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Original Investigation
February 11, 2013

Communication and Medication Refill Adherence: The Diabetes Study of Northern California

Author Affiliations

Author Affiliations: General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco (UCSF) (Drs Ratanawongsa, Lyles, and Schillinger); Division of Research, Kaiser Permanente, Oakland, California (Dr Karter, Mss Parker and Warton, and Mr Moffet); Department of Epidemiology, School of Public Health & Community Health, University of Washington, Seattle (Dr Karter); Center for Clinical Management Research, Health Services Research and Development (HRS&D) Center of Excellence, VA Ann Arbor Healthcare System, and Departments of Internal Medicine and Health Behavior and Health Education, University of Michigan, Ann Arbor (Dr Heisler); UCSF Center for Health and Community, San Francisco (Dr Adler); and California Diabetes Program, California Department of Public Health, Sacramento (Dr Schillinger).

JAMA Intern Med. 2013;173(3):210-218. doi:10.1001/jamainternmed.2013.1216

Background Poor medication refill adherence contributes to poor cardiometabolic control and diabetes outcomes. Studies linking communication between patients and health care providers to adherence often use self-reported adherence and have not explored differences across communication domains or therapeutic indications.

Methods To investigate associations between patient communication ratings and cardiometabolic medication refill adherence, we conducted a cross-sectional analysis of 9377 patients in the Diabetes Study of Northern California (DISTANCE), a race-stratified, random sample of Kaiser Permanente survey respondents. Eligible participants received 1 or more oral hypoglycemic, lipid-lowering, or antihypertensive medication in the 12 months preceding the survey. Communication was measured with a 4-item Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) score and 4 items from the Trust in Physicians and Interpersonal Processes of Care instruments. Poor adherence was classified as greater than a 20% continuous medication gap for ongoing medication therapies. Using modified least squares regression, we calculated differences in poor adherence prevalence for a 10-point decrease in CAHPS score and compared higher vs lower communication ratings on other items, adjusting for necessary sociodemographic and medical confounders derived from a directed acyclic graph.

Results In this cohort, 30% had poor cardiometabolic medication refill adherence. For each 10-point decrease in CAHPS score, the adjusted prevalence of poor adherence increased by 0.9% (P = .01). Compared with patients offering higher ratings, patients who gave health care providers lower ratings for involving patients in decisions, understanding patients' problems with treatment, and eliciting confidence and trust were more likely to have poor adherence, with absolute differences of 4% (P = .04), 5% (P = .02), and 6% (P = .03), respectively. Associations between communication and adherence were somewhat larger for hypoglycemic medications than for other medications.

Conclusions Poor communication ratings were independently associated with objectively measured inadequate cardiometabolic medication refill adherence, particularly for oral hypoglycemic medications. Future studies should investigate whether improving communication skills among clinicians with poorer patient communication ratings could improve their patients' cardiometabolic medication refill adherence and outcomes.