J Behav Med (2011) 34:244253 DOI 10.

1007/s10865-010-9304-6

Patient centered primary care is associated with patient hypertension medication adherence
Christianne L. Roumie Robert Greevy Kenneth A. Wallston Tom A. Elasy Lisa Kaltenbach Kristen Kotter Robert S. Dittus Theodore Speroff

Received: June 14, 2010 / Accepted: November 15, 2010 / Published online: December 16, 2010 Springer Science+Business Media, LLC (outside the USA) 2010

Abstract There is increasing evidence that patient centered care, including communication skills, is an essential component to chronic illness care. Our aim was to evaluate patient centered primary care as a determinant of medication adherence. We mailed 1,341 veterans with hypertension the Short Form Primary Care Assessment Survey (PCAS) which measures elements of patient centered primary care. We prospectively collected each patients antihypertensive medication adherence for 6 months. rPatients were characterized as adherent if they had medication for [80%. 654 surveys were returned (50.7%); and 499 patients with complete data were analyzed. Antihypertensive adherence increased as scores in patient centered care increased [RR 3.18 (95% CI 1.44, 16.23) bootstrap 5000 resamples] for PCAS score of 4.5 (highest quartile) versus 1.5 (lowest quartile). Future research is

needed to determine if improving patient centered care, particularly communication skills, could lead to improvements in health related behaviors such as medication adherence and health outcomes. Keywords Medication adherence Hypertension Patient centered care Communication

Introduction For patients to effectively manage chronic illness, they need understandable information, participation in decision making, goal setting, problem-solving and assistance managing psychosocial issues (Bodenheimer 2003; Bodenheimer et al. 2002a, b; Hibbard 2003; Hibbard and

C. L. Roumie R. Greevy K. A. Wallston T. A. Elasy K. Kotter R. S. Dittus T. Speroff VA Tennessee Valley Healthcare, Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA C. L. Roumie R. Greevy K. A. Wallston T. A. Elasy K. Kotter R. S. Dittus T. Speroff HSR&D Targeted Research Enhancement Program Center for Patient Healthcare Behavior, Nashville, TN, USA C. L. Roumie R. Greevy K. Kotter Tennessee Valley VA Clinical Research Training Center of Excellence (CRCoE), Nashville, TN, USA C. L. Roumie T. A. Elasy R. S. Dittus T. Speroff Department of Medicine, Vanderbilt University, Nashville, TN, USA C. L. Roumie T. A. Elasy R. S. Dittus T. Speroff VA National Quality Scholars Program, Nashville, TN, USA

R. Greevy K. Kotter T. Speroff Department of Biostatistics, Vanderbilt University, Nashville, TN, USA K. A. Wallston School of Nursing, Vanderbilt University, Nashville, TN, USA L. Kaltenbach Duke Clinical Research Institute, Durham, NC, USA T. Speroff Department of Preventive Medicine, Vanderbilt University, Nashville, TN, USA C. L. Roumie (&) Nashville VA Medical Center, 1310 24th Ave South GRECC 4B120, Nashville, TN 37212, USA e-mail: christianne.roumie@vanderbilt.edu

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Peters 2003; Rothman and Wagner 2003; Wagner et al. 1996; Wagner et al. 2001). Many of these qualities are attributes of patient-centered primary care (Cleary et al. 1993; Laine et al. 1996). The Picker Institute and the Commonwealth Fund coined the term patient centered care in 1986 (Beatrice et al. 1998). A high degree of consensus exists regarding the key attributes of patient-centered care. They include: education and shared knowledge; involvement of family; collaboration and team management; sensitivity to non medical and spiritual dimensions of care; respect for patient preferences; and accessibility of information including enhanced provider patient communication (Bergeson and Dean 2006; Bodenheimer et al. 2002b; Lewin et al. 2001; Shaller 2007). Patient centered care is postulated to lead to an increased sense of self efcacy which leads to increased self-management behaviors (Bodenheimer et al. 2002; Holman and Lorig 2004; Lorig et al. 1999). In 2001, Lewin et al. published a Cochrane review of 17 trials which included interventions to promote patient centered care. They found that interventions that included training healthcare providers in patient-centered approaches positively impacted patient satisfaction with care. Six of the 11 studies that assessed patient satisfaction demonstrated signicant differences among the intervention group on one or more measures. Few studies, however, examined healthcare behavior or health outcomes. Therefore, Lewin et al. concluded that there is limited evidence on the effects of such interventions on patient healthcare behaviors and further research was required. One key patient self management activity is taking medications. Medication non-adherence or discordance is the variance between patient medication self-administration and the regimen prescribed by their provider (Osterberg and Blaschke 2005). Poor medication adherence is one factor that accounts for worsening of disease, and increased costs (Gandhi et al. 2000; McDonnell and Jacobs 2002; Merz et al. 2002; Schiff et al. 2003). Our objective was to explore the concepts of patientcentered care and activation as a marker of productive interactions within the chronic care model. Specically we focused on the relationships between patients perceptions of patient-centered primary care (a care environment variable), medication adherence (a process of care variable), and blood pressure (BP) control (a key outcome of care) (Bodenheimer et al. 2002a, b; Wagner 2004; Wagner et al. 1996, 2001; Wagner and Groves 2002). Our hypothesis was that patients who score higher in the domain of patient-centered primary care will have greater adherence to antihypertensive medications and, subsequently, better BP control.

