Physicians prescribing a new medication often fail to discuss basic. Intervention to Enhance Communication About Newly Prescribed Medications

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1 to Enhnce Communiction About Newly Prescribed Medictions Derjung M. Trn, MD, PhD 1 Debor A. Pterniti, PhD 2 Deborh K. Orosz, BA 3 Chi-Hong Tseng, PhD 4 Neil S. Wenger, MD, MPH 4 1 Deprtment of Fmily Medicine, Dvid Geffen School of Medicine, University of Cliforni-Los Angeles, Los Angeles, Cliforni 2 Center for Helthcre Policy nd Reserch nd Deprtment of Sociology, University of Cliforni-Dvis Medicl Center, Scrmento, Cliforni 3 Hrvrd Medicl School, Boston, Msschusetts 4 Division of Generl Internl Medicine nd Helth Services Reserch, Dvid Geffen School of Medicine, University of Cliforni-Los Angeles, Los Angeles, Cliforni ABSTRACT PURPOSE Physicins prescribing new medictions often do not convey importnt mediction-relted informtion. This study tests n intervention to improve physicin-ptient communiction bout newly prescribed medictions. METHODS We conducted controlled clinicl tril of ptients in 3 primry cre prctices, combining dt from ptient surveys with udio-recorded physicinptient interctions. The intervention consisted of 1-hour physicin-trgeted interctive eductionl session encourging communiction bout 5 bsic elements regrding new prescription nd ptient informtion hndout listing the 5 bsic elements. Min outcome mesures were the Mediction Communiction Index (MCI), 5-point index ssessed by qulittive nlysis of udio-recorded interctions (giving points for discussion of mediction nme, purpose, directions for use, durtion of use, nd side effects), nd ptient rtings of physicin communiction bout new prescriptions. RESULTS Twenty-seven physicins prescribed 113 new medictions to 82 of 256 ptients. The men MCI for medictions prescribed by physicins in the intervention group ws 3.95 (SD = 1.02), significntly higher thn tht for medictions prescribed by control group physicins (2.86, SD = 1.23, P <.001). This effect held regrdless of mediction type (chronic vs nonchronic mediction). Counseling bout 3 of the 5 MCI components ws significntly higher for medictions prescribed by physicins in the intervention group, s were ptients rtings of new mediction informtion trnsfer (P =.02). Independent of intervention or control groups, higher MCI scores were ssocited with better ptient rtings bout informtion bout new prescriptions (P =.003). CONCLUSIONS A physicin-trgeted eductionl session improved the content of nd enhnced ptient rtings of physicin communiction bout new mediction prescriptions. Further work is required to ssess whether improved communiction stimulted by the intervention trnsltes into better clinicl outcomes. Ann Fm Med 2013;11: doi: /fm Confl icts of interest: uthors report none. CORRESPONDING AUTHOR Derjung Mimi Trn, MD, PhD Dvid Geffen School of Medicine t UCLA Deprtment of Fmily Medicine Wilshire Blvd, Ste 1800 Los Angeles, CA dtrn@mednet.ucl.edu INTRODUCTION Physicins prescribing new mediction often fil to discuss bsic informtion bout the mediction with ptients. 1 Yet guidelines recommend tht physicins educte older dults bout such informtion s the reson for the mediction, how to tke it, nd potentil side effects. 2,3 Furthermore, better ptient knowledge bout medictions is ssocited with better mediction dherence. 4 Though there is little empiricl evidence to guide wht physicins in n outptient setting should discuss when prescribing new medictions, studies hve shown tht ptients who reported better nd more discussions with their physicins bout prescription medictions were more dherent to their medictions thn those who reported receiving less informtion. 5-8 Physicins my rely on phrmcists to counsel ptients bout new prescriptions. 9 The Omnibus Budget Reconcilition Act of 1990 mndted tht phrmcists inform ptients bout how to use mediction, common or 28

