Abstract: Pharmacist-Patient Communication about Medication Adherence: Patient-Centered Responses to Side-Effect Concerns

◆ Paul Denvir, Albany College of Pharmacy & Health Sciences
◆ Kyle Guiffre, Mercy Medical Center
◆ Nick Rehberg, Albany College of Pharmacy & Health Sciences

BACKGROUND: According to the CDC, medication non-adherence accounts for up to 69% of hospital re-admissions and costs the healthcare system up to $300 billion per year. Non-adherence results from a wide range of factors, including: 1) health systemic factors (E.g. insurance coverage) 2) medication-level factors (E.g. regimen complexity) and 3) patient-level factors (E.g. health literacy). As medication counseling experts, pharmacists have an important role to play in helping patients address barriers to adherence. Medication Therapy Management (MTM), a comprehensive patient-centered service model mandated by the 2003 Medicare Modernization Act, was designed to improve medication adherence among at-risk populations (multiple chronic conditions and/or complex medication regimens). The core of MTM is the comprehensive medication review (CMR), an in-depth pharmacist-patient consultation conducted in-person or telephonically. The goal of the CMR is to systematically discuss each medication to identify medication-related problems and collaboratively develop solutions. Health communication scholarship focused on provider-patient interaction is well positioned to work with pharmacy educators in interdisciplinary partnerships to identify and develop the specific communication competencies needed to provide this relatively novel MTM service.
RESEARCH PROBLEM: There has been very little empirical research on pharmacist-patient interaction during comprehensive medication reviews. Although MTM is described as patient-centered and collaborative, these are relatively abstract values that must be complemented by empirical research that identifies concrete communication practices for achieving patient-centeredness. Non-adherence can be an especially challenging topic to navigate. Patients express concern that reporting non-adherence may lead clinicians to label them a “bad patient,” leading to underreporting of adherence difficulties. These discussions can also surface sensitive bases for non-adherence, such as economic hardship or sexual side-effects. Pharmacists express concern about damaging rapport by appearing invasive or skeptical about patients’ medication behavior. The goal of this research is to identify concrete patient-centered communication practices that pharmacists can use when counseling patients about adherence.
METHODS: Data: Audio-recordings and transcriptions of 53 comprehensive medication reviews (approximately 45 minutes each). Participants: 53 patients and 15 pharmacists. Setting: Single MTM clinic operating within a fully accredited college of pharmacy in the northeastern US. Analytic Method: Qualitative and quantitative discourse analysis. Data were quantitatively coded for a variety of features, including types of non-adherence, patients’ reported reason(s) for non-adherence, and pharmacists’ response types. Data were qualitatively coded into thematic categories using Atlas.ti.
FINDINGS: Data analysis yielded 80 instances in which a patient reported non-adherence; there were 14 different types of non-adherence. Patients provided 16 different reasons for non-adherence grouped into 4 major categories (side-effects; knowledge/competence; medication beliefs; practical issues). Pharmacists provided 20 different response types grouped into 5 major categories (advocate adherence; empower self-management; educate; offer practical support; empathize). For this paper, qualitative discourse analysis was conducted on all side effect cases (N=14/80) and the 3 most common pharmacist response types (validate the concern; provide information; recommend consultation with other providers). Two patient-centered communication practices that emerged from this analysis are: 1) using terms like “understandable” to receipt a report of non-adherence and and 2) employing cost/benefit logic to explore medication behaviors.