of Avonex treatment discontinuation (1.2%) than the standard care group (8.7%). This reduction in treatment discontinuation represented a potential $93,600,000 cost recovery per year.¹⁴ Similar reductions in treatment nonadherence would require MI to be implemented across multiple disease states in a variety of health care settings.

Recently, qualitative feedback has established that the benefits of implementing MI extend beyond just economic savings to the institution. MI also helps transform how people relate to each other within health care institutions. For example, the University of Florida Medication Therapy Management Communication and Care Center (UF MTMCCC) completed 3 days of MI training for their MTM pharmacists, pharmacy technicians, and students. Here is what Anna Hall, PharmD, Director, at the UF MTMCCC, said about the impact of the training:

“There are several key things that motivational interviewing training has enhanced for our program:

• The ability to engage patients on our ‘cold’ calls has improved dramatically. Patients are far more willing to learn about our MTM services and discuss medication concerns. Patients are simply less defensive.
• Call center personnel feel far more confident and comfortable in making calls and engaging patients, as a result of training and feedback.
• Motivational interviewing skills have now extended to how we talk to each other internally, and how we engage clients. It has substantially changed the culture of our organization.”

Dr. Hall emphasized that even after completing a 3-day, high-quality trainer program that incorporated baseline training, multiple practice opportunities, and expert feedback, refreshers are still necessary to reinforce skills and the MI philosophy. The more this occurs, the more all staff members internalize the skills, and MI becomes a way of being with others. Overall, patient and employee satisfaction has markedly improved, as a result of continuous MI training.

Summary

When based on sufficient high-quality training, MI is highly effective at producing better outcomes in patients across a wide range of chronic illnesses and health behaviors. As star ratings become more important in determining the compensation level for HCPs, MI will continue to grow in importance. It is crucial not to shortchange the length or quality of training in order to see substantial improvements in health behaviors from MI. The vast majority of related studies used MI interventions that were brief, lasting only 5 to 20 minutes. This makes MI well suited to community pharmacy environments. When MI interventions are done well and up front, when patients first receive a prescription for a chronic illness, less time is invested and fewer problems occur downstream.

This article is published in collaboration with the Directions in Pharmacy CE Conference program.

Bruce A. Berger, PhD, is president of Berger Consulting, LLC, and emeritus professor at Auburn University Harrison School of Pharmacy in Auburn, Alabama.

William A. Villaume, PhD, is emeritus professor at Auburn University Harrison School of Pharmacy in Auburn, Alabama.

References

• Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL. A meta-analysis of motivational interviewing: twenty-five years of empirical studies. Res Social Work Prac. 2010:20;137-160. doi: 10.1177/1049731509347850.
• Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford; 2013.
• Channon SJ, Huws-Thomas MV, Rollnick S, et al. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes Care. 2007;30(6):1390-1395.
• Chen SM, Creedy D, Lin HS, Wollin J. Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: a randomized controlled trial. Int J Nurs Stud. 2012;49(6):637-644. doi: 10.1016/j.ijnurstu.2011.11.011.
• Dilorio C, McCarty F, Resnicow K, et al. Using motivational interviewing to promote adherence to antiretroviral medications: a randomized controlled study. AIDS Care. 2008;20(3):273-283. doi: 10.1080/09540120701593489.
• Powell PW, Hilliard ME, Anderson BJ. Motivational interviewing to promote adherence behaviors in pediatric type 1 diabetes. Curr Diab Rep. 2014;14(10):531. doi: 10.1007/s11892-014-0531-z.
• Resnicow K, McMaster F, Bocian A, et al. Motivational interviewing and dietary counseling for obesity in primary care: an RCT. Pediatrics. 2015;135(4):649-657. doi: 10.1542/peds.2014-1880.
• Rollnick S, Mason P, Butler C. Health Behavior Change. 2nd ed. New York, NY: Guilford; 2010.
• VanWormer JJ, Boucher JL. Motivational interviewing and diet modification: a review of the evidence. Diabetes Educ. 2004;30(3):404-406, 408-410, 414-416 passim.
• Simpson SA, McNamara R, Shaw C, et al. A feasibility randomised controlled trial of a motivational interviewing-based intervention for weight loss maintenance in adults. Health Technol Assess. 2015;19(50):v-vi, xix-xxv, 1-378. doi: 10.3310/hta195 00.
• Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clin Pract. 2010;16(1):166-174. doi: 10.1111/j.1365-2753.2009.01300.x.
• Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract, 2005;55(513):305-312.
• Wick JY. Motivational interviewing can improve ACS medication adherence. Pharmacy Times website. pharmacytimes.com/resource-centers/ACS/motivational-interviewing-can-improve-acs-medication-adherence. Accessed April 27, 2016.
• Berger BA, Hudmon KS, Liang H. Predicting treatment discontinuation among patients with multiple sclerosis: application of the transtheoretical model of change. J Am Pharm Assoc. 2004;44(4):445-454.