NEW YORK (Reuters Health) – Several modifiable aspects of patient-provider communication contribute to poor medication adherence in patients with hypertension, researchers report.
“I found it surprising that merely talking about patients’ social issues, such as employment and housing, in the primary care visit had a potent effect on whether patients took their blood pressure medications as directed,” Dr. Antoinette Schoenthaler from New York University’s Center for Healthful Behavior Change told Reuters Health by email. “This was especially true for black patients, who were 8 times less likely to take their high blood pressure medications when those issues weren’t discussed.”
Several studies have shown that better provider communication skills are associated with improvements in medication adherence among hypertensive patients, but analyses of audiotaped patient-provider interactions have shown that providers rarely collaboratively discuss medication-taking behaviors with their patients.
Dr. Schoenthaler’s team evaluated the impact of patient-provider communication on medication adherence in their observational study of 92 hypertensive patients and their 27 primary care providers (PCPs).
Audiotaped clinic visits lasted an average of 24.8 minutes, during which 51% of PCP utterances involved information giving, 11% asking close-ended questions, 9% information-checking, and only 1% asking open-ended questions.
Patients most commonly provided information (82% of utterances), checked information (3%), or asked close-ended questions (3%), according to the August 22 online report in Circulation: Cardiovascular Quality and Outcomes.
Aspects of the provider-patient visit that were associated with poor medication adherence included less focus on social-demographic circumstances, lower patient-centeredness, less patient directedness, less psychosocial focus, and less discussion about the patients’ antihypertensive medications.
Less discussion about patients’ social-demographic circumstances and about their antihypertensive medications each was associated with roughly sixfold increased odds of poor medication adherence. Black patients were 8 times more likely to have poor medication adherence when there was less discussion about social-demographic circumstances.
“Based on our findings, we recommend that primary care providers begin with an inquiry into patients’ social issues and then have the discussion continued with other members of the care team such as nurses, community health workers, and pharmacists to provide additional support and referrals to resources,” Dr. Schoenthaler said.
“Providers have a lot to accomplish within the context of the primary care visit,” she said. “Adding a discussion on patients’ social issues may feel overwhelming or burdensome when providers are already trying to accomplish many other tasks.”
“We didn’t find any differences in length of the clinic visit among providers who discussed patients’ social issues versus those who did not,” Dr. Schoenthaler said. “This finding demonstrates that such discussions do not necessarily have to add to the time burden primary care providers are already under.”
Dr. Edward P. Havranek from Denver Health Medical Center and University of Colorado School of Medicine, Aurora, who coauthored a related editorial, told Reuters Health by email, “What I found most interesting was that relationship-building exchanges seemed to do more to improve adherence among African American patients – a hopeful finding with regard to mitigating disparities in hypertension (and potentially other chronic illnesses).”
“The main challenge, I think, is to get physicians to be open to the possibility that the way they conduct patient visits might not be producing the results they want,” he said. “I hope they might begin to see that medication adherence is not strictly a patient behavior, but is also a product of the patient-provider relationship they have some responsibility for.”
“There is probably a role for communication training for practicing physicians and perhaps some alteration in the way we treat medical students and residents,” Dr. Havranek added.
Dr. Nancy Kressin from Boston University School of Medicine’s Health/Care Disparities Research Program told Reuters Health by email, “Adherence does not just happen; there are things providers can do to improve patients’ adherence. Patients are more likely to adhere when providers address and emphasize the importance of adherence as they talk with patients, and patients – especially black patients – are affected by providers’ attention to patients’ life circumstances.”
“My colleagues and I have other data supporting the notion that black patients especially value feeling ‘known’ by their providers, and that such perceptions are associated with greater likelihood of adhering to treatment recommendations,” she said.
“I don’t think physicians/clinicians feel well prepared to raise issues regarding patients’ social-demographic circumstances, and in fact, they may view raising such topics as a bit like opening Pandora’s Box, especially if there are not clinical systems or processes in place to help patients address such concerns,” she said. “Also, many would not feel it is ethical or helpful to identify a social-demographic need without then addressing it, and many providers and systems are not prepared to do so.”
Dr. Kressin added, “My Boston University School of Medicine/Boston Medical Center colleague Arvin Garg, MD, MPH, has developed a system that providers and clinics can use to support patients and providers in this way, but few health systems have done so.”
“As healthcare payment systems move toward accountable care organizations, where providers are paid for keeping a group of people healthy rather than for the specific services they provide, healthcare systems are increasingly aware that identifying and addressing patients’ social determinants of health will impact patient outcomes and healthcare systems’ bottom lines,” she said. “This payment policy background makes the paper’s findings all that more salient in today’s environment.”
SOURCES: http://bit.ly/2wldKOe and http://bit.ly/2xq9g5F
Circ Cardiovasc Qual Outcomes 2017.
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