Methods Study design We conducted a prospective cohort study among veterans who had participated in a prior cluster randomized trial conducted at the Veterans Affairs Tennessee Valley Healthcare System (TVHS) involving interventions of increasing intensity designed to affect BP control and results have been published (Roumie et al. 2006). Two months after the trial ended, we conducted a cross-sectional follow-up survey assessing veterans perceptions of the care delivered at TVHS. Subsequently, patients antihypertensive medication adherence and BP were assessed for the 6-month period following survey completion. The Institutional Review Board and the research and development committee of the Veterans Affairs Tennessee Valley Healthcare System approved this study. Population and survey protocol The inception cohort consisted of a convenience sample of 1341 participants who were mailed the short form of the Primary Care Assessment Survey (PCAS) (Safran et al. 1998) 2 months after the trial ended (March 1, 2005). The survey packet, which also included a cover letter and return envelope, was mailed once. The cover letter stated that participation was voluntary and patients could opt out of the survey. The survey also included a one page questionnaire asking for general information about the participant as well as the 22 item patient activation measure (PAM) (Hibbard et al. 2004). Non-responders were mailed a reminder postcard 3 weeks after the initial mailing. Most responders returned surveys within 8 weeks; however, we accepted responses through 21 weeks (N = 9 responses received between 921 weeks). All patients (responders and non-responders) were followed for 6 months (184 days) following the survey. Patients were censored if they died during the follow-up period or if they stopped lling any medications through the VA; otherwise, cohort days were counted as number of medication eligible days. Survey instruments Primary care assessment survey (PCAS) The Short Form PCAS (Safran et al. 1998) is a validated patient-completed questionnaire designed to measure seven elements of primary care: access; continuity; comprehensiveness; integration of care; clinical interactions (including both communication and exam skills); interpersonal

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treatment; and trust. We report the raw mean item scores which range from 15 with higher scores representing more of the attribute being assessed. Given that many veterans are dual users of VA and private sector services, we modied the PCAS to clarify that questions are related to their VA provider. Because the questions were changed, we conducted an exploratory principal components factor analysis. A single factor explained 77% of the variance and had high internal consistency (Cronbachs a = 0.93). We named that factor patient-centered primary care. Patient activation measure (PAM) The PAM (Hibbard et al. 2004) assesses four concepts in activation: believes an active role is important; condence and knowledge to take action; taking action; and staying the course under stress. The PAM has high reliability estimates (Cronbachs a = 0.91) which are stable across health status, gender and age. Scores on the PAM were transformed from the continuous logit scale to a continuous 0100 score with high scores representing high activation. Process and outcome measures We prospectively collected all participants medication lls and outpatient blood pressure measurements for 6 months from the initial date the survey was mailed (184 days from March 1, 2005). The Mid-South Data warehouse is a relational database updated monthly which contains patient-specic information including billing, prescriptions, vital signs, diagnoses, and laboratory data. The pharmacy data les contain data for each prescription ll. Medication adherence The primary process measure was adherence to antihypertensive medications. Using prescription information we determined if a patient had any antihypertensives on each medication eligible day or medications in hand. Medications that were included in the adherence assessment included the following classes: angiotensin converting enzyme inhibitor or receptor blocker; beta-blocker; diuretics (except furosemide); calcium channel blocker; centrally acting antihypertensive or alpha adrenergic antihypertensive agents. Furosemide was excluded from the adherence calculations given the potential for variable use. Often patients stockpile medications; therefore we derived an estimate that ascertained how many pills a patient had each day. For example, if a patient received 90 days of lisinopril and relled on day 80 then the patient had 100 days of medications in hand (90 from the new ll +10 left over from initial ll). This was necessary because

many patients in the VA system receive medications through the mail and for various lengths of time (usually 3090 days supply). Days supply in hand was reset to 0 when a dosage change was made to the medication. Adherence was calculated using a modication of the Steiner method (Steiner et al. 1988, 1993; Steiner and Prochazka 1997): the number of days with at least one antihypertensive medication available divided by the number of eligible medication days. This ratio could range from 01 and higher values indicate greater adherence. A patient who received an adherence score of 1 relled their antihypertensive medication within the expected time for a rell 100% of the time. After a patients adherence score was calculated, we dichotomized each patient as adherent using C0.8 or non-adherent using \0.8 (Andrade et al. 2006; Bagchi et al. 2007; Elliott et al. 2007; Hess et al. 2006; Yang et al. 2007). For patients who lled no medications at the VA in the 184 day window their adherence was considered missing. BP control The dichotomous outcome measure was an outpatient BP of 140 mm Hg (systolic) and B90 mm Hg (diastolic) during follow-up among all patients including those with diabetes. If more than one BP reading was available, we used the BP closest to day 184 post survey to determine if the patient reached goal (range 93273 days). We coded the outcome 1 if the patient reached this BP goal, and 0 if the goal was not reached. Statistical analysis Each respondent must have completed C75% of the surveys questions to be included in the analysis. If the survey contained some unanswered questions, scale rules were applied according to instructions to calculate the score. We examined the distributions of the PCAS and all covariates. After the PCAS score was calculated it was used in a multivariate logistic regression model to independently predict the process or outcome variables (adherence C0.80 or BP 140/90 mm Hg). To avoid assuming a linear association with adherence, PCAS was t with third degree polynomial curves. Covariates were determined a priori based on clinical signicance. These included patient age, self reported race (white, nonwhite), education (\12th grade, C12th grade), duration of hypertension (less than 1, 25, 610, 1115, 1620, [20 years), and VA-only care versus any private sector care for the treatment of hypertension. We also adjusted for PAM score (degree of selfassessed patient activation). We accounted for the provider as a random effect to adjust for clustering. Given that there were 499 patients in the adjusted analysis we chose the

