An estimated 20–50% of patients do not take medications as recommended. Accepting a doctor’s recommendation is the first step in medication adherence, yet little is known about patients’ beliefs and preferences about how medications are prescribed.
To explore patients’ beliefs and preferences about medication prescribing to understand factors that might affect medication adherence.
Fifty members from 2 health plans in Massachusetts participated in in-depth telephone interviews. Participants listened to an audio-vignette of a doctor prescribing a medication to a patient and were asked a series of questions related to the vignette. Responses were reviewed in an iterative process to identify themes related to participants’ beliefs and preferences about medication prescribing.
Participants’ beliefs and preferences about medication prescribing encompassed 3 major areas: patient–doctor relationships, outside influences, and professional expertise. Important findings included participants’ concerns about the pharmaceutical industry’s influence on doctors’ prescribing practices and beliefs that there is a clear “best” medication for most health problems.
Patients’ beliefs and preferences about medication prescribing may affect medication adherence. Additional empiric studies that explore whether doctors’ relationships with pharmaceutical representatives impact medication adherence by affecting trust are indicated. In addition, it would be worthwhile to explore whether discussions between patients and doctors regarding equipoise (no clear scientific evidence for 1 treatment choice over another) affect medication adherence.
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Funding was provided by AHRQ through a Supplement to the HMO Research Network Center for Education and Research on Therapeutics (HMORN CERT) U 318 HS010391-06S1.
Conflict of Interest
Audio-vignette and Telephone Interview Content
The original study was designed to explore what aspects of cluster randomized trials (CRT) patients would find acceptable or unacceptable. During pilot testing, patient beliefs and preferences for doctors’ prescribing practices emerged as an area of potential interest. The following concepts were included in the audio-vignette to provide reference points for questions on beliefs and preferences regarding medication prescribing in the interview:
Both drugs included in the study have been on the market for “quite a while,” are safe, effective, and widely used.
No direct comparative data exists—“we don’t know whether one is more effective than the others.”
Doctors were free to prescribe a drug not in the study if the drug was not appropriate for a particular patient.
The CRT is not a drug company-sponsored study.
As part of the study, a regular $40 copayment was reduced to $10.
The script for the telephone interview and the text for the audio-vignette describing a blood pressure and an antidepressant medication are provided below.
Hello. This is Vanessa Meterko, calling from the Meyers Primary Care Institute. May I speak with  please?
Is this still a good time for me to interview you? We’ll probably need about 20 to 30 minutes.
Great. Thank you for agreeing to talk with me. Did you receive the informed consent form that I sent in the mail? It explained your rights as a participant in this research study. Have you had a chance to look at that form? Did you have any questions about it? OK, and have you sent a signed copy back to me here? (If not, please do that as soon as you can, it’s very important.)
Let me make sure that you understand that participating means that I will be taping our conversation so that we can have an accurate record for the study. (The tapes will be transcribed and the transcripts de-identified—your name and any identifying information will be removed from the transcript and the tape will be destroyed.) Of course, you’re free to decline to answer any questions. You may also decide to stop participating at any time. Would you please confirm that you are willing to participate?
Great. I’d like to start by playing a short tape for you. I’d like you to imagine yourself in the situation of the patient on the tape. After you listen to it, I’m going to ask some questions about how you would feel if you were the patient.
Vignette Describing a Blood Pressure Medication
Dr: I’m afraid your blood pressure is still high.
Pt: But I’ve been getting more exercise. I’ve been walking every day.
Dr: That’s terrific. Exercise is important. But so far it hasn’t brought your blood pressure down. I think it’s time for you to start on medication.
Pt: Do you really think I need to?
Dr: I do. High blood pressure is very serious. High blood pressure means your heart has to work harder to pump blood, which means your heart is more prone to problems. Ultimately, you could have a heart attack or a stroke.
Pt: From high blood pressure?
Dr: Yes. That’s why I’m recommending medication. I’m going to give you a prescription for a medication called BPDown.
Pt: Are there any other options?
Dr: There are other medications we could try. But right now we don’t know that any of the other options are any better. Our clinic is participating in a research study to find out which of the medications is most effective. As part of the study, all of our patients who start on this medication during the study will not have to pay any co-payment for BPdown for 2 years. So you’ll be getting this medication for free.
Pt: Wait a minute. Are you saying you’re giving me this medication as part of a study?
Dr: Yes and no. We are involved in a study. But it’s not a typical clinical trial. For one thing, we already know that all the medications being studied are effective. They’ve all been tested in standard clinical trials, they’re all safe, and they’re all widely used to treat high blood pressure. What we don’t know is whether one of them works better than the others. So all of us here are going to recommend BPdown as the first medication to try for our patients who need blood pressure medication. Of course, if there’s some reason that BPdown is not appropriate for a particular patient, we’ll use an alternative. Several other clinics around the country are also in this study; at some clinics doctors will recommend BPdown; at other clinics they’ll recommend something different.
