Psychosocial
Abstract 1487/158: Comparison between Patients' and Physicians' Perceptions of Patient Adherence to Therapy for Rheumatic Disease
Authors: Araceli Garcia-Gonzalez1, Marsha Richardson1, Aimee Kendall-Roundthree1, Michael A. Kallen1, Vanessa Cox1, Namieta Janssen1, Donald M. Marcus1, John D. Reveille2, Noranna Warner2, Maria E. Suarez-Almazor1. 1Baylor College of Medicine, Houston, TX; 2University of
Purpose: Treatment adherence is a major issue in chronic disease, often not well recognized by physicians. The purpose of this study was to compare patients’ and physicians’ perceptions of adherence to therapy in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).
Methods: Patients with RA or SLE from publicly funded clinics were surveyed about how often they missed taking their medication(s) (often, sometimes, rarely and never). At the end of the consult, each patient’s physician was asked how often they thought the patient seen missed medications (often to never). Responses for each Dr-pt dyad were classified as agreement if the response was identical or 1-point away, or disagreement if the responses were separated by 2 or more points. We also recorded demographic data, previously validated scales measuring patients’ perception of involvement in care (PICS), trust in physician, and visual analogue scales (VAS) measuring self-perceived global health, pain and disease activity.
Results: 278 patients were included in the study; 175 had RA, and 103 had SLE. Mean age was 46 years old. Patients were mostly female (82%) and of minority groups (35% African-American (AA), 47% Hispanic (H), 16% White (W) and 2% other). 37% had not completed high school and 39% had an income <$10,000. Mean disease duration was 7± 5 years. 36% of patients and 41% of physicians reported that the patients never missed medications. However, agreement between doctors and patients was low, with a weighted kappa of 0.20. Perfect agreement was observed in 44% of the dyads.
We examined potential differences between agreement and disagreement dyads (within 1-point difference). No differences were observed in patients’ gender, age, or doctor-patient communication scales. However, significant differences were observed across ethnic groups. Physicians were more likely to disagree with patients if the patient was AA (19%), than if the patient was H (9%) or W (7%) (p=0.04): 12% of AA patients reported that they sometimes or often missed medications, while physicians reported that 29% of their AA patients missed medications sometimes or often. Significant associations were also observed between self-perceived health status: physicians were more likely to disagree with patients who had lower self-reported health status.
Conclusions: Patients with RA and SLE and their physicians may have different perceptions about patients’ adherence to therapeutic recommendations. Disagreement is more prominent in AA patients, suggesting that doctor-patient communication about adherence is not as effective in this ethnic group.
Editorial note: This is an interesting study that adds to growing understanding of the discordance between patients and providers assessments of adherence. Adherence is a major concern. The World Health Organization (WHO) recently stated that 'poor adherence to treatment of chronic diseases is a worldwide problem of striking magnitude.’ Across all chronic diseases, nearly half of patients fail to fill their prescriptions or use sufficient amounts of their medicines to achieve therapeutic benefits.
Several decades of adherence research have convincingly demonstrated that self-reports of adherence are unreliable. When asked about medication use, patients generally overestimate adherence, often significantly. Providers often develop their own rating of the degree to which patients are adherent; however provider estimates also consistently underestimate the degree of nonadherence. Reasons for this include reliance on treatment outcomes for estimating adherence and positive bias such as wanting to believe patients are adherent. However, this study which focuses on concordance between patients and providers in adherence ratings, suggest that race and the patient’s health perceptions may also influence provider ratings.
Consequences of non-adherence include suboptimal disease management, increased health care costs and utilization, unnecessary escalation of therapy and use of highly expensive drugs and compromised data from clinical trials. Electronic monitoring has become the gold standard for assessing adherence in clinical trials. In clinical practice, use of electronic monitoring is less common. However, several strategies have shown promise in improving adherence. A good beginning is for providers to recognize that given the prevalence of nonadherence, one should never assume that perceptions or reports of patient adherence are reliable. Rather, it may be safer to assume there is likely to be some level of difficulty with adherence and incorporate discussions about medication use into routine visits. For example, an opening statement such as “Many patients have difficulty taking their medication on a regular basis. Have you had any difficulty in taking ______?” can creates a non-judgemental atmosphere that can facilitate the patient’s disclosure of adherence difficulties. Once adherence difficulties are disclosed, solutions to overcoming barriers often become apparent.