Associations between antidepressant adherence and shared decision-making, patient-provider trust, and communication among adults with diabetes: diabetes study of Northern California (DISTANCE)

Preventing medication nonadherence: a framework for interventions to support early engagement with treatment

ABSTRACTMedication nonadherence is common and results in avoidable morbidity, mortality, and burdens on healthcare systems. This paper proposes a preventative approach to medication nonadherence. We consider existing evidence on the prevalence and determinants of nonadherence early in a patient's medication-taking journey, and map these to potential opportunities for intervention. Many patients stop taking a new medication soon after they are prescribed it, often not collecting the medication. Early patterns of nonadherence are linked to later nonadherence via processes such as habit formation and symptom experiences. Known predictors of nonadherence may be present before someone starts a new treatment, when patients experience disruption to their lives and identity due to illness. Healthcare professionals typically have contact with patients around this time. We argue that it may be possible to prevent medication nonadherence: at the population level; by optimising the prescription process; and through low- and high-intensity interventions for patients with identified early barriers. We give examples of specific interventions and tools that might be needed to operationalise this approach in practice and propose new directions for research to promote early engagement with medication to prevent nonadherence.

How the CAHPS Clinician and Group Patient Experience Survey Data Have Been Used in Research: A Systematic Review

Purpose

Patient experience is a key aspect of care quality. The Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) survey measures experiences with ambulatory care providers to inform public reporting, pay-for-performance initiatives, interventions, patient choice of physicians/practices, and quality improvement. Since the survey's 2007 release, no systematic review of its use in research has been published.

Methods

We reviewed English-language, peer-reviewed articles published since 2008 using CG-CAHPS survey data in the U.S. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Checklist for Analytical Cross-Sectional Studies.

Results

We examined 126 articles and included 52. Twenty-seven articles focused on general primary care, and the others focused on ambulatory specialty care. Of the 52 studies, 37 were cross-sectional, and the majority conducted patient-level regression analysis, controlling for patient characteristics. The most-used CAHPS measures were overall provider rating and the provider communication composite. CG-CAHPS data were primarily utilized to evaluate interventions (24 studies) and examine cross-sectional associations (21 studies) of site-level (eg, organizational climate), provider-level (physician empathy), and patient-level (medication adherence) factors with patient experience. Four studies reported disparities in patient experience.

Conclusions

The widespread use of CG-CAHPS data implies the survey's value in measuring and improving care quality. Unlike facility or plan surveys, the CG-CAHPS survey was designed to allow attribution to medical groups and clinicians, which, as evidence shows, is its main strength. Policymakers, researchers, clinicians, and health care leaders can leverage CG-CAHPS data in quality improvement efforts and interventions supporting patient-centered care.

Trust, discrimination and preference for shared decision-making in adolescents diagnosed with depression: Implications from Chinese mental health professionals

BACKGROUND

While evidence suggests that the attitudes of healthcare providers toward medical decision-making in adolescents diagnosed with depression merit exploration, research on their preferences for Shared Decision-Making (SDM) and the factors affecting these preferences remains limited.

OBJECTIVE

To investigate Chinese mental health professionals' (MHPs) preferences for SDM in adolescents with depression and identify the relationships between their preference for SDM and trust and discrimination.

METHODS

A cross-sectional design was used in this study. Clinical Decision-making Style-Staff (CDMS-S) was applied to evaluate their preferences for SDM. Physician Trust in the Patient Scale (PTPS) was utilised to assess their trust in consumers. Social Distance Scale to Mental Illness (SDSMI) was utilised to measure their discrimination against people with mental illness.

RESULTS

A total of 581 MHPs were identified in China. MHPs rated their preference for participation in decision making (PD) as shared (1.89 ± 0.472), information (IN) as moderate (2.62 ± 0.682), and family involvement (FI) as high (3.13 ± 0.840). The preferences for three decision topics ranked from the highest to the lowest score were working-related decision (2.35 ± 0.681), general preferences in decision (1.82 ± 0.581) and medication-related decision (1.74 ± 0.826). The mean score of PTPS and SDSMI were 34.71 (SD=9.709) and 15.17 (SD=4.299), respectively. Logistic regression indicated that the preference for PD was associated with discrimination; the preference for IN was associated with trust, discrimination and SDM-related training experience; and the preference for FI was associated with both trust and discrimination.

CONCLUSIONS

While MHPs generally exhibit a favourable attitude toward SDM, this positivity is not universally observed across all contexts. There remains room for improvement in the willingness to co-develop medication regimens and share health information. Rational recognition of depression, and building trusting and friendly therapeutic relationships are key to promoting MHPs' preferences for SDM.

PRACTICAL VALUE

MHPs' preferences for SDM have a significant impact on SDM implementation, which will be promoted by implementing SDM-related training.

Patient satisfaction with the quality of care received is associated with adherence to antidepressant medications

BACKGROUND

There is a paucity of evidence on the association between satisfaction with quality of care and adherence to antidepressants.

OBJECTIVES

To examine the association between patient satisfaction with healthcare and adherence to antidepressants.

METHODS

A cohort study design was used to identify antidepressant users from the 2010-2016Medical Expenditure Panel Survey data, a national longitudinal complex survey study design on the cost and healthcare utilization of the noninstitutionalized population in the United States. The Consumer Assessment of Healthcare Providers and Systems were used to measure participants' satisfaction with access and quality of care, patient-provider communication and shared decision-making (SDM). Patients were considered satisfied if they ranked the quality of care at ≥9 (range: 0[worst]- 10[best]). Antidepressant adherence was measured based on medication refill and complete discontinuation. MEPS sampling survey-weighted multivariable-adjusted logistic regression models were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between satisfaction and adherence to antidepressants. We tested for the potential presence of reverse associations by restricting the analysis to new users of antidepressants. The roles of patient-provider communication and SDM on the satisfaction-adherence association were examined through structural equation models (SEM).

RESULTS

Among 4,990 (weighted counts = 8,661,953) antidepressant users, 36% were adherent while 39% discontinued antidepressants therapy. Half of antidepressant users were satisfied with the healthcare received. Satisfied patients were 26% (OR = 1.26, 95%CI: 1.08, 1.47) more likely to adhere and 17% (OR = 0.83, 95%CI: 0.71, 0.96) less likely to discontinue, compared to unsatisfied antidepressant users. Patient satisfaction was also associated with higher odds (OR = 1.41, 95%CI: 1.06, 1.88) of adherence among a subgroup of new users of antidepressants. The SEM analysis revealed that satisfaction was a manifestation of patient-provider communication (β = 2.03, P-value<0.001) and SDM (β = 1.14, P-value<0.001).

CONCLUSIONS

Patient satisfaction is a potential predictor of antidepressant adherence. If our findings are confirmed through intervention studies, improving patient-provider communication and SDM could likely drive both patient satisfaction and adherence to antidepressants.

Characterizing Decision-Making Surrounding Exercise in ARVC: Analysis of Decisional Conflict, Decisional Regret, and Shared Decision-Making

BACKGROUND

Limiting high-intensity exercise is recommended for patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) due to its association with penetrance, arrhythmias, and structural progression. Guidelines recommend shared decision-making (SDM) for exercise level, but there is little evidence regarding its impact. Therefore, we sought to evaluate the extent and implications of SDM for exercise, decisional conflict, and decisional regret in patients with ARVC and at-risk relatives.

METHODS

Adults diagnosed with ARVC or with positive genetic testing enrolled in the Johns Hopkins ARVC Registry were invited to complete a questionnaire that included exercise history and current exercise, SDM (SDM-Q-9), decisional conflict, and decisional regret.

