A Remedy for Intentional Rx Non-Adherence – Understanding Patients’ Beliefs

Patient non-adherence is a big problem.  Non-adherence among chronic disease patients is associated with higher rates of hospital re-admissions, higher costs and poorer outcomes.

Research has identified over 200 possible factors thought to influence patient adherence.  According to the experts, these factors can be categorized into two groups:

1. unintentional non-adherence
2. intentional non-adherence.

Unintentional non-adherence is related to a patient’s ability and resources to take their medication (e.g., problems with manual dexterity,  forgetfulness, inability to pay for medication, etc.).  Intentional non-adherence is associated with a patient’s motivation and beliefs, e.g., the reasons for needing a medication, the efficacy of a proposed treatment, concerns about side effects and so on.

Patient-Center Communication and Diabetes – An Example

One of the basic tenets of the patient-centered care model is getting to know the “person behind the patient label, i.e., their health motivations, attitudes, beliefs and so on.  Why?  It is because people that show up in the doctor’s office each have their own pre-existing set of experiences, knowledge and beliefs about their health and the health care system.

A patient’s motivations, attitudes and beliefs are shaped by a variety of experiences.  Maybe they had a family member or friend with the same health condition.  Maybe they saw or heard a TV or radio commercial.  Or maybe they had a previous bad experience with another provider.   Regardless of where this thinking come from, or whether it is “right or wrong,” patient thinking plays an important yet often overlooked role in patient adherence.

Take the following “beliefs” expressed by a type 2 diabetes patient on a diabetes social networking site:

I keep reading where (having) type 2 diabetes is virtually a certainty for heart disease and an early death. These may be the statistics but l just haven‘t witnessed this in my personal life. My grandfather, a type 2 from his mid-40s lived to be 86. My father and two of his brothers were/are type 2 and my father lived to 83, his brother to 82, and one living brother just turned 80.  These guys have out lived/are outliving most of their friends who are not diabetic.

To my way of thinking, if you read and put a lot of faith in articles like this you might as well throw your arms up and say “I give up…I’m doomed and nothing can save me.”

If you were this person’s physician, would you find it helpful if you knew this was how your patient thought?  How adherent would you expect someone like this to be if you prescribed medication to lower their risk of heart disease (BP or cholesterol)?

Not very, I expect…

The Facts

Approximately 50% of diabetes patients are non- adherent when it comes to taking diabetes-related medications according to a 2008 study by Heisler, et al.  Up to 70% of non-adherence is thought to be intentional according to researchers.

For whatever reason, lack of time, competing priorities, perceived lack of importance, etc., physicians don’t often ask patients about their health beliefs concerning their condition, treatment efficacy, or concerns about side effects.  Probably even fewer patients volunteer such information.  Such information is simply not relevant to the bio-medical, physician-centered model of care.

Makes You Wonder

It certainly makes you wonder…

1. to what degree patient outcomes could be improved?
2. how much money could be saved?

…if physician better understood what makes their patients “tick?”

Sources:

Clifford, S. et al.  Understanding different beliefs held by adherers, unintentional non-adherers, and intentional non-adherers: Application of the Necessity–Concerns Framework. Journal of Psychosomatic Research 64 (2008) 41–46.

Westbury, J.  Why do older people not always take their medications?  The Pharmaceutical Journal 2003.

Asking Our Doctor Questions – Many of Us Don’t Have Much to Say

Ask your doctor.  I think most of us would agree that is good advice…at least up to the point that we find ourselves sitting half naked on an exam table in our doctor’s office.  Then the doctor walks in and for some reason many of us just “clam up.”

Patient question-asking during the primary care office visit was and continues to be an “index” of patient health information seeking behavior. Since the first of such studies going back to the late 1970s, researchers have found that, except for patients who are highly involved in their own health care, most people ask their doctor few if any important health questions.

Here’s an example of what I am talking about.

At face value, one would think that being “put on a new medication” would prompt patients to ask their doctor a few questions.  Why do I need this medication? What are the side effects? How should I take it?  What about other medications I am taking?  When can I stop taking it?