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most clinically signicant covariates so as not to overt our adjusted models. We conducted exploratory subgroup analyses to determine if any of the individual questions or subscales in the PCAS was associated with medication adherence. For these analyses we divided the 5 point Likert response scale into a binary predictor and calculated the odds of adherence using logistic regression for those who responded positively compared to those who responded negatively to each item. We also conducted a sensitivity analysis to determine the stability of our adherence measure of 80%. We varied the adherence denition and reran the analysis for all cutoffs between 0% and 100%. Likelihood ratio tests were used to determine the statistical signicance of variables assuming a = 0.05. A bootstrap procedure (N = 5,000) was used to determine condence intervals. We report relative risks (RR) or odds ratios (OR) and 95% condence intervals (95% CI). Statistical analyses were conducted using Stata 8.2 and SAS for Windows 9.1.

P = 0.337) and hyperlipidemia (49.3 vs. 44.7%; X2(1) P = 0.434) were included in the analysis. A higher proportion of patients included in the analysis had their BP controlled at baseline compared to those excluded due to missing adherence measures or covariates (71.3 vs. 55.3%; X2(1) P = 0.003).

Primary process measure: medication adherence Adherence could be calculated for 528/560 survey responders (94.3%). As shown in Table 2, as PCAS score increased, the proportion of patients considered adherent increased (X2(3) P = 0.03). In a regression model that adjusted for covariates as well as the provider as a random effect, we observed that, as PCAS scores increased, antihypertensive medication adherence also increased (Random-effects logistic regression [N = 499 observations in 113 groups] Likelihood Ratio X2(3) P = 0.001) (Fig. 2). The relative risk of antihypertensive adherence for a patient with a PCAS score of 4.5 (highest quartile) compared to a patient in the lowest quartile (score 1.5) was 3.18 (95% CI: 1.44, 16.23 bootstrap 5,000 resamples). When we tested each covariate in the model, duration of hypertension and using the VA as the primary source of hypertension care were associated with medication adherence. Patients had increased odds of adherence if the duration of hypertension was 610 years (Odds Ratio [OR] 1.92; 95% CI: 1.09, 3.39 Random-effects logistic regression [N = 499 observations in 113 groups] X2(5) or 1115 years (OR 2.70; 95% CI: 1.27, 5.78) compared to those with hypertension for \5 years. For patients who received all of their hypertension care through the VA the odds of medication adherence was 2.30 (95% CI: 1.39, 3.83 Random-effects logistic regression [N = 499 observations in 113 groups] X2(1) P = 0.004) compared to those who received some or all of their hypertension care in the private sector. The remaining covariates in the model were non- signicant [Random-effects logistic regression [N = 499 observations in 113 groups] Likelihood Ratio tests PAM score (X2(3) P = 0.34); patient age (X2(3) P = 0.17); race (X2(1) P = 0.50); and education (X2(1) P = 0.68)]. In follow-up exploratory analyses, two questions on the PCAS that asked about the providers communication skills had the greatest association with patient medication adherence (Table 3). We conducted additional analyses including all a priori selected covariates as well as number of antihypertensive medications, and Charlson comorbidity score. We also conducted an analysis on the subgroup of patients who indicated that the VA provides all of their care. In both

Results We received 756 of the 1341 surveys (56.4%). Fifty-two surveys were returned incomplete (opt outs). After excluding surveys sent to incorrect addresses (n = 31) or to patients who were identied by family as dead or demented (n = 19), our response rate was 50.7% (654/1291). Non-responders (637/1291 = 49.3%) were those who actively chose to opt out and those who did not return surveys. Because we required that 75% of the survey be completed, 584/654 (89.3%) PCAS and 624/654 (95.4%) PAM surveys contained usable data. A total of 560/654 (85.6%) patients answered both surveys (Fig. 1).

