Calcif Tissue Int DOI 10.1007/s00223-014-9869-0
ORIGINAL RESEARCH
Clinical Setting Influences Patterns of Interaction between Osteoporosis Patient and Physician Andrea Ildiko Gasparik
Received: 10 April 2014 / Accepted: 9 May 2014 Ó Springer Science+Business Media New York 2014
Abstract The importance of healthy behavior for bone health, as well as low adherence to anti-osteoporosis medication are well-described problems. Both, lifestyle habits and compliance with drug-therapy are influenced by the relationship between patients and physicians. We analyzed 152 consecutive doctor–patient interactions conducted in public and private practices specialized in the management of osteoporosis. We recorded the duration of the consultation and the relative length of: (a) Personal and medical history collection, (b) Physical examination, (c) Explanation of the diagnosis and treatment modalities, and (d) Administrative tasks. The overall length and the respective duration of the four phases of the consultation significantly differ in private versus public practices. In the private practice, doctors spend more time with the patient and dedicate a higher proportion of their time to history collection and explanation of diagnosis/treatment for osteoporosis. While we do not integrate data on medication adherence, we believe that since more time is dedicated to health education, patients consulting in the private sector have a greater probability to adopt a healthy lifestyle and better/ longer take anti-osteoporosis medications. Further investigations are needed to assess if the differences in patient and doctor behaviors in the public–private settings have a significant impact on therapeutic adherence and subsequently fracture reduction in patients receiving antiosteoporosis treatment. Keywords Doctor–patient interaction Adherence Private Public Osteoporosis A. I. Gasparik (&) University of Medicine and Pharmacy Tg. Mures, UMF. Tirgu Mures, Str Gh. Marinescu nr. 38, 540139 Taˆrgu Mures¸ , Romania e-mail: [email protected]
Introduction The importance of healthy behavior: regular exercise, adequate diet, and avoiding harmful habits are crucial for slowing the progression of osteoporosis. Poor compliance and persistence are also common problems in the treatment of silent chronic disorders, including osteoporosis (OP) [1]. Poor adherence reduces the effectiveness of OP treatments, resulting in lower bone mineral density gain and subsequent higher fracture rates [2]. The studies addressing compliance and persistence have shown that both aspects of adherence are important drivers of medications cost-effectiveness [3]. Both, patient and medication factors are involved in adherence to therapy [4]. However, management of low adherence strategies consistently point out the positive impact of an improved relationship between patients and physicians, the latter providing adequate intake instructions, education, feedback, and support [5]. Several factors influence patients’ trust and trust influences the doctor– patient relationship [6]. Trust mediates positive outcomes including adherence to treatment and satisfaction [7]. Recent studies revealed that patients trust their primary care physician (GP) to a high extent by relying on simple signals that are based on the quality of the one-to-one communication and on behavioral and relational patterns [6]. The objective of the present trial is to explore the content of a first encounter between patients seeking information, diagnosis, or treatment for OP and ‘‘bone doctors’’. We also assessed whether the interaction between service provider (i.e., physician) and customer (i.e., patient) is influenced by the nature (i.e., public versus private) of the medical institution where the medical service is rendered.
123
A. I. Gasparik.: Osteoporosis Patient and Physician Table 1 Respective duration (%) and standard deviations of the four phases of the consultation in the private and public sector History collection
Physical examination
Explanation of diagnosis/ treatment
Administrative tasks
Private
16 (5.02)
36 (3.10)
26 (6.89)
22 (6.49)
Public
10 (6.19)
46 (6.23)
14 (6.34)
30 (5.77)
The respective duration of the four phases of the consultation in private and public practices is summarized in Table 1. The overall duration of the consultation was 12.1 min in the private sector versus 6.6 min in the public sector (p \ 0.0005). The average numbers of questions raised by physicians and patients were, respectively, 7 and 1 in the public sector compared to 10 and 2 in the private practice.