RESULTS

The response rate was 64.8%. Two-thirds of participants (68.0%, n=121) reported clinically significant decisional conflict regarding exercise at diagnosis/genetic testing (DCS [decisional conflict scale]≥25), and half (55.1%, n=98) in the past year. Prevalence of decisional regret was also high with 55.3% (n=99) reporting moderate to severe decisional regret (DRS [decisional regret scale]≥25). The extent of SDM was highly variable ranging from no (0) to perfect (100) SDM (mean, 59.6±25.0). Those diagnosed in adolescence (≤age 21) reported significantly more SDM (P=0.013). Importantly, SDM was associated with less decisional conflict (ß=-0.66, R2=0.567, P<0.01) and decisional regret (ß=-0.37, R2=0.180, P<0.001) and no difference in vigorous intensity aerobic exercise in the 6 months after diagnosis/genetic testing or the past year (P=0.56; P=0.34, respectively).

CONCLUSIONS

SDM is associated with lower decisional conflict and decisional regret; and no difference in postdiagnosis exercise. Our data thus support SDM as the preferred model for exercise discussions for ARVC.

Beliefs and expectations of patients with fibromyalgia about telerehabilitation during Covid-19 pandemic: A qualitative study

BACKGROUND

Telerehabilitation as an alternative to physiotherapeutic care has been increasingly implemented in diverse populations. However, this mode of service can evoke beliefs and expectations in patients with fibromyalgia, depending on sociocultural and clinical context, that can cause poor adaptation and dropout from treatment.

OBJECTIVE

To explore beliefs and expectations of individuals with fibromyalgia about physical exercises delivered through telerehabilitation.

METHODS

Thirty individual semi-structured interviews were conducted via videoconference with women with fibromyalgia recruited during COVID-19 pandemic through intentional sampling. These interviews were guided by four questions addressing the beliefs and expectations about telerehabilitation. The interviews were recorded after consent and transcribed using the MAXQDA® software. The inductive approach was performed in which raw data were coded into categories and subcategories.

RESULTS

Participants expect to benefit from telerehabilitation due to flexible hours, no need of travel, socialization, and lower risk of contamination. However, they believe they have difficulties related to the physical absence of the therapist, complexity of the exercises, internet connection problems, adaptation to the domestic routine and availability of schedules.

CONCLUSION

Women with fibromyalgia showed positive expectations about telerehabilitation, relating better socialization with other individuals diagnosed with fibromyalgia, home care with flexible schedule and, to provide needed service to underserved. However, they listed barriers such as the physical absence of the therapist and instability of the internet connection and, the FM symptoms themselves.

Patient-Provider Shared Decision-Making, Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid Therapy for Chronic Pain

BACKGROUND

Patient-provider shared decision-making is associated with better treatment adherence and pain outcomes in opioid-specific pain management. One possible mechanism through which shared decision-making may impact pain management outcomes is trust in one's prescribing provider. Elucidating relationships between factors that enhance the patient-provider relationship, such as shared decision-making and trust, may reduce risks associated with opioid treatment, such as opioid misuse.

OBJECTIVE

The purpose of this study was to investigate the mediating effect of trust in one's prescribing provider on the relationship between shared decision-making and current opioid misuse.

DESIGN

A secondary analysis of data from a prospective cohort study of US Veterans (N = 1273) prescribed long-term opioid therapy (LTOT) for chronic non-cancer pain.

PARTICIPANTS

Eligibility criteria included being prescribed LTOT, ability to speak and read English, and access to a telephone. Veterans were excluded if they had a cancer diagnosis, received opioid agonist therapy for opioid use disorder, or evidence of pending discontinuation of LTOT. Stratified random sampling was employed to oversample racial and ethnic minorities and women veterans.

MAIN MEASURES

Physician Participatory Decision-Making assessed level of patient involvement in medical decision-making, the Trust in Provider Scale assessed interpersonal trust in patient-provider relationships, and the Current Opioid Misuse Measure assessed opioid misuse.

KEY RESULTS

Patient-provider shared decision-making had a total significant effect on opioid misuse, in the absence of the mediator (c =  - 0.243, p < 0.001), such that higher levels of shared decision-making were associated with lower levels of reported opioid misuse. When trust in provider was added to the mediation model, the indirect effect of shared decision-making on opioid misuse through trust in provider remained significant (c' =  - 0.147, p = 0.007).

CONCLUSIONS

Shared decision-making is associated with less prescription opioid misuse through the trust that is fostered between patients and providers.

Prevalence and predictors of primary nonadherence to medications prescribed in primary care

BACKGROUND

Most research on medication adherence has focused on secondary nonadherence and persistence to therapy. Medication prescriptions that are never filled by patients (primary nonadherence) remain understudied in the general population.

METHODS

We linked prescribing data from primary care electronic medical records to comprehensive pharmacy dispensing claims between January 2013 and April 2019 in British Columbia (BC) to estimate primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date. We used hierarchical multivariable logistic regression to determine prescriber, patient and medication factors associated with primary nonadherence among community-dwelling patients in primary care.

RESULTS

Among 150 565 new prescriptions to 34 243 patients, 17% of prescriptions were never filled. Primary nonadherence was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%). In multivariable analysis, primary nonadherence was lower for prescriptions issued by male prescribers (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.50-0.88). Primary nonadherence decreased with patient age (OR 0.91, 95% CI 0.90-0.92 for each additional 10 years) but increased with polypharmacy among patients aged 65 years or older. Patients filled more than 82% of their medication prescriptions within 2 weeks after their primary care provider visit.

INTERPRETATION

The prevalence of primary nonadherence to new prescriptions was 17%. Interventions to address primary nonadherence could target older patients with multiple medication use and within the first 2 weeks of the prescription issue date.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Using Animated Videos to Promote the Accessibility and Understandability of Package Leaflets: Retrospective Observational Study Evaluating the First Year of Implementation

BACKGROUND

The medication package leaflet is the most used and trusted source of information in the home situation but is often incomprehensible for individuals, especially for those with limited health literacy. The platform "Watchyourmeds" comprises a web-based library with over 10,000 animated videos that explain the most essential information from the package leaflet in an unambiguous and simple manner to increase the accessibility and understandability of package leaflets.

OBJECTIVE

This study aimed to investigate Watchyourmeds in the Netherlands from a user perspective during the first year of implementation by investigating (1) usage data, (2) self-reported user experiences, and (3) the preliminary and potential impact on medication knowledge.

METHODS

This was a retrospective observational study. The first aim was investigated by examining objective user data from 1815 pharmacies from the first year of implementation of Watchyourmeds. User experiences (second aim) were investigated by examining individuals' completed self-report questionnaires (n=4926) that they received after completing a video. The preliminary and potential impact on medication knowledge (third aim) was investigated by examining users' self-report questionnaire data (n=67) that assessed their medication knowledge about their prescribed medication.

RESULTS

Nearly 1.8 million videos have been distributed to users by over 1400 pharmacies, with monthly numbers increasing to 280,000 in the last month of the implementation year. Most users (4444/4805, 92.5%) indicated to have fully understood the information presented in the videos. Female users reported more often to have fully understood the information than male users (χ²₄=11.5, P=.02). Most users (3662/4805, 76.2%) said that they did not think any information was missing in the video. Users with a lower educational level stated more often (1104/1290, 85.6%) than those with a middle (984/1230, 80%) or higher (964/1229, 78.4%) educational level that they did not seem to be missing any information in the videos (χ²₁₂=70.6, P<.001). A total of 84% (4142/4926) of the users stated that they would like to use Watchyourmeds more often and for all their medication, or would like to use it most of the time. Male users and older users stated more often that they would use Watchyourmeds again for other medication than the female (χ²₃=25.0, P<.001) and younger users (χ²₃=38.1, P<.001), respectively. Almost 88% (4318/4926) of the users would recommend the web-based library to friends, family, or acquaintances. Regarding the third aim, results showed that 73.8% (293/397) of the questions assessing users' medication knowledge were answered correctly.

CONCLUSIONS

The results of this study suggest that a web-based library with animated videos is a valuable and acceptable addition to stand-alone package leaflets to increase the understanding and accessibility of medication information.

Longitudinal study to assess antidepressant treatment patterns and outcomes in individuals with depression in the general population

BACKGROUND

Major depressive disorder (MDD) is largely managed in primary care, but physicians vary widely in their understanding of symptoms and treatments. This study aims to better understand the evolution of depression from initial diagnosis over a 3-year period.

