Patient Nonadherence – A Rational Reaction To Sub-Optimal Physician-Patient Communication

I have been working on a paper exploring the link between physician-patient communication and medication adherence and the implications for health care costs. Medication nonadherence among patients is and has been a “gigantic” problem for the health care industry over the last 20 to 30 years… and not just for pharma. Patients outcomes suffer and health care cost sky-rocket as nonadherent patients fill ER and hospitals across the U.S.

C. Everett Koop, MD, a former Surgeon General, “summed up” the problem:

[themify_quote]Drugs don’t work in patients who don’t take them.[/themify_quote]

So Why Don’t Patients Take Their Medications?

There are two schools of thought about medication nonadherence. The first holds that nonadherence is a patient behavior problem. Whether it’s because they are stupid, lazy or unengaged…patients just don’t take their medications as directed by their physicians.

The second school of thought holds that nonadherence is often a rational response on the patient’s part when faced with a recommendation to do something they don’t agree with – namely take a medication. There’s even a name for such behavior – it’s called intentional nonadherence. The best example of intentional nonadherence is when patients leave their doctor’s office or are discharged from the hospital and never fill, pick up or take the prescription.

How Can Nonadherence Be Considered Rational Behavior?

I can see how clinicians would feel this way. After all, doctors are acting in the patient’s best interest and prescribe medications because they believe they are necessary. The unfortunate reality however is that patients often fail to see eye to eye with their doctors on the necessity for or the benefits of taking any given prescribed medication.

According to the research, up to 50% of us as patients disagree at one time or another with our doctor regarding a diagnosis, the severity of a condition or safety or efficacy of a particular treatment. Because most patients are loath to challenge our doctors out of fear of being labeled difficult, we don’t say anything to the doctor. Rather, we just don’t do what they recommend, e.g., don’t fill, pick up or take our medication.

Researchers have shown that, when face with having to make a health decision, we employ a kind of cost/benefit analysis in our heads. Based up our knowledge at hand – that which we have via our own personal experiences and that which we learn from the doctor, internet, etc. – we assess the “necessity” for taking a recommended action and balance it against any “concerns” we may have as a result of taking the recommended action. If our perceived necessity is greater that our concerns we take the medicine. If our concerns win out….then we don’t take the medicine.

The Role Of Physician-Patient Communication

For the patient’s necessity/concerns calculus to work, they have to understand and accept that they: 1) have a medical problem, 2) understand that the problem will be serious if left untreated and 3) belief that the recommended treatment is safe and effective. This means that their physician has to take the time to communicate these salient facts to patients in a way they understand and can accept.

There’s the rub. The average primary care physician spend less than 60 seconds explaining such “ins and outs” to patients during the office visit. Figure 1 shows a breakdown of physician “talk time” by topic during visits in which a new medication was prescribed. To complicate things, patients seldom ask questions of their doctor when prescribed a new medication.

Figure 1

New Rx Talk Time

The net result of these limited exam conversations is evident in a 2011 study of low-income patient being seen at Cardiology Clinic:

55% of patients diagnosed with heart failure “did not recognize” nor agree with their doctor that they had heart failure.

85% of patients diagnosed with hypertension disagreed with their doctor’s diagnosis.

41% of patients disagree with doctor’s initial diagnosis of a psychological problem

For patients such as those in the 2011 study, given their disagreements with their doctors, the results of their necessity/concerns calculus does not bode well for their being adherent patients should medications be prescribed.

The Take Away

Physicians tend to overestimate the amount of health information they give patients and underestimate patients’ desire for information.

Clinicians and provider organizations interested in improving patient adherence and reducing preventable ER visits and hospital admission (and readmits) should invest in assessing and improving their patient communication skills as well as those of the physicians in their provider network.

The evidence suggests that patient medication adherence could be improved 10% – 20% with such interventions. This translates into much improved patient outcomes and significant cost saving.

That’s my opinion…what’s your?

Sources:

Ho, P. M., Bryson, C. L., & Rumsfeld, J. S. (2009). Medication adherence: its importance in cardiovascular outcomes. Circulation, 119(23), 3028–35.

Sokol, M. C., Mcguigan, K. A., & Verbrugge, R. R. (2005). Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care, 43(6), 521–530.