2 severe side effects, potentil interctions, nd possible contrindictions to mediction. 10 Phrmcists my not know, however, the indiction for the mediction or how long ptient should tke mediction. Furthermore, the mount of informtion given by phrmcists vries gretly by phrmcy, intensity of stte regultions, nd the phrmcist s ge, 11 suggesting tht physicins my not be ble to routinely depend on phrmcists to provide complete informtion bout new prescriptions. A number of interventions hve sought to improve ptient eduction nd counseling bout medictions, 12 but few hve trgeted physicin communiction. 13,14 Most physicin-trgeted interventions hve focused on improving interctionl skills, such s listening skills, ptient-centered cre, nd shred decision mking Those specifi c to mediction-relted discussions lrgely hve trined physicins to sk ptients to repet instructions or ddress their fers bout medicines. 13 Only few studies emphsized informtion exchnge bout medictions in the context of ctul outptient offi ce visits. These studies were conducted outside the United Sttes, required severl hours of trining, nd my not be prcticl for ppliction to busy prcticing physicins. 17,18 This study used combintion of ptient surveys nd udio recordings of offi ce visits to (1) test the effect of physicin- nd ptient-trgeted intervention to improve communiction of bsic informtion bout new mediction prescription (ssessed using ptient rtings of physicin communiction nd nlysis of the ctul content of udio recorded visits); nd (2) evlute the effect of incresed communiction bout newly prescribed medictions (ssessed by nlyzing the ctul content of udio recorded visits) on ptient rtings of the informtion they received bout the prescribed mediction. We trgeted older dults becuse more thn 40% of older dults re nondherent to their prescribed medictions. 19 METHODS Study Sites nd Prticipnts The study ws conducted from Februry 2009 to Februry 2010 in 3 cdemiclly ffi lited physicins offi ces. The investigtors recruited physicins from internl medicine nd fmily medicine offi ces t the University of Cliforni, Los Angeles. Ptients of prticipting physicins were recruited by prt-time reserch ssistnt. The ssistnt telephoned consecutive ptients ged 50 yers nd older 1 to 3 dys before their ppointment nd pproched convenience smple of ptients who hd not been reched by telephone while they wited in the clinic witing room. Ptients interested in prticipting were screened for the following inclusion criteri: were English speking; hd new, worsening, or uncontrolled problem; nd greed to prticipte in follow-up visit. The intervention trgeted physicins nd ptients. Approximtely one-hlf of the physicins in ech of the 3 prticipting offices were rndomly ssigned to the intervention group. A simple rndomiztion ws performed using computer-generted rndom numbers. The physicin intervention consisted of single, 1-hour interctive session (Supplementl Appendix 1, vilble t DC1) tht emphsized the importnce of conveying 5 bsic elements of informtion bout new mediction prescriptions (mediction nme, purpose, directions for use, durtion of use, nd side effects). The session lso ddressed typicl resons for poor provision of informtion (eg, fer of scring ptients with side effect informtion). 9 Ech physicin role-plyed incorporting the 5 bsic pieces of informtion into their norml counseling bout new prescription. Our intervention components were bsed on eductionl models used in successful physicin-trgeted communiction interventions tht included instruction, modeling, skill prctice, feedbck, nd discussion bout communiction skills. 