METHODS

This was a noninterventional, retrospective, longitudinal study, with 2 waves of participant interviews approximately 3 years apart. Phone interviews were conducted using the hybrid artificial intelligence (AI) Sleep-EVAL system, an AI-driven diagnostic deep learning tool. Participants were noninstitutionalized adults representative of the general population in 8 US states. Diagnosis was confirmed according to the DSM-5 using the Sleep-EVAL System.

RESULTS

10,931 participants completed Wave 1 and 2 (W1, W2) interviews. The prevalence of MDD, including partial and complete remission, was 13.4 % and 19.6 % in W1 and W2, respectively. About 42 % of MDD participants at W1 continued to report depressive symptoms at W2. Approximately half of antidepressant (AD) users in W1 were moderately to completely dissatisfied with their treatment; 29.6 % changed their AD for a different one, with 16.4 % switching from one SSRI to another between W1 and W2. Primary care physicians were the top AD prescribers, both in W1 (45.7 %) and W2 (59%), respectively.

LIMITATIONS

Data collected relied on self-reporting by participants. As such, the interpretation of the data may be limited.

CONCLUSIONS

Depression affects a sizeable portion of the US population. Dissatisfaction with treatment, frequent switching of ADs, and changing care providers are associated with low rates of remission. Residual symptoms remain a challenge that future research must address.

Utilization of remote e-prescription (Anat) in Saudi Arabia during COVID-19: Factors associated with primary adherence and antibiotic prescription

Background

The COVID-19 pandemic has affected healthcare systems globally. Various health care technologies have been used to mitigate the risk of disease transmission. Telemedicine is one such technology, and remote consulting and prescribing comprise one of its key aspects. In Saudi Arabia, telephone health services have been widely used through the free Medical Consultation Call Center (937). This platform facilitates medical consultations for all citizens, residents, and visitors. After consultations, healthcare providers are able to issue authenticated e-prescriptions using the Anat platform.

Objectives

To explore the utilization of the Anat remote prescription system in Saudi Arabia during the COVID-19 pandemic and to identify the factors associated with antibiotic prescription and primary medication adherence.

Methods

This retrospective analysis included data from the Anat e‑prescription system using a stratified random sample of 25000 prescriptions issued in Saudi Arabia in 2020. Predictive factors related to the patients, practitioners, and prescriptions were identified through bivariate and multivariate logistic regression analyses.

Results

Out of 25,000 e-prescriptions, 8885 were dispensed, resulting in a 35.5% primary medication adherence rate. The significant predictors of primary adherence were children, respiratory diseases, and antibacterial drugs. In addition, antibiotics made up 32.1% of the e-prescriptions. The prescription of antibiotics was significantly associated with male sex, children, genitourinary system diseases, and being treated by radiologists.

Conclusions

Almost two thirds 62.2% of e-prescriptions were undispensed, with antibiotic eprescriptions at 32.1%. Findings emphasize the need to enhance primary medication adherence and antibiotic prescription interventions. These findings could aid decision-makers in improving patient-centered e-prescribing practices.

It's not what you say but how you say it: Examining the influence of perceived voice assistant gender and pitch on trust and reliance

Voice assistants (VA) are virtual agents used to aid information seeking. Cues contained in speech, such as perceived gender and vocal pitch, may influence attitudes towards, and interactions with these agents. Given expansion of telehealth efforts and the potential for VA to advise patients on health-related topics outside of formal healthcare settings, the influence of VA vocal characteristics is examined in the context of medication instructions. Participants rated trust and reliance on VA after viewing medication labels and hearing recommendations from male and female agents with varying pitch. Results suggest agents perceived as female were rated as more trustworthy, while vocal pitch did not significantly influence trust. However, a trend of lower reliance with increasing pitch was observed. Additionally, participants relied significantly more on VA advice than medication labels when making decisions. Post-hoc analyses revealed trust and reliance primarily varied between participants. Pitch and gender explained only a small portion of within-participant variance. We found suggestive evidence for social categorizations distilled from vocal cues influencing interactions with agents delivering health-critical information. Future work should explore additional samples, vocal cues, and participant-level sources of variation.

Physician influence on medication adherence, evidence from a population-based cohort

BACKGROUND

The overall impact of physician prescribers on population-level adherence rates are unknown. We aimed to quantify the influence of general practitioner (GP) physician prescribers on the outcome of optimal statin medication adherence.

METHODS

We conducted a retrospective cohort study using health administrative databases from Saskatchewan, Canada. Participants included physician prescribers and their patients beginning a new statin medication between January 1, 2012 and December 31, 2017. We grouped prescribers based on the prevalence of optimal adherence (i.e., proportion of days covered ≥ 80%) within their patient group. Also, we constructed multivariable logistic regression analyses on optimal statin adherence using two-level non-linear mixed-effects models containing patient and prescriber-level characteristics. An intraclass correlation coefficient was used to estimate the physician effect.

RESULTS

We identified 1,562 GPs prescribing to 51,874 new statin users. The median percentage of optimal statin adherence across GPs was 52.4% (inter-quartile range: 35.7% to 65.5%). GP prescribers with the highest patient adherence (versus the lowest) had patients who were older (median age 61.0 vs 55.0, p<0.0001) and sicker (prior hospitalization 39.4% vs 16.4%, p<0.001). After accounting for patient-level factors, only 6.4% of the observed variance in optimal adherence between patients could be attributed to GP prescribers (p<0.001). The majority of GP prescriber influence (5.2% out of 6.4%) was attributed to the variance unexplained by patient and prescriber variables.

INTERPRETATION

The overall impact of GP prescribers on statin adherence appears to be very limited. Even "high-performing" physicians face significant levels of sub-optimal adherence among their patients.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Relationship Among Diabetes Distress, Health Literacy, Diabetes Education, Patient-Provider Communication and Diabetes Self-Care

OBJECTIVES

Mechanisms underlying relationships among patients' health literacy, diabetes distress, diabetes education, and provider counseling for self-care of chronic conditions are unclear. This study tested these relationships using SEM with adult patients with comorbid diabetes and hypertension in rural WV.

METHODS

Ninety-one participants of a 12-week self-management program reported on diabetes self-care (diet, exercise, blood glucose (BG) monitoring) and related provider counseling.

RESULTS

Based on patient report, providers' recommendations included following a low-fat diet, eating fruits/ vegetables, limiting sweets, a daily low-level of exercise and/or exercise ≥20 minutes three times/week, and BG monitoring. Provider recommendations were shown to be associated with patients' self-care behaviors (r=0.22, p<0.05). Multiple factors directly influenced provider recommendations: diabetes distress, health literacy, and family history of diabetes. A positive association was also noted between prior diabetes education and provider recommendations and diabetes self-care (r=0.44, p<0.001). A negative association was noted between diabetes distress and self-care, but a positive effect on provider recommendations was found. The model demonstrated good fit [CFI=0.94, and Root Mean Square Error of Approximation (RMSEA) =0.05].

CONCLUSIONS

To enhance diabetes self-care, providers should consistently provide education on self-care behaviors as well as partner with them to address diabetes distress.

Veterinary technicians contribute to shared decision-making during companion animal veterinary appointments

OBJECTIVE

To describe and compare veterinary professionals' use of shared decision-making during companion animal appointments.

DESIGN

Multi-practice cross-sectional study.

SAMPLE

A purposive sample of 4 companion animal veterinary clinics in a group practice in Texas.

PROCEDURES

A convenience sample of veterinary appointments were recorded January to March 2018 and audio-recordings were analyzed using the Observer OPTION5 instrument to assess shared decision-making. Each decision was categorized by veterinary professional involvement.

