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Table 1. 
Patient and Physician Characteristics*
Patient and Physician Characteristics*
Table 2. 
Physician MCI Scores by Medication Class, Physician Specialty, and Medication Type
Physician MCI Scores by Medication Class, Physician Specialty, and Medication Type
Table 3. 
Examples of the Range of Statements Satisfying MCI Categories
Examples of the Range of Statements Satisfying MCI Categories
Table 4. 
Multivariate Model Predicting the MCI, Including Medication, Patient, and Physician Characteristics as Independent Variables*
Multivariate Model Predicting the MCI, Including Medication, Patient, and Physician Characteristics as Independent Variables*
1.
National Center on Health Statistics, 2004 With Chartbook on Trends in the Health of Americans.  Hyattsville, Md National Center on Health Statistics2004;
2.
Osterberg  LBlaschke  T Adherence to medication. N Engl J Med 2005;353487- 497
PubMedArticle
3.
Hughes  CM Medication non-adherence in the elderly: how big is the problem? Drugs Aging 2004;21793- 811
PubMedArticle
4.
SHEP Cooperative Research Group, Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;2653255- 3264
PubMedArticle
5.
Stewart  WCChorak  RPHunt  HHSethuraman  G Factors associated with visual loss in patients with advanced glaucomatous changes in the optic nerve head. Am J Ophthalmol 1993;116176- 181
PubMed
6.
Urquhart  J Patient non-compliance with drug regimens: measurement, clinical correlates, economic impact. Eur Heart J 1996;17 ((suppl A)) 8- 15Article
7.
Kaplan  NM Cardiovascular risk reduction: the role of antihypertensive treatment. Am J Med 1991;9019S- 20S
PubMedArticle
8.
Schiff  GDFung  SSperoff  TMcNutt  RA Decompensated heart failure: symptoms, patterns of onset, and contributing factors. Am J Med 2003;114625- 630
PubMedArticle
9.
Sokol  MCMcGuigan  KAVerbrugge  RREpstein  RS Impact of medication adherence on hospitalization risk and healthcare cost. Med Care 2005;43521- 530
PubMedArticle
10.
Col  NFanale  JEKronholm  P The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990;150841- 845
PubMedArticle
11.
McDonnell  PJJacobs  MR Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother 2002;361331- 1336
PubMedArticle
12.
Chan  MNicklason  FVial  JH Adverse drug events as a cause of hospital admission in the elderly. Intern Med J 2001;31199- 205
PubMedArticle
13.
Muhlhauser  ISawicki  PTDidjurgeit  UJorgens  VTrampisch  HJBerger  M Evaluation of a structured treatment and teaching programme on hypertension in general practice. Clin Exp Hypertens 1993;15125- 142
PubMedArticle
14.
Senst  BLAchusim  LEGenest  RP  et al.  Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health Syst Pharm 2001;581126- 1132
PubMed
15.
Kaiser Commonwealth/Tufts-New England Medical Center, National Survey of Seniors and Prescription Drugs.  Boston, Mass Kaiser Commonwealth/Tufts-New England Medical Center2003;
16.
Schneider  JKaplan  SHGreenfield  SLi  WWilson  IB Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med 2004;191096- 1103
PubMedArticle
17.
Falvo  DWoehlke  PDeichmann  J Relationship of physician behavior to patient compliance. Patient Couns Health Educ 1980;2185- 188
PubMedArticle
18.
Hulka  BSCassel  JCKupper  LLBurdette  JA Communication, compliance, and concordance between physicians and patients with prescribed medications. Am J Public Health 1976;66847- 853
PubMedArticle
19.
Roter  DLHall  JAMerisca  RNordstrom  BCretin  DSvarstad  B Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care 1998;361138- 1161
PubMedArticle
20.
Quick Tips—When Getting a Prescription, Rockville, Md: Agency for Healthcare Research and Quality; May 2002. AHRQ publication 01-0040c. http://www.ahrq.gov/consumer/quicktips/tipprescrip.htm. Accessed September 3, 2005
21.
 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet  Rockville, Md Agency for Healthcare Research and Quality February2000;AHRQ publication 00-PO38. http://www.ahrq.gov/consumer/20tips.htm. Accessed September 3, 2005
22.
Knight  ELAvorn  J Quality indicators for appropriate medication use in vulnerable elders. Ann Intern Med 2001;135703- 710
PubMedArticle
23.
Morris  LA A survey of patients' receipt of prescription drug information. Med Care 1982;20596- 605
PubMedArticle
24.
Morris  LATabak  ERGondek  K Counseling patients about prescribed medication: 12-year trends. Med Care 1997;35996- 1007
PubMedArticle
25.
Morris  LAGrossman  RBarkdoll  GLGordon  ESoviero  C A survey of patient sources of prescription drug information. Am J Public Health 1984;741161- 1162
