Schoenthaler ICCH 2011

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  • Patient-provider communication that is characterized by shared-decision making and patient-centeredness is associated with better self-reported adherence in patients with chronic diseases Patients’ views about satisfaction, trust, and feeling respected during the medical encounter have emerged as important outcomes that differ by patient race. Race-concordant relationships: longer medical visits with higher ratings of positive affect, shared-decision making, and satisfaction Although the effect of race-concordant relationships on improved processes of care (i.e., patient satisfaction and healthcare utilization) has been clearly documented, the effect on patient outcomes such as medication adherence is unclear Recent studies have found no association between racial composition of the relationship and health outcomes, including medication adherence, treatment intensification, and BP control However, these studies did not assess factors that may contribute to this relationship, limiting the ability to understand the potential reasons for the lack of association.
  • Associated hypothesis: Provider communication rated as more collaborative would be associated with better adherence for patients in race-concordant relationships compared to those in race-discordant relationships
  • The present study was embedded within the Counseling African Americans to Control Hypertension (CAATCH). The purpose of CAATCH is to evaluate the effectiveness of a multi-level intervention designed to improve blood pressure control. All dyads were identified through C/MHCs participating in CAATCH, which were selected for the parent trial if they included more than 25 percent of patients self-identified as African American/Black and serving an economically disadvantaged population. Cross sectional using survey methods. All measures were self-report and required either a categorical response (yes/no) or based on Likert scales. Due to a potential race-of-interviewer effect, all data was collected by CAATCH study staff during the patient’s baseline visit, prior to the inception of the intervention (to avoid confounding).
  • Of the 97 providers participating in CAATCH, 69 (71%) were eligible to participate in the present study because they self-identified as white or black. Ineligible providers included those that self-identified as Latino (8%), Asian (11%), East Indian (4%), and as Other ( 4%). Patients were more likely to report receiving care for less than 5 years with ineligible providers as compared to eligible providers (36% vs. 29%, respectively, p = 0.004); otherwise provider characteristics were similar for both groups.
  • The final sample comprised 597 patients and 69 providers (27 white and 42 black), yielding 207 race-discordant relationships and 390 race-concordant relationships
  • Responses for the first 11 questions range from 1 = not at all to 4 = very much while the final two are based on a categorical yes/no response. Communication style was also treated as a continuous measure however, exploring the range of responses revealed a negatively skewed distribution. To normalize the measure, the items were reverse scored and data transformed into a natural log scale. As a result, lower scores were indicative of a more collaborative communication style. In current sample the reliability was .92.
  • Medication adherence was assessed with Morisky self-report adherence measure, a well-validated 4-item scale that specifically addresses medication-taking behavior ¹. Adherence was coded as a continuous variable with higher scores indicating better adherence. Patients were given a score of “1” for each question they answered “no”. Total score of 4 indicating perfect adherence With the current sample the Cronbach’s alpha .67 ; this is consistent with reliability estimates reported by Morisky et al.
  • Demographic characteristics were collected for both the patient and the provider. For the patient.. Race, gender, age, marital status, employment status, insurance status and educational attainment [SES], medical comorbidity, baseline systolic and diastolic blood pressure, and number of anti-hypertensive medications were collected. Provider: Race, gender, age, country of birth, medical degree and specialty, years spent practicing at CC, and exposure to cultural competency training. Cultural Competency was included to adjust for the potential confounding effects increased cultural sensitivity may have on the quality of communication across the relationship types. The CCCQ was developed as a tool to measure clinician’s knowledge, skills, and attitudes relating to the provision of culturally competent healthcare to diverse patient populations.
  • Two GLMM models were conducted to determine the effect modification of the association between provider communication and medication adherence, by racial composition, of the patient-provider relationship Given the nested nature of the data (patients within providers within sites), all analyses were conducted using generalized linear mixed models (GLMM). Providers were modeled as the random effect to adjust for potential nesting caused by multiple patients seeing the same provider. All independent variables were modeled as fixed effects, including patient demographics and provider characteristics. Two GLMM models were conducted to determine whether the association between patients’ ratings of provider communication and medication adherence was modified by racial composition of the relationship. In the first model, independent associations between the two main factors (communication and racial composition) and the dependent variable (medication adherence) were assessed, while adjusting for selected patient- and provider-level covariates. In Model 2, the product term between racial composition of the relationship and provider communication was added to Model 1. SPSS version 18 31 was used for all analyses and significance levels were set at p ≤ .05.