Materials and Methods
Discussion
We analyzed 152 doctor–patient interactions, conducted in 14 Romanian practices (i.e., 7 from the public health system and 7 from private clinics, 2 ? 2 ? 3 pairs in three big cities from two different Romanian regions) specialized in the management of OP. All patients consulted the OP specialist for the first time, either spontaneously or at the request of their GP. One investigator (AIG) attended the consultation without any intervention and without any interaction, neither with the physician nor with the patient. The structure of each doctor–patient interaction was divided into 4 phases, i.e.,
The complexity of the doctor–patient relationship requires in-depth analysis to enable a better understanding of the nature of the doctor’s appointment. Each participant can explicitly provide emotional support for the other, despite the evident asymmetry in the roles of doctor and patient [8]. If several studies previously focused on the quantitative aspects of doctor’s consultations [9, 10], to the best of our knowledge, this was never previously done in the osteoporosis field. Consultation length in general and specialized practice is determined by variables related to the doctor and the doctor’s country as well as by those related to patients. Patient variables account for 55 % of the variance [9]. However, it is known that consultation length may vary, for the same doctor, when consulting at different rates [10], an observation in agreement with our findings that consultation length in the private sector exceeds by 80 % the length recorded in the public sector. Longer interactions are associated with greater patient’s satisfaction and increases health education and prevention measures [10]. In silent chronic disorders (e.g., osteoporosis) health education is a major determinant of adherence to treatment [11]. In our survey, in addition to an overall longer consultation in the private practice, history collection and discussion of osteoporosis care also accounted for a greater relative part of the patient–doctor interaction in the private sector. The latter appears critical, since perception of long-term acceptability, perceptions of health consequences of osteoporosis and perceptions of knowledge about osteoporosis were ranked as variables predominantly influencing compliance and persistence in osteoporosis [12]. In a previous study undertaken to assess persistence with bisphosphonates and raloxifene and to identify determinants of adherence among women with osteoporosis in three different settings in Denmark, no differences in persistence were observed between University Hospitals and private practices [13]. However, in this study, persistence at 2 years was significantly higher than reported in other countries [14, 15], and the authors related the absence of differences observed between the three clinical settings to the high level of public information available on
(a) (b) (c) (d)
Personal and medical history collection, Physical examination, Explanation of the diagnosis and modalities, Administrative tasks.
treatment
The length and the time of onset of each phase was measured by a stopwatch and carefully recorded on a standardized checklist. Subsequently, the overall time spent by the patient in the physician’s office, as well as the respective duration of the various phases of the consultation were calculated. The number of questions asked by both parties was also recorded. Statistical analyses were performed using Graph Pad Prisma. Unpaired Student’s t test was selected to assess differences in means of continuous variables between public and private practices. A two-tailed p value of 0.05 was considered as the threshold of statistical significance.
Results Our population included 152 subjects, 97 women and 55 men. Mean age of the patients was 56 (females‘‘ 55, males’’ 58, range 44–88), whereas the 14 physicians had a mean age of 45 (range 35–59, 46 in the public, 44 in the private group). Gender distribution showed a 64 %/36 % and a 43 %/57 % female/male ratio for the patients and the doctors, respectively.
123
A. I. Gasparik.: Osteoporosis Patient and Physician
osteoporosis in Denmark [12], a situation which would significantly differ from the one existing in Romania. Our study does not integrate short- or long-term data on medication adherence in patients from the two clinical settings we investigated. Therefore, we cannot conclude that the significant differences, we observed in patient– doctor interaction between the private and public sectors in Romania, will result in differential outcomes for the patients. However, since patients treated in the private sector benefit from longer consultations, with, in particular, more time dedicated to health education, we can reasonably assume that those patients have a greater probability to adopt a healthy behavior and longer take their medications. These results support further investigation to assess whether the difference in patient and doctor behaviors in the public–private settings has a significant impact on lifestyle habits and therapeutic adherence and subsequently fracture reduction in patients receiving anti-osteoporosis treatment. Conflicts of Interest
None.
