Health, Spirituality and Medical Ethics - Vol.3, No.4, Dec 2 Keywords: Medication Adherence, Orientation, Physician-Patient Relations, Religious, Diabetes Mellitus. Original .. medication compliance: a primary care investigation. Ann Fam Med. Sep-Oct;2(5) Physician-patient relationship and medication compliance: a primary care investigation. Kerse N(1), Buetow S. Introduction: Medication adherence has been found to be an Patient satisfaction, Physician-patient relationship, Adherence, 1 Primary Care Department, Faculty of Medicine, Universiti Teknologi MARA Selayang campus, .. Investigation.
For heart disease, statin medications reduce major vascular events by 20 percent [ 6 ]. Yet, just percent of those on a statin regimen adhere to it sufficiently to experience the benefits of the treatment [ 78 ]. For diabetes, the clinical impact of many simple and effective diabetic therapies has been limited by poor adherence rates [ 9 ].
As a result, non-adherent patients have poorer clinical outcomes and higher medical costs than medication-adherent patients [ 313 ]. Understanding and predicting medication adherence is complicated by the diverse set of factors affecting this behavior [ 14 ]. Two social factors of medication adherence Clinician-patient communication is considered an important and modifiable determinant of patient adherence behaviors.
The physician communication literature has found that positive physician communication patterns result in 1. Positive physician communication patterns are enhanced during the initial regimen discussion by using patient-centered counseling that proactively engages the patient [ 18 ].
When the patient believes that there is concordance between their preferences and the physician prescribed regimen, greater medication adherence rates result [ 19 ]. These communications offer opportunities to sustain individual motivation, assess progress, provide feedback, and adjust behavior plans. Patient health beliefs are directly related to medication adherence behavior [ 25 ]. Investigating the causal chain that occurs between provider communication patterns, the development of patient health beliefs, and medication adherence could provide insights into how patients arrive at medication adherence decisions [ 26 ].
In practice, understanding which of these pathways are most relevant to medication adherence behavior could guide physicians in how to design meaningful communication patterns to enhance medication adherence. The effectiveness of physician-patient communication may not be an isolated activity and could be affected by the environment patients will return to following their physician visits.
Family environment does impact medication adherence [ 27 ]. Medication adherence is 1. Several theories suggest that family resilience or hardiness can help individual members cope with stressors in the environment, leading to better chronic disease outcomes [ 15 ].
Additionally, a family with high resilience can use an adverse health episode to strengthen the family and actually improve the health of family members [ 28 ]. How these traits influence medication adherence beliefs and behaviors could affect how patients process and act on medical information and advice provided by physicians.
Study model and hypotheses The aim of the study was to a model how physician communication patterns and family hardiness affect behavioral beliefs, and b predict six-month medication adherence for patients on an existing regimen. The TPB projects that all health beliefs will influence behavioral intent, which, in turn, influences the actual behavior. In contrast to its predecessor, the Theory of Reasoned Action, TPB includes control beliefs that describe how individuals can control behavior [ 30 ].
Control beliefs are projected to influence both behavioral intent and actual behavior. We hypothesize that a model with physician communication and family hardiness external variables will influence patient health beliefs, which in turn will influence both the behavioral intent to adhere to the medication and their medication adherence behavior Figure 1.
Methods Design This longitudinal study assessed the relationship of selected external exogenous factors and health beliefs on medication adherence over a six-month period, from April 1 to September 30, The external factors and health beliefs were assessed using a structured questionnaire mailed in February to 6, adult health plan United Healthcare members from a national sample drawn specifically for this study.
The representativeness of the survey sample was assessed by comparing characteristics of the respondents against the characteristics of the nonrespondents. Sample, sampling and data collection Individuals identified in the sample selection met the eligibility criteria of: HMG CoA reductase inhibitors statins for hyperlipidemia and oral diabetic agents glipizide, glimepiride, glyburide, metforminand rosiglita zone were selected as the target study medications because of their high incidence in managing chronic disease, impact on health, and because they require long-term daily use for chronic disease management.
In addition, all medications were used solely to treat a specific disease at the time of the trial. This allowed for the differentiation between medication switching to another drug and non-adherence to a medication regimen.