Patient characteristics Responders were 97.3% male, and older than nonresponders (67.0 11.3 vs. 63.4 12.7; t (1289) P \ 0.0001). Responders were more likely to have their BP controlled at survey baseline than non-responders [68.5% vs. 57.3%; X2(1) P \ 0.0001] and responders were more likely to be adherent to their antihypertensive medications at survey baseline (58.0% vs. 42.1%; X2(1) P \ 0.0001) and continued to be more adherent at the 6 month follow up (72.7% vs. 57.8%; X2(1) P \ 0.0001). Table 1 demonstrates the characteristics of persons included in the adherence analysis (N = 499). The majority of patients were older white males. The mean PCAS item score was 3.57 (Standard deviation [SD] 0.84; Median 3.65 [Interquartile Range (IQR)] 34.23]). A slightly higher proportion of patients with diabetes (7.6 vs. 4.7%; X2(1)

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1341 surveys sent to participants of randomized trial

31 returned for incorrect address

19 sent to dead/demented patients

Non responders (49.3% N=637/1291) 52 returned with no data (opt-outs) 585 never returned

654 returned with some survey data (50.7%) Exclude surveys with <75% complete (70 PCAS and 30 PAM)

584 with completed PCAS

624 with completed PAM

560 patient s with both PAM and PCAS complete 491 Non responders with adherence measure available 382 Non responders with 6 month BP available

528 patients with adherence available

400 patients with follow up 6 month BP available

Missing covariates 29 excluded (adherence analysis) 24 excluded (BP analysis) 499 PCAS and PAM responders included in adherence analysis 376 PCAS and PAM responders included in BP analysis

Fig. 1 Study ow and eligible patients included in each analysis

additional analyses we demonstrated that patient centered care remains associated with antihypertensive medication adherence (data not shown).

Primary outcome measure: BP control Follow-up BP measurements at 6 months were available for 400/560 (71.43%) responders (table 2). There was no relationship between increasing PCAS score and 6 month BP control (X2(3) P = 0.56). After adjusting for covariates (N = 376) there was no statistically signicant relationship between BP control and the PCAS (RR 1.85; 95% CI: 0.80, 6.42; P = 0.28 bootstrap 5,000 resamples) for highest quartile PCAS compared to lowest. To examine whether

medication adherence predicted BP control we performed an unadjusted logistic regression analysis predicting BP control for the subsample (N = 861) with both 6 month adherence and BP measures. With increasing medication adherence the odds of BP control also increased (Logistic regression X2(1) OR 1.52; 95% CI: 1.04, 2.24; P = 0.03).

Sensitivity analysis Our denition assigns patients as adherent if they have at least 1 antihypertensive pill for 80% of the medication eligible days. Our sensitivity analysis varied the denition of adherence. The signicant association between adherence and PCAS was robust to the cutoff choice. While 80%

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J Behav Med (2011) 34:244253 Table 1 Characteristics of responders included in adherence analysis N = 499 M (SD) Age Male gender White race Location of carea Teaching hospital Community based clinic Primary care provider type Staff Physician (N = 68 providers) Resident Physician (N = 12 providers) Non Physician Clinician (N = 33 providers) Source of Hypertension treatmentb VA care only Non VA care only Combination VA and Non VA care Diabetes Hyperlipidemia Baseline Antihypertensives prescribedc 1 Antihypertensive medication 2 Antihypertensive medications C 3 Antihypertensive medications Baseline adherence [ 0.8 Baseline BP controlled Education C 12th grade Years of hypertension B1 25 610 1115 1620 [ 20
a

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Count (%)

66.75 (11.06) 489 (98.00) 454 (90.98) 169 (33.87) 286 (57.31) 310 (62.12) 21 (4.21) 168 (33.67)

361 (72.34) 10 (2.00) 94 (18.84) 38 (7.62) 246 (49.30) 345 (69.14) 99 (19.84) 13 (2.60) 336 (67.33) 356 (71.34) 387 (77.56) 37 (7.41) 188 (37.68) 114 (22.85) 65 (13.03) 38 (7.62) 57 (11.42)

All providers were primary care providers: 44 persons missing Location of primary care 34 persons reported no treatment or did not answer question 42 persons had no antihypertensive or only furosemide prescribed

b c

is often reported in the literature, any cutoff between 55 and 91% would have yielded the same conclusions.

Discussion Our ndings show an association between perceived patient-centered primary care, particularly providers communication skills, and patient antihypertensive medication adherence behavior. Patients reporting the lowest patientcentered primary care scores had the lowest adherence

