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Provider-patient Adherence Dialogue in HIV Care: Results of a Multisite Study

Abstract

Few studies have analyzed physician–patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician–patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African–American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients’ understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.

Resumen

Pocos estudios han analizado en detalle el diálogo entre médicos y pacientes sobre la adherencia del paciente al tratamiento con antirretrovirales (ARVs). Se describe globalmente encuentros entre médicos y pacientes en el tratamiento del VIH, con enfoque en el diálogo sobre ARVs, usando un sistema que aplica a cada enunciado un código para el tema, y para el acto de del habla.Estudio observaciónal con uso de grabaciones de consultas externas rutinarias de personas con VIH en clínicas especializadas.Los proveedores fueron 34 médicos y 11 proveedores de otras clases. De 415 pacientes, 66% fueron hombres, 59% Africano-Americanos. 78% informaron tomar ARVs actualmente.Aproximadamente 10% de los enunciados se refirieron al tratamiento con ARVs. Entres los que usaron ARVs, 15% tuvieron algún diálogo sobre la resolución de problemas de adherencia al tratamiento. El diálogo sobre la resolución de problemas incluyó significativamente más actos directivos y enunciados en la clase de control, comparado a otros temas. Los proveedores dominaron la conversación, hicieron 5 veces más preguntas que los pacientes, y 21 veces más enunciados directivos. Los proveedores hicieron pocas preguntas abiertas, y raras veces chequearon el entendimiento del paciente.Los médicos responden al reto de atender a los pacientes con VIH adoptando un acercamiento que se centra en el médico, lo que se evidencia particularmente en la discusión sobre la adherencia al tratamiento con ARVs.

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References

  1. 1.

    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487–97.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA. 2002;288(4):455–61.

    PubMed  Article  Google Scholar 

  3. 3.

    Dailey G, Kim MS, Lian JF. Patient compliance and persistence with antihyperglycemic drug regimens: evaluation of a medicaid patient population with type 2 diabetes mellitus. Clin Ther. 2001;23(8):1311–20.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Wilson IB, Laws MB, Safren SA, Lee Y, Lu M, Coady W, et al. Provider focused intervention increases HIV antiretroviral adherence related dialogue, but does not improve antiretroviral therapy adherence in persons with HIV. J Acquir Immune Defic Syndr Human Retrovirol. 2010;53(3):338–47.

    Article  Google Scholar 

  5. 5.

    Dunbar-Jacob J, Mortimer-Stephens MK. Treatment adherence in chronic disease. J Clin Epidemiol. 2001;54(Suppl 1):S57–60.

    PubMed  Article  Google Scholar 

  6. 6.

    Sterne JA, Hernan MA, Ledergerber B, Tilling K, Weber R, Sendi P, et al. Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study. Lancet. 2005;366(9483):378–84.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Hogg R, Yip B, O’Shaughnessy M, Montaner J (2000) Non-adherence to triple combination therapy is predictive of AIDS progression and death in HIV-positive men and women. The XIII International AIDS 2000.

  8. 8.

    Kleeberger CA, Phair JP, Strathdee SA, Detels R, Kingsley L, Jacobson LP. Determinants of heterogeneous adherence to HIV-antiretroviral therapies in the Multicenter AIDS Cohort Study. J Acquir Immune Defic Syndr Human Retrovirol. 2001;26(1):82–92.

    CAS  Google Scholar 

  9. 9.

    Kleeberger CA, Buechner J, Palella F, Detels R, Riddler S, Godfrey R, et al. Changes in adherence to highly active antiretroviral therapy medications in the Multicenter AIDS Cohort Study. AIDS. 2004;18(4):683–8.

    PubMed  Article  Google Scholar 

  10. 10.

    Wensing AM, van de Vijver DA, Angarano G, Asjo B, Balotta C, Boeri E, et al. Prevalence of drug-resistant HIV-1 variants in untreated individuals in Europe: implications for clinical management. J Infect Dis. 2005;192(6):958–66.