Tarn, D. M., Paterniti, D. A., Kravitz, R. L., Heritage, J., Liu, H., Kim, S., & Wenger, N. S. (2008). How much time does it take to prescribe a new medication? Patient Education and Counseling, 72, 311–319.

Sarkar, U., Schillinger, D., Bibbins-domingo, K., Na, A., Karliner, L., & Pe, E. J. (2010). Patient Education and Counseling Patient – physicians ’ information exchange in outpatient cardiac care : Time for a heart to heart

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The Secret To Patient Engagement – More Engaging Physicians And Health IT

I was the keynote speaker recently at a national Patient Engagement Symposium I opened my presentation by asking the audience how many considered themselves to be engaged in their health. You know…just a show of hands. Everyone in the room appeared to put their hand up….and no one admitted to not being engaged in their own health.

[pullquote]When asked how to describe “how they are engaged in their health”, true to form most people responded by saying they “I try to take care of myself” by doing X, Y and Z.[/pullquote]

The evidence bears this out. 82% of U.S. adults have a regular doctor who their visit at least once a year with the average number of doctor visits being 3/year – double that for people with chronic conditions.

You would think that this level of patient engagement would be music to the ears of physicians, administrators and health IT vendors everywhere…but you would be wrong.

Why?

You would be wrong because physicians, administrators, health IT vendors and the like each have their own definition as to what constitutes patient engagement. To understand these definitions just look at how they measure engagement.
Physicians/Providers Definition Of Engagement

Simply “showing up” for their appointment, even if it is 6-7 times a year, interspersed with copious amounts of self-care, does not constitute patient engagement from the physicians’ perspective. After all, patients often don’t do what they are told by physicians – many patients are non-compliant.

Since many physicians tend to equate patient engagement with patient compliance today’s high non-compliance rates (30%-70%) suggest to them that most patient are not engaged. What clinicians are often unaware of is that up to 20% of non-compliance is a function of poor physician-patient communications (disengaging communications) not a lack of engagement.
Health IT Professionals and Vendors

Neither “showing up” nor “the patient’s level of compliance” count for much when it comes to how health IT professionals define or measure patient engagement. The HIMSS (NeHC) Patient Engagement Framework leads you to believe that the true path to patient engagement is all about the use of health information technology and the achievement of Stage 2 Meaningful Use. As long as patients use the right health IT tools they are engaged.

What Health IT folks often ignore is the fact that 85% of patients want the ability to meet face-to-face with their doctor when they feel the need.. They don’t want health technology to get in between they and their doctor which is what some health technologist seem to believe is the answer.
The Challenge For Physicians And Health IT Professionals In Not How To Engage More Patients….But Rather How To Be More Engaging To Patients Who Are Already Engaged

Let’s face it. Health care is still about everyone except the patient. Most physicians still relate to patients using a paternalistic, physician-directed communication style where the clinician knows best, does most of the talking and makes all the decisions for the patient. Patients are not supposed to be engaged – rather they are supposed to be passive and compliant.

Health IT tends to treat patients as stupid and superfluous when it comes to engagement. Health IT folks turn a deaf ear to the fact that 85% of adults want to be able to meet with their physician face-to-face when they want despite their “willingness” to use secure email, patient portals, open notes, etc. People aren’t stupid – they know you want to insert technology in between themselves and their doctor. They are already complaining about the introduction of laptops and computers in the exam room and how it is interfering with the doctor-patient relationship. How is that supposed to be engaging to patients?
Patient Engagement Is Not Hard

So what is the secret to improving patient engagement? Try being more engaging to patients. That means being more patient-centered versus you centered in how you think about what you do to/for patients, how you talk to/listen to patients, design products and services for patients and what you measure when it comes to assessing patient engagement. It means soliciting the patient’s story…their health beliefs, fears and concerns, understanding their health information needs and interests, understanding their previous health experiences and so on. It means giving the patient credit for having a brain as well as already having a stake in their own health.

That’s what I think. What’s your opinion?

Interview With Stephen Wilkins, Author Of Mind The Gap Blog

This week I was interviewed by Richard Just, MD and Gregg Masters from This Week in Oncology. The focus of the brief interview was on – you guessed it – physician-patient communications in the medical exam room.

