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On the Road to Patient Centeredness: Comment on: “Communication and Medication Refill Adherence”

On the Road to Patient Centeredness: Comment on: “Communication and Medication Refill Adherence” With the publication of Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (IOM) enshrined patient centeredness as 1 of 6 distinct dimensions of health care quality.1 In the subsequent decade, patient centeredness gained acceptance as a quality dimension among patients and health care providers, but broad agreement on how to measure patient centeredness and its impact on health outcomes has lagged.2 If you ask most health system administrators to define patient centeredness, they would likely invoke Justice Potter Stewart by answering “I can't define patient centeredness, but I know it when I see it.” As a result, hospitals routinely advertise a “patient-centered approach” to care without actually communicating specific attributes that confirm their patient centeredness or demonstrate how patient centeredness leads to better patient experiences or outcomes.3 Redesigning a patient-centered health system The IOM defines patient centeredness as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”1 The new vision statement by the Patient-Centered Outcomes Research Institute confirms this definition. Achieving patient centeredness will require health system redesign, likely through iterative processes occurring in 2 distinct phases. In the first phase, the dynamics of patient-clinician communication and decision making shift to focus on patient-defined outcomes with scientific evidence and professional judgment informing treatment options and processes.4 In fee-for-service medicine, evidence and professional standards define outcomes with patient preferences informing the processes of care.1 Patient-centered communication, defined as a free flow between patients and clinicians about values and goals as well as data and experiences relevant to a clinical decision, facilitates collaborative treatment plans that are personalized to achieve patient-oriented outcomes.5 The patient-centered medical home (PCMH) model, supported by a broad coalition of health care providers and stakeholders, is a coherent example of how the first phase of patient centeredness may function. The second phase of patient centeredness is more controversial because it gives patients and their families some accountability for determining quality and use of health care.6 The IOM principles for system redesign that best define this second phase are the “need for transparency” and the “patient as the source of control.”1 As of today, information defining quality either does not exist or cannot be understood universally. Many patients, clinicians, hospitals, and insurers are, therefore, reluctant about this phase of patient centeredness. Models of patient-centered communication and decision making In this issue, the findings by Ratanawongsa et al7 advance our understanding of patient-centered communication and decision making (ie, first phase of patient-centered redesign) and how patient centeredness relates to outcomes like medication adherence. Patients reporting low ratings of patient-centered communication and trust with their personal clinician had 7% to 16% worse nonadherence rates to medication refills compared with patients reporting high ratings after adjusting for clinical and sociodemographic characteristics.7 The study has a number of methodological strengths that further its relevance and importance. First, the investigators measure adherence using objective pharmacy utilization data for medication refills across a number of medication classes rather than patient self-report.Second, the study population was large and sociodemographically diverse and had established primary care relationships to frame perceptions of patient-clinician communication. Third, the study used a variety of sophisticated analytical methods to strengthen its validity including a stratified sampling design, adjustment for potential nonresponse bias, and directed acyclic graphs to account for the direct and indirect effects of known covariates on medication refill adherence.7 The conceptualization of patient centeredness used by Ratanawongsa et al7 relies on an accepted 4-item construct for patient-centered communication, another 2 items related to shared decision making and problem solving, and an additional 2 items reflecting trust within patient-clinician relationships. The investigators' decision to use self-reported measures of patient centeredness has validity despite limitations.2,3 Their construct for patient-centered communication elicits patients' perceptions of how often clinicians listen, spend adequate time, show respect, and explain things simply and is best suited for measuring patient centeredness across a health care setting.3,7 Prior studies of communication and diabetes control, using different self-reported items, defined patient centeredness in terms of patients' perceptions that their clinicians were open and honest, encouraged their questions, facilitated collaboration, managed uncertainty, and encouraged them