Human and Animal Rights and Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
References 1. Hiligsmann M, Boonen A, Rabenda V, Reginster JY (2012) The importance of integrating medication adherence into pharmacoeconomic analyses: the example of osteoporosis. Expert Rev Pharmacoecon Outcomes Res 12:159–166 2. Rabenda V, Reginster JY (2010) Overcoming problems with adherence to osteoporosis medications. Expert Rev Pharmacoecon Outcomes Res 10:677–689 3. Hiligsmann M, Rabenda V, Gathon HJ, Ethgen O, Reginster JY (2010) Potential clinical and economic impact of non-adherence with osteoporosis medications. Calcif Tissue Int 86:202–210
4. Lekkerkerker F, Kanis JA, Alsayed N, Bouvenot G, Burlet N, Cahall D, Chines A, Delmas P, Dreiser RL, Ethgen D, Hughes N, Kauman JM, Korte S, Kreutz G, Laslop A, Mitlak B, Rabenda V, Rizzoli R, Santora A, Schimmer R, Tsouderos Y, Viethel P, Reginster JY (2007) Adherence to treatment of osteoporosis: a need for study. Osteoporos Int 18:1311–1317 5. Papaioannou A, Kennedy CC, Dolovich L, Lau E, Adachi JD (2007) Patient adherence to osteoporosis medications: problems, consequences and management strategies. Drugs Aging 24:37–55 6. Riva S, Monti M, Iannello P, Pravettoni G, Schulz PJ, Antonietti A (2014) A preliminary mixed-method investigation of trust and hidden signals in medical consultations. PLoS One 11:e90941 7. Goold SD, Klipp G (2002) Managed care members talk about trust. Soc Sci Med 54:879–888 8. Marcinowicz L, Pawllkowska T, Konstantynowicz J, Chlabicz S (2014) New insight into the role of patients during medical appointments: a synthesis of three qualitative studies. Patient Mar. 25 [Epub ahead of print] 9. Deveugele M, Derese A, van den Btink-Muinen A, Bensing J, De Maeseneer J (2002) Consultation length in general practice: cross sectional study in six European countries. BMJ 325:472 10. Wilson A (1991) Consultation length in general practice: a review. Br J Gen Pract 41:119–122 11. Jensen AL, Lomborg K, Wind G, Langdahl BL (2014) Effectiveness and characteristics of multifaceted osteoporosis group education-a systematic review. Osteoporos Int 25:1209–1224 12. Huss D, Deblals F, Blotman F, Cortet B, mercier F, Rousseaux C, Berger V, Gaudin AF, Cotte FE (2010) Compliance and treatment satisfaction of post-menopausal women treated for osteoporosis. Compliance with osteoporosis treatment. BMC Womens Health 10:26 13. Nielsen DS, Langdahl BL, Sorensen OH, Sorensen HA, Brixen KT (2010) Persistence to medical treatment of osteoporosis in women at three different clinical settings—a historical cohort study. Scand J Public Health 38:502–507 14. Rabenda V, Mertens R, Fabri V, Vanoverloop J, Sumkay F, Vanneck C, Deswaef A, Verpooten GA, Reginster JY (2008) Adherence to bisphosphonates therapy and hip fracture risk in osteoporotic women. Osteoporos Int 19:811–818 15. Cramer JA, Amonkar MM, Hebborn A, Altman R (2005) Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis. Curr Med Res Opin 21:1453–1460
123
ORIGINAL RESEARCH
Clinical Setting Influences Patterns of Interaction between Osteoporosis Patient and Physician Andrea Ildiko Gasparik
Received: 10 April 2014 / Accepted: 9 May 2014 Ó Springer Science+Business Media New York 2014
Abstract The importance of healthy behavior for bone health, as well as low adherence to anti-osteoporosis medication are well-described problems. Both, lifestyle habits and compliance with drug-therapy are influenced by the relationship between patients and physicians. We analyzed 152 consecutive doctor–patient interactions conducted in public and private practices specialized in the management of osteoporosis. We recorded the duration of the consultation and the relative length of: (a) Personal and medical history collection, (b) Physical examination, (c) Explanation of the diagnosis and treatment modalities, and (d) Administrative tasks. The overall length and the respective duration of the four phases of the consultation significantly differ in private versus public practices. In the private practice, doctors spend more time with the patient and dedicate a higher proportion of their time to history collection and explanation of diagnosis/treatment for osteoporosis. While we do not integrate data on medication adherence, we believe that since more time is dedicated to health education, patients consulting in the private sector have a greater probability to adopt a healthy lifestyle and better/ longer take anti-osteoporosis medications. Further investigations are needed to assess if the differences in patient and doctor behaviors in the public–private settings have a significant impact on therapeutic adherence and subsequently fracture reduction in patients receiving antiosteoporosis treatment. Keywords Doctor–patient interaction Adherence Private Public Osteoporosis A. I. Gasparik (&) University of Medicine and Pharmacy Tg. Mures, UMF. Tirgu Mures, Str Gh. Marinescu nr. 38, 540139 Taˆrgu Mures¸ , Romania e-mail: [email protected]
Introduction The importance of healthy behavior: regular exercise, adequate diet, and avoiding harmful habits are crucial for slowing the progression of osteoporosis. Poor compliance and persistence are also common problems in the treatment of silent chronic disorders, including osteoporosis (OP) [1]. Poor adherence reduces the effectiveness of OP treatments, resulting in lower bone mineral density gain and subsequent higher fracture rates [2]. The studies addressing compliance and persistence have shown that both aspects of adherence are important drivers of medications cost-effectiveness [3]. Both, patient and medication factors are involved in adherence to therapy [4]. However, management of low adherence strategies consistently point out the positive impact of an improved relationship between patients and physicians, the latter providing adequate intake instructions, education, feedback, and support [5]. Several factors influence patients’ trust and trust influences the doctor– patient relationship [6]. Trust mediates positive outcomes including adherence to treatment and satisfaction [7]. Recent studies revealed that patients trust their primary care physician (GP) to a high extent by relying on simple signals that are based on the quality of the one-to-one communication and on behavioral and relational patterns [6]. The objective of the present trial is to explore the content of a first encounter between patients seeking information, diagnosis, or treatment for OP and ‘‘bone doctors’’. We also assessed whether the interaction between service provider (i.e., physician) and customer (i.e., patient) is influenced by the nature (i.e., public versus private) of the medical institution where the medical service is rendered.
