乌鸦传媒

Instead of just writing a prescription, providers who explained the need for antihypertensive medications and asked patients about their home life were more likely to inspire good medication adherence, a study found.

At three safety net practices in New York City, with hypertension who were recruited into the study were deemed non-adherent. Only 14.1% had high medication adherence, taking 97.0% of prescribed doses on average, Antoinette Schoenthaler, EdD, of New York University School of Medicine and colleagues reported in Circulation: Cardiovascular Quality and Outcomes.

Patients were less likely to adhere to hypertension medication if primary care physicians in the average 24.8-minute visit:

• Spent more time talking about medicine than building the provider-patient relationship (OR 3.08, 95% CI 1.04-9.12)
• Talked less about patients' social-demographic circumstances (OR 6.03, 95% CI 2.15-17.0)
• Spent less time discussing the blood pressure medications being prescribed (OR 6.48, 95% CI 1.83-23.0)

"Our data suggest several reasons why a provider's inquiry into patients' social-demographic circumstances (i.e., unemployment, unstable housing) might be associated with adherence," according to Schoenthaler's group. "One possibility is that such discussion signals to the patient genuine caring and concern by the provider, which strengthens the patient's ability to cope with their life and illness, along with motivation and confidence related to self-management of their disease."

Notably, not having sociodemographic circumstances addressed with providers made black patients particularly less likely to stick to their medications (OR 8.01, 95% CI 2.80-22.9). "The interaction with race suggests an intriguing possibility that this expression of caring might be particularly important for Black patients where social distance is greater," the authors suggested.

"Although its lessons apply to all patients, [the study] also suggests, persuasively, that better communication might help mitigate African American health disparities," agreed Edward P. Havranek, MD, of Denver Health Medical Center, and Stacie L. Daugherty, MD, MSPH, of University of Colorado School of Medicine in Aurora, in an accompanying editorial.

Of patients in the study, 61% were black and 58% women. Providers were 56% white and 67% women.

"For the patient, subtle experiences of bias can result in stereotype threat. Stereotype threat occurs when cues in the environment (such as visiting a doctor's office) trigger the threat of confirming, as self-characteristic, a negative stereotype about one's group. A patient feeling stereotype threat can experience increased anxiety and reduced memory, which may impair the patient's communication and ability to absorb information during a doctor's visit."

"Based on this poor clinical interaction, the patient may feel less activated to adhere to treatment recommendations," Havranek and Daugherty said.

Schoenthaler and colleagues recruited and had sufficient data for 92 hypertensive participants and 27 providers, whose in-office conversations were recorded and coded using the Medical Interaction Process System. Medication adherence data were collected over 3 months with a pill bottle with an electronic cap that records each time the bottle is opened.

A weakness of the study was that clinicians and patients were allowed to turn off tape recorders at any point during the encounter. It also did not include higher-income patients or other racial groups.

"Although a strength of the study was the use of EMDs [electronic monitoring devices], which are currently considered the 'gold standard' of adherence measurement, they are still limited in that they do not provide a direct confirmation that a dose is actually taken. Moreover the devices are bulky, easily lost, or subject to malfunctions, which may increase bias. In this study, 12% of the data was unusable due to cap malfunctions (50%), non-use by the patient (33%), and patients' failure to return the EMD (17%)," the authors added.

Moreover, Havranek and Daugherty noted that a fair number of patients in the poor adherence category actually had adherence rates over the 80% threshold often used in other studies.

Nonetheless, "we believe that the evidence base for linking communication and is strong enough that the focus should begin to be on implementation. The paper by Schoenthaler et al suggests that simple recommendations, such as exploring patients' psychosocial situations, may improve adherence and diminish racial disparities," the editorialists wrote.

"It will be important to understand the barriers to implementing simple recommendations such as this one, and to devise means to work past the barriers."

Comment