in setting and reaching treatment goals.8,9 Furthermore, these studies found robust relationships between patient centeredness and the outcomes of overall self-management and diabetes (glycemia and blood pressure) control.8,9 All 3 studies are consistent with the theoretical model by Street et al10 describing “how communication heals.” This theoretical model acknowledges that, although patient-centered communication may have direct pathways to improved health (eg, reducing emotional distress), more often there will be indirect pathways involving proximal psychosocial outcomes and intermediate health care outcomes.10 For example, among the other variables explored by Ratanawongsa et al,7 rapport and trust within the patient-clinician relationship is a proximal outcome in the indirect pathway and self-management behaviors, such as medication refill adherence, are intermediate outcomes in the indirect pathway.10 Furthermore, PCMH innovations are an appropriate clinical context for designing and testing interventions informed by the model by Street et al.10 Patient centeredness as transparency and patient control Promoting patient centeredness is a laudable objective even without better health outcomes.3 Studies of patient-centered communication such as Ratanawongsa et al7 are an important stop on the road to patient centeredness. Nevertheless, in addition to patient-centered communication and decision making, the quality dimension of patient centeredness also consists of transparency and the locus of control centered on patients and their families.6 In other words, Patient centeredness is much more than what clinicians do to achieve quality, it requires engaged and responsible patients and families. Without this second phase of patient centeredness, innovations like PCMH may potentially exacerbate the problems of hyperinflation and overutilization. An increased awareness of and focus on patients' needs may result in greater health care utilization, as patients gain trust and acceptance of physicians' recommendations. Clinicians should help patients assume responsibility for their decisions as much as they inform and motivate them. Transparency, as a key attribute of the second phase of patient centeredness, is more than the free flow of information or even patient-centered communication. Transparency exists when patients intuitively understand the consequences of their condition and how treatment choices will affect their daily lives. Patient control exists when one chooses not to pursue a recommendation, such as prostate-specific antigen testing, because the recommendation could result in an outcome not consistent with ones' life goals. System redesign, if stalled at the first phase of patient centeredness, will produce greater access to effective services but may not meaningfully improve patient centeredness. Back to top Article Information Correspondence: Dr Naik, Michael E. DeBakey VAMC (152), 2002 Holcombe Blvd, Houston, TX 77030 (anaik@bcm.edu). Published Online: December 31, 2012. doi:10.1001/jamainternmed.2013.1229 Conflict of Interest Disclosures: None reported. Funding/Support: Dr Naik receives resources and support from the Houston HSR&D Center of Excellence (grant HFP90-020) and a Clinical Scientist Development Award from the Doris Duke Charitable Foundation. Additional Contributions: Richard L. Street Jr, PhD, and Whitney Mills, PhD, provided reviews to earlier drafts of the manuscript. References 1. Committee on Quality of Health Care in America; Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001:6 2. Lin GA, Dudley RA. Patient-centered care: what is the best measuring stick? Arch Intern Med. 2009;169(17):1551-155319786671PubMedGoogle ScholarCrossref 3. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-10321403134PubMedGoogle ScholarCrossref 4. Wagner EH, Bennett SM, Austin BT, Greene SM, Schaefer JK, Vonkorff M. Finding common ground: patient-centeredness and evidence-based chronic illness care. J Altern Complement Med. 2005;11:(suppl 1) S7-S1516332190PubMedGoogle ScholarCrossref 5. Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Educ Couns. 2006;63(1-2):145-15116406471PubMedGoogle ScholarCrossref 6. Berwick DM. What “patient-centered” should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-w56519454528PubMedGoogle ScholarCrossref 7. Ratanawongsa N, Karter AJ, Parker MM, et al. Communication and medication refill adherence: The Diabetes Study of Northern California [published online December 31, 2012]. JAMA Intern Med. 2013;173(3):210-218Google Scholar 8. Heisler M, Cole I, Weir D, Kerr EA, Hayward RA. Does physician communication influence older patients' diabetes self-management and glycemic control? results from the Health and Retirement Study (HRS). J Gerontol A Biol Sci Med Sci. 2007;62(12):1435-144218166697PubMedGoogle ScholarCrossref 9. Naik AD, Kallen MA, Walder A, Street RL Jr. Improving hypertension control in diabetes mellitus: the effects of collaborative and proactive health communication. Circulation. 2008;117(11):1361-136818316489PubMedGoogle ScholarCrossref 10. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295-30119150199PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