123
A. I. Gasparik.: Osteoporosis Patient and Physician Table 1 Respective duration (%) and standard deviations of the four phases of the consultation in the private and public sector History collection
Physical examination
Explanation of diagnosis/ treatment
Administrative tasks
Private
16 (5.02)
36 (3.10)
26 (6.89)
22 (6.49)
Public
10 (6.19)
46 (6.23)
14 (6.34)
30 (5.77)
The respective duration of the four phases of the consultation in private and public practices is summarized in Table 1. The overall duration of the consultation was 12.1 min in the private sector versus 6.6 min in the public sector (p \ 0.0005). The average numbers of questions raised by physicians and patients were, respectively, 7 and 1 in the public sector compared to 10 and 2 in the private practice.
Materials and Methods
Discussion
We analyzed 152 doctor–patient interactions, conducted in 14 Romanian practices (i.e., 7 from the public health system and 7 from private clinics, 2 ? 2 ? 3 pairs in three big cities from two different Romanian regions) specialized in the management of OP. All patients consulted the OP specialist for the first time, either spontaneously or at the request of their GP. One investigator (AIG) attended the consultation without any intervention and without any interaction, neither with the physician nor with the patient. The structure of each doctor–patient interaction was divided into 4 phases, i.e.,
The complexity of the doctor–patient relationship requires in-depth analysis to enable a better understanding of the nature of the doctor’s appointment. Each participant can explicitly provide emotional support for the other, despite the evident asymmetry in the roles of doctor and patient [8]. If several studies previously focused on the quantitative aspects of doctor’s consultations [9, 10], to the best of our knowledge, this was never previously done in the osteoporosis field. Consultation length in general and specialized practice is determined by variables related to the doctor and the doctor’s country as well as by those related to patients. Patient variables account for 55 % of the variance [9]. However, it is known that consultation length may vary, for the same doctor, when consulting at different rates [10], an observation in agreement with our findings that consultation length in the private sector exceeds by 80 % the length recorded in the public sector. Longer interactions are associated with greater patient’s satisfaction and increases health education and prevention measures [10]. In silent chronic disorders (e.g., osteoporosis) health education is a major determinant of adherence to treatment [11]. In our survey, in addition to an overall longer consultation in the private practice, history collection and discussion of osteoporosis care also accounted for a greater relative part of the patient–doctor interaction in the private sector. The latter appears critical, since perception of long-term acceptability, perceptions of health consequences of osteoporosis and perceptions of knowledge about osteoporosis were ranked as variables predominantly influencing compliance and persistence in osteoporosis [12]. In a previous study undertaken to assess persistence with bisphosphonates and raloxifene and to identify determinants of adherence among women with osteoporosis in three different settings in Denmark, no differences in persistence were observed between University Hospitals and private practices [13]. However, in this study, persistence at 2 years was significantly higher than reported in other countries [14, 15], and the authors related the absence of differences observed between the three clinical settings to the high level of public information available on
(a) (b) (c) (d)
Personal and medical history collection, Physical examination, Explanation of the diagnosis and modalities, Administrative tasks.
treatment
The length and the time of onset of each phase was measured by a stopwatch and carefully recorded on a standardized checklist. Subsequently, the overall time spent by the patient in the physician’s office, as well as the respective duration of the various phases of the consultation were calculated. The number of questions asked by both parties was also recorded. Statistical analyses were performed using Graph Pad Prisma. Unpaired Student’s t test was selected to assess differences in means of continuous variables between public and private practices. A two-tailed p value of 0.05 was considered as the threshold of statistical significance.