If you think that way…you would be wrong.

By way of evidence, I cite a 2008 study in which 181 patients were prescribed a new medication by their primary care physician or a cardiologist during an office visit.  In total, patients initiated 199 questions or comments (1.09 per patient) based upon a coding of audio tapes of each patient visit.   Table 1 shows a breakdown of the frequency of patient questions by type and duration of patient talk time (in seconds) associated with each question topic.

Of those patients that did ask questions, the focus was on the important questions – how to take the medication, side effects, and the purpose of taking the medication.   The brief amount of “patient time” spent on these important topics was compensated for during physician talk time, e.g., physicians spoke for 10 seconds on the purpose of the Rx and 8.25 seconds on how to take the medication.  Keep in mind that physician talk time for all physician comments related to “starting a new medication” was less than a minute for the entire visit.

These findings may seem very counter intuitive given all the reports of coming out of the Pew Research and other survey research about patients “wanting more health information.”   There are after all at least 500 pages listed on Google of health websites recommending “questions to ask your doctor.”  But according to many studies on the subject, what people say they want (more health information) and what they actual do (engage in question-asking behavior) can be and usually is very different.

The low level of question-asking behavior exhibited by patients in the small study cited above study is not an isolated finding.  Numerous studies going back to the landmark work done by Roter et al. in the late 1970s have produced similar findings.  According to Donald Cegala, PhD, Professor Emeritus of Communication and Family Medicine at Ohio State, who has written extensively on this subject, “the literature and my research experience suggests that most patients do not ask any questions, and those that do average about 2 questions (per visit). ”

So what are the factors that explain why so few patients actively engage in question-asking?  Are there strategies for getting patients more engaged in addressing this interesting challenge?  Stay tuned.  I will be elaborating on these questions in future posts.

Sources:

Kravitz, R., Hertiage, J. et al.  How much time does it take to prescribe a new medication? Patient Education & Counseling.  72 (2008) 311–319.

Roter, D. L. Patient Question Asking in Physician- Patient Interaction.   Health Psychology. 1984; 3 (5) 395-409.

Cegala, D.  Personal notes. 3/12/2010.

Too many errors are made because of over-reliance on the EMR

A cautionary tale from Ciro Attardo MD, Family Physician, Founding Partner, and Director at Horizon Family Medical Group.  This is a re-print of his reply to an earlier post of mine on the Medical Home Group on LinkedIn.

The best EMR will not create a good doctor where there is none. When it comes to communication, there is probably nothing more depersonalizing that a doctor pecking at a keyboard when the patient is pouring his heart out. I would like to pay homage to all the great diagnosticians who are long gone. They made accurate diagnosis without ordering multiple tests and certainly without an EMR (pre-Bush). They relied on good history taking and physical examination. They cared about their patients more than their medical record. Don’t get good health care confused with good-looking health care. EMR’s are good at generating 5 page progress notes for a patient who comes in for a splinter. They rarely help make any diagnosis.

Reminders are a waste of time because they are not used properly. There are just too many for the wrong reason. Instead of warning you of dangerous interactions, every drug prescribed generated pages of warning. Just imagine driving your car and every 5 seconds you are reminded to check your gas, or your tire pressure, or to make sure your inspection is up to date and so on. It would not take long before you turn off the volume. That’s what happens with EMR reminders.

Communication = caring + good listening + clear thought expression + time x 2 (patient and doctor)

An EMR will help communication only if it reduces the time requirement. So far, I think it’s a wash. Time alone will not fix communication problems. I do believe that cognitive skills are undervalued. Our insurers rarely cover time spent on prevention and counseling. Communication would improve in a health care system that values proactive health intervention. Instead our compensation is procedure based. Talking with the patient is not a procedure.

In terms of medications and EMR; it’s still a mess. I still have to rely on what the patient tells me. Too many changes occur in the patient database beyond the reach of the EMR. I still have older patients bring all their meds in even though they are listed in the EMR. And then there are changes made by other providers, facilities, insurance companies that are not automatically updated in my computer. Too many errors are made because of over-reliance on the EMR.