  • Mean medication adherence score was 2.86 (SD 1.23) with a non-adherence rate of 59%.
  • Mean medication adherence score was 2.86 (SD 1.23) with a non-adherence rate of 59%.
  • On average, patients in race-discordant relationships rated their provider as more likely to listen to them, provide clear instructions on how to take their medications, talk about things that could help the patient feel better, and help solve problems than patients in race-concordant relationships
  • Several Limitations warrant mention: Cross-sectional -- prohibits definitive conclusions regarding the directionality of the findings Self-report measures: Medication adherence – overestimation but 56% reported being non-adherent, similar to 50 to 70 % estimated by WHO. Relation to BP: Patients in race-concordant relationship who were adherent had lower baseline SBP than similar patients in race-discordant relationships. Communication relied on self-reported perception of the interaction, scores may reflect characteristics of patient rather than actual dialogue. Subjective interpretations may be more influential determinant of their actions, undetected by a more objective measure. Representativeness of providers: Practicing in medically underserved communities in CHCS driven toward issues of social justice and equity in healthcare. Providers who work with underserved patients more attuned to non-clinical factors such as SES, cultural competency. Inclusion of NPs —despite controlling for provider type inclusion may have conflated effects. Evident in this sample-- NPs tended to report a higher degree of exposure to cultural competency training then physicians. Continuity of care with primary care provider was not assessed. Patients report greater satisfaction with care with they have a regular provider . In this study, Caucasian providers tended to be at their sites longer—plausible that received more reg. care . An assessment of how well the patient knew the provider was not included --Turnover rate: lrg variance yrs at clinic. Patient choice of provider, including race of provider, was not assessed. Just discussed, important influence on outcomes in previous studies
  • Future research should address how cultural and other socio-demographic factors influence interpersonal processes within the patient-provider relationship
  • Schoenthaler ICCH 2011

    1. 1. The effect of patient-provider communication on medication adherence in hypertensive African Americans: Does race matter? Antoinette Schoenthaler EdD Center for Healthful Behavior Change NYU School of Medicine Supported by NHLBI NSRA F31 Fellowship and K23 HL098564-01A1 ICCH October 2011
    2. 2. Background <ul><li>Patient-provider communication has emerged as an important and potentially modifiable factor associated with improved patient outcomes </li></ul><ul><li>Despite mounting evidence of the positive relationship between collaborative communication and medication adherence, particularly in minority patients, the basis of this association has not been well-studied 1-4 </li></ul><ul><li>Race-concordant relationships may contribute to the higher rates of medication adherence noted in collaborative patient-provider interactions </li></ul>¹ Traylor et al JGIM 2011; 25:1172-1177. ²Howard et al. Research on Aging 2001;23:83-108; ³Konrad et al. AJPH 2005;95:2186-2190; 4 Cooper et al., Ann Intern Med 2003;139:907-915
    3. 3. Study Aim <ul><li>Among 597 hypertensive African American patients followed </li></ul><ul><li>in 30 Community Healthcare Centers (CHC): </li></ul><ul><li>The aim of the study was: </li></ul><ul><li>To determine whether the association between patients’ ratings of provider communication and medication adherence is modified by the racial composition of the patient-provider relationship </li></ul>