Results Our population included 152 subjects, 97 women and 55 men. Mean age of the patients was 56 (females‘‘ 55, males’’ 58, range 44–88), whereas the 14 physicians had a mean age of 45 (range 35–59, 46 in the public, 44 in the private group). Gender distribution showed a 64 %/36 % and a 43 %/57 % female/male ratio for the patients and the doctors, respectively.
123
A. I. Gasparik.: Osteoporosis Patient and Physician
osteoporosis in Denmark [12], a situation which would significantly differ from the one existing in Romania. Our study does not integrate short- or long-term data on medication adherence in patients from the two clinical settings we investigated. Therefore, we cannot conclude that the significant differences, we observed in patient– doctor interaction between the private and public sectors in Romania, will result in differential outcomes for the patients. However, since patients treated in the private sector benefit from longer consultations, with, in particular, more time dedicated to health education, we can reasonably assume that those patients have a greater probability to adopt a healthy behavior and longer take their medications. These results support further investigation to assess whether the difference in patient and doctor behaviors in the public–private settings has a significant impact on lifestyle habits and therapeutic adherence and subsequently fracture reduction in patients receiving anti-osteoporosis treatment. Conflicts of Interest
None.
Human and Animal Rights and Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
References 1. Hiligsmann M, Boonen A, Rabenda V, Reginster JY (2012) The importance of integrating medication adherence into pharmacoeconomic analyses: the example of osteoporosis. Expert Rev Pharmacoecon Outcomes Res 12:159–166 2. Rabenda V, Reginster JY (2010) Overcoming problems with adherence to osteoporosis medications. Expert Rev Pharmacoecon Outcomes Res 10:677–689 3. Hiligsmann M, Rabenda V, Gathon HJ, Ethgen O, Reginster JY (2010) Potential clinical and economic impact of non-adherence with osteoporosis medications. Calcif Tissue Int 86:202–210
4. Lekkerkerker F, Kanis JA, Alsayed N, Bouvenot G, Burlet N, Cahall D, Chines A, Delmas P, Dreiser RL, Ethgen D, Hughes N, Kauman JM, Korte S, Kreutz G, Laslop A, Mitlak B, Rabenda V, Rizzoli R, Santora A, Schimmer R, Tsouderos Y, Viethel P, Reginster JY (2007) Adherence to treatment of osteoporosis: a need for study. Osteoporos Int 18:1311–1317 5. Papaioannou A, Kennedy CC, Dolovich L, Lau E, Adachi JD (2007) Patient adherence to osteoporosis medications: problems, consequences and management strategies. Drugs Aging 24:37–55 6. Riva S, Monti M, Iannello P, Pravettoni G, Schulz PJ, Antonietti A (2014) A preliminary mixed-method investigation of trust and hidden signals in medical consultations. PLoS One 11:e90941 7. Goold SD, Klipp G (2002) Managed care members talk about trust. Soc Sci Med 54:879–888 8. Marcinowicz L, Pawllkowska T, Konstantynowicz J, Chlabicz S (2014) New insight into the role of patients during medical appointments: a synthesis of three qualitative studies. Patient Mar. 25 [Epub ahead of print] 9. Deveugele M, Derese A, van den Btink-Muinen A, Bensing J, De Maeseneer J (2002) Consultation length in general practice: cross sectional study in six European countries. BMJ 325:472 10. Wilson A (1991) Consultation length in general practice: a review. Br J Gen Pract 41:119–122 11. Jensen AL, Lomborg K, Wind G, Langdahl BL (2014) Effectiveness and characteristics of multifaceted osteoporosis group education-a systematic review. Osteoporos Int 25:1209–1224 12. Huss D, Deblals F, Blotman F, Cortet B, mercier F, Rousseaux C, Berger V, Gaudin AF, Cotte FE (2010) Compliance and treatment satisfaction of post-menopausal women treated for osteoporosis. Compliance with osteoporosis treatment. BMC Womens Health 10:26 13. Nielsen DS, Langdahl BL, Sorensen OH, Sorensen HA, Brixen KT (2010) Persistence to medical treatment of osteoporosis in women at three different clinical settings—a historical cohort study. Scand J Public Health 38:502–507 14. Rabenda V, Mertens R, Fabri V, Vanoverloop J, Sumkay F, Vanneck C, Deswaef A, Verpooten GA, Reginster JY (2008) Adherence to bisphosphonates therapy and hip fracture risk in osteoporotic women. Osteoporos Int 19:811–818 15. Cramer JA, Amonkar MM, Hebborn A, Altman R (2005) Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis. Curr Med Res Opin 21:1453–1460
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