The government is hoping that technology can help address the “lack of time” for physician-patient communication

I received this reply to a post on LinkedIn regarding the issues of
poor physician communication and lack of time.

The government is hoping…that technology can help the time issue. A good Electronic Medical Record system will flag issues that need to be addressed during a visit, so that the physician can quickly review the suggested items with the patient. Sophisticated systems will suggest best practices in each case.

My reply:

The operative word is “hoping.” A meta-analysis study was just released by the Cochrane Collaboration entitled: The effects of on-screen, point of care computer reminders on processes and outcomes of care. (Review)

The study examined 28 studies that evaluated the effects of different on-screen computer reminders. The studies tested reminders to prescribe specific medications, to warn about drug interactions, to provide vaccinations, or to order tests.

The review found small to moderate benefits. The reminders improved physician practices by a median of 4%. In eight of the studies, patients’ health improved by a median of 3%.

One reason why these interventions are not more effective is that “their use, (by physicians) is not widespread or always successful.” Journal American Board of Family Practice. 2003.

Like so much of health care, real change must occur in the way physicians and patients communicate face-to-face during the office visit.

Source:

Shojania, KG. et al. The effects of on-screen, point of care computer reminders on processes and outcomes of care. (Review). The Cochrane Collaboration. 2010.

Frame, P. Automated Health Maintenance Reminders: Tools Do Not Make a System. Journal American Board of Family Practice. 2003:Vol.16 No.4.

Poor Physician-Patient Communication – Is “Lack of Time” Really the Problem?

If the lack of time is the chief barrier to poor physician-patient communications, it logically follows that longer patient appointments are the solution.  Ok…lets’ say that I could wave a magic wand and add 5 or even 10 more minutes to the average primary care office visit.  Would more time really make a difference?

Probably not. A quick examination of just some of the key drivers of  physician-patient communications reveals why:

• More Time Will Not Change How Physicians View the Physician-Patient Relationship

A physician’s communication style is a “window” into how they view the physician-patient relationship, e.g., physician-centered versus patient-centered.  One landmark study of physician communication styles found that almost two-thirds of physicians (IM and FP) in the study had a physician-centered view of how physicians and patients should relate to one-another.

• More Time Will Not Change a Physician’s Communication Style

While even the most physician-centered physician can incorporate elements of patient-centered communication in the medical interview process, the reality is that providers revert back to type. A provider with physician-centered directed orientation will still most likely interrupt the patient, not ask if the patient has questions and not use “teach-back” to make sure the patient understood what the physician said and so on.

• More Time Will Not Likely Change a Physician’s Reliance on Observable Patient Characteristics When Deciding How to Treat Patients

In addition to observable patient characteristics like age, gender, race and education, there is the person “behind the disease” who comes to the doctor with their own set of health beliefs, life experiences and treatment preferences.   When the physician recommends a treatment that the patient does not believe will work, the likelihood of patient non-adherence is much greater than if the physician took the time to ask the patient their thoughts and collaborate with the patient on exploring the treatment that will work for both parties.

Time is not the problem when it comes to improving physician-patient communications.  I don’t really believe that additional reimbursement to physicians for sub-optimal patient communications is the answer either.

Numerous studies have shown that patient-centered communication techniques in primary care practices can improve patient outcomes, change behavior and increase patient and provider satisfaction without increasing the length of the office visit.

So how do we improve the quality of physician-patient communications?  I have some thoughts that I will share with you in future posts.  In the mean time…please let me know what you think.

Sources:

Roter, D. et al.  Communication Patterns of Primary Care Physicians. JAMA. 1997:277:350-356.

Mauksch, L. et al.  Relationship, Communication, and Efficiency in the Medical Encounter. Archives of Internal Medicine. 2008;168(13):1387-1395.

Aita, V. et al.  Patient-centered care and communication in primary care practice: what is involved? Patient Education and Counseling. 58 (2005) 296–304.

Braddock, C. et al.  The Doctor Will See You Shortly – The Ethical Significance of Time for the Patient-Physician Relationship. Journal General Internal Medicine. 2005 November; 20(11): 1057–1062.