PubMedArticle
26.
Stewart  JEMartin  JL Correlates of patients' perceived and real knowledge of prescription directions. Contemp Pharm Pract 1979;2144- 148
PubMed
27.
Svarstad  BL Physician-patient communication and patient conformity with medical advice. Mechanic  DedThe Growth of Bureaucratic Medicine An Inquiry Into the Dynamics of Patient Behavior and the Organization of Medical Care. New York, NY John Wiley & Sons1976;220- 238
28.
Cockburn  JReid  ALSanson-Fisher  RW The process and content of general-practice consultations that involve prescription of antibiotic agents. Med J Aust 1987;147321- 324
PubMed
29.
Makoul  GArntson  PSchofield  T Health promotion in primary care: physician-patient communication and decision making about prescription medications. Soc Sci Med 1995;411241- 1254
PubMedArticle
30.
Kravitz  RLBell  RAAzari  RKrupat  EKelly-Reif  SThom  D Request fulfillment in office practice: antecedents and relationship to outcomes. Med Care 2002;4038- 51
PubMedArticle
31.
Ware  J SF-36 health survey. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment. 2nd ed. Mahwah, NJ Lawrence Album1999;1227- 1246
32.
Stedman  TL Stedman's Medical Dictionary. 27th ed. Philadelphia, Pa Lippincott Williams & Wilkins2000;
33.
Scherwitz  LHennrikus  DYusim  SLester  JVallbona  C Physician communication to patients regarding medications. Patient Educ Couns 1985;7121- 136
PubMedArticle
34.
Svarstad  BL The Doctor-Patient Encounter: An Observational Study of Communication and Outcome.  Madison, University of Wisconsin1974;
35.
Strong  PM The Ceremonial Order of the Clinic: Parents, Doctors, and Medical Bureaucracies.  London, England Routledge & Kegan Paul1979;
36.
Glaser  BGStrauss  AL The Discovery of Grounded Theory: Strategies for Qualitative Research.  Chicago, Ill Aldine1967;
37.
Tarn  DM What Do Doctors Communicate When Prescribing New Medications? [doctoral dissertation]. Los Angeles University of California, Los Angeles2006;
38.
Garvin  BJKennedy  CWCissna  KN Reliability in category coding systems. Nurs Res 1988;3752- 55
PubMedArticle
39.
Kravitz  RLBell  RAFranz  CE  et al.  Characterizing patient requests and physician responses in office practice. Health Serv Res 2002;37217- 238
PubMed
40.
Questions to Ask With a New Prescription Medicine, Bethesda, Md: National Council on Patient Information and Education; 2005. http://www.talkaboutrx.org/questions_new_prescrip2005.jsp. Accessed September 3, 2005
41.
Sleath  BRoter  DChewning  BSvarstad  B Asking questions about medication: analysis of physician-patient interactions and physician perceptions. Med Care 1999;371169- 1173
PubMedArticle
42.
Nair  KDolovich  LCassels  A  et al.  What patients want to know about their medications: focus group study of patient and clinician perspectives. Can Fam Physician 2002;48104- 110
PubMed
43.
Gardner  MERulien  NMcGhan  WFMead  RA A study of patients' perceived importance of medication information provided by physicians in a health maintenance organization. Drug Intell Clin Pharm 1988;22596- 598
PubMed
44.
Bailey  BJCarney  SLGillies  AHMcColm  LMSmith  AJTaylor  M Hypertension treatment compliance: what do patients want to know about their medications? Prog Cardiovasc Nurs 1997;1223- 28
PubMed
45.
Fletcher  SWFletcher  RHThomas  DCHamann  C Patients' understanding of prescribed drugs. J Community Health 1979;4183- 189
PubMedArticle
46.
Shi  CWAsch  SMFielder  EGelberg  LNichol  MB Consumer knowledge of over-the-counter phenazopyridine. Ann Fam Med 2004;2240- 244
PubMedArticle
47.
DiMatteo  MRSherbourne  CDHays  RD  et al.  Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol 1993;1293- 102
PubMedArticle
48.
Hall  JARoter  DLKatz  NR Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988;26657- 675
PubMedArticle
49.
Vermeire  EHearnshaw  HVan Royen  PDenekens  J Patient adherence to treatment: three decades of research: a comprehensive review. J Clin Pharm Ther 2001;26331- 342
PubMedArticle
50.
McGrath  JM Physicians' perspectives on communicating prescription drug information. Qual Health Res 1999;9731- 745
PubMedArticle
51.
Wiederholt  JBClarridge  BRSvarstad  BL Verbal consultation regarding prescription drugs: findings from a statewide study. Med Care 1992;30159- 173
PubMedArticle
52.
Mason  HLSvarstad  BL Medication counseling behaviors and attitudes of rural community pharmacists. Drug Intell Clin Pharm 1984;18409- 414
PubMed
53.
Beckman  AGParker  MGThorslund  M Can elderly people take their medicine? Patient Educ Couns 2005;59186- 191
PubMedArticle
Original Investigation
September 25, 2006