    PubMed  Article  Google Scholar 

  11. 11.

    World Health Organization. Adherence to long-term therapies. In: Sabate E, editor. Geneva: World Health Organization; 2003.

  12. 12.

    Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33(12):1176–87.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26(7):657–75.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997;277(4):350–6.

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991;32(2):175–81.

    PubMed  CAS  Google Scholar 

  16. 16.

    Beach MC, Sugarman J, Johnson RL, Arbelaez JJ, Duggan PS, Cooper LA. Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? Ann Fam Med. 2005;3(4):331–8.

    PubMed  Article  Google Scholar 

  17. 17.

    Lerman CE, Brody DS, Caputo GC, Smith DG, Lazaro CG, Wolfson HG. Patients’ perceived involvement in care scale: relationship to attitudes about illness and medical care. J Gen Intern Med. 1990;5(1):29–33.

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Brody DS, Miller SM, Lerman CE, Smith DG, Caputo GC. Patient perception of involvement in medical care: relationship to illness attitudes and outcomes. J Gen Intern Med. 1989;4(6):506–11.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Friedman DS, Hahn SR, Gelb L, Tan J, Shah SN, Kim EE, et al. Doctor-patient communication, health-related beliefs, and adherence in glaucoma results from the Glaucoma Adherence and Persistency Study. Ophthalmology. 2008;115(8):1320–7. 7.e1-3.

    PubMed  Article  Google Scholar 

  20. 20.

    Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease [published erratum appears in Med Care 1989 Jul;27(7):679]. Med Care. 1989;27(3 Suppl):S110–27.

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Braddock CH, Fihn SD, Levinson W, Jonsen AR, Pearlman RA. How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting. J Gen Intern Med. 1997;12(6):339–45.

    PubMed  Google Scholar 

  22. 22.

    Friedman DS, Hahn SR, Quigley HA, Kotak S, Kim E, Onofrey M, et al. Doctor–patient communication in glaucoma care: analysis of videotaped encounters in community-based office practice. Ophthalmology. 2009;116(12):2277–85.e1–3.

    Google Scholar 

  23. 23.

    Gilliam F, Penovich PE, Eagan CA, Stern JM, Labiner DM, Onofrey M, et al. Conversations between community-based neurologists and patients with epilepsy: results of an observational linguistic study. Epilepsy Behav. 2009;16(2):315–20.

    PubMed  Article  Google Scholar 

  24. 24.

    Nelson M, Hamilton HE. Improving in-office discussion of chronic obstructive pulmonary disease: results and recommendations from an in-office linguistic study in chronic obstructive pulmonary disease. Am J Med. 2007;120(8 Suppl 1):S28–32.

    PubMed  Article  Google Scholar 

  25. 25.

    Beck RS, Daughtridge R, Sloane PD. Physician–patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002;15(1):25–38.

    PubMed  Google Scholar 

  26. 26.

    Fine E, Reid MC, Shengelia R, Adelman RD. Directly observed patient–physician discussions in palliative and end-of-life care: a systematic review of the literature. J Palliat Med. 2010;13(5):595–603.

    PubMed  Article  Google Scholar 

  27. 27.

    Stewart MA. Effective physician–patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423–33.

    PubMed  CAS  Google Scholar 

  28. 28.

    Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3(5):448–57.

    PubMed  Article  CAS  Google Scholar 

  29. 29.

    Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor–patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903–18.

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Ford S, Hall A, Ratcliffe D, Fallowfield L. The Medical Interaction Process System (MIPS): an instrument for analysing interviews of oncologists and patients with cancer. Soc Sci Med. 2000;50(4):553–66.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Searle JR. Speech acts. An essay in the philosophy of language. Cambridge: Cambridge University Press; 1969.

    Book  Google Scholar 

  32. 32.

