Thomas S. Inui

Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy

OBJECTIVES To evaluate the validity of patient report, pharmacy dispensing records, and pill counts as measures of antihypertensive adherence using electronic monitoring as the validation standard. METHODS The study was conducted among 286 members of Harvard Pilgrim Health Care, a managed care organization, who were at least 18 years of age, on monotherapy for hypertension, and had prescription drug coverage. Prescription refill adherence during the 12 months before enrollment was determined from their automated pharmacy dispensing records. Participants were interviewed about their medication adherence before and after a 3-month electronic monitoring period during which pill counts were also performed. Adherence to both recommended number and timing of doses was estimated from electronic monitoring data. Data analysis was based on statistical correlation and analysis of variance. RESULTS Electronic adherence monitoring revealed that the proportion of prescribed doses consumed was higher (0.92) than the proportion of doses taken on time (0.63). The correlation between adherence to quantity and timing of doses was 0.32. Concurrent pill counts and earlier refilling patterns were moderately correlated with electronic monitoring (pill count: r = .52 with quantity and r = .17 with timing; refill adherence r = .32 with quantity and r = .22 with timing). There was considerable misclassification of adherence reported by patients, although nonadherence was generally accurately reported. CONCLUSIONS Deviation from recommended timing of doses appears to be greater than from prescribed number of doses. Pharmacy dispensing records demonstrate predictive validity as measures of cumulative exposure and gaps in medication supply. Adherence levels determined from pill counts and pharmacy dispensing records correlate more closely with quantity than with timing of doses. Nonadherence reported by patients can serve as a qualitative indicator and predictor of reduced adherence.

A general method of compliance assessment using centralized pharmacy records. Description and validation.

The prescription refill records of centralized pharmacies are a potential source of information about patient compliance with long-term medications. We developed a method for assessing compliance in such settings and validated our measures using pharmacy data and clinical information from patients with seizure disorders and hypertension. For patients taking the anticonvulsant medication phenytoin, compliance with the drug correlated significantly with mean plasma phenytoin level. For patients on antihypertensive medications, compliance with the treatment regimen correlated with control of diastolic blood pressure. Many patients (15% in the phenytoin validation, and 33% in the blood pressure validation) obtained substantial oversupplies of medications; for these patients, the direct relationship between compliance and drug effect was not evident. A majority of seizure patients with “subtherapeutic” mean plasma phenytoin levels were identified as noncompliant using our measures. We conclude that our method of assessing compliance in obtaining medications is feasible in “managed care” settings, appears to be a valid correlate of drug effects, and may be useful in research and patient care.

Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence

Objective:We sought to synthesize the findings of studies examining interventions to enhance the communication behaviors of physicians and patients during outpatient encounters. Methods:We conducted searches of 6 databases between 1966 and 2005 to identify studies for a systematic review and synthesis of the literature. Eligible studies tested a communication intervention; were randomized controlled trials (RCTs); objectively assessed verbal communication behaviors as the primary outcome; and were published in English. Interventions were characterized by type (eg, information, modeling, feedback, practice), delivery strategy, and overall intensity. We abstracted information on the effects of the interventions on communication outcomes (eg, interpersonal and information exchanging behaviors). We examined the effectiveness of the interventions in improving the communication behaviors of physicians and patients. Results:Thirty-six studies were reviewed: 18 involved physicians; 15 patients; and 3 both. Of the physician interventions, 76% included 3 or 4 types, often in the form of practice and feedback sessions. Among the patient interventions, 33% involved 1 type, and nearly all were delivered in the waiting room. Intervention physicians were more likely than controls to receive higher ratings of their overall communication style and to exhibit specific patient-centered communication behaviors. Intervention patients obtained more information from physicians and exhibited greater involvement during the visit than controls. Conclusions:The interventions were associated with improved physician and patient communication behaviors. The challenge for future research is to design effective patient and physician interventions that can be integrated into practice.

Relationship-centered Care: A Constructive Reframing

All illness, care, and healing processes occur in relationship—relationships of an individual with self and with others. Relationship-centered care (RCC) is an important framework for conceptualizing health care, recognizing that the nature and the quality of relationships are central to health care and the broader health care delivery system. RCC can be defined as care in which all participants appreciate the importance of their relationships with one another. RCC is founded upon 4 principles: (1) that relationships in health care ought to include the personhood of the participants, (2) that affect and emotion are important components of these relationships, (3) that all health care relationships occur in the context of reciprocal influence, and (4) that the formation and maintenance of genuine relationships in health care is morally valuable. In RCC, relationships between patients and clinicians remain central, although the relationships of clinicians with themselves, with each other and with community are also emphasized.

The practice orientations of physicians and patients: the effect of doctor–patient congruence on satisfaction

This study investigated the extent to which the individual orientations of physicians and patients and the congruence between them are associated with patient satisfaction. A survey was mailed to 400 physicians and 1020 of their patients. All respondents filled out the Patient-Practitioner Orientation Scale, which measures the roles that doctors and patients believe each should play in the course of their interaction. Patients also rated their satisfaction with their doctors. Among patients, we found that females and those who were younger, more educated, and healthier were significantly more patient-centered. However, none of these variables were significantly related to satisfaction. Among physicians, females were more patient-centered, and years in practice was related to satisfaction and orientation in a non-linear fashion. The congruence data indicated that patients were highly satisfied when their physicians either had a matching orientation or were more patient-centered. However, patients whose doctors were not as patient-centered were significantly less satisfied.

Having the right chemistry: a qualitative study of mentoring in academic medicine.