Physician Communication When Prescribing New Medications

Author Affiliations

Author Affiliations: Department of Family Medicine (Dr Tarn) and Division of General Internal Medicine and Health Services Research (Drs Hays and Wenger), David Geffen School of Medicine, University of California, Los Angeles; Department of Sociology, University of California, Los Angeles (Dr Heritage); and UC Davis Center for Health Services Research in Primary Care (Drs Paterniti and Kravitz) and Department of Sociology (Dr Paterniti), University of California–Davis Medical Center, Sacramento.

Arch Intern Med. 2006;166(17):1855-1862. doi:10.1001/archinte.166.17.1855
Abstract

Background  Communication about taking a new medication is critical to proper use of drug therapy and to patient adherence. Despite ample evidence that medications are not taken as prescribed, few investigations have detailed the elements of communication about new medication therapy. This article describes and assesses the quality of physician communication with patients about newly prescribed medications.

Methods  This was an observational study that combined patient and physician surveys with transcribed audiotaped office visits from 185 outpatient encounters with 16 family physicians, 18 internists, and 11 cardiologists in 2 Sacramento, Calif, health care systems between January and November 1999, in which 243 new medications were prescribed. We measured the quality of physician communication when prescribing new medications.

Results  Physicians stated the specific medication name for 74% of new prescriptions and explained the purpose of the medication for 87%. Adverse effects were addressed for 35% of medications and how long to take the medication for 34%. Physicians explicitly instructed 55% of patients about the number of tablets to take and explained the frequency or timing of dosing 58% of the time. Physicians fulfilled a mean of 3.1 of 5 expected elements of communication when initiating new prescriptions. They counseled the most about psychiatric medications, fulfilling a mean of 3.7, 3.5, and 3.4, pulmonary, and cardiovascular elements, respectively.

Conclusions  When initiating new medications, physicians often fail to communicate critical elements of medication use. This might contribute to misunderstandings about medication directions or necessity and, in turn, lead to patient failure to take medications as directed.

Medications are critical to treating and preventing disease. Medication use in the United States has risen from approximately 4 drugs prescribed per person from 1995 to 1996 to 5.2 drugs from 2001 to 2002.1 Almost half of all Americans take at least 1 prescription medication, and half of older patients take 3 or more medications.1

Although pharmaceuticals must be used properly to be effective, patients often do not use medications as prescribed.2,3 This misuse sometimes results in progression of disease and treatment failure.49 In addition, medication nonadherence can lead to adverse drug events, drug overdose or underuse, unnecessary hospitalizations1012 and prescriptions,13 and higher costs.9,14 Patients may not take new medications because of fear of interactions with other medications or adverse effects, perceived lack of efficacy, misunderstandings regarding necessity, or concerns about costs.15

Patients who report better general physician communication,16 better explanations about how to take their medications,17,18 and more medication information18 are more adherent. One-on-one educational interventions can improve patient adherence and health outcomes.19 In an effort to increase patient medication adherence and reduce medical errors, the Agency for Healthcare Research and Quality recommends that patients ask questions about their prescriptions to inform themselves about the following: the medication name, whether the medication is a trade or generic medication, medication purpose, how and when to take the medication, how long to take it, possible adverse effects and what to do if they occur, when to expect the medication to work and how to tell if it is working, and food, other medications, or dietary or herbal supplements to avoid when taking the medication prescribed.20,21 Similarly, quality indicators for vulnerable older patients specify that physicians who prescribe new medications should educate their patients about the medication's purpose, how and when to take it, and expected adverse effects and important adverse reactions.22 Education about these topics may reduce nonadherence that results from poor understanding about medication instructions.

It is unknown how well physician communication reflects counseling recommendations for prescribing new medications. Although survey studies suggest that physicians provide no verbal instructions for 19% to 39% of prescriptions23,24 and medication dosing directions for only 50% to 62% of prescriptions,2326 these studies are subject to deficits in patient recall. Studies that observed actual behavior showed physicians offering no instruction for 17% of prescriptions given in a community health center27 and for approximately one quarter of prescriptions for antibiotics.28 In addition, physicians discussed medication adverse effects less than one third of the time.28,29 Most of these studies did not address the individual components of medication instructions and did not compare counseling behaviors among medication types.