RESULTS

A total of 76/85 (89%) appointments included at least 1 decision between the client and veterinary professional(s), with a total of 129 shared decisions. Decisions that involved both a veterinary technician and veterinarian scored significantly higher for elements of shared decision-making (OPTION5 = 29.5 ± 8.4; n = 46), than veterinarian-only decisions (OPTION5 = 25.4 ± 11.50; P = .040; n = 63), and veterinary technician-only decisions (OPTION5 = 22.5 ± 7.15; P = .001; n = 20). Specific elements of shared decision-making that differed significantly based on veterinary professional involvement included educating the client about options (OPTION5 Item 3; P = .0041) and integrating the client's preference (OPTION5 Item 5; P = .0010).

CLINICAL RELEVANCE

Findings suggest that clients are more involved in decision making related to their pet's health care when both the veterinary technician and veterinarian communicate with the client. Veterinary technicians' communication significantly enhanced client engagement in decision-making when working collaboratively with the veterinarian.

Factors Influencing Drug Use Information Received at Primary Healthcare Centre Pharmacies in Ghana

Background

Health literacy addresses environmental, political, and social factors that determine health. Drug dispensers play a major role in educating patients on drug use to increase effective and efficient drug utilisation, thereby promoting positive healthcare outcomes. From the patients' perspective, this study examined the communication quality between patients and drug dispensers at primary healthcare centres in the Cape Coast Metropolis of Ghana.

Method

We conveniently surveyed 269 patients seeking health care at primary healthcare facilities using a researcher-constructed 13-item instrument. In SPSS version 21 software, we analysed the data using percentages, chi-square analysis, and logistic regression.

Results

Almost half of the participants (n = 132) reported low health literacy, with 81% (n = 218) reporting that drug side effects were not discussed with them at the pharmacies. The findings further indicated that health literacy and educational level predicted general communication quality between participants and drug dispensers; participants with secondary education were about 3 times more likely to report not being told of the side effects of prescribed drugs as compared with those who had completed only basic education.

Conclusions

There is still a high level of low health literacy among patients seeking healthcare at primary healthcare centres and a very high percentage of patients did not receive any education on side effects of dispensed drugs. Drug use directives from dispensers at primary healthcare facilities can make a difference between any 2 patients.

Antidepressant decision aid for major depressive disorder patients (ADAM): Development and pilot testing

OBJECTIVES

This study aimed to develop and assess the effectiveness of an encounter decision aid for Malaysian patients with MDD to support treatment decision-making during the consultation.

METHODS

The decision aid prototype was developed following a literature review and six focus groups. Alpha testing assessed its comprehensibility, acceptability, usability and desirability through user-centered cognitive interviews. Beta-testing evaluated preliminary evidence on its efficacy using the SDM Scale and PDMS. Feasibility was assessed by timing the consultation.

RESULTS

The alpha testing demonstrated that the decision aid was patient-oriented, comprehensible, comprehensive, concise and objective with an appealing design. Beta-testing indicated that PtDA significantly increased patients satisfaction with SDM from patients' [83.32 (13.92) vs 85.76 (13.80); p < 0.05] and physicians' [81.07 (10.09) vs 86.36 (10.10); p < 0.05] perspectives and prepared the patients for decision making from the patients' [PDMS patients: 84.10 (12.69)] and physicians' [PDMS physicians: 83.78 (16.62)] perspectives as well. There was no change in the consultation time between the control and the intervention groups.

CONCLUSIONS

We developed an antidepressant PtDA for Malaysian patients with MDD that increases patients' involvement in shared decision making and enhances their preparedness for decision making.

PRACTICE IMPLICATIONS

Using the PtDA can support collaborative decision-making in routine clinical practice without extending the consultation time.

Recall of Care Objectives by Patients with Inflammatory Bowel Diseases

The management of IBD is highly complex, given the heterogeneity of treatment plans for an equally diverse patient population. Given the intricacy of treatment, improved health literacy may be associated with better outcomes. Methods: Patients were assessed before and after their endoscopy and for their knowledge of their disease status, their correct recall of the endoscopy results, their provider–patient communication, and communication preferences. Results: A total of 37 patients completed both surveys and were included in the final analysis. The median age was 45 years. The median number of years diagnosed with IBD was 13. Most patients correctly recalled the results of their surveillance endoscopy after their procedure (84%). Many patients (65%) felt they were equally involved in the decision making process in regard to their surveillance endoscopies. Most patients (92%) reported having results clearly explained to them. Most patients (76%) preferred receiving an email or patient message with results, and 69% of patients reported receiving results in the way they preferred. Conclusions: Most of the patients with IBD who were surveyed had adequate knowledge of their disease process and could accurately recall the results of their endoscopy. However, the delivery of health information can be optimized, as nearly one-third of our patients did not receive their endoscopy results in their preferred method.

An integrated continuity of care measure improves performance in models predicting medication adherence using population-based administrative data

Objectives

Continuity of care (COC) is considered an important determinant of medication adherence based on measures such as the usual provider continuity index (UPCI) that are derived exclusively from physician visit claims. This study aimed to: a) determine if high UPCI values predict physicians who deliver different clinical services; and b) compare UPCI with an integrated COC measure capturing physician visits, prescribing, and a complete medical examination in a multivariable model of patients receiving statin medications.

Methods

This was a retrospective cohort study of new statin users between 2012 and 2017 in Saskatchewan, Canada. We calculated sensitivity/specificity of a high UPCI value for predicting physicians who were prescribers of statins and/or providers of complete medical examinations. Next, we used logistic regression models to test two measures of COC (high UPCI value or an integrated COC measure) on the outcome of optimal statin adherence (proportion of days covered ≥80%). The DeLong test was used to compare predictive performance of the two models.

Results

Among 55,144 new statin users, a high UPCI was neither a sensitive or specific marker of physicians who prescribed statins or performed a complete medical examination. The integrated COC measure had a stronger association with optimal adherence [adjusted odds ratio (OR) = 1.56, 95% confidence interval (CI) 1.50 to 1.63] than UPCI (adjusted OR = 1.23, 95% CI 1.19 to 1.28), and improved predictive performance of the adherence model.

Conclusion

The number of physician visits alone appears to be insufficient to represent COC. An integrated measure improves predictive performance for optimal medication adherence in patients initiating statins.

A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community

Older adults taking multiple chronic medications experience an increased risk of adverse drug events and other medication-related problems (MRP). Most current literature on medication management involves researcher-driven intervention, yet few studies investigate patients' understanding of MRP in a diverse community setting. This report investigates patients' perception of MRP and patient-centered strategies among a cohort of the older adult group in a historically Black urban community. The study design is qualitative using structured open-ended questions in a multidisciplinary patient-centered focus group. Patients (age 65 years or older) taking seven or more medications were recruited. The group comprises patients, caregivers, pharmacists, health educators, a physician, and a nurse. Recordings of the group discussion are transcribed verbatim and analyzed using thematic content analysis and categorized by codes developed from the social-ecological model. The group reports patient-provider relationships, previous experience, fear of side effects played important roles in medication adherence. There is an unmet need for medication management education and tools to organize complex medication lists from multiple providers. This study provides important insights into MRP experienced by minority older adults and provided researchers with potential strategies for future interventions.

The Impact of Age and Sex Concordance Between Patients and Physicians on Medication Adherence: A Population-Based Study

PURPOSE

Age or sex concordance (same sex or same age range) may also be associated with medication adherence but was not fully investigated. We aim to quantify the impact of age and sex concordance on optimal adherence to statin medications.

PATIENTS AND METHODS

A retrospective cohort study was conducted using population-based health administrative data from Saskatchewan, Canada. Participants were individuals newly initiated on statin medications between January 1, 2012, and December 31, 2017. The outcome was optimal adherence (proportion of days covered ≥ 80%) measured at one year after the first statin claim. The independent variables were sex and age concordance (age within five years) between patients and prescribers. The association between adherence outcome and sex/age concordance was analyzed by multivariable logistic regression models using generalized estimating equations controlled by a package of potential confounding factors.