20,21 Ptients of physicins in the intervention group were given 1-pge hndout to whet their interest in the 5 pieces of informtion reviewed during the physicin eduction session (Supplementl Appendix 2, vilble t DC1). The hndout stted tht ptients receiving new mediction on the dy of the visit should mke sure they know the nme of the medicine, wht it is for, how much nd how often to tke it, how long to tke it, nd potentil side effects. The 5 pieces of informtion were presented in bullet form. Physicins could write on the hndout if they chose, but we did not specifi clly encourge doing so during the physicin eductionl sessions, nd we did not ssess whether they did. The reserch ssistnt ensured tht hndouts were given only to ptients of intervention group physicins nd were not left in witing rooms or exmintion rooms. group physicins were sked not to shre the study ims or eductionl session content with the control group physicins, who did not receive trining. group physicins nd their ptients were told tht the study purpose ws to investigte best prctices for physicin-ptient communiction. Study Design nd Dt Collection Ptients were surveyed immeditely before nd fter n offi ce visit with their physicin. The previsit questionnire could be completed either before or fter the 29

3 offi ce visit. All visits were udio-recorded nd trnscribed verbtim. The study protocol ws pproved by the Institutionl Review Bord t the University of Cliforni, Los Angeles. Previsit Survey Ptients nswered questions bout their demogrphics (ge, sex, ethnicity, eduction), the number of prior visits with the physicin being seen, nd whether the physicin ws their regulr doctor. They lso were sked to rte their confi dence in intercting with physicins (on scle from 0 to 10, where higher numbers indicted more confi dence). 22 Postvisit Survey Immeditely fter the visit, ptients completed questionnire contining previously vlidted mesures of overll physicin-ptient communiction (6 items from the Consumer Assessment of Helthcre Providers nd Systems Clinicin nd Survey), 23 trust in physicin (3 items), nd helth litercy (Rpid Estimte of Adult Litercy in Medicine Short Form). 24 Ptients lso were sked whether they hd received new mediction prescription. Those who did were sked whether they were plnning to tke the mediction (yes/no), nd to rte their certinty bout tking the new mediction ( On scle from 0 to 10 how sure re you tht you will be ble to tke your new mediction exctly s prescribed over the next 30 dys? ). Ptients who were prescribed new mediction lso rted the importnce of the new mediction nd their worry bout the condition for which the mediction ws prescribed (4-point Likert scle). Ptients perception of communiction bout the new mediction ws ssessed by summing their rtings of informtion received bout 10 new mediction-relted topics (Cronbch s α =.84). Responses were dichotomized (1 = bout right, 0 = too much, too little, or none received), verged, nd trnsformed into scle rnging from 0 to 10. Qulittive Anlysis We nlyzed trnscripts of visits in which ptients reported receiving new mediction prescription. We defi ned new mediction prescription s one tht the ptient hd never tken nd ws in mediction clss tht differed from previously prescribed medictions. If ptient hd been previously prescribed medictions, but never strted tking it, the prescription ws not included in our nlysis. Anlysis ws performed t the mediction level. Three uthors used previously estblished codes nd coding rules for mediction prescriptions to code for sttements bout mediction nme, purpose of use, number of tblets or sprys, dosing frequency, durtion of use, nd side effects nd dverse rections. 1,25 They lso coded for whether sttements were physicin- or ptient-initited. Coders hd diverse bckgrounds fmily physicin experienced in qulittive reserch methods (D.M.T.), medicl sociologist (D.A.P.), nd premedicl student reserch ssistnt with no qulittive reserch experience (D.K.O.). Coders were blinded to whether visits were to physicins in the intervention or control group. The nme of the mediction ws coded only if the ctul nme (either generic or brnd nme) ws mentioned. We did not code references such s n ntibiotic or blood pressure mediction s stisfctory sttements of mediction s nme. The led uthor (D.M.T.) coded ll of the