    4. 4. <ul><li>Provider communication rated as more collaborative would be associated with better adherence for patients in race-concordant relationships compared to those in race-discordant relationships </li></ul>Hypothesis
    5. 5. Methods <ul><li>Embedded within a group-randomized controlled trial Counseling African Americans to Control Hypertension (CAATCH) in 30 CHCs in NYC. </li></ul><ul><li>Cross sectional research design using survey methods. </li></ul><ul><li>All measures were self-report and required either a categorical response (yes/no) or based on Likert scales. </li></ul><ul><li>All data was collected by CAATCH study staff prior to the delivery of the intervention. </li></ul>
    6. 6. Participants <ul><li>Patient Eligibility: </li></ul><ul><ul><li>Self-identified as non-Hispanic African American (Black) receiving care in CHC site; </li></ul></ul><ul><ul><li>Diagnosed with hypertension (ICD: 401-401.9); </li></ul></ul><ul><ul><li>Taking at least one anti-hypertensive medication; </li></ul></ul><ul><ul><li>18 years of age or older; </li></ul></ul><ul><ul><li>Fluent in English. </li></ul></ul><ul><li>Provider Eligibility: </li></ul><ul><ul><li>MD/DO, NP, or PA providing care in CHC sites; </li></ul></ul><ul><ul><li>Self-identified as non-Hispanic African American (Black) or Caucasian (White); </li></ul></ul><ul><ul><li>Providing care to at least 5 patients with uncontrolled hypertension. </li></ul></ul>
    7. 7. Moderator <ul><li>Racial composition of patient-provider relationship </li></ul><ul><li>Race-Concordant: Patient-provider relationship where both the patient and provider are of the same race (e.g. black/African American provider and patient) </li></ul><ul><li>Race-Discordant: Patient-provider relationship where the patient is black/African American and the provider Caucasian American/white </li></ul><ul><li>Analytical sample included 597 patients and 69 providers </li></ul><ul><ul><li>207 patients were in a race-discordant relationship </li></ul></ul><ul><ul><li>390 patients were in a race-concordant relationship </li></ul></ul>
    8. 8. Independent Measure: Communication <ul><li>11-item measure derived from a study assessing the effect of patient’s perception of provider communication on adherence to anti-depressant medications¹ </li></ul><ul><li>Sample questions include “To what degree is your doctor: </li></ul><ul><ul><li>Friendly during the visit, </li></ul></ul><ul><ul><li>Asked if you had questions and concerns, </li></ul></ul><ul><ul><li>Gave clear instructions on how to take medications. </li></ul></ul><ul><li>Responses range from 1 = not at all to 4 = very much. </li></ul><ul><li>Treated as a continuous measure where lower scores indicate more collaborative communication. </li></ul><ul><li>¹Bultman & Svarstad, 2000 </li></ul>
    9. 9. Dependent Measure: Medication Adherence <ul><li>Self-reported medication adherence was assessed with the well-validated Morisky scale ¹ </li></ul><ul><li>Patients were given a score of “1” for each question they answered “no” to: </li></ul><ul><ul><li>Have you ever forgotten to take your BP medicine?; </li></ul></ul><ul><ul><li>Are you careless in regards to your medicine?; </li></ul></ul><ul><ul><li>Do you skip your medicine when you are feeling well?; and </li></ul></ul><ul><ul><li>Do you skip your medication when you are not feeling well? </li></ul></ul><ul><li>Adherence was coded as a continuous variable with higher scores indicating better adherence. </li></ul><ul><li>¹Morisky, Green, & Levine (1989) </li></ul>