RESULTS

Among 51,874 new statin users, 20.6% (n = 10,710) were age concordant with prescriber. The vast majority of age concordance occurred in patients younger than 66 years (88.6%, 9,486/10,710). Sex concordance was observed in 62.8% (n = 32,551) of patients and age-sex combined concordance in 13.2% (n = 6,856). Among patients younger than 66 years (n = 36,641/51,874, 70.6%), age concordance did not have a significant impact on optimal adherence [adjusted OR (aOR) = 1.02, 95% CI 0.97 to 1.07]. Weak association between sex concordance (aOR = 1.05, 95% CI 1.00 to 1.11), and age-sex combined concordance (aOR = 1.05, 95% CI 0.99 to 1.12) was observed.

CONCLUSION

Age and sex concordance were not statistically significant predictors of optimal statin adherence. However, a weak association was detected for sex concordance. Future studies should examine this factor in different health care settings.

Precision communication: Physicians' linguistic adaptation to patients' health literacy

Little quantitative research has explored which clinician skills and behaviors facilitate communication. Mutual understanding is especially challenging when patients have limited health literacy (HL). Two strategies hypothesized to improve communication include matching the complexity of language to patients’ HL (“universal tailoring”); or always using simple language (“universal precautions”). Through computational linguistic analysis of 237,126 email exchanges between dyads of 1094 physicians and 4331 English-speaking patients, we assessed matching (concordance/discordance) between physicians’ linguistic complexity and patients’ HL, and classified physicians’ communication strategies. Among low HL patients, discordance was associated with poor understanding (P = 0.046). Physicians’ “universal tailoring” strategy was associated with better understanding for all patients (P = 0.01), while “universal precautions” was not. There was an interaction between concordance and communication strategy (P = 0.021): The combination of dyadic concordance and “universal tailoring” eliminated HL-related disparities. Physicians’ ability to adapt communication to match their patients’ HL promotes shared understanding and equity. The ‘Precision Medicine’ construct should be expanded to include the domain of ‘Precision Communication.’

Care processes and structures associated with higher medication adherence in adolescent and young adult transplant recipients

BACKGROUND

We aimed to identify care processes and structures that were independently associated with higher medication adherence among young transplant recipients.

METHODS

We conducted a prospective, observational cohort study of 270 prevalent kidney, liver, and heart transplant recipients 14-25 years old. Patients were ≥3 months post-transplant, ≥2 months post-discharge, and followed in one of 14 pediatric or 14 adult transplant programs in Canada. Patients were enrolled between June 2015 and March 2018 and followed for 6 months. Adherence was assessed at baseline, 3, and 6 months using the BAASIS^© self-report tool. Patients were classified as adherent if no doses were missed in the prior 4 weeks. Transplant program directors and nurses completed questionnaires regarding care organization and processes.

RESULTS

Of the 270 participants, 99 were followed in pediatric programs and 171 in adult programs. Median age was 20.3 years, and median time since transplant was 5 years. At baseline, 71.5% were adherent. Multivariable mixed effects logistic regression models with program as a random effect identified two program-level factors as independently associated with better adherence: minimum number of prescribed blood draws per year for those >3 years post-transplant (per 1 additional) (OR 1.12 [95% CI 1.00, 1.26]; p = .047), and average time nurses spend with patients in clinic (per 5 additional minutes) (OR 1.15 [1.03, 1.29]; p = .017).

CONCLUSION

Program-level factors including protocols with a greater frequency of routine blood testing and more nurse time with patients were associated with better medication adherence. This suggests that interventions at the program level may support better adherence.

Examining the Relationships Between Experienced and Anticipated Stigma in Health Care Settings, Patient-Provider Race Concordance, and Trust in Providers Among Women Living with HIV

Stigma in health care settings can have negative consequences on women living with HIV, such as increasing the likelihood of missed visits and reducing trust in their clinical providers. Informed by prior stigma research and considering knowledge gaps related to the effect of patient-provider race concordance, we conducted this study to assess if patient-provider race concordance moderates the expected association between HIV-related stigma in health care settings and patients' trust in their providers. Moderation analyses were conducted using Women's Interagency HIV Study data (N = 931). We found significant main effects for patient-provider race concordance. Higher experienced stigma was associated with lower trust in providers in all patient-provider race combinations [White-White: B = -0.89, standard error (SE) = 0.14, p = 0.000, 95% confidence interval, CI (-1.161 to -0.624); Black patient-White provider: B = -0.19, SE = 0.06, p = 0.003, 95% CI (-0.309 to -0.062); and Black-Black: B = -0.30, SE = 0.14, p = 0.037, 95% CI (-0.575 to -0.017)]. Higher anticipated stigma was also associated with lower trust in providers [White-White: B = -0.42, SE = 0.07, p = 0.000, 95% CI (-0.552 to -0.289); Black patient-White provider: B = -0.17, SE = 0.03, p = 0.000, 95% CI (-0.232 to -0.106); and Black-Black: B = -0.18, SE = 0.06, p = 0.002, 95% CI (-0.293 to -0.066)]. Significant interaction effects indicated that the negative associations between experienced and anticipated HIV-related stigma and trust in providers were stronger for the White-White combination compared with the others. Thus, we found that significant relationships between HIV-related experienced and anticipated stigma in health care settings and trust in providers exist and that these associations vary across different patient-provider race combinations. Given that reduced trust in providers is associated with antiretroviral medication nonadherence and higher rates of missed clinical visits, interventions to address HIV-related stigma in health care settings may improve continuum of care outcomes.

Predicting longitudinal service use for individuals with substance use disorders: A latent profile analysis

INTRODUCTION

Substance use disorders (SUD) are chronic conditions that often warrant coordinated medical care throughout a relapsing and remitting course. However, SUD treatment is frequently measured as a binary outcome, where individuals either receive or do not receive care following the immediate treatment seeking event. This study aimed to describe longitudinal treatment seeking behaviors by assessing service use patterns among individuals with diagnosed SUDs in a safety net hospital that offers a "no wrong door" care model. This study also examined whether certain patient subgroups were more likely to transition to service use patterns that support recovery or treatment disengagement over time.

METHODS

The team conducted a retrospective cohort study using electronic health record data from adult patients diagnosed with SUDs (n = 1157) who regularly accessed services at a safety net hospital over a five-year period. The study used latent class analysis (LCA) and latent profile analysis to empirically identify distinct treatment utilization profiles of individuals with SUDs. We used multinomial logistic regression to evaluate predictors of class membership and transitions over a five-year period.

RESULTS

The research team identified five distinct service use classes, including patients who disengaged from services (42.4%), or those who predominantly used outpatient substance use services (7.0%), mental health services (13.0%), primary care services (24.7%), or other specialty care services (13.1%). Being female and an older adult were statistically significant predictors for membership in any service use-driven status. Black patients had increased odds for "substance use service" and "primary care" service statuses over time.

CONCLUSION

LCA and latent transition analysis (LTA) methods are novel approaches for identifying profiles of patients with higher risk for health services disengagement. SUD treatment engagement strategies are needed to reach males, young adults, and individuals with non-opioid SUDs.

Will Improvements in Patient Experience With Care Impact Clinical and Quality of Care Outcomes?: A Systematic Review

BACKGROUND

Patient experiences with health care have been widely used as benchmark indicators of quality for providers, health care practices, and health plans.

OBJECTIVE

The objective of this study was to summarize the literature regarding the associations between Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experiences and clinical and quality outcomes.

RESEARCH DESIGN

A systematic review of the literature was completed using PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature on December 14, 2019. Separate searches were conducted to query terms identifying CAHPS surveys with clinical and quality outcomes of care. Two reviewers completed all components of the search process.

STUDY SELECTION

Studies investigating associations between CAHPS composite ratings and health care sensitive clinical outcomes or quality measures of care were included in this review. Studies were excluded if they did not investigate patient experiences using CAHPS composite ratings or if CAHPS composites were not treated as the independent variable.

RESULTS

Nineteen studies met inclusion criteria, 10 investigating associations of CAHPS composite ratings with clinical outcomes and 9 investigating these associations with quality measures. Patient-provider communication was the most studied CAHPS composite rating and was significantly associated with self-reported physical and mental health, frequency of emergency room visits and inpatient hospital stays, hospitalization length, and CAHPS personal physician global ratings.

