Annals of Family Medicine -- Comments for Kerse et al., 2 (5) 455-461

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Original Research:
Ngaire Kerse, Stephen Buetow, Arch G. Mainous, III, Gregory Young, Gregor Coster, and Bruce Arroll
Physician-Patient Relationship and Medication Compliance: A Primary Care Investigation
Ann Fam Med 2004; 2: 455-461 [Abstract] [Full text] [PDF]

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Electronic letters published:

Data needed on patient-provider relationships and long-term adherence in chronic illness: James E. Aikens (10 October 2004)

Data needed on patient-provider relationships and long-term adherence in chronic illness 10 October 2004

James E. Aikens,
Ann Arbor, United States of America
Assistant Professor of Family Medicine and Psychiatry, Univ. of Michigan
Send response to journal:
Re: Data needed on patient-provider relationships and long-term adherence in chronic illness

Kerse et al. present their original and important work on patient- provider relationships and medication adherence. Because the patient-provider relationship is so potentially complex and difficult to model, the investigators are to be commended for their thoughtful selection of multiple measures, which also allowed them to identify the relationship feature that best accounts for subsequent medication adherence. The sample was large and representative, and followup attrition was fairly low. The implication of their findings is that interventions to enhance short-term medication adherence might target patients who report that their provider disagrees or does not understand the patient’s perspective on the nature of the presenting problem.
And yet, before the findings can guide intervention design, it will be important clarify the meaning of concordance… Did patients actively disagree with their provider, or vise-versa, or both? Does a patient’s “feeling misunderstood” correlate with actual within-encounter behavior patterns? Who is responsible for the misunderstanding: the patient, the provider, the healthcare system, or some other entity? Could feeling misunderstood actually be a proxy for generalized distress? Or perhaps correlate with drug- seeking, secondary gain, or some other inappropriate use of services? Which of these many factors are operating, and which are appropriate for intervention?
Another issue is that readers should bear in mind that 4-day adherence to an diverse set of acute regimens has very different determinants than long term adherence to a chronic disease regimen. Adherence even varies widely between chronic diseases (due to differences in illness severity and illness meanings) and regimens for a given chronic disease (due to differences in regimen-specific barriers like side effects). One of the best-known adherence predictors is symptom severity, which was beyond the study focus. It is even possible that the discordance was about the severity of presenting symptoms.
Finally, I wonder whether the prediction model might vary whether the actual patient was an independent adult that was seeking his or her own care, versus a child or non-autonomous adult.
James E. Aikens, Ph.D.
Competing interests: None declared