    Austin JL. How to do things with words. Oxford: Oxford University Press; 1962.

    Google Scholar 

  33. 33.

    Laws MB Epstein L, Lee YJ, Rogers WH, Beach MC, Wilson I. The association of visit length and measures of patient-centered communication in HIV care: a mixed method study. Patient Educ Couns. 2011;85:e183–8.

    PubMed  Article  Google Scholar 

  34. 34.

    Roter DL. The Roter method of interaction process analysis. RIAS Manual. Johns Hopkins University; 1991.

  35. 35.

    Laws MB, Lu M, Coady W, Bradshaw Y, Safren SA, Skolnik PR, et al. Impact of an intervention on physician-patient dialogue related to antiretroviral (ARV) adherence. Oral presentation, 3rd international conference on HIV treatment adherence, Jersey City, NJ, Mar 17–18, 2008. 2008.

  36. 36.

    Wilson IB, Laws MB, Bradshaw Y, Howe E, Safren SA, Skolnik P, et al. Racial differences in physician-patient dialogue: use of a new method to code and analyze audiotapes of office visits. XVII international AIDS conference, Mexico City, Aug 3–8, 2008 #THPE0141. 2008.

  37. 37.

    Laws MB, Bradshaw YS, Safren SA, Beach MC, Lee Y, Rogers W, et al. Discussion of sexual risk behavior in HIV care is infrequent and appears ineffectual: a mixed methods study. AIDS Behav. 2011;15(4):812–22.

    PubMed  Article  Google Scholar 

  38. 38.

    Laws MB, Epstein L, Lee Y, Rogers W, Beach MC, Wilson IB. The association of visit length and measures of patient-centered communication in HIV care: a mixed methods study. Patient Educ Couns. 2011, May 16.

  39. 39.

    Epstein RM, Franks P, Fiscella K, Shields CG, Meldrum SC, Kravitz RL, et al. Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61(7):1516–28.

    PubMed  Article  Google Scholar 

  40. 40.

    Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100(11):1275–85.

    PubMed  Google Scholar 

  41. 41.

    Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60(3):301–12.

    PubMed  Article  Google Scholar 

  42. 42.

    Miller W, Rollnick S. Motivational interviewing, preparing people for change. New York: The Guilford Press; 2002.

    Google Scholar 

  43. 43.

    Rollnick S, Miller W, Butler C. Motivational interviewing in heath care, helping patients change behavior. New York: The Guilford Press; 2008.

    Google Scholar 

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Acknowledgments

This research was supported by award numbers R34MH089279; and R01MH083595 from the National Institute Of Mental Health; and by a contract from the Health Resources Service Administration and the Agency for Healthcare Research and Quality (AHRQ 290-01-0012). In addition, Dr. Korthuis was supported by the National Institute of Drug Abuse (K23 DA019809), Dr. Saha was supported by the Department of Veterans Affairs, Dr. Beach was supported by the Agency for Healthcare Research and Quality (K08 HS013903-05) and both Drs. Beach and Saha were supported by Robert Wood Johnson Generalist Physician Faculty Scholars Awards. Dr. Wilson was supported by the National Institute of Mental Health (2 K24MH092242). The views expressed here are those of the authors, and no official endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services is intended or should be inferred. We gratefully acknowledge the contributions of Emily Howe, Tatiana Taubin, M. A., Tanya Bezreh, M. A., Ylisabyth Bradshaw, D. O., and Amanda Barrett, M. A. to development of the GMIAS and coding for this study.

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Correspondence to M. Barton Laws.

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Laws, M.B., Beach, M.C., Lee, Y. et al. Provider-patient Adherence Dialogue in HIV Care: Results of a Multisite Study. AIDS Behav 17, 148–159 (2013). https://doi.org/10.1007/s10461-012-0143-z

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Keywords

  • Physician–patient communication
  • Adherence
  • HIV
  • Pharmaceutical treatment