CONCLUSIONS

Ratings of patient experience with care may influence clinical and quality outcomes of care. However, key inconsistencies between studies affirm that more research is needed to solidify this conclusion and investigate how patient experiences differentially relate to outcomes for various patient groups.

Racism, Mental Health, Healthcare Provider Trust, and Medication Adherence Among Black Patients in Safety-Net Primary Care

There has been a growing research focus on social determinants to health disparities in general and medication adherence more specifically in low-income Black populations. The purpose of this study was to examine whether prior experiences of racism among Black patients in safety-net primary care indirectly predicts poor medication adherence through increased mental health symptoms and low healthcare provider trust. Two competing models were run whereby mental health leads to provider trust or provider trust leads to mental health in this multiple mediational chain. A group of 134 Black patients (76 men, average age 45.39 years) in a safety-net primary care clinic completed measures of these constructs. Results revealed that in the first model, mental health mediated the relationship between racism and provider trust, and provider trust mediated the relationship between mental health and medication adherence. All paths within this model were statistically significant, except the path between provider trust and medication adherence which approached significance. In the second model, provider trust and mental health significantly mediated the relationship between racism and medication adherence, and all direct and indirect paths were statistically significant, though the path between provider trust and medication adherence was omitted. These results may serve as catalysts to assess and attempt to mitigate specific minority-based stressors and associated outcomes within safety-net primary care settings.

Measuring the multiple domains of medication nonadherence: findings from a Delphi survey of adherence experts

Consensus on a gold-standard measure of patient medication nonadherence has been elusive, in part because medication nonadherence involves multiple, distinct behaviors across three phases (initiation, implementation, and persistence). To assess these behaviors, multiple measurement approaches may be needed. The purpose of this study was to identify expert-recommended approaches to measuring nonadherence behaviors. Thirty medication nonadherence experts were e-mailed two consecutive surveys. In both, respondents rated their agreement with definitions of nonadherence behaviors and measurement approaches. In the second survey, respondents rated the suitability of each measurement approach for assessing each behavior and identified the optimal measurement approach for each behavior. Consensus was achieved for eight patient medication nonadherence behaviors: not filling initial prescription and not taking first dose (noninitiation); refilling prescription late, missing doses, taking extra doses, taking doses at wrong time, and improperly administering medication (incorrect implementation); and discontinuing medication early (nonpersistence). Consensus was achieved for seven measurement approaches: self-report, prescription fill data, pill count, drug levels, electronic drug monitoring (EDM), smart technology, and direct observation. Self-report questionnaires were most commonly rated "at least somewhat suitable" for measuring behaviors. EDM was rated as optimal for measuring missing doses, taking extra doses, and taking doses at the wrong time. Prescription fill data were rated as optimal for not filling initial prescription, refilling late, and discontinuing. Direct observation was rated as optimal for measuring improper administration. Suitable and optimal measurement approaches varied across nonadherence behaviors. Researchers should select the measurement approach best suited to assessing the behavior(s) targeted in their research.

Shared decision-making and the implementation of treatment recommendations for depression

OBJECTIVE

This study aimed to examine the relationship between shared decision-making (SDM) and the implementation of treatment recommendations amongst outpatients at a specialist Depression Clinic.

METHODS

A total of 110 adult outpatients in a specialist Depression Clinic in Sydney, Australia, completed an online survey examining their experiences of shared decision-making (SDM) during their psychiatrist consultation and the extent to which they later implemented Depression Clinic treatment recommendations.

RESULTS

The odds of implementing treatment recommendations were over four times higher in patients who reported a high level of SDM in their consultation, compared to those who reported a low level of SDM. Further, three elements of patient-rated SDM were significantly associated with an increased likelihood of implementing depression treatment recommendations. These three elements were: i) being given the opportunity to ask questions or voice concerns; ii) being asked about any problems or side effects from previous treatments; and iii) being involved in deciding their treatment plan.

CONCLUSIONS

SDM was significantly associated with an increased likelihood of implementing psychiatrists' treatment recommendations at a specialist Depression Clinic.

PRACTICE IMPLICATIONS

We recommend that clinicians be informed of the potential benefits of SDM and adopt SDM when developing treatment plans with patients living with depression.

Association Between Patient-Clinician Relationships and Adherence to Antihypertensive Medications Among Black Adults: An Observational Study Design

Background We assessed the associations between patient-clinician relationships (communication and involvement in shared decision-making [SDM]) and adherence to antihypertensive medications. Methods and Results The 2010 to 2017 Medical Expenditure Panel Survey (MEPS) data were analyzed. A retrospective cohort study design was used to create a cohort of prevalent and new users of antihypertensive medications. We defined constructs of patient-clinician communication and involvement in SDM from patient responses to the standard questionnaires about satisfaction and access to care during the first year of surveys. Verified self-reported medication refill information collected during the second year of surveys was used to calculate medication refill adherence; adherence was defined as medication refill adherence ≥80%. Survey-weighted multivariable-adjusted logistic regression models were used to measure the odds ratio (OR) and 95% CI for the association between both patient-clinician constructs and adherence. Our analysis involved 2571 Black adult patients with hypertension (mean age of 58 years; SD, 14 years) who were either persistent (n=1788) or new users (n=783) of antihypertensive medications. Forty-five percent (n=1145) and 43% (n=1016) of the sample reported having high levels of communication and involvement in SDM, respectively. High, versus low, patient-clinician communication (OR, 1.38; 95% CI, 1.14-1.67) and involvement in SDM (OR, 1.32; 95% CI, 1.08-1.61) were both associated with adherence to antihypertensives after adjusting for multiple covariates. These associations persisted among a subgroup of new users of antihypertensive medications. Conclusions Patient-clinician communication and involvement in SDM are important predictors of optimal adherence to antihypertensive medication and should be targeted for improving adherence among Black adults with hypertension.

Enhancing Primary Care Experiences for Homeless Patients with Serious Mental Illness: Results from a National Survey

Objectives:

Patients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients (Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences.

Methods:

We surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs.

Results:

Among respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7).

Conclusions:

Homeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.

Understanding Veterans' Causal Attributions of Physical Symptoms

BACKGROUND

Illness beliefs are significant contributors to health outcomes. Beliefs about the cause of physical symptoms are considered particularly important among those with medically unexplained symptoms and illnesses (MUS); yet little is known about causal beliefs among those with the most severe MUS (i.e., Veterans). The goal of the current study was to examine Veteran's causal attributions of their physical symptoms.

METHOD

A total of 91 combat Veterans with MUS were surveyed using a mixed-methods design about the cause of their physical symptoms, physical symptom severity, and PTSD symptoms. Causal attributions of physical symptoms were analyzed through thematic response analysis and grouped into categories. Chi-square analysis was used to assess the distribution of causal attribution types across Veterans with varying physical symptom severity and PTSD symptom severity.

RESULTS

Veterans with MUS reported an average of 7.9 physical symptoms, and attributed the cause of their symptoms to seven different categories ("Do not Know," "Stress/Mental Health," "Deployment/Environment," "Functional/Symptom," "Medically Explained," "Medically Unexplained Syndrome," and "Lifestyle"). Exploratory chi-square analysis revealed significant differences in causal attributions across physical symptom severity and severity of PTSD symptoms. Veterans with more severe PTSD and Veterans with more severe physical symptoms were more likely to attribute their MUS to stress/mental health or to a medically unexplained syndrome compared with those with low/no PTSD symptoms and physical symptom severity. Veterans with minimal PTSD and Veterans with minimal physical symptom severity were more likely to attribute the cause of their MUS to lifestyle choices (e.g., exercise/diet) compared with those with high PTSD and physical symptom severity.

CONCLUSION

Veterans with MUS endorse multiple, varied causal attributions for their physical symptoms, suggesting more complex causal beliefs than typically assumed. This has important implications for patient-provider communication and development of concordance around MUS treatment.

