Patient-Provider Concordance in the Prioritization of Health Conditions Among Hypertensive Diabetes Patients
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Many patients with diabetes have multiple other chronic conditions, but little is known about whether these patients and their primary care providers agree on the relative importance that they assign these comorbidities.
To understand patterns of patient-provider concordance in the prioritization of health conditions in patients with multimorbidity.
Prospective cohort study of 92 primary care providers and 1,169 of their diabetic patients with elevated clinic triage blood pressure (≥140/90) at nine Midwest VA facilities.
We constructed a patient-provider concordance score based on responses to surveys in which patients were asked to rank their most important health concerns and their providers were asked to rank the most important conditions likely to affect that patient’s health outcomes. We then calculated the change in predicted probability of concordance when the patient reported having poor health status, pain or depression, or competing demands (issues that were more pressing than his health), controlling for both patient and provider characteristics.
For 714 pairs (72%), providers ranked the patient's most important concern in their list of three conditions. Both patients and providers ranked diabetes and hypertension most frequently; however, providers were more likely to rank hypertension as most important (38% vs. 18%). Patients were more likely than providers to prioritize symptomatic conditions such as pain, depression, and breathing problems. The predicted probability of patient-provider concordance decreased when a patient reported having poor health status (55% vs. 64%, p < 0.01) or non-health competing demands (46% vs. 62%, p < 0.01).
Patients and their primary care providers often agreed on the most important health conditions affecting patients with multimorbidity, but this concordance was lower for patients with poor health status or non-health competing demands. Interventions that increase provider awareness about symptomatic concerns and competing demands may improve chronic disease management in these vulnerable patients.
- Partnership For Solutions. Diabetes: The impact of multiple chronic conditions. http://www.partnershipforsolutions.org/DMS/files/Diabetes_Common_Comorbidities_Fact_Sheet.doc. Accessed August 15, 2009.
- Struijs JN, Baan CA, Schellevis FG, Westert GP, van den Bos GA. Comorbidity in patients with diabetes mellitus: impact on medical health care utilization. BMC Health Serv Res. 2006;6:84. CrossRef
- Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269–2276. CrossRef
- Schoenthaler A, Chaplin WF, Allegrante JP, et al. Provider communication effects medication adherence in hypertensive African Americans. Patient Educ Couns. 2009;75(2):185–191. CrossRef
- Kerr EA, Heisler M, Krein SL, et al. Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? J Gen Intern Med. 2007;22(12):1635–1640. CrossRef
- Krein SL, Hofer TP, Holleman R, Piette JD, Klamerus ML, Kerr EA. More than a pain in the neck: how discussing chronic pain affects hypertension medication intensification. J Gen Intern Med. 2009;24(8):911–916. CrossRef
- Krein SL, Heisler M, Piette JD, Makki F, Kerr EA. The effect of chronic pain on diabetes patients’ self-management. Diabetes Care. 2005;28(1):65–70. CrossRef
- Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med. 2000;160(21):3278–3285. CrossRef
- Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care. 2002;25(3):464–470. CrossRef
- Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med. 2008;23(12):2058–2065. CrossRef
- Fung CH, Setodji CM, Kung FY, et al. The relationship between multimorbidity and patients’ ratings of communication. J Gen Intern Med. 2008;23(6):788–793. CrossRef
- Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209–214. CrossRef
- Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care. 2006;29(3):725–731. CrossRef
- Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716–724. CrossRef
- Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27(3 Suppl):S110–127. CrossRef
- Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J. 1995;152(9):1423–1433.
- Street RLJ, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295–301. CrossRef
- Bass MJ, Buck C, Turner L, Dickie G, Pratt G, Robinson HC. The physician’s actions and the outcome of illness in family practice. J Fam Pract. 1986;23(1):43–47.
- Chesney AP, Brown KA, Poe CW, Gary HE Jr. Physician-patient agreement on symptoms as a predictor of retention in outpatient care. Hosp Community Psychiatry. 1983;34(8):737–739.
- Starfield B, Steinwachs D, Morris I, Bause G, Siebert S, Westin C. Patient-doctor agreement about problems needing follow-up visit. JAMA. 1979;242(4):344–346. CrossRef
- Starfield B, Wray C, Hess K, Gross R, Birk PS, D'Lugoff BC. The influence of patient-practitioner agreement on outcome of care. Am J Public Health. 1981;71(2):127–131. CrossRef
- Krupat E, Bell RA, Kravitz RL, Thom D, Azari R. When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract. 2001;50(12):1057–1062.
