Physicians and Adherence: What Does ‘Good’ Look Like?

By | October 7, 2013

Physicians are very well placed to drive improvements in medication adherence. But are they fully engaged in the task? This is the first in a two-part post – “Physicians and Adherence: the Good, the Bad, and the Ugly” – that will explore this question. This part focuses on: What does ‘good’ look like?

‘Volume’-to-‘Value’ and the Role of Adherence

With healthcare emphasis shifting to ‘value of care’ and away from ‘volume’, there are clear incentives for physicians to look at medication adherence in a fresh light.

‘Volume’ placed emphasis on the number of tests carried out and prescriptions written. As the focus moves to ‘value’, health outcomes will become the dominant measure. For example, patients’ health status or efficient use of health resources will become much more important measures.

In making the change to ‘value’, medication adherence is a vital mediator. This is explained in the visual below. Treatments (representing ‘volume’) will only work when taken according to prescribing instructions. If patients don’t take medications as instructed, desired outcomes (‘value’) will not be achieved. And physicians’ performance may be downgraded.

Healthcare focus is shifting from 'volume' to 'value'. Medication adherence is a key mediator in achieving health outcomes and 'value of care' goals.

Improving adherence becomes a critical factor
in helping doctors achieve their intended treatment value.

Physicians Can Strongly Influence Medication Adherence

Physicians are very well positioned to influence good medication adherence.

It’s well documented that patients being treated for chronic conditions have the highest risk of non-adherence. Such patients see their physicians regularly for routine follow-ups and examinations. These frequent contacts are helpful, as they create opportunities to foster good doctor-patient relationships.

To translate patient relationships into a springboard for improved adherence, doctors need to adopt patient-centered approaches that address five vital areas:

  1. Focus on high quality communication
  2. Invest appropriate time to spent with patients
  3. Achieve patient engagement and activation
  4. Support shared decision-making
  5. Gain patient trust

Nurturing patient relationships in these five ways opens the door to productive two-way conversations; sets the table for patient engagement and collaborative working; and begins the process of gaining patient trust.

Rationale for the Five Key Areas

High Quality Communications

“What is unique about our study is that we found that medication adherence is better if the physician has established a trusting relationship with the patient and prioritizes the quality of communication, …”

This comment was by Dr Ratanawongsa (see here), an author of: “Communication and Medication Adherence: The Diabetes Study of Northern California” (see here). The study showed when patients give their physicians high marks for communication, they are more likely to fill their prescriptions. This association of good communication and better patient adherence confirmed earlier meta-analysis findings.

The main meta-analysis (see here) was based on 106 studies and found a 19% higher risk of non-adherence among patients whose physician communicated poorly than among patients whose physician communicated well.

A second part to the meta-analysis, involving 21 studies, looked at adherence as an outcome of physician communication skills training. This analysis found a 12% higher risk of non-adherence among patients whose physicians had not been trained in communication skills than among patients whose physicians had been trained.

Communication, activation, time, shared decision-making and all trust drive adherence, which helps physicians achieve quality and value of care goals.

“Adherence Doc”

Investing Time

Time physicians invest with patients is both a necessity and a challenge. Time is required to build patient relationships, engagement, and trust; and to have quality conversations. Given their many administrative demands, time has become a precious commodity for physicians,

In a recent AHRQ survey (see here), almost 70% of respondents felt rushed when taking care of patients. To maintain the quality of interactions needed to improve adherence, physicians and their practices will need to find new ways to achieve necessary face time with patients*.

Engagement, with the Aim of Patient Activation

To explain patient engagement, I like the words of a Mayo Clinic physician (see here), with a few extra thoughts from here.

In brief, engagement is described as:

  • Giving relevant information
  • Helping patients understand their options
  • Listening to their priorities
  • Understanding their beliefs and behaviors
  • Helping them choose the best solution for their lifestyle
  • ALL BEFORE WRITING A SCRIPT

The patient is central. And the dynamic shifts from treating a disease to allowing the patient to be the person he/she wants to be.

Engagement promotes patient activation and self-management through collaborative goal-setting and planning, which improves self-care, adherence, and outcomes.

Shared Decision-making

Shared decision-making is now widely accepted as a way to combine physician expertise with a patient’s right to be fully informed of care options, harms, and benefits. This process provides patients with the support they need to make the best individualized care decisions, while allowing providers to feel confident in the care they prescribe.

Shared decision-making with diabetic patients has been shown to improve HbA1c and LDL levels, by improving patient activation and improving medication adherence (see here).

Gaining Trust

As might be expected, patient trust is linked to the length of relationship with a physician (see here). The good news is that patient trust in doctors is quite high (see here, Table 2). To the question: “Have you felt confidence and trust in your personal physician?” 78% of respondents said “usually” or “always”.

Studies have shown that patient trust in physicians is associated with better adherence (see here and here).

In Summary

Physicians are a critical cog in the ‘adherence machine’. A paragraph from a recent brief by NEHI summarized this nicely:

“It seems unlikely that significant and lasting improvements in patient medication adherence will occur unless community-based providers and the daily practice of medicine support good adherence behavior among patients.”

Patient-centered communication is a core strategy by which physicians can create patient trust. In addition to prioritizing the quality of their communications with patients, doctors can further exert strong influences over patients’ adherence to medications, by:

  • Devoting appropriate time to talking with their patients
  • Activating patients to self-manage and self-care
  • Committing to shared decision-making
  • Building trusting relationships with their patients

 

* More about this in part 2 of this post.