The Mediating Role of Shared Decision-Making in the Effect of the Patient-Physician Relationship on Compliance With Treatment

Background:

For a successful treatment outcome, the components of the treatment process are very important. The patient–physician relationship plays a key role in the successful therapeutic process and effective health service delivery. The patient’s compliance with the treatment directly affects the success of the treatment.

Objective:

This study aims to determine the effect of the patient–physician relationship on compliance with the treatment and to determine whether shared decision-making has an mediating role in this effect.

Patient Involvement:

Most of the study participants (55%) were younger than 35 and their average age was 30. The majority of the participants have an associate degree or higher education.

Method:

The study used a 4-part survey form as the data collection tool. The sample in this study consisted of 399 participants. To analyze the obtained data, Structural Equation Modeling was used by employing the Smart PLS3 software.

Results:

The results of the study show that the patient–physician relationship positively affects the patient’s compliance with the treatment and shared decision-making. In addition, shared decision-making positively affects the patient’s compliance with the treatment. The effect of the patient–physician relationship on compliance with treatment was strengthened through shared decision-making.

Discussion:

The results of the study revealed that patient–physician relationship and shared decision-making are two important factors in patients’ compliance with the treatment. Accordingly, the stronger the patient–physician relationship and the more patients participate in their treatment decisions, the higher their compliance with the treatment.

Experiences and Views of Domestic Summer Travelers During the COVID-19 Pandemic: Findings from a National Survey

Domestic travel creates a serious risk of spreading COVID-19, including novel strains of the virus. Motivating potential travelers to take precautions is critical, especially for those at higher risk for severe illness. To provide an evidence base for communication efforts, we examined the experiences and views of travelers during the summer of 2020 through a telephone survey of 1,968 US adults, conducted in English and Spanish, July 2 through July 16, 2020. The survey found that more than one-quarter (28%) of adults had traveled domestically in the prior 30 days, most commonly for "vacation" (43%), and less than half wore masks (46%) or practiced social distancing (47%) "all of the time." Although high-risk adults were significantly less likely to travel than non-high-risk adults (23% vs 31%; P < .001), they were no more likely to take precautions. Many travelers did not wear a mask or practice social distancing because they felt such actions were unnecessary (eg, they were outside or with friends and family). Although a substantial share of travelers (43% to 53%) trusted public health agencies "a great deal" for information about reducing risks while traveling, more travelers (73%) trusted their own healthcare providers. Findings suggest that outreach may be improved by partnering with providers to emphasize the benefits of layering precautions and provide targeted education to high-risk individuals. Messages that are empathetic to the need to reduce stress and convey how precautions can protect loved ones may be particularly resonant after more than a year of pandemic-related restrictions.

Racial-Ethnic Disparities in Diabetes Technology use Among Young Adults with Type 1 Diabetes

Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.

Depressive Symptoms and Trust of Healthcare Provider in Rural Adolescents: Relationships and Predictors

The purpose of this study was to evaluate associations among depressive symptoms, trust of healthcare provider, and health behavior in adolescents who live in a rural area. Two hundred twenty-four adolescents aged 14-19 years old attending public high school in the Midwestern United States were surveyed. Results showed a diagnosis of depression, trust of healthcare provider, health awareness, and stress management predicted depressive symptoms in adolescents living in a rural area. Healthcare providers should take extra care to promote trust in the healthcare provider-patient relationship with adolescents and to follow guidelines for annual screening of adolescents for depressive symptoms. Nursing implications include adolescent psychoeducation to improve health awareness and stress management.

Patient preferences for medication adherence financial incentive structures: A discrete choice experiment

BACKGROUND

Medication adherence for chronic conditions continues to be a challenge for patients. Patient incentives for medication adherence may help. Financial incentives delivered at the point of care may act as cues for medication-taking behavior.

OBJECTIVES

The purpose of this study was to investigate patient preferences for specific structures of financial medication adherence incentives that could feasibly be delivered at the point of care.

METHODS

A discrete choice experiment (DCE) was performed using a national online survey. Study participants were adults who self-reported taking at least one prescription medication for one or more chronic conditions. Following an orthogonal design generated in SAS, the DCE included 32 paired-choice tasks. Data were analyzed using mixed logit models and stratified on participants' income level.

RESULTS

In the full cohort (n = 933), form of financial reward (such as gift-card or cash) was 1.02 times as important to participants as the probability of incentive receipt, 1.58 times as important as monetary value, and 1.93 times as important as timing of receipt. Participants were willing to give up $31.04 of an incentive's monetary value (95% CI = $27.11-$34.98) to receive the incentive 5 months sooner (1-month vs. 6-month time-lag); $60.79 (95% CI = $53.19-$68.39) for probability of receipt to increase from a 1 out of 100 chance to a 1 out of 20 chance; and $10.52 (95% CI = $6.46-$14.58) to receive an incentive in the form of a Visa® gift-card instead of grocery store voucher. These patterns of trade-offs between attributes were generally consistent among participants with lower and higher income.

CONCLUSIONS

Regardless of socioeconomic status, patient preferences for financial medication adherence incentives delivered at the point of care may be most heavily influenced by incentive form and probability of receipt. This has implications for designing medication adherence programs in terms of incentive sustainability, patient engagement, plan star ratings, and patient outcomes.

The Shared Decision-Making Process in the Pharmacological Management of Depression

Shared decision making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. There is an international consensus across medicine about the importance of SDM interventions, which have raised great interest in mental healthcare over the last decade. Yet SDM is not widely adopted, particularly in the field of psychiatry. The purpose of the present article is to examine, from a patient and physician perspective, the importance of SDM in the management of healthcare with a focus on mental health; it reviews the enablers and barriers (and how to overcome them) to implementing a SDM process in psychiatric practice. SDM models have been developed recently for involving patients with depression in the decision-making process, which could result in augmenting the proportion of patients who adhere to their antidepressant or other treatments for a duration that complies with the current recommendations. To implement this approach, more physicians need training in the SDM approach and access to appropriate tools that help engage in collaborative deliberation, and practice generally needs to be reorganized around the principles of patient engagement.

Effects of an eHealth Intervention on Patient-Provider Interaction and Functional Health Literacy in Adults With Hypertension

INTRODUCTION

Hypertension is a life-limiting, chronic condition affecting millions of Americans. Modifiable factors, quality of the patient-provider interaction and functional health literacy, have been linked to effective hypertension self-management. However, there has been limited interventional research targeting these modifiable factors. Electronic hypertension self-management interventions, in particular those incorporating virtual simulation, may positively influence the quality of the patient-provider interaction and functional health literacy status of adults with hypertension. Yet there is a dearth of evidence examining the efficacy of eHealth interventions targeting these modifiable factors of hypertension self-management.

OBJECTIVE

Evaluate the effects of two electronic hypertension self-management interventions on the quality of the patient-provider interaction and functional health literacy in adults with hypertension.

METHODS

A convenience sample of community-dwelling adults (>18 years) with hypertension were recruited and randomized to an avatar-based simulation (eSMART-HTN) or a video presentation on hypertension self-management (attention control). Participants were administered questionnaires to capture demographic characteristics, the quality of the patient-provider interaction, and functional health literacy. Questionnaire data were collected at baseline, and then monthly across three months. Two separate repeated measures analysis of covariance models were conducted to assess the effects of the interventions across the time points.

RESULTS

The sample included 109 participants who were predominately middle-aged and older, nonwhite, and female. Scores for the quality of the patient-provider interaction demonstrated significant within-group changes across time. However, there were no significant differences in the quality of the patient-provider interaction or functional health literacy scores between experimental conditions while adjusting for covariates.

CONCLUSION

An avatar-based simulation (eSMART-HTN) intervention proved to have a positive effect on patient-provider interaction compared to an attention control condition. Although the results are promising, future research is needed to optimize the effectiveness of eSMART-HTN and enhance its efficacy and scalability in a larger cohort of adults with hypertension.