It also permitted the researchers to assign the hyperlidemia and diabetes diagnoses. Eligible participants were contacted by mail and asked to complete the University of Wisconsin Institutional Review Board IRB approved self-report survey instrument.
Three thousand two hundred and thirty-two returned surveys were received from the sample of 6, for a response rate of Of the returned surveys, subjects left the health plan during the period measuring medication adherence, and either had their regimen changed by their physician or disclosed that they had completed the survey for a family member.
These subjects were removed from the dataset. If the MCAR condition was not met, multiple imputation of missing data points would have been performed [ 31 ]. The correlation analysis of missing values found correlation among no variable in the study. Due to the low number of missing values and no correlations of variables being found, list wise deletion of missing values was employed. Health plan disenrollment, prescription discontinuation, survey completion errors, or the presence of missing data resulted in a final dataset of 2, subjects from the 3, returned surveys.
The questionnaire included factors projected to have greatest impact on long-term medication use. These factors were derived by an expert panel using an evidence-based solicitation model from the decision science field [ 32 ]. The member panel included representatives from medicine, nursing, psychiatrypharmacy, and public health who each had published multiple peer-reviewed publications on medication adherence.
The panel applied a conjoint modeling decision science approach that arrived at the set of external factors and health beliefs. The approach consisted of the following steps: Measures The patient questionnaire was populated with the full set of expertderived measures. The dataset was parsed into three datasets to allow for cross-validation of the measurement and structural models, following criteria set forth by Kroonenberg and Lewis [ 33 ].
The data was parsed using a random selection process, SAS 8. The measures derived from measurement model testing and modifications are described in the external exogenous and health belief variables sections below. Latent variables in structural equation modeling represent variables that are not directly observed but are inferred, through a mathematical model, from other observed variables.
External exogenous variables The study investigated how the latent variables Initial Physicianpatient Regimen Discussion, Follow-up Physician Communication, and Family Hardiness modeled with health beliefs e.
Initial regimen discussion The Initial Regimen Discussion scale was based on how the physician initially discussed the regimen with the patient see Table 2 for variable description. Patients were in a position to evaluate follow-up physician communication patterns since they had been on their regimen for more than six months. The McCubbin FHI scale was chosen, as opposed to another family resilience scale, because FHI had been negatively associated with family caregiver traits of sense of caregiver burden [ 36 ] and caregiver depression [ 37 ].
Independent health belief variables The latent variable labeled Benefit and Risk was a two-item latent variable based on a scale validated by van den Putte [ 39 ]. The variable was based on the outcome expectancy construct, where it is projected that the patient considers the benefit of the health behavior along with the risk, or negative consequences, when deciding to perform a health behavior.
Two single-item observed variables were included because of their importance in the ability of the patient to perform the medication regimen [ 38 ].
The Money for Regimen variable was designated as a control variable and projected to affect behavioral intent as well as medication adherence behavior. Dependent variables Two outcome variables were utilized. Behavioral Intent was applied because it is projected to be a precursor to health behaviors and adherence to medication regimen [ 23 ]. Data was collected from April 1 to September 30, using United Healthcare claims data. The adherence data was reported in the form of a mean medication possession ratio MPR.
MPRs divide days supplied by total days for a given period and have been correlated with clinical outcomes across several studies [ 40 - 42 ]. Lastly, a mediation analysis, using the Sobel test [ 44 ], is used to determine if the external variables Initial Regimen Discussion Physician Communication, Follow-up Physician Communication, or Family Hardiness had a significant effect on behavioral intent or medication. Several indices of fit were used. Race and ethnicity Studies carried out in the U.
American studies typically identify higher rates of both cost-related and non-cost-related initial non-adherence among patients identified as Hispanic or African American [ 253237404146 - 48 ] There are exceptions, however, such as two cost-specific studies which found race to be inconsequential, [ 2431 ] and another study which associated Asian ethnicity with cost-related non-adherence, but found no difference between other groups [ 39 ].