We assessed physician medication counseling in terms of important consensus panel–specified areas of communication.21,22 We calculated a Medication Communication Index (MCI), which measures the quality of physician communication about medications, and characterized variation according to medication class and physician specialty.

METHODS

We analyzed data from the Physician Patient Communication Project, a study of physician-patient interactions in 2 health care systems in Sacramento, Calif, which audiotaped outpatient visits to family physicians, internists, and cardiologists. Survey data were gathered from patients before their visit and from physicians before and immediately after the patient's visit. Study design details have been described previously.30 The University of California–Davis Institutional Review Board approved the overall study (992212), and the University of California–Los Angeles Institutional Review Board approved the analyses reported herein (exemption 04-193).

PHYSICIAN AND PATIENT SAMPLES

Twenty-two physicians were recruited from Kaiser Permanente and 23 from the University of California–Davis Medical Group. Sixteen family physicians, 18 internists, and 11 cardiologists participated; 1 family physician prescribed no new medications and was dropped from our sample. Physicians had a mean (SD) age of 44 (8.4) years and spent 87% of their time on patient care. All but 1 of the physicians was board certified, 71% were men, 89% were white, and 52% belonged to the University of California–Davis Medical Group.

Between January and November 1999, patients were randomly sampled from physician appointment books 1 to 2 days before anticipated office visits and telephoned by research assistants. Enrolled patients were English speaking and aged 18 years or older. All patients described a new or worsening medical problem or reported being “somewhat concerned” about their health or about having a potentially serious undiagnosed condition. Of 4560 patients selected for telephone contact, the response rate was 32%, and 909 (68%) of 1332 eligible patients were enrolled and provided informed consent.

NEWLY PRESCRIBED MEDICATIONS

Office visits were audiotaped and transcribed for 860 of the 909 participating patients. In the postvisit survey, physicians identified 270 visits in which new medications were prescribed. To verify the appropriateness of physician responses, we showed that in 90 randomly selected transcripts physicians correctly identified 24 of 25 encounters that involved a new prescription.

We defined a newly prescribed medication as a medication never before taken by the patient or a medication given for an acute symptom or condition (ie, an antibiotic or analgesic). A prescription in the same medication class as a previously prescribed medication was not considered a new medication. Medications that did not meet these criteria were excluded, leaving a total of 185 visits in which 243 new medications were prescribed.

MEASURES
Patient and Physician Characteristics

Patients provided information about demographic characteristics and prior visits to the physician seen. Patients also evaluated their physical functioning (α = .93) using the 36-Item Short-Form Health Survey physical functioning scale, version 1 (with 100 indicating maximum functioning).31 Physicians provided basic demographic information and characteristics of their practice.

Medication Characteristics

Medications were separated into medication classes according to their purpose. Over-the-counter (OTC) medications were defined as “medications sold over the counter.” If an OTC medication was recommended at prescription strength, it was classified as a non-OTC medication. Medications recommended by physicians to be taken on an as needed basis were classified as pro re nata (PRN).32 Absent a specific physician statement, a medication was classified as PRN if it was presumed acceptable for the patient to stop taking it on his or her own accord.

Qualitative Analysis

Based on previous literature28,33,34 and clinical experience, 2 coders (D.M.T. and J.H.) of different disciplines developed codes characterizing all communication about newly prescribed medications. Using analytic induction, coding categories were expanded, split, merged, and adjusted until they were mutually exclusive, yet incorporated every conversational element about new medications.35,36 These codes are described in detail elsewhere.37

One coder applied the codes to all 185 transcripts. A third coder independently coded 16% of the transcripts, achieving a mean κ score of 0.90 (range, 0.79-0.98). The most common source of inconsistency (81% of the disagreements) was caused by failure of coders to appropriately identify the specific statements for which a category was to be assigned.38,39 Discrepancies between coders were resolved by consensus. ATLAS TI 4.2 was used to manage and analyze the transcripts (Thomas Muhr, Scientific Software Development, Berlin, Germany).

Statistical Analysis

Each qualitative code was assigned a variable corresponding to a communication behavior. The variables formed a data set that contained information about new medication prescription communication, where the unit of analysis was the medication. Using Stata statistical software, version 8.0 (StataCorp, College Station, Tex), descriptive frequencies of major medication communication behaviors were calculated, overall, by medication characteristics and physician specialty.

Based on guidelines for communication about new medications,20,40 we created a Medication Communication Index (MCI) to assess the quality of physician communication about new prescriptions. The MCI is a 5-point index that gives points for physician communication about the following: medication name (1 point), purpose or justification for taking the medication (1 point), duration of use (1 point), adverse effects (1 point), number of tablets or sprays to be taken (0.5 point), and frequency or timing of medication ingestion (0.5 point). For dermatologic medications, a full point was given for discussing the frequency or timing of medication use, since it is difficult to quantify an amount of cream or lotion. Assigning 0.5 point to the number of tablets and frequency of medication use reflects “directions” carrying an equal weight relative to the other MCI components. The MCI was computed for each general medication class, OTC and PRN medication status, and physician specialty.