trnscripts. Other investigtors independently coded 28% (D.A.P.) nd 31% (D.K.O.) of rndomly selected trnscripts; they chieved men Cohen s κ for interrter relibilities of 0.91 (SD = 0.13, rnge = ) nd 0.90 (SD = 0.09, rnge = ), respectively. Discrepncies between coders were resolved by consensus or group discussions mong ll uthors. Mediction Communiction Index The Mediction Communiction Index (MCI) ws clculted for ech newly prescribed mediction bsed on qulittive nlysis of the trnscripts. It is previously developed 5-point index in which 1 point is given for discussion bout ech of 5 topics relted to new prescription: mediction nme, purpose of use, directions for use (comprised of 0.5 points for number of tblets or sprys, nd 0.5 points for dosing frequency), durtion of use, nd side effects nd dverse rections. 1 Sttisticl Anlyses Stt 11.0 (SttCorp LP) ws used for ll sttisticl nlyses. Becuse ptients were clustered within physicins, we used generlized estimting equtions (GEE) method to ssess the reltionship of the intervention on the MCI, overll, by physicin chrcteristics (prcticing vs resident physicin), nd by mediction type (chronic vs nonchronic mediction). The GEE method djusted for physicin effects to control for the possible correltion of ptient outcomes within the sme physicin. Similrly, we used the GEE method to exmine the effect of the intervention on the individul MCI components. Bivrite nlyses were conducted, using the GEE method to exmine the reltionship of (1) the intervention, nd (2) the MCI, with ptient reports bout the physicin nd the new mediction prescription. RESULTS Of 1,117 ptients who were pproched in witing rooms or telephoned, 917 were reched. Of these,

4 Figure 1. Flowchrt of study prticipnts. Approched or telephoned 1,117 ptients 50 yers 917 Contcted 695 Interested ptients ssessed for eligibility 256 Prticipted in study 200 Unble to be contcted 210 Refused 12 Could not be ssessed 420 Not eligible 87 Not English-speking 295 No new, worsening, or uncontrolled problem 32 Plnned to cncel ppointment 6 Unble to return for follow-up visit 19 Eligible but logisticl issues prevented prticiption refused or could not be ssessed, nd 420 ptients were ineligible (295 hd no new, worsening, or uncontrolled problem; 87 did not spek English; 32 plnned to cncel their ppointment; nd 6 were unble to follow-up). Two hundred fifty-six ptients were enrolled (Figure 1). The eligibility rte mong those screened for study prticiption ws 39.6% (eligible ptients / totl ptients for whom eligibility ws determined = ( ) /( ), nd the response rte mong ll potentil eligible ptients ws 57.9% (ie, 256 /[ ( [ ])]), which is consistent with other studies using similr methodologies. 26 Twenty-seven of 29 physicins Chrcteristic pproched prticipted. Physicins consisted of 13 prcticing physicins (7 generl internists nd 6 fmily physicins) nd 14 internl medicine residents. Approximtely one-hlf of the physicins (7 prcticing physicins nd 8 resident physicins) were rndomly ssigned to the intervention group. Of the 27 prticipting physicins, 18 prescribed 113 new medictions to 82 ptients. We were unble to cpture new mediction prescriptions for 9 of 14 physicins in trining becuse of their limited offi ce schedules nd smll number of offi ce visits with older ptients. Among physicins for whom we cptured t lest 1 new mediction prescription, most were white (61%) nd mle (61%) (Tble 1). There were no signifi cnt differences between intervention nd control group physicin chrcteristics. Ptients were mostly white (61.7%), hd men ge of 64.8 yers (SD = 10.5 yers), nd hd t lest some college eduction (82.3%) (Tble 2). Most common mong newly prescribed medictions were nlgesics (13.3%) nd cough nd cold preprtions (10.6%). Dermtologic preprtions, decongestnts nd nsl sprys, gstrointestinl medictions, nd ntibiotics ech comprised slightly more thn 8% of new medictions; ntihypertensive medictions, inhlers, nd ntidepressnts or mood