scores. Our results also conrm a relationship between medication adherence and blood pressure control; the greater the adherence, the better the control. Our analysis, however, was unable to demonstrate a relationship between patient centered care and blood pressure control outcomes. Several studies establish the connection between a strong patient-physician relationship and medication adherence (Inui et al. 1976; Piette et al. 2005; Roberts 2002; Schneider et al. 2004; Wroth and Pathman 2006). A study of patients with HIV tested six patient centered care scales (communication, HIV-specic information, participatory decision making, satisfaction, willingness to recommend physician, and trust). Scores on these scales were compared to self reported adherence. In four domains-communication, satisfaction, willingness to recommend and trustthere was a strong association with adherence (Schneider et al. 2004). Finally, in a study of 752 patients with diabetes, information giving and collaborative decision making were associated with better medication adherence, diet, exercise and self management behaviors (Piette et al. 2003). The shift in patterns of disease toward chronic illness necessitates greater patient participation in disease management but also requires the provider to engage in education and collaborative decision making (Bodenheimer 2007; Roter and Hall 1991). A survey of patients and physicians asked each group to rate domains of outpatient care (Laine et al. 1996). Both groups agreed that the most important element was clinical skills; however, they disagreed on the relative importance of effective information communication. Patients ranked provision of information second in importance whereas physicians ranked it sixth. Few potentially modiable determinants of medication adherence have emerged and most have targeted a variety of potentially important factors, each with a small contribution such as, simplifying dose regimens, patient medication understanding, motivation and self efcacy, components of patients drug-taking behavior such as organization of medications (pillboxes) or behavioral cues (alarms) and cost (waiving co-payments) (DiMatteo 2004; DiMatteo et al. 2002; Gregoire et al. 2002; Zolnierek and Dimatteo 2009). Results have been mixed, and these multifaceted complex programs are difcult to sustain in regular practice (Schroeder et al. 2004). The relationship between the provider and patient and the focus on communication skills is one in which there has been less research. However, two recent studies are of particular note. The rst was conducted in Canada where starting in 1992, all physicians had to complete the Medical Council of Canada national clinical skills examination (Tamblyn et al. 2010). The clinical skills examination assesses communication, history, and physical examination skills and clinical management by direct observation of physicians in 1820

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250 Table 2 Unadjusted relationship between PCAS measure with 6 month antihypertensive adherence or 6 month BP control N adherenta/N in quartile (%) total N = 528 PCAS Quartile 1 score [ 1 to B 3.0 PCAS Quartile 2 score C 3.01 to \ 3.65 PCAS Quartile 3 score C 3.65 to \ 4.22 PCAS Quartile 4 score C 4.22 Responders to PCAS and had an adherence measure available (N = 528) and responders to PCAS with6 month BP available (N = 400)
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N BP controlledb/N in quartile (%) total N = 400 47/88 (53.4) 52/107 (48.6) 58/100 (58.0) 53/105 (50.5)

83/132 (62.8) 97/131 (74.0) 95/131 (72.5) 106/134 (79.1)

Adherence dened as having antihypertensive medications available for at least 80% of medication eligible days

BP control dened as 6 month BP with Systolic \ 140 mmHg and Diastolic BP \ 90 mmHg

Estimated Proportion adherent 95% Confidence Intervals

Patient centered care score

Fig. 2 PCAS Score versus the estimated proportion adherent (black line) and 95% condence intervals (gray lines). Dashed line indicates 80% adherent to antihypertensive medications

standardized patients. Previous research has shown that lower exam scores predict complaints about poor communication and quality of care (Tamblyn et al. 2002, 2007). The investigators hypothesized that physicians who possess greater prociency in communication and/or medical management will achieve better medication adherence among their patients with hypertension. Within 6 months after starting treatment, 2,926 of the 13,205 newly diagnosed hypertensive patients discontinued antihypertensives. The risk of discontinuation was reduced for patients who were treated by physicians with better communication ability (OR 0.88; 95% CI 0.781.00) specically data collection skills.

A second important contribution in physician patient communication and the potential link to adherence was a meta-analysis published in 2009 (Zolnierek and Dimatteo 2009). The meta-analysis sought to address 2 questions. The rst, based on the patient centered care model, was is there a positive association between provider communication and patient adherence across studies? The second question was does physician training (in communication) have a positive effect on patient adherence? The rst question yielded 106 journal articles while the second only 21 studies. Among the 106 articles which were pooled to answer the question regarding the relationship between patient adherence and provider communication (all except 2 demonstrated a positive relationshipthat better communication was predictive of better adherence). Nonadherence was 1.47 times greater (standardized relative risk) among physicians who were poor communicators compared to good communicators. Among the 21 studies reporting patient adherence as an outcome of an intervention designed to train physicians in communication skills, all effects were positive (training in better communication skills was predictive of better patient adherence). The standardized relative risk of non adherence is 1.27 times greater among patients of untrained physicians. While communication is an important component of patient centered care; trust, knowledge of the patient, and interpersonal treatment appeared to also be important components within the PCAS, while system factors such as integration of care and organizational access surprisingly, appeared less important in their associations with medication adherence. We also postulated a high degree of patient activation, a measure similar to patient self efcacy would be associated with medication adherence (Bandura 1991). We found no relationship between high levels of activation and medication adherence; however, this was the rst time this measure has been used in the veteran population. In prior studies in a Medicare population (Hibbard et al. 2004, 2007) the PAM was associated with decreased healthcare utilization, better medication adherence and improved self management behaviors. Our negative ndings with the PAM may be due to multiple factors including our response rate and the administration to a veteran population in which this survey may not have performed as robustly as the population in which it was developed. Limitations to our study may have impacted our ndings. Non response is a common, well recognized limitation of survey methodology; our response rate of 50.7% is within expected range (Reijneveld and Stronks 1999). We suspect we also had non-response bias that is typically seen in surveys, including fewer responses from younger, healthier patients and nonwhites (Ives et al. 1994; Lasek et al. 1997; Solberg et al. 2002). We demonstrate that our responders differed from nonresponders in adherence and

medication adherence

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J Behav Med (2011) 34:244253 Table 3 Adjusted odds of adherence based on response to PCAS item for 499 respondents PCAS questions