We performed bivariate analyses to assess the relationship between the MCI and patient, physician, and medication characteristics using t tests and analysis of variance, as appropriate, for continuous and categorical measures. Continuous variables included physician and patient age, physical functioning, measured visit length, and total number of new medications prescribed during the visit. Categorical variables included patient sex, race, educational achievement, and prior visits to the physician; physician sex, specialty, and site of practice; and medication class and OTC and PRN status.

All independent variables were included in a multiple linear regression model with the MCI score as the outcome variable. Since intraclass correlation estimates were small (<0.001) at the patient, physician, specialty, and site levels, we did not adjust for clustering. Model goodness of fit was evaluated using adjusted R2.

RESULTS

Forty-four physicians prescribed 244 new medications to 185 patients. Physicians prescribed a mean of 5.5 new medications (range, 1-17) and gave new prescriptions to a mean of 4.2 patients (range, 1-9). Forty-seven patients received more than 1 new prescription and 9 patients received 3 prescriptions or more.

Patients had a mean age of 55 years, half were male, most had at least some college education, and almost all had health insurance. Most were white, just more than half were Kaiser Permanente patients, and 75% had a prior visit to the physician who prescribed the new medication. Internists saw 47% of the patients; family physicians, 31%; and cardiologists, 23%. Patients receiving new medications had similar characteristics to the 909 patients in the full sample, except they were more likely to be male (Table 1). New medications included 46 cardiovascular medications; 42 ear, nose, and throat (ENT) preparations; 35 analgesics; 35 antibiotics; 21 dermatologic creams; 21 psychiatric medications; and 11 pulmonary medications.

Examining the individual components of the MCI, physicians described 97% of the new prescriptions but stated trade or generic names for 74%. Physicians stated the purpose of or justification for taking a medication for 87% of the prescriptions, duration of intake for 34%, the number of tablets or sprays for 55%, frequency or timing of intake for 58%, and adverse effects for 35% (Table 2). Table 3 presents examples of the range of statements that satisfied these communication categories.

Significant differences among the medication classes were found concerning education about medication name, duration of use, and adverse effects. Generic or trade names were stated for 95% of psychiatric medications but for only 54% of antibiotics. Education about duration of medication intake ranged from 17% for cardiovascular medications to 54% for antibiotics, whereas adverse effect counseling ranged from less than 15% for dermatologic preparations and antibiotics to more than 60% for psychiatric and cardiovascular medications. Directions concerning the number of tablets or sprays were addressed for 40% of antibiotics and more than 70% of psychiatric and pulmonary medications. Directions about frequency of medication ingestion ranged from 46% for antibiotics to more than 80% for psychiatric and pulmonary medications (Table 2).

Cardiologists specified the medication name and duration of intake less than primary care physicians but counseled their patients more frequently about adverse effects. Overall, physicians described the medication's generic or trade name more often for OTC medications than for non-OTC medications but conveyed less education about medication purpose or justification, frequency or timing, and adverse effects. Compared with medications prescribed on a regular basis, PRN medications were associated with less communication in all categories except for medication name and with significantly less conversation about frequency or timing of intake (Table 2).

The mean MCI score was 3.1 on a 5-point scale, indicating that 62% of necessary elements of new medication prescribing education were communicated. The MCI score differed significantly among medication classes, ranging from 2.7 for dermatologic preparations to 3.7 for psychiatric medications. There was no significant difference between specialists and primary care physicians or between medications taken regularly and those taken PRN. However, the MCI was higher for non-OTC (compared with OTC) medications.

In multivariate analysis with the MCI score as the outcome variable, psychiatric and analgesic medication prescriptions were associated with significantly higher communication scores than ENT preparations. For example, patients receiving psychiatric medications received nearly 1 additional element of counseling when compared with those receiving ENT prescriptions, largely because of better adverse effect counseling. Increased patient physical functioning at the time of the visit and non-OTC medication status also were associated with better communication. No significant associations were found between sex or patient or physician age and the quality of communication and no significant difference among medical specialties related to communication (Table 4).

COMMENT

This study demonstrates spotty physician counseling about new medication prescriptions. Although physicians educated patients more about psychiatric and analgesic medications, the overall quality of communication was poor even for these medication types and could contribute to patient misunderstandings about how and why to take their new medications. Physicians conveyed full medication dosing directions for less than 60% of all medications and informed patients about duration of intake and adverse effects or adverse events only approximately one third of the time. Although patients may seek information about their medications from a variety of sources, including pharmacists and medication package inserts, information offered by physicians is inadequate to meet patient needs. For example, patients not educated about the expected duration of medication use may not realize that medications given for chronic conditions need to be refilled. Furthermore, patients tend to be concerned about the adverse effects of a medication,4144 and adequate physician discussions could allay fears.

