Clinician Communication Skills and Medication Adherence

Patients with diabetes mellitus, who are at high risk for cardiovascular morbidity and mortality, are often prescribed hypoglycemic, antihypertensive, and lipid-lowering medications. The success of this therapy depends on a high rate of medication adherence; poor medication refill adherence can lead to less-than-optimal cardiometabolic control and poor clinical outcomes.

Improved communication between patients and healthcare providers is one strategy for enhancing medication refill adherence. The Institute of Medicine has designated patient-centeredness as a core measure for healthcare quality. Patient-centered communication increases patient trust and provides clinicians with information on patient preferences, needs, and values that can be incorporated into treatment decisions.

Noting that research utilizing self-reported medication refill adherence measures may overestimate adherence across sociodemographic characteristics, researchers recently conducted a study designed to investigate whether patient assessments of communication with their healthcare provider were associated with objective measures of poor adherence for cardiometabolic medications. Pharmacy utilization data from a diverse sample of fully insured persons with diabetes were analyzed. Analysis results were reported in JAMA Internal Medicine [2013;173(3):210-218].

The researchers analyzed data from the Diabetes Study of Northern California (DISTANCE) survey, which was conducted from May 2003 to December 2006 among a sample of 20,188 patients with diabetes, 30 to 75 years of age. Respondents completed a written or online survey.

For this study, eligible respondents answered questions about patient-provider communication (not included in the Short Version of the DISTANCE survey), reported having a primary care provider, and were dispensed ≥1 oral hypoglycemic, antihypertensive, or lipid-lowering medication in the 12 months preceding the survey.

There were 9377 respondents who met the inclusion criteria. Of those, 7303 were prescribed hypoglycemic medications, 7052 were prescribed lipid-lowering medications, and 7967 were prescribed antihypertensive medications. Mean age was 59.5 years, 52% were female, and 27% were white, 19% African American, 16% Latino, 12% Asian, 11% Filipino, and 11% multiracial.

Forty-four percent had Charlson comorbidity index scores of ≥2, and 45% had a hemoglobin A1c level >7.0%. Patients were dispensed a mean of 5.2 cardiometabolic medications (excluding insulin).

Thirty percent of the cohort had poor adherence to their cardiometabolic medication regimens (continuous medication gap >20% for regimens of ≥1 cardiometabolic medication). For antihypertensive, lipid-lowering, and oral hypoglycemic medications, poor adherence was observed in 20%, 21%, and 25% of patients, respectively.

For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, the adjusted prevalence of poor refill adherence increased by 1.9% (95% confidence interval [CI], 0.2%-1.7%; P=.01). Compared with patients giving higher ratings, patients who gave lower ratings for healthcare providers involving patients in decisions, understanding patients’ problems with treatment, and eliciting confidence and trust were more likely to have poor adherence, with absolute difference of 4% (95% CI, 0%-7%; P=.04), 5% (95% CI, 1%-10%; P=.02), and 6% (95% CI, 1%-11%; P=.03), respectively.

There were larger associations between communication and adherence for hypoglycemic medications than for other medications.