    10. 10. Covariates <ul><li>Demographics </li></ul><ul><li>Patient and Provider </li></ul><ul><li>Medical Comorbidity </li></ul><ul><li>Charlson Comorbidity Index was used to record the # of comorbid conditions. </li></ul><ul><li>Cultural Competency </li></ul><ul><li>Provider’s exposure to cultural competency training across medical education and training. </li></ul><ul><li>Clinical Cultural Competency Questionnaire (CCCQ). </li></ul><ul><li>Continuous measure with higher scores indicating more exposure to cultural competency training (range: 1 - 4). </li></ul>
    11. 11. Analysis <ul><li>Demographics between the patient-provider relationships were compared and significant differences were included in the main analyses </li></ul><ul><li>General linear mixed models (GLMM) were used to account for nested nature of the data (patients within providers within sites) </li></ul><ul><ul><ul><li>Model 1: Main effects model </li></ul></ul></ul><ul><ul><ul><li>Model 2: Addition of Dyad typeXCommunication Interaction term </li></ul></ul></ul><ul><li>Post hoc analysis of simple slopes </li></ul><ul><li>Significance levels were set at p ≤ .05. </li></ul>
    12. 12. Patient Characteristics <ul><li>Majority of patients were female, unemployed, and reported a household income of less than $20,000/year </li></ul><ul><li>Mean BP = 151/91 mmHg; 36% reported a comorbidity score of > 3, with ¼ reporting some form of target organ damage </li></ul><ul><li>Majority (88%) reported seeing current provider for ≥ 1 year </li></ul><ul><li>Self-reported non-adherence rate of 59% </li></ul><ul><li>Mean score on the communication scale was 2.88 (SD 0.39; lower scores reflect more collaborative communication) </li></ul>
    13. 13. Patient Characteristics by Racial Composition of the Relationship <ul><li>Patients in race-discordant relationships were more likely to report being never married and/or widowed ( p = 0.05) and prescribed more antihypertensive medications (2.05 vs. 1.88 p = 0.09). </li></ul><ul><li>Patients in race-concordant relationships were more likely to report having 3 or more comorbid conditions than those in race-discordant relationships (36% vs. 26% p = 0.02). </li></ul>
    14. 14. Provider Characteristics <ul><li>Majority of providers were female and internists, with a mean age of 49 years and practice duration of 8.5 years </li></ul><ul><li>On average, providers reported a little to some exposure to cultural competency training (mean = 2.7, SD= 1.0) </li></ul><ul><li>White providers worked at their clinics significantly longer than black providers (10.4 years vs. 8.3 years, p = 0.03); and were more likely to be nurse practitioners (21% vs. 13%; p = 0.05) </li></ul>
    15. 15. Association between Racial Composition and Components of Collaborative Communication Lower scores indicate more collaborative communication Scale Item* (range: 1 – 4) Mean Score (SD) p Race-Concordant Relationship (n = 390) Race-Discordant Relationship (n = 207) Asked if had questions or concerns 2.08 (1.05) 1.99 (0.99) 0.30 Helped with concerns related to the use of medication 1.91 (0.99) 1.84 (0.97) 0.75 Friendly during the visit 1.41 (0.68) 1.34 (0.61) 0.08 Gave clear instructions on how to take medication 1.60 (0.86) 1.40 (0.72) 0.001 Listened to you 1.48 (0.74) 1.36 (0.61) 0.001 Gave clear explanation about how medication would affect you 1.88 (1.04) 1.68 (0.96) 0.14 Talked about things that you could do to help you feel better 1.82 (1.01) 1.59 (0.86) 0.003 Encourages expression of problems 1.99 (1.08) 1.73 (0.97) 0.11 Asks about concerns 2.01 (1.12) 1.69 (0.98) 0.08 Listens to your concerns 1.72 (0.90) 1.53 (0.86) 0.43 Helped solve problems 2.03 (1.11) 1.76 (0.94) 0.006
    16. 16. Results of the GLMM Testing the Effect Modification of Racial Composition Model 1 Model 2 df F B (SE) p df F B (SE) p Patient age 1 3.12 0.01 (0.01) 0.08 Stroke 1 5.10 -0.69 (0.31) 0.03 ‡ Length of relationship ≥ 1 year 1 3.65 0.52 (0.27) 0.06 Provider birthplace U.S. 1 4.15 -0.35 (0.17) 0.04 ‡ Communication 1 4.46 -0.46 (0.22) 0.04 ‡ 1 8.25 -1.11 (0.39) 0.005 ‡ Dyad type 1 0.75 0.17 (0.20) 0.39 1 1.38 0.23 (0.20) 0.24 CommunicationxDyad 1 4.14 0.95 (0.47) 0.04 ‡