stbilizers ech comprised 6.2%, nd lipid-lowering medictions comprised 3.5% of newly prescribed medictions. Effect of the The men MCI for medictions prescribed by physicins in the intervention group ws 3.95 (SD = 1.02), signifi cntly higher thn the MCI for medictions prescribed by control group physicins (2.86, SD = 1.23, P <.001). This effect held for ttending nd resident physicins nd for medictions prescribed for chronic nd nonchronic conditions (Figure 2). Ech of the MCI components (nme, purpose, number of tblets or sprys, dosing frequency, durtion of use, side effects) ws discussed more frequently for medictions prescribed by intervention group physicins. These differences were signifi cnt for ll but mediction purpose nd side effects. Compred with the control group physicins, intervention group physicins provided informtion bout the mediction nme, number of tblets, dosing frequency, durtion of use, nd side effects for t lest 20% more of their newly prescribed Tble 1. Chrcteristics of Physicins Prescribing New Mediction (N = 18) (n = 10) (n = 8) Age, men (SD), y 38.8 (11.3) 41.6 (13.7) 35.3 (6.5) Femle, No. (%) 7 (39) 4 (40) 3 (38) Rce/ethnicity, No. (%) White 11 (61) 6 (60) 5 (63) Asin 7 (39) 4 (40) 3 (38) Yers in prctice, men (SD) 13.7 (11.8) 16.4 (14.3) 10.3 (7.3) Note: No difference between intervention nd control group physicins ws sttisticlly significnt. 31

5 Tble 2. Chrcteristics of Ptients Chrcteristic All Ptients (N = 256) Prescribed New Mediction (n = 82) Not Prescribed New Mediction (n = 174) Prescribed New Mediction (n = 46) (n = 36) Age, men (SD), y 64.8 (10.5) 60.5 (8.0) 66.8 (11.0) 60.3 (7.9) 60.7 (8.3) Femle, No. (%) 150 (58.6) 50 (61.0) 100 (57.5) 30 (65.2) 20 (55.6) Rce/ethnicity, No. (%) White 158 (61.7) 49 (59.8) 109 (62.6) 26 (56.5) 23 (63.9) Africn-Americn 43 (16.8) 15 (18.3) 28 (16.1) 7 (15.2) 8 (22.2) Hispnic 24 (9.4) 12 (14.6) 12 (6.9) 9 (19.6) 3 (8.3) Asin 21 (8.2) 5 (6.1) 16 (9.2) 3 (6.5) 2 (5.6) Other 8 (3.1) 1 (1.2) 7 (4.0) 1 (2.2) 0 (0) Eduction, No. (%) High school or less 45 (17.7) 15 (18.5) 30 (17.4) 10 (22.2) 5 (13.9) Some college 85 (33.3) 28 (34.8) 57 (32.8) 15 (33.3) 13 (36.1) College grdute 125 (49.0) 38 (46.9) 87 (50.0) 20 (44.4) 18 (50.0) Helth litercy score, men (SD) 6.7 (0.89) 6.8 (0.49) 6.7 (1.0) 6.8 (0.53) 6.9 (0.44) Medictions nd dietry supplements, men 6.8 (4.4) 6.7 (3.9) 6.8 (4.6) 6.7 (3.6) 6.6 (4.2) (SD), No. Confidence bout intercting with physicins, 8.6 (1.5) 8.6 (1.5) 8.6 (1.6) 8.9 (1.1) 8.3 (1.9) men score (SD) b Seen by internl medicine physicin, No. (%) 158 (61.7) 55 (67.1) 103 (59.2) 30 (65.2) 25 (69.4) Seen by ttending physicin, No. (%) 225 (87.9) 71 (86.6) 154 (88.5) 40 (87.0) 31 (86.1) Seen by ptient s regulr physicin, No. (%) 214 (86.0) 64 (82.1) 150 (87.7) 36 (83.7) 28 (80.0) Previous visits to physicin, No. (%) Never 36 (14.8) 15 (19.2) 21 (12.7) 5 (11.9) 10 (27.8) (14.4) 11 (14.1) 24 (14.6) 7 (16.7) 4 (11.1) (20.2) 13 (16.7) 36 (21.8) 7 (16.7) 6 (16.7) (19.7) 14 (18.0) 34 (20.6) 8 (19.1) 6 (16.7) >12 75 (30.9) 25 (32.1) 50 (30.3) 15 (35.7) 10 (27.8) Helth litercy rnges from 0-7, with higher scores indicting greter helth litercy. b Confidence bout intercting with physicins rnges from 0-10, with higher scores indicting greter self-efficcy. Figure 2. Medicl Communiction Index scores for medictions prescribed by intervention nd control group physicins. Mediction Communiction Index (MCI) Score <.001. b < Overll Prcticing Physicins b Resident Physicins Medictions for Chronic Conditions b Medictions for Nonchronic Conditions medictions (Figure 3). Ptients initited few discussions bout the MCI components: 1.8% of discussions were bout mediction purpose; 3.6% of discussions were bout mediction nme, number of tblets or sprys, dosing frequency nd durtion of use; nd 5.5% of discussions were bout side effects. Tble 3 illustrtes the effect of the intervention on ptients reports bout physicin communiction nd new mediction prescriptions. There were no signifi cnt differences between intervention nd control group ptients in reported overll physicin communiction or trust in the physicin. On scle from 0 to 10 (with higher scores indicting better communiction), however, ptients reported signifi cntly better communiction bout medictions 32