These findings suggest that patient reports of poor physician education concerning medication prescriptions2326,45 may not so much reflect lack of patient recall as missed opportunities for physician prescribing education. Communication is particularly sketchy when OTC medications are recommended. Although it might be argued that patients may not need as much instruction about OTC medication use, patients not understanding the indications for OTC medications may be unaware when to seek help if their condition is not improving.46 Similarly, education about PRN medications is important because patients not educated about the maximum number of tablets to take or about the frequency of dosing may be at risk for medication overdose. Patients also may not realize that use of PRN medications can be stopped in the absence of symptoms.

Psychiatric and analgesic medications, which have the potential for serious adverse effects or adverse reactions, were associated with more medication prescribing communication. Yet there remains room for improvement, even with these medications. Better physical functioning at the time of the visit was significantly associated with better communication. This finding is disconcerting, since patients with more serious or chronic diseases are likely to be following more complicated drug regimens and also may be in need of more intensive discussions about new prescriptions. No differences in the quality of communication about prescribed medications were found between cardiologists and primary care physicians, suggesting that the higher medication adherence rates of cardiologists' patients, when compared with patients of other physician specialties (found in a previous study47), may be because of factors other than differences in physician communication.

Patients receiving less counseling about their medications may be less likely to adhere to their prescribed regimen,34,48,49 in part because they may not understand how to take their medications. It was common for the physicians in our study to neglect giving specific directions about how to take medications. The following exchange is a physician's complete set of instructions to a patient about an antibiotic:

  • Physician: “If I'm writing antibiotics, are you allergic to penicillin?”

  • Patient: “No, I'm not allergic to anything.”

  • Physician: “Okey dokey.”

It is unclear what medication is being prescribed, and there was no instruction about how to take the medication or about potential adverse effects. Although physicians may expect pharmacists to provide patient education about medications,50 this may not always be the case.24,51,52 Lack of instructions might lead patients not to complete an antibiotic course and may be a particular problem for patients who have difficulty reading medication container labels.53

The deficits in medication prescribing noted in this analysis should be viewed in the context of several limitations. Findings may not be generalizable to patients in other settings. Since these data were collected, medication conversation may have shifted because of societal and insurance changes. The Hawthorne effect may have altered physician behavior during office visits, yet the presence of a tape recorder may have stimulated increased physician counseling. Computations of the MCI scores are conservative, since we required little clarity in communication for physicians to receive credit and counted vague statements as fulfilling communication categories. In addition, under circumstances when a medication is named by its functional purpose (eg, blood thinner), 2 of 5 points (name and purpose) on the MCI were conferred.

Unless it was explicitly mentioned during the office visit, we were unable to capture whether patients were given written information to supplement or replace verbal communication. Our findings do not capture environments where health care systems employ pharmacists or nurses to fully educate patients about new medications after physician visits. Yet even in such systems, it is unknown whether patient adherence or health outcomes are affected by the type of health care clinician discussing the new prescriptions.

This study provides evidence of suboptimal patient counseling about newly prescribed medications, especially about the duration of medication use and potential adverse effects. Patients not understanding these aspects of their new medications may discontinue taking medications unnecessarily. The MCI provides a means to assess the quality of physician communication about new prescriptions and might be used to measure the effect of interventions to improve prescribing communication. Efforts to promote better communication about new prescriptions should not focus solely on improving the quality of discussions without considering the tradeoffs that may occur in time-compressed visits. More research is needed to investigate how much time physicians spend educating patients about new medications and whether better communication is associated with more appropriate patient medication use and health outcomes.

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Article Information

Correspondence: Derjung M. Tarn, MD, PhD, Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, 10880 Wilshire Blvd, Suite 1800, Los Angeles, CA 90024 (dtarn@mednet.ucla.edu).

Accepted for Publication: June 8, 2006.

Financial Disclosure: None reported.

Funding/Support: Data used in this study were collected with support from the Robert Wood Johnson Foundation (grant 034384). Dr Tarn was a National Research Service Award fellow from 2002 to 2005 under training grant PE19001-09 from the Health Resources Services Administration. Dr Hays was supported in part by the UCLA/DREW Project EXPORT, National Institutes of Health, National Center on Minority Health & Health Disparities (P20-MD00148-01), and the UCLA Center for Health Improvement in Minority Elders/Resource Centers for Minority Aging Research, National Institutes of Health, National Institute of Aging (AG-02-004). Dr Kravitz was supported in part by a midcareer research and mentoring award from the National Institute of Mental Health (1K24MH072756-01).