    17. 17. Adherence Association by Racial Composition of the Relationship p = 0.91
    18. 18. Discussion <ul><li>African-American patients in race-discordant relationships who rated their communication with providers as more collaborative, had better medication adherence compared to those in race-concordant relationships. </li></ul><ul><li>White providers’ communication that was rated as less collaborative was associated with poor adherence. </li></ul><ul><li>There was no association between medication adherence and ratings of provider communication in race-concordant relationships </li></ul>
    19. 19. Limitations <ul><li>Cross-sectional design using self-report measures. </li></ul><ul><li>Representativeness of providers practicing in ‘safety net’ CHCs. </li></ul><ul><li>Continuity of care with primary care provider was not assessed. </li></ul><ul><li>Patient choice of provider, including race of provider, was not assessed. </li></ul>
    20. 20. Implications <ul><li>Patient-provider relationships characterized by mutual respect, collaboration, and understanding may enable providers to bridge sociocultural gaps </li></ul><ul><li>Need to extend beyond examining race as a demographic characteristic to a multi-dimensional identity to understand the role race con(dis)cordance plays in explaining differential outcomes between black and white patients </li></ul><ul><ul><ul><li>Ex., new concepts of social concordance and shared identity </li></ul></ul></ul>
    21. 21. Model 1 Model 2 df F B (SE) p df F B (SE) p Patient age 1 3.12 0.01 (0.01) 0.08 Patient gender Male 1 0.15 -0.07 (0.17) 0.70 Marital Status 3 0.62 0.61 Insurance status 3 0.45 0.72 Diabetes 1 0.88 0.16 (0.17) 0.35 Stroke 1 5.10 -0.69 (0.31) 0.03 ‡ # HTN meds 1 0.54 0.06 (0.08) 0.46 Length of relationship ≥ 1 year 1 3.65 0.52 (0.27) 0.06 Provider birthplace U.S. 1 4.15 -0.35 (0.17) 0.04 ‡ Type of provider MD 1 2.59 0.42 (0.26) 0.11 Cultural competency training 1 1.64 -0.10 (0.08) 0.20 Years at CHC 1 0.01 0.001 (0.01) 0.93 Communication 1 4.46 -0.46 (0.22) 0.04 ‡ 1 8.25 -1.11 (0.39) 0.005 ‡ Dyad type 1 0.75 0.17 (0.20) 0.39 1 1.38 0.23 (0.20) 0.24 CommunicationxDyad 1 4.14 0.95 (0.47) 0.04 ‡
    22. 22. All Patients (N = 597) Race- Concordant † (n = 390) Race-Discordant ‡ (n = 207) p* Mean age (  SD) Range: 24-89 years 57.3 (12.3) 57.4 (12.7) 58.6 (13.4) 0.30 Female: n (%) 405 (69) 258 (68) 147 (72) 0.26 Born in US: n (%) 420 (73) 270 (72) 150 (75) 0.24 Marital status: n (%)* Single Married Divorced/Separated Widowed 155 (28) 145 (26) 173 (31) 85 (15) 92 (26) 104 (29) 115 (32) 48 (13) 63 (32) 41 (21) 58 (29) 37 (19) 0.05 Education: n (%) < High school High school and above 218 (38) 352 (61) 140 (38) 228 (62) 78 (39) 124 (61) 0.89 Unemployed: n (%) 378 (66) 128 (63) 138 (68) 0.24 Income (%) ≤ $20,000 398 (70) 261 (69) 137 (70) 0.41 Insurance status: n (%) None HMO/Private Medicare Medicaid 52 (9) 100 (19) 158 (28) 242 (43) 37 (10) 65 (18) 103 (28) 164 (44) 15 (8) 43 (23) 55 (29) 78 (41) 0.56 Comorbidity score: n (%) 0 1 - 2 ≥ 3 107 (19) 261 (45) 206 (36) 74 (20) 168 (45) 131 (35) 33 (16) 93 (46) 75 (37) 0.61 Comorbity: n (%) Stroke Diabetes 57 (10) 185 (33) 31 (8) 110 (30) 26 (13) 75 (37) 0.09 0.07 SBP ( 114-211mm Hg) DBP ( 67-141mm Hg) 151 (15.7) 91 (10.9) 151 (15.3) 91 (10.9) 151 (16.3) 90 (10.9) 0.36 0.86 Mean N of meds (  SD) Range: 1-5 1.94 (0.9) 1.88 (0.89) 2.05 (1.04) 0.09 % seeing provider ≥ 1 year 526 (88) 345 (89) 181 (87) 0.71 Mean Communication Score ¥ Range: 1-4 2.88 (0.39) 2.91 (0.4) 2.82 (0.37) 0.02 Mean adherence score Range: 0 - 4 2.86 (1.23) 2.88 (1.22) 2.81 (1.26) 0.36 % non-adherent 59 58.3 60.0 0.38

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