A Population Health Approach to Improving Medication Adherence

The American Journal of Accountable Care, September 2014, Volume 2, Issue 3

In this article, the author explores how accountable care organizations and other provider organizations can apply population health methods to physician populations to predict which physicians may unknowingly be promoting patient medication nonadherence based upon their patient communication and engagement skills. Training interventions for improving physician communications with patients are also discussed.

About the Adopt One! Challenge

The Adopt One! Challenge is a program that encourages physicians to adopt at least 1 new patient-centered communication skill per year. Adopt One! uses audio recordings of physician-patient examination room conversations to measure and evaluate physicians’ patient communication skills. The measures used by Adopt One! along with the skills training component are based upon widely recognized evidence-based best practices. The Adopt One! Challenge was developed by the author of this article, Stephen Wilkins.Population health management is an approach taken by accountable care organizations (ACOs) and other provider organizations to proactively manage the healthcare behavior of patient populations based upon predictable patterns of behavior. While this concept is generally associated with managing the clinical and financial risks associated with patients, the notion of predicting and intervening to mitigate risk can also be applied to physician populations. In this article, I explore how population health methods can be used to predict and intervene with physicians whose communications skills and “bedside manner” predispose them to promoting high levels of intentional medication nonadherence among patients.

The Link Between Medication Nonadherence and Physicians’ Communications Styles

• Disagreeing with the physician’s diagnosis necessitating the medication.

• Disagreeing with the physician’s assessment of the severity of the health problem necessitating the medication.

• Concerns about the safety and/or efficacy of the medication prescribed.

• Concerns about the cost of the medication.

Clinicians have long attributed nonadherence to a lack of patient commitment to their treatment plan. In recent years, however, research has indicated that such “lack of commitment” may actually be a rational response to something said or not said by the patient’s physician.1 Nonadherence may result, for example, from:

A 2003 report by the Boston Consulting Group revealed that an estimated 75% of all medication nonadherence is intentional2—that is, a conscious decision by the patient to not fill, pick up, or take a prescribed medication. Unintentional nonadherence, resulting from forgetfulness and other causes, accounts for the remaining 25%.

• 27% of preventable emergency department visits.3

• 33% to 69% of all medical hospital admissions.4

• 11% of all hospital readmissions.4

• In addition, the cost of treating nonadherent chronic disease patients is at least twice as high as that of treating adherent patients with the same conditions.4

The costs associated with medication nonadherence—no matter what its cause—are significant in terms of both impact on patient health outcomes utilization and costs. Medication nonadherence results in:

The contributing role of physician communications in patient medication adherence was stated plainly decades ago, in a 1990 report in which the Office of Inspector General (DHHS) speculated that “inadequate communication about medications accounts for up to 55% of medication nonadherence.”5 In fact, over the last 40 years, at least 106 studies have reported “strong, positive correlations” between physician communication and patient medication adherence.6 In a much-publicized 2005 meta-analysis of these studies, Zolnierek and DiMatteo stated that “Patients of physicians who communicate well are 19% more adherent than patients of physicians who do not communicate well.”

This “odds ratio” places “physician communications” squarely among other important predictors of medication adherence, including social support (patients who have it will, on average, have 3.6x higher adherence), emotional support (1.83x higher), depression (3.03x higher), and accurate perception of disease severity (2.5x higher).6

Medication Nonadherence Is Higher for Patients of Physicians Whose Communication Style Is Physician-Directed

Physicians engage in observable and measurable communication styles. Figure presents a continuum depicting the range of communication styles employed by physicians when talking with patients.

At one end of the continuum is the biomedical (disease-oriented) communication style, an undesirable style as characterized in Zolnierek and DiMatteo’s study. Physicians employing this style—also called physician-directed—focus on only obtaining the biomedical information they feel they need to arrive at a diagnosis and treatment. The patient’s “voice” is largely absent from the interaction. An estimated 75% of practicing physicians employ the biomedical communication style (presumably the one they learned in medical school), assuming the “expert” role, taking control of the visit, doing most of the talking, and making all decisions while the patient assumes what Roter, Hibbard, and others have referred to as the “passive sick role.”8,9

At the other end of the communication continuum is the psychosocial or patient-centered style. Physicians who communicate well use this style, according to Zolnierek and DiMatteo, resulting in high overall levels of patient medication adherence. These clinicians strike a balance, focusing enough but not solely on the patient’s medical condition and taking the person behind the medical complaint into consideration. The patient-centered communication style is characterized by a shared or collaborative approach to the visit; the physician actively invites the patient to share their agenda, “story,” illness perspectives, and concerns; to ask questions; and to participate in collaborative decision making.

Taking a Population Health Approach to Tackling Medication Nonadherence

The Adopt One! Challenge embodies a fresh approach to managing medication adherence. It begins with a sample of audio physician-patient recordings collected from every physician within the population. Using conversation analysis methods, each recording is transcribed; everything said by all parties is coded, measured, and evaluated using a set of evidence-based measures of patient-centered communications. The evidence-based communication measures used by Adopt One! are adapted from the Kalamazoo Consensus Statements and models such as the Four-Habit Model. The conversation analysis reveals where the physician’s patient communication style is on the physician-directed versus patient-centered continuum. Physicians with a physician-directed style are labeled as “high risk” for promoting intentional medication nonadherence among their patients; the opposite is true of physicians with a patient-centered style. The high-risk physicians would then participate in a tailored training intervention designed to develop their patient-centered communication skills. According to Zolnierek and DiMatteo, “training physicians in communication skills improves patient adherence by 12%...the odds of patient adherence are 1.62 times higher with training than when a physician receives no training.”6

After the training intervention is complete, new audio recording samples are collected, transcribed, and evaluated to assess the levels of change in the physicians’ patient communications style, and the associated nonadherence risk. The process can be repeated until the communication skills of the targeted population have improved to the desired patient-centered level.Author affiliations: Stephen Wilkins, MPH, is the founder of the Adopt One! Challenge.

Address correspondence to: Stephen Wilkins, 1154 Illiad Court, Ste 200, San Jose, CA 95118. E-mail: stwilkins@adoptonechallenge.com.1. Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25(4):284-290.

2. Lovish D, Lubkeman, M, Roeslund T. The Hidden Epidemic Finding a Cure for Unfilled Prescriptions and Missed Doses. 2003. Boston Consulting Group. https://www.bcgperspectives.com/content/articles/biopharma_hidden_epidemic.

3. Dragomir A, Côté R, Roy L, et al. Impact of adherence to antihypertensive agents on clinical outcomes and hospitalization costs. Med Care. 2010;48(5):418-425.

4. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43(6):521-530.

5. Feng B, Bell R. What do doctors say when prescribing medications? an examination of medical recommendations from A Communication perspective. Health Communication. 2011;26(3)286-296.

6. Zolnierek KB, DiMatteo, MR. (2010). Physician communication and patient adherence to treatment: a meta-analysis. 2010; 47(8);826-834. Medical Care.

7. Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997;277(4):350-356.

8. Roter D. The enduring and evolving nature of the patient — physician relationship. Patient Education and Counseling. 2000;39(1)5-15.

9. Hibbard JH. Using Systematic Measurement to Target Consumer Activation Strategies. Medical Care Research And Review, 66