 

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New Health Podcasts with JustOncology on BlogTalkRadio

Patient-Centered Physicians Have Lower Diagnostic Testing Costs

For many physicians, the term “patient-centered” conjures up fears of longer office visits and patients demanding expensive diagnostic tests and procedures they don’t need.

There concerns are completely understandable. After all, medical schools until recently never really taught physicians what it meant to be patient-centered…or the intrinsic benefits of being patient-centered. It doesn’t help that the only exposure many physicians have had to patient-centered care have comes from ill informed, caustic comments found all too frequently on physician websites like KevinMD.com.

But the reality is that these “perceptions”, while real to the beholder, don’t necessarily stand up to the evidence.

Take the belief that patient-centered care is synonymous with increased diagnostic costs in the ambulatory or office setting.

Several US and Canadian studies in recent years have shown just the opposite…that physicians with a patient-centered communication style ordered fewer diagnostic tests resulting in significantly lower diagnostic costs. The cost trends shown in Figure 1 are representative of the trends found in these studies looking at the relationship between diagnostic costs and physician patient-centeredness.

Dx Cost and patient CenterednessCompared to physicians with the lowest patient-centered rating, e.g., Lowest Tercile, (aka the highest physician-directed rating), physicians in the Highest Tercile (highest patient-centered rating) reported 10.4% lower diagnostic costs followed by physicians in the Middle Tercile who reported a 9.7% lower diagnostic costs.

[pullquote]In a 2011 article Is Patient-Centered Care Associated With Lower Diagnostic Costs, noted researcher Moria Stewart et al. projected a 30% savings in diagnostic testing costs across Canada if all physicians there were as proficient in their patient-centered communication skills as those physicians in the top performing quartile of their study.[/pullquote]
So Why Are Diagnostic Costs Lower For Patient-Centered Physicians?

To understand the answer to this question one first must understand the difference between a patient-centered communication style and its opposite, a physician-directed or paternalistic patient communication style.

A patient-centered communications approach begins by trying to understand the person behind the medical problem. The focus is on inviting the patient (and family members) into the exam room conversation. This is accomplished by asking patients questions designed to encourage them to open up and share their perspective, e.g., this includes their reasons for the visit (visit agenda), their expectations, fears and health beliefs. Patients’ opinion are sought and their participation in health treatment decisions is encouraged and welcomed by clinicians.

In contrast, the physician-directed communication style focuses on the biomedical facts behind the patient’s presenting problems. The physician is in charge of the visit, does most of the talking and makes all the decisions. The patient is expected to assume what for years has been referred to as a passive sick role…their role being to answer the doctor’s questions and do as they are instructed by the doctor.

Not surprisingly, a patient-centered communication style is preferred by many patients, at least after having been exposed to it (many of us have never experienced it). Not only is it associated with greater patient engagement, but it also is associated with a higher level of patient trust in their physician. And trust in one’s physician is what helps explain why diagnostic use/costs are lower for patient-centered physicians than their physician-directed counterparts.

Patients with physician trust issues (over 50% of US adults have moderate to low trust in medical professionals), are more likely to go into the office visit with requests and expectations for specific lab tests or procedures. For whatever reason, some patients over time come to distrust that their doctor always does the “right thing” or always has the patient’s best interests at heart.

To protect themselves, distrustful patients drop subtle hints about what they want…and in some case come right out and demand the lab test or procedure regardless of what the physician thinks. And physicians, often concerned about upsetting patients by denying their request, acquiesce to at least the less onerous requests thereby driving up costs.

This is not to say that patients that trust their doctor do not make requests for service. They do. But patients who trust their doctor are much open to seeking out and comply with their physician’s recommendation than their less trusting peers.
The Take Away?

As I have discussed in other posts, most physicians today employ the same physician-centered, physician -directed patient communication skills they learned years ago in medical school. Put that together with the fact that over 50% of US adults only have a moderate to low level of trust in medical professions and you have a kind of “perfect storm” when it comes to patients requesting and physicians agreeing to expensive and unnecessary diagnostic tests. A situation that is only made worse by incentivizing physicians to worry more about satisfying patients (giving them what they want) than collaboratively deciding what the patient really needs.

