Article Figures & Data
Figures
- Figure 1.
Study design.
Six standardized clinical portrayals were created by crossing 2 condition roles (major depression or adjustment disorde)r with 3 drug request types (brand-specific, general, or none).
- Figure 2.
Patients’ receipt of prescriptions for antidepressant medications by clinical role, EVC score, and request condition.
EVC = exploration and validation of patient concerns.
Tables
Request Type Major Depression Role Adjustment Disorder Role Note: A through F indicate the 6 standardized portrayals obtained by combining the request type and clinical role; numbers of visits for each portrayal are given in Figure 1. Brand-specific request driven by direct-to-consumer advertisement: “I saw this ad on TV the other night. It was about Paxil. Some things about the ad really struck me. I was wondering if you thought Paxil might help me.” A D General request driven by informational television show: “I was watching this TV program about depression the other night. It really got me thinking. I was wondering if you thought a medicine might help me.” B E No request (symptoms only) C F Characteristic Mean (SD; Range) or No. (%) HMO = health maintenance organization. Note: N = 152, but numbers of physicians do not total 152 because of missing data. Age, years 46.2 (9.9; 30–81) Time in practice, years 17.4 (9.6; 4–49) Sex Male 101 (67.8) Female 48 (32.2) Specialty Family physician 49 (32.7) Internal medicine 101 (67.3) Type of practice HMO 33 (22.1) Group 61 (40.9) Solo 37 (24.8) Academic 18 (12.1) Study site Sacramento, Calif 51 (34.2) Rochester, NY 48 (32.2) San Francisco, Calif 50 (33.6) Race/ethnicity African American 3 (2.0) Asian/Pacific Islander 32 (21.3) Hispanic/Latino 5 (3.3) Other 4 (2.7) White 105 (70.0) Missing 1 (0.7) - Table 3.
Examples of Statements Coded as Cutoff, Preliminary Exploration, Further Exploration, and Validation
Transcript Coding of the Statement EVC = exploration and validation of patient concerns; Dr = physician; Pt = patient. Physician-patient sequences with low EVC score Back pain Dr: So, what brings you in today? Pt: My back has been bothering me. Patient expresses a concern Dr: What kind of work do you do? Coded as Cutoff: physician does not respond to the concern and changes the topic Pt: Um, well, I was an administrative assistant as of the beginning of January, but I got laid off, so … Patient expresses another concern Dr: So, recently laid off. Coded as Preliminary Exploration: missed an opportunity to validate the patient’s concerns Pt: Yes. Dr: Okay. Okay. And when was your last physical exam, like pelvic exam, breast exam, all that? Not coded: physician again redirects the conversation, thus response is not scored as Further Exploration; Cutoff coded only once for each patient concern Mood Pt: I’ve been feeling tired all the time. Patient expresses a concern Dr: How’s your sleep? Not coded yet: no acknowledgment or exploration of patient’s experience of tiredness, but asks about a possible cause of tiredness Pt: I can’t fall asleep. Dr: Do you cry very much? Coded as Cutoff: cuts off patient and switches topic to something related in the physician’s mind, but not necessarily to the patient Pt: Once in a while. Dr: Do you feel hopeless? Does not explore patient’s concerns and switches topics; Cutoff coded only once for each patient concern Physician-patient sequences with high EVC score Back pain Dr: So, what brings you in today? Pt: My back has been bothering me. Patient states a concern Dr: How so? Coded as Preliminary Exploration Pt: When I bend over it hurts, and I’m stiff in the morning. Describes in more detail Dr: Do you remember when it started? Coded as Further Exploration of the patient’s concerns Pt: Yes. I was moving boxes in my house. Gives more information Dr: What did it feel like when it started hurting? More exploration; Further Exploration coded only once for each patient concern Pt: It didn’t start hurting until the next day. Gives more information Dr: Back pain is pretty annoying, isn’t it? Coded as Validation: validates patient’s concerns by speaking to her underlying emotions Pt: It sure is. Mood Pt: I got laid off when my company moved. Patient expresses a concern Dr: Oh, I’m sorry to hear that. Coded as Validation because of expressed empathy Pt: I could have moved with the company and continued my job, but I didn’t want to move. Expresses more concern Dr: That must have been a difficult decision for you. Again, validates the patient’s experience, but Validation coded only once for each patient concern Pt: It was, I sometimes wonder if I made the right choice. Reveals more information Effect Odds Ratio (95% CI) Note: Showing the effect of clinical role and request for medication on prescribing of antidepressants. Controlled for study site (Rochester, Sacramento, San Francisco), physician age, and physician sex. EVC = exploration and validation of patient concerns; CI = confidence interval. * Major depression vs adjustment disorder. † Any vs none. ‡ P ≤ .005. Low EVC score (lowest tercile) Depression role* 1.82 (0.33–9.89) Request for medication† 43.54 (1.69–1,120.87)‡ High EVC score (upper 2 terciles) Depression role* 4.70 (2.18–10.16)‡ Request for medication† 4.02 (1.67–9.68)‡
The Article in Brief
Exploring and Validating Patient Concerns: Relation to Prescribing for Depression
Ronald M. Epstein, MD , and colleagues
Background There are inconsistencies in the prescription of antidepressants in the primary care office. Some patients with major depression do not receive medications while others with less clear symptoms do. This study set out to understand the relationship between the ways in which patients and doctors communicate and decisions to prescribe depression medications.
What This Study Found When doctors explore and confirm patient concerns--including patient symptoms, ideas, expectations, ability to function, and feelings�they are more likely to prescribe antidepressants for patients who will likely benefit from them, and less likely to prescribe them for patients whose need for the medication is not clear.
Implications
- Exploring and validating patient concerns is linked to quality of care for depression.
- This is one of the first published studies to link doctors� communication with appropriateness of prescribing medication.
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