Acknowledgment: We appreciate the collaboration of Honghu Liu, PhD, and the technical assistance of Victor Gonzalez.

References
1.
National Center on Health Statistics, 2004 With Chartbook on Trends in the Health of Americans.  Hyattsville, Md National Center on Health Statistics2004;
2.
Osterberg  LBlaschke  T Adherence to medication. N Engl J Med 2005;353487- 497
PubMedArticle
3.
Hughes  CM Medication non-adherence in the elderly: how big is the problem? Drugs Aging 2004;21793- 811
PubMedArticle
4.
SHEP Cooperative Research Group, Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;2653255- 3264
PubMedArticle
5.
Stewart  WCChorak  RPHunt  HHSethuraman  G Factors associated with visual loss in patients with advanced glaucomatous changes in the optic nerve head. Am J Ophthalmol 1993;116176- 181
PubMed
6.
Urquhart  J Patient non-compliance with drug regimens: measurement, clinical correlates, economic impact. Eur Heart J 1996;17 ((suppl A)) 8- 15Article
7.
Kaplan  NM Cardiovascular risk reduction: the role of antihypertensive treatment. Am J Med 1991;9019S- 20S
PubMedArticle
8.
Schiff  GDFung  SSperoff  TMcNutt  RA Decompensated heart failure: symptoms, patterns of onset, and contributing factors. Am J Med 2003;114625- 630
PubMedArticle
9.
Sokol  MCMcGuigan  KAVerbrugge  RREpstein  RS Impact of medication adherence on hospitalization risk and healthcare cost. Med Care 2005;43521- 530
PubMedArticle
10.
Col  NFanale  JEKronholm  P The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990;150841- 845
PubMedArticle
11.
McDonnell  PJJacobs  MR Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother 2002;361331- 1336
PubMedArticle
12.
Chan  MNicklason  FVial  JH Adverse drug events as a cause of hospital admission in the elderly. Intern Med J 2001;31199- 205
PubMedArticle
13.
Muhlhauser  ISawicki  PTDidjurgeit  UJorgens  VTrampisch  HJBerger  M Evaluation of a structured treatment and teaching programme on hypertension in general practice. Clin Exp Hypertens 1993;15125- 142
PubMedArticle
14.
Senst  BLAchusim  LEGenest  RP  et al.  Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health Syst Pharm 2001;581126- 1132
PubMed
15.
Kaiser Commonwealth/Tufts-New England Medical Center, National Survey of Seniors and Prescription Drugs.  Boston, Mass Kaiser Commonwealth/Tufts-New England Medical Center2003;
16.
Schneider  JKaplan  SHGreenfield  SLi  WWilson  IB Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med 2004;191096- 1103
PubMedArticle
17.
Falvo  DWoehlke  PDeichmann  J Relationship of physician behavior to patient compliance. Patient Couns Health Educ 1980;2185- 188
PubMedArticle
18.
Hulka  BSCassel  JCKupper  LLBurdette  JA Communication, compliance, and concordance between physicians and patients with prescribed medications. Am J Public Health 1976;66847- 853
PubMedArticle
19.
Roter  DLHall  JAMerisca  RNordstrom  BCretin  DSvarstad  B Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care 1998;361138- 1161
PubMedArticle
20.
Quick Tips—When Getting a Prescription, Rockville, Md: Agency for Healthcare Research and Quality; May 2002. AHRQ publication 01-0040c. http://www.ahrq.gov/consumer/quicktips/tipprescrip.htm. Accessed September 3, 2005
21.
 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet  Rockville, Md Agency for Healthcare Research and Quality February2000;AHRQ publication 00-PO38. http://www.ahrq.gov/consumer/20tips.htm. Accessed September 3, 2005
22.
Knight  ELAvorn  J Quality indicators for appropriate medication use in vulnerable elders. Ann Intern Med 2001;135703- 710
PubMedArticle
23.
Morris  LA A survey of patients' receipt of prescription drug information. Med Care 1982;20596- 605
PubMedArticle
24.
Morris  LATabak  ERGondek  K Counseling patients about prescribed medication: 12-year trends. Med Care 1997;35996- 1007
PubMedArticle
25.
Morris  LAGrossman  RBarkdoll  GLGordon  ESoviero  C A survey of patient sources of prescription drug information. Am J Public Health 1984;741161- 1162
PubMedArticle
26.
Stewart  JEMartin  JL Correlates of patients' perceived and real knowledge of prescription directions. Contemp Pharm Pract 1979;2144- 148
PubMed
27.