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Adjusted OR of adherencea (95% CIs)

Physician patient interaction Communication How would you rate the thoroughness of your doctors questions about your symptoms and how you are feeling?b When you visit and talk with your provider how often do you leave with unanswered questions?c Interpersonal treatment How would you rate your providers caring and concern for you?d Knowledge of patient Doctors knowledge of what worries you most about your healthd Doctors knowledge of you as a person (your values and beliefs)d Trust I completely trust my providers judgments about my medical careb I would recommend this provider to my family and friendsb Thoroughness of physical exam How would you rate the thoroughness of the doctors physical examination of you to check your health problems?d Structural and organizational factors Visit based continuity When you are sick and go to the doctor, how often do you see your regular doctor (not an assistant or partner)?b Organizational access How would you rate the usual wait for an appointment when you are sick and call the doctors ofce asking to be seen?d How would you rate the ability to speak to your doctor by phone when you have a question or need medical advice?d When you phone your doctors ofce, how often are you able to get your concern addressed within 24 h?b Integration of care How often does your provider seem informed and up to date about the care you received from specialists that he/she sent you to?b How would you rate the coordination between other providers and your regular provider?d
a rd

3.74 (1.86, 7.49) 5.34 (1.24, 22.99) 1.92 (0.99, 3.73) 2.83 (1.59, 5.01) 1.75 (1.07, 2.87) 1.93 (1.04, 3.55) 1.66 (0.93, 2.99) 1.88 (0.96, 3.67)

0.81 (0.48, 1.35)

1.57 (0.97, 2.55) 1.43 (0.91, 2.25) 1.40 (0.86, 2.27)

1.04 (0.60, 1.77) 1.66 (0.93, 2.94)

Odds of adherence adjusted for PAM score (3 degree polynomial), patient age (3rd degree polynomial), self reported race, education, duration of hypertension (6 categories), use of VA care versus any private sector care and clustering by the provider (logistic regression model N = 499 patients in 113 groups (15 df)
b c

Patients who answered: often, usually or always are compared to those who answered never or sometimes

Reverse scoring item: Patients who answered this question as Never or sometimes are compared versus those who answered often usually or always d Patients who answered: good, very good or excellent are compared to those who answered poor or fair

in BP control, but we are uncertain if they differed in their perception of patient centered care because nonresponders did not complete the PCAS. Second, it is possible that the patients assessment of patient centered primary care is a global positive or negative patient attitude regarding medical care in general rather than an independent measure of their particular patient provider relationship. Our outcome measures, however, were objective, thereby reducing confounding. Third, nine persons included in the adherence analysis returned their survey after 8 weeks. At that time, medication lls may have already occurred. Therefore, for

a small number of patients (1.80%), a portion of the outcome assessment may have preceded exposure however, our sensitivity analysis determined alternative cut points for adherence and our results remained robust. Furthermore, our denition of adherence only takes into account prescription lling, not consumption. Finally, although we found positive relationships between PCAS and adherence and between adherence and BP control, we were unable to demonstrate an association between PCAS score and BP control. This could be due to multiple factors including reduced statistical power or variables other than adherence

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J Behav Med (2011) 34:244253 Journal of the American Medical Association, 298, 20482055. doi:10.1001/jama.298.16.jrr70000. Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002a). Patient self-management of chronic disease in primary care. Journal of the American Medical Association, 288, 24692475. Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002b). Improving primary care for patients with chronic illness. Journal of the American Medical Association, 288, 17751779. doi: 10.1001/jama.288.14.1775. Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002c). Improving primary care for patients with chronic illness: The chronic care model, Part 2. Journal of the American Medical Association, 288, 19091914. doi:10.1001/jama.288.15.1909. Cleary, P. D., Edgman-Levitan, S., Walker, J. D., Gerteis, M., & Delbanco, T. L. (1993). Using patient reports to improve medical care: A preliminary report from 10 hospitals. Quality Management in Health Care, 2, 3138. DiMatteo, M. R. (2004). Variations in patients adherence to medical recommendations: A quantitative review of 50 years of research. Medical Care, 42, 200209. DiMatteo, M. R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes: A meta-analysis. Medical Care, 40, 794811. Elliott, W. J., Plauschinat, C. A., Skrepnek, G. H., & Gause, D. (2007). Persistence, adherence, and risk of discontinuation associated with commonly prescribed antihypertensive drug monotherapies. Journal of the American Board of Family Medicine, 20, 7280. doi:10.3122/jabfm.2007.01.060094. Gandhi, T. K., Burstin, H. R., Cook, E. F., Puopolo, A. L., Haas, J. S., Brennan, T. A., et al. (2000). Drug complications in outpatients. Journal of General Internal Medicine, 15, 149154. doi: 10.1046/j.1525-1497.2000.04199.x. Gregoire, J. P., Moisan, J., Guibert, R., Ciampi, A., Milot, A., Gaudet, M., et al. (2002). Determinants of discontinuation of new courses of antihypertensive medications. Journal of Clinical Epidemiology, 55, 728735. doi:10.1016/S0895-4356(02)00400-6. Hess, L. M., Raebel, M. A., Conner, D. A., & Malone, D. C. (2006). Measurement of adherence in pharmacy administrative databases: A proposal for standard denitions and preferred measures. Annals of Pharmacotherapy, 40, 12801288. doi: 10.1345/aph.1H018. Hibbard, J. H. (2003). Engaging health care consumers to improve the quality of care. Medical Care, 41, I61I70. Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation result in improved self-management behaviors? Health Services Research, 42, 14431463. Hibbard, J. H., & Peters, E. (2003). Supporting informed consumer health care decisions: Data presentation approaches that facilitate the use of information in choice. Annual Review of Public Health, 24, 413433. Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39, 10051026. Holman, H., & Lorig, K. (2004). Patient self-management: A key to effectiveness and efciency in care of chronic disease. Public Health Reports, 119, 239243. Inui, T. S., Yourtee, E. L., & Williamson, J. W. (1976). Improved outcomes in hypertension after physician tutorials. A controlled trial. Annals of Internal Medicine, 84, 646651. Ives, D. G., Traven, N. D., Kuller, L. H., & Schulz, R. (1994). Selection bias and nonresponse to health promotion in older adults. Epidemiology, 5, 456461. Laine, C., Davidoff, F., Lewis, C. E., Nelson, E. C., Nelson, E., Kessler, R. C., et al. (1996). Important elements of outpatient