It has been found, however, that dementia, depression and anxiety can be linked to increased odds of initial non-adherence [ 4149 ]. A separate study found that Medicare beneficiaries with psychiatric conditions were more likely to report primary non-adherence [ 25 ]. Additional studies, which have associated cost-related non-adherence with various aspects of mental health [ 2231333739 ], would seem to support these findings Comorbidities Studies, including several specific to cost, have found that the rate of initial noncompliance is higher among patients with chronic conditions particularly if they have a multiple comorbidities and with a lower health status [ 1622 - 2530 - 323739405051 ].
In contrast, the relationships between specific health conditions and primary non-adherence are inconsistent. While some diseases, such as cancer and renal disease, have actually been associated with decreased odds of prescription non-fulfillment [ 41 ] other conditions, such as arthritis and lung diseases, have had opposite relationships with adherence in different studies [ 1925273341 ].
Polypharmacy Conflictingly, some researchers have found that individuals on more drugs are significantly more likely to not fill prescriptions [ 2728 ], while others have found the opposite [ 16 ]. With the exception of a study which found no relationship between polypharmacy and cost-related primary non-adherence [ 31 ], most evidence would point to polypharmacy as a predictor of primary non-adherence.
For example, two studies found that patients receiving multiple prescriptions on the date of the index prescription were more likely to be non-adherent [ 4145 ] and a survey-based study found that nearly 1 in 10 senior, non-institutionalized Medicare beneficiaries did not acquire new prescriptions as they were already on an immoderate number of medications [ 50 ].
Side effects Like polypharmacy, the possibility of adverse events can make a drug regimen seem like more of a burden and prevent therapy initiation.
Physician-patient relationship and medication compliance: a primary care investigation.
According to one study, individuals who have experienced adverse drug events are more than two times more likely to report cost-related primary non-adherence [ 33 ]. Such negative medication beliefs may be related to the low levels of trust in the health care system commonly reported among initially non-adherent patients [ 235859 ].
Alternatively, the lack of belief in the efficacy and importance of prescriptions may be related to the findings that many non-adherent patients report uncertainty or dissatisfaction in regards to the directions provided [ 5455 ] and that rates of nonfulfillment are greater among individuals who report not having received directions for using their prescriptions [ 192958 ]. These findings are supported by a unique study comparing totally adherent individuals to those who were persistent with the exception of one unfilled medication.
This study found that completely adherent individuals had a higher perceived need for medications and a greater level of knowledge about their prescriptions [ 60 ].
Affordability In a group of researchers asked approximately 1, individuals from each of 5 different nations whether they or a family member had ever not filled a prescription due to cost. It is therefore, unsurprising that many socioeconomic factors, which presumably play a role in drug affordability, have been linked to prescription nonfulfillment.
These include food insecurity [ 3937 ], financial strain [ 23 ], poor financial status [ 17 ], low net worth [ 33 ], economic problems [ 30 ] and severe socioeconomic disadvantage [ 59 ]. Unemployment may also predict primary non-adherence [ 293239 ], except among the elderly, for whom employment may be a sign of financial instability [ 37 ]. Moreover, with the exception of two studies, which did not find patient income to be significant [ 3141 ] increasing patient income level has unanimously been associated with decreased odds of primary non-adherence, including cost-related nonadherence [ 22242527 - 293236373940505263 ].
Despite this evidence, high income cannot be relied upon as a predictor of medication fulfillment. When Gardner et al. Consequently, it would seem that high income individuals are more likely to adhere only when compared to low income patients facing identical copayments.
Additional studies examining costrelated primary non-adherence have supported the link between health insurance and adherence [ 2433373950526163 ]. In Israel, however, where universal health coverage is provided to every citizen, supplemental insurance has no impact on the rate of cost-related primary non-adherence [ 29 ]. Education The majority of studies examining patient education level have not identified a link to initial medication adherence [ 2223272931323759 ], though there are exceptions.
Two studies found that primary non-adherence was more common with increasing education level [ 3039 ] and another study, which was specific to the U. Military Health System, found education level to be mainly insignificant, but did show that primary non-adherence is less common for individuals with more than a 4-year college degree [ 19 ].
Patient-physician relationship An American study found that individuals with a regular source of care were 6 times more likely to be adherent compared to individuals who did not attend a regular clinic or consistently see the same physician [ 66 ]. In contrast, a study carried out in New Zealand found that cost-related primary non-adherence occurs twice as often among patients who reported being affiliated with a primary care provider.