6 Figure 3. Percentge of medictions for which Mediction Communiction Index component ws discussed Percentge of Medictions Nme Purpose Tblets b Frequency c Durtion Side Effects P <.01. b P <.05. c P.001. Tble 3. Effect of on Ptients Reports About Physicin Communiction nd Mediction Report No. of Ptients All Ptients P Vlue About physicin Overll communiction, men score (SD) (0.60) 5.74 (0.54) 5.59 (0.66).49 Trust in physicin, men score (SD) (0.55) 4.72 (0.52) 4.62 (0.59).68 Communiction bout new mediction, No. (%) b (2.81) 8.78 (2.23) 6.87 (3.09).02 Wht medicine is clled (96.3) 56 (94.9) 47 (97.9).53 Wht medicine is for (99.1) 57 (98.3) 48 (100).36 Why medicine is importnt to tke (87.4) 51 (89.5) 39 (84.8).63 How to tke the medicine (93.1) 54 (96.4) 41 (89.1).07 How long to tke medicine (89.3) 56 (96.6) 36 (80.0).03 How to get further medicine supply (if pplicble) (85.2) 42 (82.4) 30 (90.9).37 Whether medicine hs side effects (72.8) 50 (86.2) 25 (55.6).001 Risk of getting side effects (61.0) 43 (76.8) 21 (42.9).003 Wht to do if side effects occur (63.0) 40 (74.1) 23 (50.0).008 Interctions with other medicines (62.0) 43 (81.1) 19 (40.4) <.001 About new mediction immeditely fter the visit Plnning to tke new mediction, No. (%) (97.3) 59 (98.3) 48 (96.0).56 Certinty bout tking new mediction, men score (SD) (2.16) 9.30 (1.96) 8.51 (2.29).04 Importnce of new mediction, men score (SD) (0.62) 3.65 (0.61) 3.57 (0.64).52 Worry bout condition mediction is for, men score (SD) (1.02) 2.45 (1.08) 2.25 (0.93).32 Note: Dt re presented s men (SD) unless otherwise indicted. Unit of nlyses for overll communiction nd trust in physicin is the ptient; unit of nlyses for ll other outcomes is the new mediction. Overll communiction rnges from 1 to 6; trust in physicin rnges from 1 to 5; communiction bout new mediction nd certinty bout tking new mediction rnge from 0 to 10; nd importnce of new mediction nd worry bout condition rnge from 1 to 4. Higher scores indicte better communiction, more trust, nd greter certinty, importnce, nd worry. P vlue describes difference between intervention nd control group ptients. b The 10 items comprising the communiction bout new mediction scle re listed nd describe the number nd percentge of ptients who reported receiving bout the right mount of informtion bout the item. 33

7 prescribed by intervention group physicins (8.78, SD = 2.23) thn those prescribed by control group physicins (6.87, SD = 3.09) (P =.02). These differences were driven lrgely by differences in communiction bout how long to tke the mediction (P =.03), whether the medicine hs side effects (P =.001), the risk of hving side effects (P =.003), wht to do if side effects occur (P =.008), nd potentil interctions with other medictions (P <.001). Immeditely fter the visit, intervention group ptients generlly hd reports bout new medictions tht were more positive thn those of control group ptients, though the only report tht ws sttisticlly signifi cnt ws certinty bout tking new medictions over the next 30 dys (P =.04). Effect of Incresed Communiction About New Prescriptions (Mediction Communiction Index) Tble 4 reltes MCI scores to ptients reports of physicins nd new mediction prescriptions. Higher MCI scores (indicting discussion of more MCI components) were signifi cntly relted to better ptients reports of communiction bout new medictions (P =.003). This difference ws lrgely becuse higher MCI scores resulted in signifi cntly better ptients reports of wht the medicine ws for (P <.001), how long to tke mediction (P =.03), whether the medicine hs side effects (P =.02), the risks of hving side