Derjung M. Tarn

A Decade of Controversy: Balancing Policy With Evidence in the Regulation of Prescription Drug Advertising

Direct-to-consumer advertising (DTCA) of prescription drugs has remained controversial since regulations were liberalized by the Food and Drug Administration in 1997. We reviewed empirical evidence addressing the claims made in the policy debate for and against DTCA. This advertising has some benefits, but significant risks are evident as well, magnified by the prominence of DTCA in population-level health communications. To minimize potential harm and maximize the benefits of DTCA for population health, the quality and quantity of information should be improved to enable consumers to better self-identify whether treatment is indicated, more realistically appraise the benefits, and better attend to the risks associated with prescription drugs. We propose guidelines for improving the utility of prescription drug advertising.

Trust in One’s Physician: The Role of Ethnic Match, Autonomy, Acculturation, and Religiosity Among Japanese and Japanese Americans

PURPOSE Trust is a cornerstone of the physician-patient relationship. We investigated the relation of patient characteristics, religiosity, acculturation, physician ethnicity, and insurance-mandated physician change to levels of trust in Japanese American and Japanese patients. METHODS A self-administered, cross-sectional questionnaire in English and Japanese (completed in the language of their choice) was given to community-based samples of 539 English-speaking Japanese Americans, 340 Japanese-speaking Japanese Americans, and 304 Japanese living in Japan. RESULTS Eighty-seven percent of English-speaking Japanese Americans, 93% of Japanese-speaking Japanese Americans, and 58% of Japanese living in Japan responded to trust items and reported mean trust scores of 83, 80, and 68, respectively, on a scale ranging from 0 to 100. In multivariate analyses, English-speaking and Japanese-speaking Japanese American respondents reported more trust than Japanese respondents living in Japan (P values <.001). Greater religiosity (P <.001), less desire for autonomy (P <.001), and physician-patient relationships of longer duration (P <.001) were related to increased trust. Among Japanese Americans, more acculturated respondents reported more trust (P <.001), and Japanese physicians were trusted more than physicians of another ethnicity. Among respondents prompted to change physicians because of insurance coverage, the 48% who did not want to switch reported less trust in their current physician than in their former physician (mean score of 82 vs 89, P <.001). CONCLUSIONS Religiosity, autonomy preference, and acculturation were strongly related to trust in one’s physician among the Japanese American and Japanese samples studied and may provide avenues to enhance the physician-patient relationship. The strong relationship of trust with patient-physician ethnic match and the loss of trust when patients, in retrospect, report leaving a preferred physician suggest unintended consequences to patients not able to continue with their preferred physicians.

How much time does it take to prescribe a new medication

OBJECTIVE To measure the length of time spent discussing all aspects of new prescriptions and guideline-recommended aspects of counseling, and to evaluate factors associated with duration of discussion. METHODS We analyzed tape recordings in which 181 patients received 234 new medication prescriptions from 16 family physicians, 18 internists, and 11 cardiologists in 2 healthcare systems in Sacramento, California between January and November 1999. RESULTS Of the mean total visit time of 15.9min (S.D.=434s), a mean of 26s (S.D.=28s) was allocated to guideline-recommended components and a mean of 23s (S.D.=25s) was allocated to discussion of all other aspects of new prescription medications. The majority of time spent discussing individual new prescriptions was dedicated to: medication purpose or justification, directions and duration of use, and side effects. On average, more complete discussion of these components was associated with more time. More time was spent talking about guideline-recommended information if patients were in better health, if there was a third party in the room, and if the medication belonged to a psychiatric, compared to an ear, nose, throat medication class. Less time was spent discussing over-the-counter (OTC) medications and those prescribed to patients with a previous visit to the physician. CONCLUSION Higher quality information transmission between physicians and patients about new medications requires more time, and may be difficult to achieve in short office visits. PRACTICE IMPLICATIONS Time-compressed office visits may need to be redesigned to promote improved provider-patient communication about new medications.

Which Providers Should Communicate Which Critical Information About a New Medication? Patient, Pharmacist, and Physician Perspectives

OBJECTIVES: To investigate older patient, pharmacist, and physician perspectives about what information is essential to impart to patients receiving new medication prescriptions and who should provide the information.

Older patient, physician and pharmacist perspectives about community pharmacists' roles.

Objectives  To investigate older patient, physician and pharmacist perspectives about the role of pharmacists in pharmacist‐patient interactions.

How do physicians conduct medication reviews

BACKGROUNDMedication reviews are recommended annually for older patients. A medication review is a discussion of a patient’s complete set of medications, but the actual content of a review is not well specified. The medical literature suggests that it is an exhaustive evaluation, but what physicians actually ask about their patients’ medication regimens has been little studied.OBJECTIVETo describe what physicians do when they review medications in the office setting.METHODSQualitative content analysis of audio-taped encounters between 100 patients aged 65 and older and 28 primary care physicians in two health care systems in Sacramento, California.RESULTSPhysicians use a combination of non-mutually exclusive strategies when reviewing chronic medications that include: (1) efforts to obtain a complete list of patient medications (36% of visits), (2) discussion of a topic related to the management of each of a patient’s chronic medications (47% of visits), and (3) sequential discussion of the majority of a patient’s medications without intervening discussion (45% of visits). Of 10 medication management topics that were discussed in medication reviews, a mean of 1.5 topics (SD = 1.7, range 0–7) were mentioned for each medication, with efficacy and directions being most common. Physicians conducted a sequential discussion that included discussion of each of a patient’s medications in only 32% of visits.CONCLUSIONSComprehensive discussions about chronic medications are uncommon in routine practice. Practical conceptualization of what constitutes a physician-conducted medication review is needed.