that are unrelated to patient centered care that could affect BP control. The goal of this research was to test the hypothesis that higher quality patient-provider relationships are predictors of better health behaviors and outcomes. Our results conrm this nding and suggest that the patient physician relationship, particularly enhanced communication skills, is potentially a point for interventions designed to increase adherence. Improving the providers communication skills could have an important impact on health outcomes in chronic diseases and deserves further investigation. Although we applied the PCAS to patients treated for hypertension, the questions are certainly not limited to this population. Further investigation is necessary to determine if patients who report high levels of patient centered care, particularly in the domain of communication have higher levels of adherence in other chronic diseases including diabetes and hyperlipidemia.
Acknowledgments This material is based upon work supported by the Veterans Affairs Clinical Research Center of Excellence and the Geriatric Research Education and Clinical Center Tennessee Valley Healthcare System, Nashville Tennessee. VA Career Development Transition Award 04-342-2. Conicts of interest There are no conicts of interest to disclose. The principal investigators and co-investigators had full access to the data and were responsible for the study protocol, statistical analysis plan, progress of the study, analysis, reporting of the study and the decision to publish.

References
Andrade, S. E., Kahler, K. H., Frech, F., & Chan, K. A. (2006). Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiology and Drug Safety, 15, 565574. doi:10.1002/pds.1230. Discussion 575567. Bagchi, A. D., Esposito, D., Kim, M., Verdier, J., & Bencio, D. (2007). Utilization of, and adherence to, drug therapy among medicaid beneciaries with congestive heart failure. Clinical Therapeutics, 29, 17711783. doi:10.1016/j.clinthera.2007.08. 015. Bandura, A. (1991). Self-efcacy mechanism in physiological activation and health-promoting behavior. In M. S. Madden & J. Barchas (Eds.), Adaption, learning and affect (pp. 226269). New York: Raven Press. Beatrice, D. F., Thomas, C. P., & Biles, B. (1998). Grant making with an impact: the picker/commonwealth patient-centered care program. Health Affairs (Millwood), 17, 236244. Bergeson, S. C., & Dean, J. D. (2006). A systems approach to patientcentered care. Journal of the American Medical Association, 296, 28482851. Bodenheimer, T. (2003). Interventions to improve chronic illness care: Evaluating their effectiveness. Disease Management, 6, 6371. Bodenheimer, T. (2007). A 63-year-old man with multiple cardiovascular risk factors and poor adherence to treatment plans.