The simplest and most cost effective answer lies in promoting the adoption of new patient-centered communication skills by physicians and other members of the health care team. And the easiest way and most affordable way to accomplish this (heck it’s free to many) is by getting physicians across the US to sign up for the 2014 Adopt One! Challenge.

That what I think…what’s your opinion?

Sources:

Stewart, M. et al. Is Patient-Centered Care Associated With Lower Diagnostic Costs. (2011) Health Care Policy. Volume 6 No. 4.

Stewart, M. et al. The Impact Of Patient-Centered Care On Outcomes. (2000) Journal of Family Practice. Volume 49 No. 9.

Epstein, R. et al. Patient-Centered Communication And Diagnostic Testing. (2005) Annals of Family Medicine. Volume 3.

What Makes A Good Doctor…And Can We Measure It?

The following is a authorized re-post of a recent piece by Ashish Jha, MD from his blog An Ounce of Evidence.

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change. We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay.

doctor patient communication2But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes. Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:

Twitter- what makes a good doctor

Over 200 answers came rolling in. Listed below are the top 10. Top answer? Having empathy. #2? Being a good listener. It wasn’t until we get to #5 that we see “competent/effective”.

What Makes A Good Doctor

Even though the survey results above come from those I interact with on twitter, I suspect the results reflect what most Americans would want. As I read the discussions that followed, I came to conclude one thing: most people assume that physicians meet a threshold of intelligence, knowledge, and judgment and therefore, what differentiates good doctors from mediocre ones is the “soft” stuff.

It’s an interesting set of assumptions, but is it true? It is, at least somewhat. Most American physicians meet a basic threshold of competence – our system of licensure, board exams, etc. ensure that a vast majority of physicians have at least a basic level of knowledge. What most people don’t appreciate, however, is that even among this group, there are large, meaningful variations in capability and clinical judgment. And, of course, a small minority of people are able to get licensed without meeting the threshold at all. We all know these physicians – a small number to be sure — that are dangerously ineffective. We, the medical community, have been terrible about singling these physicians out and asking them to get better – or leave the profession.

In the twitter discussion, there was a second point raised by John Birkmeyer and that was likely on the minds of many respondents. He said “I’d want different things from my PCP and heart surgeon. Humility. Over-rated for the latter” John was raising a key distinction between what we want out of a physician (an Internist or a family practitioner) versus a surgeon. Yes, in order to be “good”, humility and empathy are important, even for cardiac surgeons. But when they are cutting into your sternum? You want them to be technically proficient and that trait trumps their ability (or lack thereof) to be empathic. Surgeons’ empathy and kindness matter – but it may not be as critical to their being an effective surgeon as their technical and team management skills. For Internists, effectiveness is much more dependent on their ability to listen, be empathic, and take patients’ values into consideration.

A final point. My favorite tweet came from Farzad Mostashari, who asked: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” In all the discussions about being a good doctor, we heard little about effective use of beta-blockers for heart disease, or good management of diabetes care. That’s the stuff we measure, and it’s important. We use them as part of the Physician Quality Reporting System (PQRS). But I’m not sure they really measure the quality of the physician. They measure quality of the system in which the physician practices. You can have a mediocre physician, but on a good team with excellent clinical support staff, those things get done. Even the smartest physician who knows the evidence perfectly can’t deliver consistently reliable care if there isn’t a system built around him or her to do so.

So, when it comes to thinking about ambulatory care quality – we should think about two sets of metrics: what it means to be a good doctor and what it means to work in a good system. In measuring doctor quality, we might focus on “soft” skills like empathy, which we can measure through patient experience surveys. But we also have to focus on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, such as the ability to collaborate and effectively lead teams – and we don’t really measure these things at all, erroneously assuming that all clinicians have them. For measuring good systems, we could use our current metrics such as whether they achieve good hypertension and diabetes control. We need to keep these two sets of metrics separate and not confuse one for the other. And, alas, for surgeons, we need a different approach yet. Yes, I still believe that humility and empathy go a long way – but these qualities are no substitute for sound judgment and a steady hand.