On the Road to Patient Centeredness: Comment on: “Communication and Medication Refill Adherence”

Naik, Aanand D.
JAMA Internal Medicine , Volume 173 (3) – Feb 11, 2013
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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.1229
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Abstract

With the publication of Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (IOM) enshrined patient centeredness as 1 of 6 distinct dimensions of health care quality.1 In the subsequent decade, patient centeredness gained acceptance as a quality dimension among patients and health care providers, but broad agreement on how to measure patient centeredness and its impact on health outcomes has lagged.2 If you ask most health system administrators to define patient centeredness, they would likely invoke Justice Potter Stewart by answering “I can't define patient centeredness, but I know it when I see it.” As a result, hospitals routinely advertise a “patient-centered approach” to care without actually communicating specific attributes that confirm their patient centeredness or demonstrate how patient centeredness leads to better patient experiences or outcomes.3 Redesigning a patient-centered health system The IOM defines patient centeredness as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”1 The new vision statement by the Patient-Centered Outcomes Research Institute confirms this definition. Achieving patient centeredness will require health system redesign, likely through iterative processes occurring in 2 distinct phases. In the first phase, the dynamics of patient-clinician communication and decision making shift to focus on patient-defined outcomes with scientific evidence and professional judgment informing treatment options and processes.4 In fee-for-service medicine, evidence and professional standards define outcomes with patient preferences informing the processes of care.1 Patient-centered communication, defined as a free flow between patients and clinicians about values and goals as well as data and experiences relevant to a clinical decision, facilitates collaborative treatment plans that are personalized to achieve patient-oriented outcomes.5 The patient-centered medical home (PCMH) model, supported by a broad coalition of health care providers and stakeholders, is a coherent example of how the first phase of patient centeredness may function. The second phase of patient centeredness is more controversial because it gives patients and their families some accountability for determining quality and use of health care.6 The IOM principles for system redesign that best define this second phase are the “need for transparency” and the “patient as the source of control.”1 As of today, information defining quality either does not exist or cannot be understood universally. Many patients, clinicians, hospitals, and insurers are, therefore, reluctant about this phase of patient centeredness. Models of patient-centered communication and decision making In this issue, the findings by Ratanawongsa et al7 advance our understanding of patient-centered communication and decision making (ie, first phase of patient-centered redesign) and how patient centeredness relates to outcomes like medication adherence. Patients reporting low ratings of patient-centered communication and trust with their personal clinician had 7% to 16% worse nonadherence rates to medication refills compared with patients reporting high ratings after adjusting for clinical and sociodemographic characteristics.7 The study has a number of methodological strengths that further its relevance and importance. First, the investigators measure adherence using objective pharmacy utilization data for medication refills across a number of medication classes rather than patient self-report.Second, the study population was large and sociodemographically diverse and had established primary care relationships to frame perceptions of patient-clinician communication. Third, the study used a variety of sophisticated analytical methods to strengthen its validity including a stratified sampling design, adjustment for potential nonresponse bias, and directed acyclic graphs to account for the direct and indirect effects of known covariates on medication refill adherence.7 The conceptualization of patient centeredness used by Ratanawongsa et al7 relies on an accepted 4-item construct for patient-centered communication, another 2 items related to shared decision making and problem solving, and an additional 2 items reflecting trust within patient-clinician relationships. The investigators' decision to use self-reported measures of patient centeredness has validity despite limitations.2,3 Their construct for patient-centered communication elicits patients' perceptions of how often clinicians listen, spend adequate time, show respect, and explain things simply and is best suited for measuring patient centeredness across a health care setting.3,7 Prior studies of communication and diabetes control, using different self-reported items, defined patient centeredness in terms of patients' perceptions that their clinicians were open and honest, encouraged their questions, facilitated collaboration, managed uncertainty, and encouraged them in setting and reaching treatment