Impact of Interpreters on the Receipt of New Prescription Medication Information Among Spanish-Speaking Latinos

Background:For Latinos, limited English proficiency (LEP) is a barrier to receiving important information about a new medication prescription. Access to interpreters may impact the receipt of important medication-related information. Objective:To examine the association between interpreter use and reports of new prescription medication advice among Latinos with LEP. Methods:We examined cross-sectional survey data from 1590 Latino adults with LEP from 8 sites across the United States. The main outcomes are 5 measures of new prescription medication advising: (1) explanation of medication purpose, (2) explanation of possible side effects, (3) explanation of medication directions, (4) receipt of written information in Spanish from pharmacy, and (5) receipt of medicine bottle with Spanish language label. Results:Among patients prescribed a new medication, 72% reported being told about the purpose of the medication, 52% about possible side effects, and 70% about how to take the new medicine. Forty-four percent said they received written medication information in Spanish from pharmacy, and 47% said their medicine bottle label was written in Spanish. Interpreter use was independently associated with receiving explanations about: possible side effects (adjusted odds ratio [AOR] = 1.81; 95% confidence intervals [CI]: 1.16–2.45); medication directions (AOR = 2.50; 95% CI: 1.67–3.59); and medication purpose (AOR = 3.55; 95% CI: 2.14–4.65). Conclusions:Among Latinos with LEP, interpreter use increases patient receipt of important information when a new medication is prescribed. There is a continuing need for effective policies and interventions to improve provider communication with LEP patients.

Intervention to Enhance Communication About Newly Prescribed Medications

PURPOSE Physicians prescribing new medications often do not convey important medication-related information. This study tests an intervention to improve physician-patient communication about newly prescribed medications. METHODS We conducted a controlled clinical trial of patients in 3 primary care practices, combining data from patient surveys with audio-recorded physician-patient interactions. The intervention consisted of a 1-hour physician-targeted interactive educational session encouraging communication about 5 basic elements regarding a new prescription and a patient information handout listing the 5 basic elements. Main outcome measures were the Medication Communication Index (MCI), a 5-point index assessed by qualitative analysis of audio-recorded interactions (giving points for discussion of medication name, purpose, directions for use, duration of use, and side effects), and patient ratings of physician communication about new prescriptions. RESULTS Twenty-seven physicians prescribed 113 new medications to 82 of 256 patients. The mean MCI for medications prescribed by physicians in the intervention group was 3.95 (SD = 1.02), significantly higher than that for medications prescribed by control group physicians (2.86, SD = 1.23, P <.001). This effect held regardless of medication type (chronic vs nonchronic medication). Counseling about 3 of the 5 MCI components was significantly higher for medications prescribed by physicians in the intervention group, as were patients’ ratings of new medication information transfer (P = .02). Independent of intervention or control groups, higher MCI scores were associated with better patient ratings about information about new prescriptions (P = .003). CONCLUSIONS A physician-targeted educational session improved the content of and enhanced patient ratings of physician communication about new medication prescriptions. Further work is required to assess whether improved communication stimulated by the intervention translates into better clinical outcomes.

Negotiating complementary and alternative medicine use in primary care visits with older patients

OBJECTIVE To empirically investigate the ways in which patients and providers discuss Complementary and Alternative Medicine (CAM) treatment in primary care visits. METHODS Audio recordings from visits between 256 adult patients aged 50 years and older and 28 primary care physicians were transcribed and analyzed using discourse analysis, an empirical sociolinguistic methodology focusing on how language is used to negotiate meaning. RESULTS Discussion about CAM occurred 128 times in 82 of 256 visits (32.0%). The most frequently discussed CAM modalities were non-vitamin, non-mineral supplements and massage. Three physician-patient interactions were analyzed turn-by-turn to demonstrate negotiations about CAM use. Patients raised CAM discussions to seek physician expertise about treatments, and physicians adopted a range of responses along a continuum that included encouragement, neutrality, and discouragement. Despite differential knowledge about CAM treatments, physicians helped patients assess the risks and benefits of CAM treatments and made recommendations based on patient preferences for treatment. CONCLUSION Regardless of a physicians stance or knowledge about CAM, she or he can help patients negotiate CAM treatment decisions. PRACTICE IMPLICATIONS Providers do not have to possess extensive knowledge about specific CAM treatments to have meaningful discussions with patients and to give patients a framework for evaluating CAM treatment use.

Physician-patient communication about dietary supplements

OBJECTIVE Describe the content and frequency of provider-patient dietary supplement discussions during primary care office visits. METHODS Inductive content analysis of 1477 transcribed audio-recorded office visits to 102 primary care providers was combined with patient and provider surveys. Encounters were collected in Los Angeles, CA (2009-2010), geographically diverse practice settings across the United States (2004-2005), and Sacramento, CA (1998-1999). RESULTS Providers discussed 738 dietary supplements during encounters with 357 patients (24.2% of all encounters in the data). They mentioned: (1) reason for taking the supplement for 46.5% of dietary supplements; (2) how to take the supplement for 28.2%; (3) potential risks for 17.3%; (4) supplement effectiveness for 16.7%; and (5) supplement cost or affordability for 4.2%. Of these five topics, a mean of 1.13 (SD=1.2) topics were discussed for each supplement. More topics were reviewed for non-vitamin non-mineral supplements (mean 1.47 (SD=1.2)) than for vitamin/mineral supplements (mean 0.99 (SD=1.1); p<0.001). CONCLUSION While discussions about supplements are occurring, it is clear that more discussion might be needed to inform patient decisions about supplement use. PRACTICE IMPLICATIONS Physicians could more frequently address topics that may influence patient dietary supplement use, such as the risks, effectiveness, and costs of supplements.