Associations between Trust of Healthcare Provider and Body Mass Index in Adolescents

Adolescent obesity continues to be a serious concern around the world, placing young people at risk for chronic conditions and early death. Research has shown that social relationships are important in making health behavior changes, such as following health-care recommendations for eating and physical activity. Specifically, the trust of health-care providers has been shown to be important in making health behavior change. Evidence suggests that obese young adults are less trusting of health-care providers than their healthy weight peers, but it is not known if this also applies to obese adolescents. The purpose of this secondary analysis study was to determine relationships between the trust of health-care providers and body mass index percentile in adolescents. Participants were 224 adolescents aged 14-19 years attending a public high school in the Midwestern United States. The Wake Forest Physician Trust scale measured the trust of health-care providers. Height and weight were collected at a school screening; body mass index percentile categories were determined according to age- and sex-adjusted body mass index percentiles. One-way analysis of variance and post hoc Tukey tests showed trust scores varied significantly between body mass index percentile categories of girls. Results suggest it may be necessary for health-care providers to make additional efforts to build trust with obese adolescent girls than with other groups of adolescents.

"I Had Nobody to Represent Me": How Perceptions of Diabetes Health-Care Providers' Age, Gender and Ethnicity Impact Shared Decision-Making in Adults With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to investigate how patients' perceptions of their diabetes health-care providers' (HCP) age, gender and ethnicity impact shared decision-making using the Theory of Planned Behaviour.

METHODS

Adult participants receiving diabetes care at community sites, primary care or specialty clinics participated in semistructured, one-on-one interviews conducted from November 2018 to January 2019. Responses were transcribed and qualitatively analyzed for emergent themes using statistical software (NVivo version 9).

RESULTS

We conducted 28 interviews with participants 34 to 81 years of age. The following themes were identified: 1) participants' gestalt of their diabetes HCP was strongly gender dependent 2) there was a hidden preference for Caucasian HCPs, 3) age evoked a less defensive response with regard to shared decision-making and 4) degree of trust in self and in their diabetes HCP directed participants' readiness to be part of the shared decision-making.

CONCLUSIONS

Participants' narrative experiences strongly suggest that they view their diabetes HCPs through a gendered and racialized lens.

Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration

BACKGROUND

While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration.

METHODS

The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine.

RESULTS

Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4).

CONCLUSIONS

In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

Adherence to Antidepressants in Underserved Communities: A Comparison of Electronic Monitoring and Self-report Measures

Nonadherence to antidepressants is widespread and poses a significant barrier to optimal management and treatment of depression in community settings. The objective of this study was to compare self-reported and electronic monitoring of adherence to antidepressants and to examine the relationship of these measures with depressive symptoms in a medically underserved community. Adherence to antidepressants was measured in 38 primary care patients from the West Philadelphia area using self-report and electronic monitoring (Medication Event Monitoring System caps). Self-report and electronic monitoring of antidepressant adherence showed fair agreement at baseline, slight agreement at 6 weeks, and slight agreement at 12 weeks. Adherence to antidepressants as assessed by electronic monitors was significantly associated with depression remission at 12 weeks [adjusted odds ratio 18.6, 95% confidence interval (1.05, 330.56)]. Compared with electronic monitoring, self-reported adherence tended to overestimate medication adherence to antidepressants. Adherence assessed by electronic monitoring was associated with depression remission.

Characteristics Associated with Trust in and Disclosure of Sexual Behavior to Primary Care Providers Among Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

Purpose: Characteristics associated with having a primary care provider (PCP), patient-provider trust, and sexual behavior disclosure were examined among men who have sex with men (MSM). Methods: MSM (N = 4239) were surveyed regarding demographic, behavioral, and medical characteristics. Multivariable logistic regression analyses were used. Results: Among 86.3% of MSM with a PCP, characteristics associated with lower patient-provider trust included younger age, Asian, bisexual, HIV-negative-not-on-pre-exposure prophylaxis, HIV-unknown, and lower medical literacy; with nondisclosure: Asian, bisexual, straight, HIV-negative, HIV-unknown, fewer partners, recruitment source, lower medical literacy, and lower patient-provider trust. Conclusion: Medical literacy and patient-provider trust are promising points of intervention to improve health outcomes among MSM.

The Effects of Patient-Centered Communication: Exploring the Mediating Role of Trust in Healthcare Providers

This study examined the effects of patient-centered communication (PCC) on two major outcomes: patients' trust in healthcare providers and their evaluation of the quality of healthcare received. Based on conceptual model regarding the impacts of PCC, the former is considered a proximal communication outcome and the latter an intermediate outcome. Both are known to be associated with ultimate health outcomes. Analyses conducted on a dataset of 3273 respondents from the 2012 Health Information National Trends Survey in the U.S. showed that PCC was positively associated with both patients' trust in healthcare providers and evaluation of healthcare quality. Moreover, trust was a significant mediator between PCC and patients' perceptions of the quality of healthcare, and stronger mediation of trust was observed as the frequency of hospital visits increased. Some theoretical and practical implications are discussed.

Clients' experiences of shared decision making in an integrative psychotherapy for depression

Mental health and general health care research has shown that practitioners can facilitate patient involvement in shared decision making (SDM) and that the approach can benefit patients who wish to take part in decisions around their care. Yet patient experiences of SDM within a psychotherapy context have been little researched. This study examined how clients experienced SDM in a collaborative-integrative psychotherapy. A grounded theory approach used interpersonal process recall interviewing and supplementary semi-structured interviews to investigate 14 clients' experiences of SDM in pluralistic psychotherapy for depression. Verbatim transcripts were coded into 819 meaning units across six categories containing 13 subcomponents that comprised a single, core category. The six categories were (a) experiencing decisions as shared, (b) psychotherapists supporting clients to become more active in the decision-making process, (c) both parties presenting and recognizing expert knowledge, (d) clients felt recognized as an individual and accommodated for by their psychotherapist, (e) clients felt comfortable engaging with the decision-making process, and (f) daunting for clients to be asked to take part in decision discussions. A core category emerged of "Psychotherapists encourage client participation and progressively support clients to provide information and contributions towards shared treatment decisions that could be led equally, or marginally more by one party." Such support was particularly useful when clients had difficulty contributing as part of decision discussions. Client preferences for SDM change across clients and across decisions, highlighting the importance of practitioners remaining flexible to individual clients when using the approach.

Examining and adapting the information-motivation-behavioural skills model of medication adherence among community-dwelling older patients with multimorbidity: protocol for a cross-sectional study

INTRODUCTION

Multimorbidity is highly prevalent among older patients and has been shown to be associated with poor health outcomes and lower quality of life. Adherence to medication treatments is essential in order to maximise the efficacy of treatments and improve health outcomes. However, nearly half of the older patients with multimorbidity fail to adhere to their medications, which can result in an increased risk of adverse health events, lower quality of life and higher healthcare cost. Only a few studies have explored the underlying mechanism and influencing factors of medication adherence among older patients with multimorbidity, which are inadequate to provide robust evidence for the development and evaluation of the medication adherence interventions. This study aims to examine and adapt the information-motivation-behavioural skills (IMB) model, a widely used social behaviour theory, to explain the medication adherence behaviour among community-dwelling older patients with multimorbidity.

METHODS AND ANALYSIS

A cross-sectional study will be conducted in community settings in China. Around 309 older patients with multimorbidity will be recruited to complete questionnaires on adherence knowledge, adherence motivation, adherence self-efficacy, medication adherence, medication treatment satisfaction, depressive symptoms, treatment burden, disease burden and basic demographic information. Structural equation modelling will be used to analyse and validate the relationships among variables in the IMB model.

ETHICS AND DISSEMINATION

This study has been approved by the Survey and Behavioral Research Ethics Committee of the Chinese University of Hong Kong (reference number SBRE-18-675). The study results will be published in peer-reviewed journals and presented in academic conferences and workshops.

TRIAL REGISTRATION NUMBER

ChiCTR1900024804.