effects (P <.001), nd wht to do if side effects occur (P <.001). DISCUSSION A simple intervention combining physicin eduction nd role plying with ptient informtion hndout cn improve communiction bout bsic medictionrelted elements (nme, purpose, directions for use, durtion of use, side effects) when new mediction is prescribed. On verge, intervention group physicins ddressed more thn 1 of 5 dditionl elements Tble 4. Reltionship between Mediction Communiction Index (MCI) nd Ptients Reports bout Physicin nd Mediction Report No. Men MCI P Score (SD) R 2 Vlue About physicin Communiction bout new mediction Wht medicine is clled (bout right) (1.2).17 Wht medicine is clled (insufficient) (1.0) Wht medicine is for (bout right) (1.2) <.001 Wht medicine is for (insufficient) 1 4 (-) Why medicine is importnt to tke (bout right) (1.2).42 Why medicine is importnt to tke (insufficient) (1.4) How to tke the medicine (bout right) (1.2).87 How to tke the medicine (insufficient) (1.4) How long to tke medicine (bout right) (1.2).03 How long to tke medicine (insufficient) (1.3) How to get further medicine supply (1.2) (if pplicble) (bout right).71 How to get further medicine supply (1.3) (if pplicble) (insufficient) Whether medicine hs side effects (bout right) (1.1).02 Whether medicine hs side effects (insufficient) (1.3) Risks of getting side effects (bout right) (1.1) <.001 Risks of getting side effects (insufficient) (1.3) Wht to do if side effects occur (bout right) (1.1) <.001 Wht to do if side effects occur (insufficient) (1.3) Interctions with other medicines (bout right) (1.1).07 Interctions with other medicines (insufficient) (1.3) About new mediction Plnning to tke new mediction (1.2).46 Not plnning to tke new mediction (1.8) Certinty bout tking new mediction Importnce of new mediction 108 < Worry bout condition mediction is for Note: The MCI is 5-point index clculted by ssigning 1 point to ech of the following elements if they re discussed during n office visit: mediction nme, purpose of use, durtion of use, potentil side effects. Counseling bout the number of tblets or sprys nd how often to use mediction is given 0.5 points ech. P vlue describes differences between MCI scores for ctegoricl vribles, nd reltionship between MCI nd ptient reports for continuous vribles. of bsic informtion compred with control group physicins; they lso hd more discussions thn control group physicins bout ll 5 mjor elements emphsized by the intervention. Furthermore, the intervention resulted in ptients reporting better communiction bout mediction informtion. Previous studies hve shown tht ptient eductionl interventions cn improve mediction dherence nd ptient helth outcomes. 27,28 Though recent literture review suggested tht there is insuffi cient evidence to support ptient eductionl interventions lone for improving ptient knowledge bout nd dherence to helth tretments, 12 the interventions reviewed were not mediction specifi c nd used mixture of written nd verbl counseling strtegies. Though physicin communiction is only one mong mny fctors infl uencing ptient mediction dher- 34

8 ence, 4 the physicin-ptient interction often serves s ptient s introduction to mediction, my ffect whether the ptient decides to fi ll mediction, nd cretes the context in which new mediction is experienced, including nticiption of therpeutic effects nd interprettion of side effects. More thn 25% of ptients never fi ll new prescriptions for chronic conditions, such s hypertension, hyperlipidemi, nd dibetes, 29 nd 20% to 50% discontinue these medictions within 6 months of strting them. 30 Mesures to enhnce dherence (eg, reminder telephone clls nd phrmcist interventions 12 ) re not slient if the originl prescription is never fi lled. This study did not evlute whether better communiction ffected mediction dherence; this reltionship should be explored. This study shows tht the MCI cptures elements of mediction communiction tht re