Svarstad  BL Physician-patient communication and patient conformity with medical advice. Mechanic  DedThe Growth of Bureaucratic Medicine An Inquiry Into the Dynamics of Patient Behavior and the Organization of Medical Care. New York, NY John Wiley & Sons1976;220- 238
28.
Cockburn  JReid  ALSanson-Fisher  RW The process and content of general-practice consultations that involve prescription of antibiotic agents. Med J Aust 1987;147321- 324
PubMed
29.
Makoul  GArntson  PSchofield  T Health promotion in primary care: physician-patient communication and decision making about prescription medications. Soc Sci Med 1995;411241- 1254
PubMedArticle
30.
Kravitz  RLBell  RAAzari  RKrupat  EKelly-Reif  SThom  D Request fulfillment in office practice: antecedents and relationship to outcomes. Med Care 2002;4038- 51
PubMedArticle
31.
Ware  J SF-36 health survey. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment. 2nd ed. Mahwah, NJ Lawrence Album1999;1227- 1246
32.
Stedman  TL Stedman's Medical Dictionary. 27th ed. Philadelphia, Pa Lippincott Williams & Wilkins2000;
33.
Scherwitz  LHennrikus  DYusim  SLester  JVallbona  C Physician communication to patients regarding medications. Patient Educ Couns 1985;7121- 136
PubMedArticle
34.
Svarstad  BL The Doctor-Patient Encounter: An Observational Study of Communication and Outcome.  Madison, University of Wisconsin1974;
35.
Strong  PM The Ceremonial Order of the Clinic: Parents, Doctors, and Medical Bureaucracies.  London, England Routledge & Kegan Paul1979;
36.
Glaser  BGStrauss  AL The Discovery of Grounded Theory: Strategies for Qualitative Research.  Chicago, Ill Aldine1967;
37.
Tarn  DM What Do Doctors Communicate When Prescribing New Medications? [doctoral dissertation]. Los Angeles University of California, Los Angeles2006;
38.
Garvin  BJKennedy  CWCissna  KN Reliability in category coding systems. Nurs Res 1988;3752- 55
PubMedArticle
39.
Kravitz  RLBell  RAFranz  CE  et al.  Characterizing patient requests and physician responses in office practice. Health Serv Res 2002;37217- 238
PubMed
40.
Questions to Ask With a New Prescription Medicine, Bethesda, Md: National Council on Patient Information and Education; 2005. http://www.talkaboutrx.org/questions_new_prescrip2005.jsp. Accessed September 3, 2005
41.
Sleath  BRoter  DChewning  BSvarstad  B Asking questions about medication: analysis of physician-patient interactions and physician perceptions. Med Care 1999;371169- 1173
PubMedArticle
42.
Nair  KDolovich  LCassels  A  et al.  What patients want to know about their medications: focus group study of patient and clinician perspectives. Can Fam Physician 2002;48104- 110
PubMed
43.
Gardner  MERulien  NMcGhan  WFMead  RA A study of patients' perceived importance of medication information provided by physicians in a health maintenance organization. Drug Intell Clin Pharm 1988;22596- 598
PubMed
44.
Bailey  BJCarney  SLGillies  AHMcColm  LMSmith  AJTaylor  M Hypertension treatment compliance: what do patients want to know about their medications? Prog Cardiovasc Nurs 1997;1223- 28
PubMed
45.
Fletcher  SWFletcher  RHThomas  DCHamann  C Patients' understanding of prescribed drugs. J Community Health 1979;4183- 189
PubMedArticle
46.
Shi  CWAsch  SMFielder  EGelberg  LNichol  MB Consumer knowledge of over-the-counter phenazopyridine. Ann Fam Med 2004;2240- 244
PubMedArticle
47.
DiMatteo  MRSherbourne  CDHays  RD  et al.  Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol 1993;1293- 102
PubMedArticle
48.
Hall  JARoter  DLKatz  NR Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988;26657- 675
PubMedArticle
49.
Vermeire  EHearnshaw  HVan Royen  PDenekens  J Patient adherence to treatment: three decades of research: a comprehensive review. J Clin Pharm Ther 2001;26331- 342
PubMedArticle
50.
McGrath  JM Physicians' perspectives on communicating prescription drug information. Qual Health Res 1999;9731- 745
PubMedArticle
51.
Wiederholt  JBClarridge  BRSvarstad  BL Verbal consultation regarding prescription drugs: findings from a statewide study. Med Care 1992;30159- 173
PubMedArticle
52.
Mason  HLSvarstad  BL Medication counseling behaviors and attitudes of rural community pharmacists. Drug Intell Clin Pharm 1984;18409- 414
PubMed
53.
Beckman  AGParker  MGThorslund  M Can elderly people take their medicine? Patient Educ Couns 2005;59186- 191
PubMedArticle
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