Purpose To develop a deeper understanding of mentoring by exploring lived experiences of academic medicine faculty members. Mentoring relationships are key to developing productive careers in academic medicine, but such alliances hold a certain “mystery.” Method Using qualitative techniques, between November 1999 and March 2000, the authors conducted individual telephone interviews of 16 faculty members about their experiences with mentoring. Interviews were taped and transcribed and authors identified major themes through multiple readings. A consensus taxonomy for classifying content evolved from comparisons of coding by four reviewers. Themes expressed by participants were studied for patterns of connection and grouped into broader categories. Results Almost 98% of participants identified lack of mentoring as the first (42%) or second (56%) most important factor hindering career progress in academic medicine. Finding a suitable mentor requires effort and persistence. Effective mentoring necessitates a certain chemistry for an appropriate interpersonal match. Prized mentors have “clout,” knowledge, and interest in the mentees, and provide both professional and personal support. In cross-gender mentoring, maintaining clear boundaries is essential for an effective relationship. Same-gender or same-race matches between mentor and mentee were not felt to be essential. Conclusions Having a mentor is critical to having a successful career in academic medicine. Mentees need to be diligent in seeking out these relationships and institutions need to encourage and value the work of mentors. Participants without formalized mentoring relationships should look to peers and colleagues for assistance in navigating the academic system.

Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction".

AbstractOBJECTIVE: To explore perceptions of the impact of erectile dysfunction on men who had undergone definitive treatment for early nonmetastatic prostate cancer. DESIGN: Seven focus groups of men with early prostate cancer. The groups were semistructured to explore men’s experiences and quality-of-life concerns associated with prostate cancer and its treatment. SETTING: A staff model health maintenance organization, and a Veterans Affairs medical center. PATIENTS: Forty-eight men who had been treated for early prostate cancer 12 to 24 months previously. RESULTS: Men confirmed the substantial effect of sexual dysfunction on the quality of their lives. Four domains of quality of life related to men’s sexuality were identified: 1) the qualities of sexual intimacy; 2) everyday interactions with women; 3) sexual imagining and fantasy life; and 4) men’s perceptions of their masculinity. Erectile problems were found to affect men in both their intimate and nonintimate lives, including how they saw themselves as sexual beings. CONCLUSIONS: Erectile dysfunction, the most common side effect of treatment for early prostate cancer, has far-reaching effects upon men’s lives. Assessment of quality of life related to sexual dysfunction should address these broad impacts of erectile function on men’s lives. Physicians should consider these effects when advising men regarding treatment options. Physicians caring for patients who have undergone treatment should address these psychosocial issues when counseling men with erectile dysfunction.

Problems and prospects for health services research on provider-patient communication.

The effectiveness of medical practice is largely dependent on the quality of provider-patient communication. Inputs to the provider-patient encounter include prior experience with medical care, patient objectives for the visit, patient age, type of medical problem, the number of patient concerns, and characteristics of the physicians practice setting. Outcomes linked to the communication process include patient knowledge, provider-patient congruence on problems or recommendations, patient satisfaction, patient compliance with provider recommendations, and resolution of patient concerns or symptoms. The development of interactional analysis systems for the description of provider-patient communication processes in medical encounters should permit reasonably detailed descriptive research on these phenomena. Among the problems in this area have been the lack of a theoretical base for taxonomic categories of behavior, overlapping categories, the arcane nature of many disciplinary taxonomies, and lack of rigorous operational definitions for measurements. Given the rudimentary state of development of this field, descriptive designs for research will continue to be appropriate. However, interactional analysis systems will require additional development so that provider-patient encounters can be understood as episodes of information transfer through several channels. The development of hypotheses for experimental testing of efficacy of clinical strategies for communication requires measurement of pre to postencounter change.

Delving below the surface. Understanding how race and ethnicity influence relationships in health care.

There is increasing evidence that racial and ethnic minority patients receive lower quality interpersonal care than white patients. Therapeutic relationships constitute the interpersonal milieu in which patients are diagnosed, given treatment recommendations, and referred for tests, procedures, or care by consultants in the health care system. This paper provides a review and perspective on the literature that explores the role of relationships and social interactions across racial and ethnic differences in health care. First, we examine the social and historical context for examining differences in interpersonal treatment in health care along racial and ethnic lines. Second, we discuss selected studies that examine how race and ethnicity influence clinician-patient relationships. While less is known about how race and ethnicity influence clinician-community, clinician-clinician, and clinician-self relationships, we briefly examine the potential roles of these relationships in overcoming disparities in health care. Finally, we suggest directions for future research on racial and ethnic health care disparities that uses a relationship-centered paradigm.

Neurologic Recovery After Out-of-Hospital Cardiac Arrest

A retrospective cohort study of the neurologic sequelae of out-of-hospital cardiac arrest was done using 459 consecutive patients resuscitated and admitted to a teaching hospital over 10 years. Awakening was defined as having comprehensible speech or following commands. One hundred and eighty patients (39%) never awakened and 279 (61%) awakened, 188 without and 91 with persistent neurologic deficits. Fifty-nine patients had cognitive deficits and 32 patients had motor and cognitive deficits. Patients who did not awaken died, with a median survival of 3.5 days. The longer a patient survived without awakening, the smaller the probability of ever awakening and awakening without deficits. Fourteen patients awakening after 4 days had some deficits, and after 14 days six had severe deficits. Neurologic sequelae of cardiac arrest are common and related to awakening. The probability of future awakening and neurologic sequelae for patients not awake at specific times after cardiac arrest can be estimated.