Crucially, the authors of this study noted that patients who have a consistent relationship with a provider may have more opportunities to receive prescriptions, leading to higher drug costs and a greater likelihood of cost-related non-adherence [ 22 ].
Physician-patient relationship and medication compliance: A primary care investigation
Even if a patient regularly sees a physician, he or she is much less likely to be adherent if there is not a certain level of agreement and understanding between the patient and the physician.
Consequently, patients tend to be less adherent if they do not trust, respect or have confidence in their prescriber [ 326667 ]. The latter was found to be insignificant in some of studies [ 1636 ] while others suggest that less experienced physicians have less adherent patients [ 384144 ].
The single study exploring the role of prescriber race and ethnicity only found minor differences between different groups of physicians, but did discover that primary non-adherence was more common among patients who visited a prescriber of the same race or ethnicity as themselves [ 41 ].
Other factors such as physician specialty and prescribing volume have received limited analysis to date. While two studies found that specialists have higher rates of primary non-adherence compared to internists [ 3536 ], other studies examined different specialties, preventing any meaningful comparison [ 4145 ]. Similarly, prescribing volume has not been consistently defined, though two of the three studies considering prescription volume have suggested that high prescribers have more adherent patients [ 363857 ].
Forgetfulness Among studies identifying forgetfulness as a cause of primary non-adherence, anywhere from 2. Some studies have supported this idea by showing that interventions to reduce forgetfulness, such as mail and telephone reminders, have limited effect on prescription fulfillment [ 182043 ]. Convenience Patient reports commonly show that inconvenience is an important barrier to prescription fulfillment with issues such overly long pharmacy wait times, being too busy and lacking time being cited frequently [ 19255667 ].
To the same effect, Esposito et al. An additional consideration is that a complex, and therefore inconvenient, drug regimen can be a cause for non-fulfillment [ 55 ]. Other factors One survey found that 7. The cheaper options may have entailed over-the-counter products or generic medications, which are significantly less expensive than brand name drugs [ 6970 ].
Consequently, this finding may relate to the evidence that patients appear to be less likely to obtain brand name drugs compared to generic alternatives [ 2841 ]. The rate of primary non-adherence also appears to depend upon whether the treatment is for an acute condition or a chronic condition.
For many of the previously described determinants, the distinction between acute and chronic treatments was demonstrated by the differing trends identified by Shin and colleagues [ 41 ]. The only other study which considered this potential difference found primary non-adherence to be more common for acute complaints [ 26 ]. A related issue explored by Shin et al.
In addition to demonstrating that prescriptions for asymptomatic diseases were less likely to be filled, the study found that medications for symptomatic, chronic conditions were almost 2 times more likely to be filled compared to those for asymptomatic, chronic conditions [ 41 ]. It is therefore unsurprising that one study found that the absence of symptoms was a factor contributing to primary non-adherence for one third of patients [ 54 ].
On a similar note, one study ranking drugs according to the Belfast Classification found that drugs that were frequently given for specific and certain diagnoses were the most likely to be filled, drugs given solely for symptomatic relief were second most likely to be filled and drugs that were frequently given for presumptive diagnoses were least likely to be filled [ 15 ].
A further factor investigated by Shin et al. More specifically, it was found that prescriptions given on weekends were less likely to be filled if they were for chronic conditions, but more likely to be filled if they were for acute conditions [ 41 ]. The only other study examining the day of the week did not differentiate between chronic and acute diseases, but did find that prescriptions given on the weekend were more likely to be abandoned [ 38 ].
Physician-patient relationship and medication compliance: a primary care investigation.
Finally, a few studies identified ambiguous causes for prescription nonfulfillment. Similarly, two studies found that 6. All of these reasons are limited as it remains unclear if patients are opposed to therapy because they find medicine taking inconvenient or if another issue, such as the possibility of side effects, is responsible for this aversion.
Discussion The current literature reveals and highlights a multitude of factors which may play a role in primary adherence. Many of the identified factors, including mental health, side effects, medication beliefs, patient-provider relationships and affordability, have also been associated with secondary nonadherence.