- Roter D. The enduring and evolving nature of the patient-physician relationship. Patient Educ Couns. 2000;39(1):5–15. CrossRef
- Street RL Jr, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation in medical consultations: why some patients are more involved than others. Med Care. 2005;43(10):960–969. CrossRef
- Bell RA, Kravitz RL, Thom D, Krupat E, Azari R. Unmet expectations for care and the patient-physician relationship. J Gen Intern Med. 2002;17(11):817–824. CrossRef
- Zebiene E, Svab I, Sapoka V, et al. Agreement in patient-physician communication in primary care: a study from Central and Eastern Europe. Patient Educ Couns. 2008;73(2):246–250. CrossRef
- Boland BJ, Scheitel SM, Wollan PC, Silverstein MD. Patient-physician agreement on reasons for ambulatory general medical examinations. Mayo Clin Proc. 1998;73(2):109–117. CrossRef
- Greer J, Halgin R. Predictors of physician-patient agreement on symptom etiology in primary care. Psychosom Med. 2006;68(2):277–282. CrossRef
- Heisler M, Vijan S, Anderson RM, Ubel PA, Bernstein SJ, Hofer TP. When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make? J Gen Intern Med. 2003;18(11):893–902. CrossRef
- Scheuer E, Steurer J, Buddeberg C. Predictors of differences in symptom perception of older patients and their doctors. Fam Pract. 2002;19(4):357–361. CrossRef
- Sewitch MJ, Abrahamowicz M, Dobkin PL, Tamblyn R. Measuring differences between patients’ and physicians’ health perceptions: the patient-physician discordance scale. J Behav Med. 2003;26(3):245–264. CrossRef
- Stewart MA, McWhinney IR, Buck CW. The doctor/patient relationship and its effect upon outcome. J R Coll Gen Pract. 1979;29(199):77–81.
- Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717–727.
- DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question: a meta-analysis. J Gen Intern Med. 2005;20:267–275. CrossRef
- DeSalvo KB, Fisher WP, Tran K, Bloser N, Merrill W, Peabody J. Assessing measurement properties of two single-item general health measures. Qual Life Res. 2006;15(2):191–201. CrossRef
- Eriksson I, Unden AL, Elofsson S. Self-rated health. Comparisons between three different measures. Results from a population study. Int J Epidemiol. 2001;30(2):326–333. CrossRef
- Mossey JM, Shapiro E. Self-rated health: a predictor of mortality among the elderly. Am J Public Health. 1982;72(8):800–808. CrossRef
- Corson K, Gerrity MS, Dobscha SK. Screening for depression and suicidality in a VA primary care setting: two items are better than one item. Am J Manag Care. 2004;10(11 Pt 2):839–845.
- Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163(20):2433–2445. CrossRef
- Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36(5):728–739. CrossRef
- Yu W, Ravelo A, Wagner TH, et al. Prevalence and costs of chronic conditions in the VA health care system. Med Care Res Rev. 2003;60(3 Suppl):146S–167S. CrossRef
- Long JS, Freese J. Regression Models for Categorical Outcomes Using Stata. 2nd ed. College Station: Stata Press; 2005.
- Rogers WH. Regression standard errors in clustered samples. Stata Tech Bull. 1993;13:19–23.
- Oehlert GW. A note on the delta method. Am Stat. 1992;46:27–29. CrossRef
- Carlin JB, Galati JC, Royston P. A new framework for managing and analyzing multiply imputed data in Stata. Stata J. 2008;8:49–67.
- Parchman ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med. 2007;5(3):196–201. CrossRef
- Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care. 2003;26(2):355–359. CrossRef
- Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118):1755–1762. CrossRef
- Snow V, Weiss KB, Mottur-Pilson C. The evidence base for tight blood pressure control in the management of type 2 diabetes mellitus. Ann Intern Med. 2003;138(7):587–592.
- Subramanian U, Hofer TP, Klamerus ML, Zikmund-Fisher BJ, Heisler M, Kerr EA. Knowledge of blood pressure targets among patients with diabetes. Prim Care Diabetes. 2007;1(4):195–198. CrossRef
- Wong N, Wang SS, Lamoureux E, et al. Blood pressure control and awareness among patients with diabetes and hypertension attending a tertiary ophthalmic clinic. Diabet Med. 2009;26(1):34–39. CrossRef
- Katon WJ, Rutter C, Simon G, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care. 2005;28(11):2668–2672. CrossRef
- Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23(7):934–942. CrossRef
- Staiger TO, Jarvik JG, Deyo RA, Martin B, Braddock CH 3rd. BRIEF REPORT: patient-physician agreement as a predictor of outcomes in patients with back pain. J Gen Intern Med. 2005;20(10):935–937. CrossRef
- Schoenberg NE, Leach C, Edwards W. “It’s a toss up between my hearing, my heart, and my hip”: prioritizing and accomodating multiple morbidities by vulnerable older adults. J Health Care Poor Underserved. 2009;20(1):134–151. CrossRef
- Glasgow RE, Nutting PA, King DK, et al. Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care. Diabetes Care. 2005;28(1):33–39. CrossRef
- Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102(4):520–528.
- Liaw ST, Young D, Farish S. Improving patient-doctor concordance: an intervention study in general practice. Fam Pract. 1996;13(5):427–431. CrossRef
- Schillinger D, Handley M, Wang F, Hammer H. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care. 2009;32(4):559–566. CrossRef
- Williams GC, Lynch M, Glasgow RE. Computer-assisted intervention improves patient-centered diabetes care by increasing autonomy support. Health Psychol. 2007;26(6):728–734. CrossRef
- Patient-Provider Concordance in the Prioritization of Health Conditions Among Hypertensive Diabetes Patients
Journal of General Internal Medicine
Volume 25, Issue 5 , pp 408-414
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- chronic disease
- competing demands
- Industry Sectors
- Author Affiliations
- 1. Department of Veterans Affairs, Health Services Research and Development Center of Excellence, Ann Arbor, MI, USA
- 2. Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- 3. The Robert Wood Johnson Clinical Scholars Program, University of Michigan, 6312 Medical Science Building I, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109-5604, USA