123

J Behav Med (2011) 34:244253 care: a comparison of patients and physicians opinions. Annals of Internal Medicine, 125, 640645. Lasek, R. J., Barkley, W., Harper, D. L., & Rosenthal, G. E. (1997). An evaluation of the impact of nonresponse bias on patient satisfaction surveys. Medical Care, 35, 646652. Lewin, S. A., Skea, Z. C., Entwistle, V., Zwarenstein, M., & Dick, J. (2001). Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews, CD003267. doi:10.1002/14651858.CD003267. Lorig, K. R., Sobel, D. S., Stewart, A. L., Brown, B. W., Jr., Bandura, A., Ritter, P., et al. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37, 514. McDonnell, P. J., & Jacobs, M. R. (2002). Hospital admissions resulting from preventable adverse drug reactions. Annals of Pharmacotherapy, 36, 13311336. doi:10.1345/aph.1A333. Merz, C. N., Buse, J. B., Tuncer, D., & Twillman, G. B. (2002). Physician attitudes and practices and patient awareness of the cardiovascular complications of diabetes. Journal of the American College of Cardiology, 40, 18771881. Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487497. Piette, J. D., Heisler, M., Krein, S., & Kerr, E. A. (2005). The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Archives of Internal Medicine, 165, 17491755. Piette, J. D., Schillinger, D., Potter, M. B., & Heisler, M. (2003). Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. Journal of General Internal Medicine, 18, 624633. doi:10.1046/j.1525-1497.2003. 31968.x. Reijneveld, S. A., & Stronks, K. (1999). The impact of response bias on estimates of health care utilization in a metropolitan area: The use of administrative data. International Journal of Epidemiology, 28, 11341140. doi:10.1093/ije/28.6.1134. Roberts, K. J. (2002). Physician-patient relationships, patient satisfaction, and antiretroviral medication Adherence among HIVinfected adults attending a public health clinic. AIDS Patient Care and STDS, 16, 4350. doi:10.1089/108729102753429398. Roter, D. L., & Hall, J. A. (1991). Health education theory: An application to the process of patient-provider communication. Health Education and Research, 6, 185193. doi:10.1093/her/ 6.2.185. Rothman, A. A., & Wagner, E. H. (2003). Chronic illness management: What is the role of primary care? Annals of Internal Medicine, 138, 256261. Roumie, C. L., Elasy, T. A., Greevy, R., Grifn, M. R., Liu, X., Stone, W. J., et al. (2006). Improving blood pressure control through provider education, provider alerts, and patient education: A cluster randomized trial. Annals of Internal Medicine, 145, 165175. Safran, D. G., Kosinski, M., Tarlov, A. R., Rogers, W. H., Taira, D. H., Lieberman, N., et al. (1998). The primary care assessment survey: Tests of data quality and measurement performance. Medical Care, 36, 728739. Schiff, G. D., Fung, S., Speroff, T., & McNutt, R. A. (2003). Decompensated heart failure: symptoms, patterns of onset, and contributing factors. American Journal of Medicine, 114, 625630. doi:10.1016/S0002-9343(03)00132-3. Schneider, J., Kaplan, S. H., Greeneld, S., Li, W., & Wilson, I. B. (2004). Better physicianpatient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. Journal of General Internal Medicine, 19, 10961103. doi:10.1111/j.1525-1497.2004.30418.x.

253 Schroeder, K., Fahey, T., & Ebrahim, S. (2004). Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database of Systematic Reviews, CD004804. Shaller, D. (2007). Patient-centered care: What does it take? The Commonwealth Fund, 74. Retrieved from http://www.common wealthfund.org/publications/publications_show.htm?doc_id=55 9715 Solberg, L. I., Beth Plane, M., Brown, R. L., Underbakke, G., & McBride, P. E. (2002). Nonresponse bias: Does it affect measurement of clinician behavior? Medical Care, 40, 347352. Steiner, J. F., Koepsell, T. D., Fihn, S. D., & Inui, T. S. (1988). A general method of compliance assessment using centralized pharmacy records. Description and validation. Medical Care, 26, 814823. Steiner, J. F., & Prochazka, A. V. (1997). The assessment of rell compliance using pharmacy records: Methods, validity, and applications. Journal of Clinical Epidemiology, 50, 105116. doi:10.1016/S0895-4356(96)00268-5. Steiner, J. F., Robbins, L. J., Roth, S. C., & Hammond, W. S. (1993). The effect of prescription size on acquisition of maintenance medications. Journal of General Internal Medicine, 8, 306310. doi:10.1007/BF02600143. Tamblyn, R., Abrahamowicz, M., Dauphinee, W. D., Hanley, J. A., Norcini, J., Girard, N., et al. (2002). Association between licensure examination scores and practice in primary care. Journal of the American Medical Association, 288, 30193026. doi:10.1001/jama.288.23.3019. Tamblyn, R., Abrahamowicz, M., Dauphinee, D., Wenghofer, E., Jacques, A., Klass, D., et al. (2007). Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. Journal of the American Medical Association, 298, 9931001. doi:10.1001/jama.298.9.993. Tamblyn, R., Abrahamowicz, M., Dauphinee, D., Wenghofer, E., Jacques, A., Klass, D., et al. (2010). Inuence of physicians management and communication ability on patients persistence with antihypertensive medication. Archives of Internal Medicine, 170, 10641072. Wagner, E. H. (2004). Chronic disease care. British Medical Journal, 328, 177178. doi:10.1136/bmj.328.7433.177. Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001a). Improving chronic illness care: Translating evidence into action. Health Affairs (Millwood), 20, 6478. Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Quarterly, 74, 511544. Wagner, E. H., & Groves, T. (2002). Care for chronic diseases. British Medical Journal, 325, 913914. doi:10.1136/bmj.325. 7370.913. Wagner, T. H., Hu, T. W., & Hibbard, J. H. (2001b). The demand for consumer health information. Journal of Health Economics, 20, 10591075. doi:10.1016/S0167-6296(01)00107-2. Wroth, T. H., & Pathman, D. E. (2006). Primary medication adherence in a rural population: The role of the patient-physician relationship and satisfaction with care. Journal of the American Board of Family Medicine, 19, 478486. Yang, M., Barner, J. C., & Worchel, J. (2007). Factors related to antipsychotic oversupply among Central Texas Veterans. Clinical Therapeutics, 29, 12141225. doi:10.1016/j.clinthera.2007. 06.013. Zolnierek, K. B., & Dimatteo, M. R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826834. doi:10.1097/MLR.0b013e31 819a5acc.

123

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