trnsmitted to nd then reclled by ptients. Ptients reported receiving better communiction bout new mediction when physicins conveyed more MCI elements bout new mediction. Interestingly, higher MCI scores lso were ssocited with more reports of communiction bout topics not directly included in the intervention. For exmple, the intervention encourged physicins to discuss potentil mediction side effects with ptients, but ptients lso reported better communiction bout the risk of experiencing side effects nd wht to do if side effects occurred. We did not code trnscripts for these elements of discussion. This fi nding, however, suggests tht new mediction discussions which include more bsic elements of mediction communiction re lso more complete in other wys. Our study hs severl limittions. First, the ptients were convenience smple, nd dt were not collected to evlute differences between study prticipnts nd those who declined to prticipte. Ptients in the study were predominntly white, most hd t lest some college eduction, nd few were of lower helth litercy. group ptients were comprised of lrger percentge of Hispnics nd lower percentge of Africn-Americns. Further investigtion is needed to exmine how these imblnces my hve ffected our results regrding communiction bout new mediction prescriptions. Second, hving n udio recorder in the exmintion room my introduce the Hwthorne effect, nd thus my hve enhnced mediction communiction for physicins in the intervention group compred with those physicins in the control group. Third, the study did not exmine interctionl components of communiction, such s style of communiction. It lso did not ssess the qulity of the informtion trnsmitted, nd the intervention did not trget these elements. Fourth, we hd long recruitment period becuse most of the cdemic physicins in our study did not see ptients full-time (some only hlf-dy per week), nd reserch ssistnts were vilble only prt-time. In ddition, some of the physicins, prticulrly the physicins in trining, sw few ptients ged 50 yers nd older. These fctors prolonged recruitment nd potentilly incresed opportunities for contmintion between the invention nd control groups, lthough this would hve minimized the intervention effect. Lstly, we did not exmine whether the intervention incresed the time spent communicting bout new prescriptions, or whether ny dditionl time spent discussing new prescriptions lengthened visits or dversely ffected counseling bout other spects of cre. When physicins introduce new mediction, the stge is set for whether nd how ptients will initite use of this mediction. In 2008, the Institute of Medicine clled for more reserch to support physicin counseling t the time of prescribing. 31 This study shows tht brief, prcticl intervention cn improve physicin communiction bout newly prescribed mediction in wys tht ffect ptients. The intervention should be tested for its clinicl impct. To red or post commentries in response to this rticle, see it online t Key words: physicin-ptient reltions; prescriptions; communiction; intervention studies Submitted November 28, 2011; submitted, revised, Mrch 25, 2012; ccepted April 10, Funding support: Dr Trn ws supported by UCLA Mentored Clinicl Scientist Development Awrd (5K12AG001004) nd by the UCLA Clude D. Pepper Older Americns Independence Center, funded by the Ntionl Institute of Aging (5P30 AG028748). Disclimer: The rticle content does not necessrily represent the officil views of the Ntionl Institute on Aging or the Ntionl Institutes of Helth. The investigtors retined full independence in the conduct of this study. Previous presenttion: This study ws presented t the North Americn Primry Cre Reserch meeting in Bnff, Albert, Cnd, on November 13, Acknowledgments: The uthors would like to thnk the physicins nd ptients from the UCLA Internl Medicine nd Fmily Medicine prctices who prticipted in the study. 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