Pt: Are the drug companies behind this? Is that what this is about?
Dr: No, this is not a drug company study. Drug companies don’t usually do this type of study, because they don’t want to find out that their drug is LESS effective than the competition’s. But the government—specifically the Agency for Healthcare Research and Quality which is sponsoring this study—does want to find out which drugs work best. They also want to know if two drugs work equally well—that’s especially important if one of them costs a lot less.
Pt: Ok. Let me make sure I understand. You think I need to start on medication for my blood pressure. You’re recommending BPdown, because that’s what you’re supposed to do as part of this study.
Dr: Right—AND because I think it’s an appropriate choice for you. I don’t think there’s some other drug that would be better—in terms of effectiveness or side effects. There may be another drug that is as good, but I don’t think there’s one that’s better.
Pt: Ok. And there’s no co-payment for this BPdown for 2 years.
Pt: Ok. I guess I’ll try it.
Medication-prescribing Questions are in Italics
If you had been the patient in this situation, what would have been going through your mind?
Is there anything (else) that you would be concerned about?
Is there anything (else) you would be pleased about?
Would you have any (other) questions for the doctor?
Is there any other information that you would want?
Would you have any reservations about accepting the doctor’s recommendation?
*In this example, the doctor was clear that the clinic was participating in a study, and that she was recommending [Bpdown/Yulift] because of the study. How would you feel if the doctor recommended [Bpdown/Yulift], but didn't mention that the clinic was participating in a study?
[*key question – follow up as needed]
You might have noticed that the doctor didn’t explicitly ask the patient if he wanted to be part of the study. Do you think the doctor should have asked the patient straight out if he was willing to be part of the study?
In clinical trials, researchers must fully inform every participant of the risks and benefits of the study, stress the voluntary nature of participation, and get the person’s written consent to participate. Do you think the doctor should have done this in the situation you heard?
In the example the doctor mentioned a reduced co-payment. Would it make a difference to you if there were no financial benefit to you – that is, if the medication cost the usual price?
Some people think that offering a financial incentive in a study – like a reduced co-payment - may be coercive, that is, it could make people feel pressured to participate. What do you think about this?
In the case you heard, the drug [Bpdown/Yulift] had been on the market for a while, and was widely used. What if the drug in the study were newer; for instance, it had only been on the market for a year? Would you feel any differently about the study?
How would you feel if you were already on blood pressure medication/an antidepressant, and the doctor recommended that you switch medications as part of the study?
In the case you heard, all of the doctors in the practice would recommend [Bpdown/Yulift]. What if, instead, some doctors in the practice were going to recommend [Bpdown/Yulift], whereas others, in the same practice, were going to recommend a different drug? If different doctors in the same group were recommending different drugs for the same condition, would that make a difference to you?
People taking [high blood pressure/antidepressant] medication often take it for months or years. So, in the case you heard, the patient might continue to need treatment after the study is over. In contrast, some medications, like antibiotics, are used for shorter periods - days or weeks. If the study were comparing two short term drugs, rather than two long-term drugs, would that make a difference to you?
What if the decision to join the study and to offer the reduced co-payment was made by the health insurance plan? Doctors would know that the cost of [Bpdown/Yulift] was lower, but they wouldn’t necessarily know it was lowered as part of a study. The insurance company wouldn’t put any special rules or guidelines in place – they’d simply change the patients’ co-payment. Just changing the co-payment would probably affect how much doctors prescribed it. What would you think about this? Would you feel any differently about the study?
Considering the dialogue you heard, and all we’ve talked about, what, if any, recommendations would you have to help to make this sort of study acceptable?
Now, a couple of questions about what you think about how doctors usually practice.
How do you think your doctor decides what specific medication you should start on, if he/she thinks you need to start a medication and there are several alternatives available? What do you think he/she considers?
[If they mention evidence or research, say “what if the evidence is not clear?”]
Do you think that he/she considers how much the medication will cost you? For instance, what your co-payment would be?
How do you think doctors should decide which medication to prescribe when there is more than one drug that is widely used for a given condition?
Thanks so much for being so patient and thinking through all these questions. We’re just about done. I have only a few very quick questions left.
Could you please tell me what the highest grade you completed was?
Would you mind telling me how old you are? [lt 30; 31 to 40; 41–50; 51–60; over 60]
Finally, would you mind telling me how you prefer to identify yourself in terms of race and ethnicity?
Are you or have you ever been involved in a research study (besides this one)? What [is] was your role?
Thank you again for your help—I truly do appreciate your being willing to talk with me. (Remind interviewee to send in informed consent if they haven’t done so yet so you can send them their “thank you”.)
End of Health Plan Member Interview Guide
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Goff, S.L., Mazor, K.M., Meterko, V. et al. Patients’ Beliefs and Preferences Regarding Doctors’ Medication Recommendations. J GEN INTERN MED 23, 236–241 (2008). https://doi.org/10.1007/s11606-007-0470-3