goals.8,9 Furthermore, these studies found robust relationships between patient centeredness and the outcomes of overall self-management and diabetes (glycemia and blood pressure) control.8,9 All 3 studies are consistent with the theoretical model by Street et al10 describing “how communication heals.” This theoretical model acknowledges that, although patient-centered communication may have direct pathways to improved health (eg, reducing emotional distress), more often there will be indirect pathways involving proximal psychosocial outcomes and intermediate health care outcomes.10 For example, among the other variables explored by Ratanawongsa et al,7 rapport and trust within the patient-clinician relationship is a proximal outcome in the indirect pathway and self-management behaviors, such as medication refill adherence, are intermediate outcomes in the indirect pathway.10 Furthermore, PCMH innovations are an appropriate clinical context for designing and testing interventions informed by the model by Street et al.10 Patient centeredness as transparency and patient control Promoting patient centeredness is a laudable objective even without better health outcomes.3 Studies of patient-centered communication such as Ratanawongsa et al7 are an important stop on the road to patient centeredness. Nevertheless, in addition to patient-centered communication and decision making, the quality dimension of patient centeredness also consists of transparency and the locus of control centered on patients and their families.6 In other words, Patient centeredness is much more than what clinicians do to achieve quality, it requires engaged and responsible patients and families. Without this second phase of patient centeredness, innovations like PCMH may potentially exacerbate the problems of hyperinflation and overutilization. An increased awareness of and focus on patients' needs may result in greater health care utilization, as patients gain trust and acceptance of physicians' recommendations. Clinicians should help patients assume responsibility for their decisions as much as they inform and motivate them. Transparency, as a key attribute of the second phase of patient centeredness, is more than the free flow of information or even patient-centered communication. Transparency exists when patients intuitively understand the consequences of their condition and how treatment choices will affect their daily lives. Patient control exists when one chooses not to pursue a recommendation, such as prostate-specific antigen testing, because the recommendation could result in an outcome not consistent with ones' life goals. System redesign, if stalled at the first phase of patient centeredness, will produce greater access to effective services but may not meaningfully improve patient centeredness. Back to top Article Information Correspondence: Dr Naik, Michael E. DeBakey VAMC (152), 2002 Holcombe Blvd, Houston, TX 77030 (anaik@bcm.edu). Published Online: December 31, 2012. doi:10.1001/jamainternmed.2013.1229 Conflict of Interest Disclosures: None reported. Funding/Support: Dr Naik receives resources and support from the Houston HSR&D Center of Excellence (grant HFP90-020) and a Clinical Scientist Development Award from the Doris Duke Charitable Foundation. Additional Contributions: Richard L. Street Jr, PhD, and Whitney Mills, PhD, provided reviews to earlier drafts of the manuscript. References 1. Committee on Quality of Health Care in America; Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001:6 2. Lin GA, Dudley RA. Patient-centered care: what is the best measuring stick? Arch Intern Med. 2009;169(17):1551-155319786671PubMedGoogle ScholarCrossref 3. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-10321403134PubMedGoogle ScholarCrossref 4. Wagner EH, Bennett SM, Austin BT, Greene SM, Schaefer JK, Vonkorff M. Finding common ground: patient-centeredness and evidence-based chronic illness care. J Altern Complement Med. 2005;11:(suppl 1) S7-S1516332190PubMedGoogle ScholarCrossref 5. Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Educ Couns. 2006;63(1-2):145-15116406471PubMedGoogle ScholarCrossref 6. Berwick DM. What “patient-centered” should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-w56519454528PubMedGoogle ScholarCrossref 7. Ratanawongsa N, Karter AJ, Parker MM, et al. Communication and medication refill adherence: The Diabetes Study of Northern California [published online December 31, 2012]. JAMA Intern Med. 2013;173(3):210-218Google Scholar 8. Heisler M, Cole I, Weir D, Kerr EA, Hayward RA. Does physician communication influence older patients' diabetes self-management and glycemic control? results from the Health and Retirement Study (HRS). J Gerontol A Biol Sci Med Sci. 2007;62(12):1435-144218166697PubMedGoogle ScholarCrossref 9. Naik AD, Kallen MA, Walder A, Street RL Jr. Improving hypertension control in diabetes mellitus: the effects of collaborative and proactive health communication. Circulation. 2008;117(11):1361-136818316489PubMedGoogle ScholarCrossref 10. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295-30119150199PubMedGoogle ScholarCrossref

Journal

JAMA Internal Medicine – American Medical Association

Published: Feb 11, 2013

Keywords: patient-centered care,prescription refills

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