In contrast, other factors related to secondary nonadherence, such as poor understanding of illness, insufficient follow-up and missed appointments, were not identified in this review [ 71 ]. Unfortunately, the studies included in this review are inconsistent in terms of which factors were investigated. This lack of standardization precluded our ability to include homogeneity in our analysis. The clear exception to this would be determinants related to affordability, which were considered in 37 of 53 studies.
With the exception of 3 studies, which found either income or copayment to be inconsequential, all of these studies suggested that affordability plays a key role in adherence behaviour. Two other factors which were explored relatively frequently included patient age and patient gender. Younger patient age was a reasonably strong predictor of primary non-adherence, but the fact that 8 out of 26 studies contradicted this relationship clearly weakens the evidence.
Findings regarding gender were even more inconsistent, with 10 of 28 studies finding gender to be insignificant. Among the studies evaluating causes of primary nonadherence, cost, concerns regarding side effects, low expectations of drug efficacy and forgetfulness all emerged as potentially significant reasons for prescription abandonment.
While the evidence is mixed for most of the other factors outlined in this review, it is important to acknowledge that most have not been evaluated to the point that any well-reasoned conclusion regarding their significance may be reached. There are many limitations to this review, with the most significant being the lack of a standard approach for the study of primary non-adherence.
Physician-Patient Relationship and Medication Compliance: A Primary Care Investigation
The decision to adopt a non-systematic approach was motivated by this lack in the research literature. In brief, there is no consensus as to whether a survey-based or a prescription-record based approach is most appropriate since both have significant and distinct limitations.
In the case of survey-based studies, this most notably includes recall bias, social desirability bias and non-response bias. Record-based studies, on the other hand, are susceptible to the incorrect classification of patients as non-adherent as a consequence of issues such as duplicate prescriptions and prescriptions which should have been cancelled due to a change in therapy.
There also is no clear guideline as to how primary non-adherence should be defined, particularly in terms of how long a prescription can remain unfilled before a patient is considered initially non-adherent. While the failure to exclude articles on the basis of poor quality may weaken the findings of this review, a comprehensive listing of factors contributing to primary non-adherence was created and that potentially important factors that were evaluated in a limited number of articles, have not been ignored.
This listing is the first of its kind, and will contribute to the growing body of evidence-based research on this topic. The review is also limited by the inclusion of supplementary studies specifically evaluating cost-related primary nonadherence, which may partially explain the importance attributed to affordability.
Finances are an important issue regardless and affordability was cited in 25 of the 37 studies that were not specific to cost. The cost-specific articles may also be problematic in that they classify patients who did not fill prescriptions for reasons other than cost as adherent. Despite this limitation, the studies specific to cost-related primary nonadherence generally supported the findings of the other sources.
Another limitation is the inclusion of studies from nations as varied as Scotland [ 3865 ] Denmark [ 27 ], New Zealand [ 21 ] and Turkey [ 17 ]. While this gives a broad, universal perspective of adherence behaviour, country-based biases must be considered.
An obvious example, which was demonstrated by the sole study conducted in Israel, is that affordability is a less important issue in countries where more extensive drug coverage is provided. It is also meaningful to consider that attitudes towards medicine and subsequent prescription adherence may be influenced by cultural norms.
Finally, the review is limited by the fact that few of the included articles evaluated the specific indications for both the filled and unfilled prescriptions.
This made it impossible to evaluate the prevalence of gender-specific or age-related therapies which may prompt prescription nonfulfillment and explain the significance of age and gender in terms of adherence. This also precluded any evaluation of which factors were associated with the most clinically significant instances of non-redemption. Conclusion Given the heterogeneity of the studies identified in this investigative review, it is unsurprising that no strong conclusions can be made at this time regarding the predictors and causes of primary non-adherence.
Nonetheless, this study clearly illustrates that many factors warrant further investigation regarding potential associations with prescription non-fulfillment. The number of contributing factors is vast, and the health care implications are even vaster.
Future studies may find it more effective to focus on the unique and individual factors contributing to non-adherence, but the evidence to-date suggests a more systemic problem exists.
Future studies will only help to unravel the mysteries of non-adherence. After all, better adherence will lead to an increase in treatment, which in turn will result in better health outcomes, not just for individuals, but for groups, communities and entire health care systems.
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