This article was downloaded by: [ECU Libraries] On: 24 April 2015, At: 22:19 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Health Communication Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hhth20
Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits ab
a
a
a
c
Betsy Sleath , Robyn Sayner , Susan J. Blalock , Delesha M. Carpenter , Kelly W. Muir , Mary d
e
fg
h
ij
E. Hartnett , Gail Tudor , Scott Lawrence , Annette L. Giangiacomo & Alan L. Robin a
Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy b
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill c
Department of Ophthalmology, School of Medicine, Duke University and Durham VA Medical Center
Click for updates
d
Department of Ophthalmology and Visual Sciences, University of Utah
e
Department of Science and Mathematics, Husson University
f
University of North Carolina Kittner Eye Center
g
Department of Ophthalmology, University of North Carolina at Chapel Hill
h
Department of Ophthalmology, Emory University School of Medicine
i
Department of International Health, Bloomberg School of Public Health, Johns Hopkins University School of Medicine j
Department of Ophthalmology, Johns Hopkins University School of Medicine Published online: 25 Jul 2014.
To cite this article: Betsy Sleath, Robyn Sayner, Susan J. Blalock, Delesha M. Carpenter, Kelly W. Muir, Mary E. Hartnett, Gail Tudor, Scott Lawrence, Annette L. Giangiacomo & Alan L. Robin (2015) Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits, Health Communication, 30:7, 660-668, DOI: 10.1080/10410236.2014.888387 To link to this article: http://dx.doi.org/10.1080/10410236.2014.888387
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
Downloaded by [ECU Libraries] at 22:19 24 April 2015
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Health Communication, 30: 660–668, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.888387
Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits Betsy Sleath
Downloaded by [ECU Libraries] at 22:19 24 April 2015
Division of Pharmaceutical Outcomes and Policy University of North Carolina Eshelman School of Pharmacy and Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill
Robyn Sayner, Susan J. Blalock, and Delesha M. Carpenter Division of Pharmaceutical Outcomes and Policy University of North Carolina Eshelman School of Pharmacy
Kelly W. Muir Department of Ophthalmology, School of Medicine Duke University and Durham VA Medical Center
Mary E. Hartnett Department of Ophthalmology and Visual Sciences University of Utah
Gail Tudor Department of Science and Mathematics Husson University
Scott Lawrence University of North Carolina Kittner Eye Center and Department of Ophthalmology University of North Carolina at Chapel Hill
Annette L. Giangiacomo Department of Ophthalmology Emory University School of Medicine
Alan L. Robin Department of International Health Bloomberg School of Public Health and Department of Ophthalmology Johns Hopkins University School of Medicine
Correspondence should be addressed to Betsy Sleath, Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 2212 Kerr Hall CB # 7573, Chapel Hill, NC 27599-7573. E-mail: [email protected]
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
661
Downloaded by [ECU Libraries] at 22:19 24 April 2015
We applied the ecologic model of communication in medical consultations to examine how patient, physician, and situational/contextual factors are associated with whether patients ask one or more questions about glaucoma and glaucoma medications during visits to ophthalmologists. Patients with glaucoma who were newly prescribed or already on glaucoma medications were recruited at six ophthalmology clinics. Patients’ visits with their doctors were videorecorded and patients were interviewed after visits. Generalized estimating equations were used to analyze the data. Two hundred and seventy-nine patients participated. Patients asked one or more questions about glaucoma during 59% of visits and about glaucoma medications during 48% of visits. Patients who were newly prescribed glaucoma medications were significantly more likely to ask one or more questions about glaucoma and glaucoma medications. Whether providers asked patients if they had questions was not significantly associated with patient question-asking. Patients were significantly more likely to ask older providers questions about glaucoma medications and female providers questions about glaucoma. Eye care providers should encourage glaucoma patients to ask questions during their medical visits.
Between 9 and 12% of all blindness in the United States is attributed to glaucoma (Glaucoma Research Foundation, 2010). The absence of symptoms in glaucoma patients increases the risk of regimen nonadherence among these patients. Approximately 50% of individuals who start on glaucoma medications discontinue them within 6 months (Nordstrom, Friedman, Mozaffari, Quigley, & Walker, 2005; Schwartz, Platt, Reardon, & Mychaskiw, 2007). Also, research has shown that continued users of glaucoma medications are nonadherent (Friedman et al., 2009; Muir et al., 2006; Sleath et al., 2006; Sleath, Blalock, Stone, et al., 2012). Further, even when patients attempt to adhere to their eye drop medications, research has shown that patient performance during eye drop administration is poor (Sleath, Blalock, Stone, et al., 2012; Stone, Robin, Novack, Covert, & Cagle, 2009). In a recent study where 140 experienced glaucoma patients were videotaped while instilling their eye drops, 18% of patients missed their eye when administering their drops, only 60% of patients correctly instilled the correct number of drops, and 65% of patients contaminated the bottle by touching it to the eye (Stone et al., 2008). Research has also shown that 60% or more of glaucoma patients express problems in using their glaucoma medications as prescribed (Sleath et al., 2006; Sleath et al., 2009; Sleath, Blalock, Covert, et al., 2012), including, paying for the medication, difficulty getting the drops in the eyes, reading the print on the bottle, and remembering to take the medication (Sleath et al., 2006; Sleath et al., 2009; Sleath, Blalock, Covert, et al., 2012). This suggests that many patients might have reasons to ask their ophthalmologists questions about their glaucoma and how to correctly use prescribed glaucoma medications, yet little is known about ophthalmologist–patient communication during glaucoma visits. Two qualitative studies found that glaucoma patients reported poor communication with their providers as negatively impacting adherence (Taylor et al., 2002; Tsai et al., 2003). Unfortunately, these studies did not investigate actual communication (Taylor et al., 2002; Tsai et al., 2003). Another prior study found that patients who reported being less likely to ask their eye doctor
questions during visits also reported being less adherent to their glaucoma medications (Stryker et al., 2010). One prior study that did examine ophthalmologist and patient communication during 51 videotaped glaucoma visits found that patients asked questions about the following topics most often during visits: intraocular pressure (20%), details about the medication regimen (20%), and disease status (14%) (Friedman et al., 2009). However, the study did not describe the types of questions asked in any detail, nor did it try to examine what factors predicted patient question-asking (Friedman et al., 2009). Patient question-asking is important because it is a form of active patient participation during medical visits where patients can ask for more information (Cegala, Street, & Clinch, 2007; Street, Gordon, Ward, Krupat, & Kravitz, 2005). Patient question-asking can potentially improve patient self-efficacy in managing glaucoma, because if patients ask questions about how to correctly use eye drops or resolve problems in using glaucoma medications, they can receive information from the doctor and gain more confidence in managing their glaucoma (Sleath et al., 2010; Sleath et al., 2011; Sleath, Blalock, Covert, et al., 2012). Patient activation has been found to increase patient satisfaction, perceived health, and adherence; decrease anxiety levels; and improve diabetes and hypertension management (Greenfield, Kaplan, Ware, Yano, & Frank, 1988; Harrington, Noble, & Newman, 2004; Katz, Jacobson, Veledar, & Kripalani 2007; Venetis, 2013). The theoretical rationale for this study is the ecologic model of communication in medical consultations (Street, 2003; Street et al., 2005). This model hypothesizes that the way patients communicate with physicians is influenced by personal, physician, and contextual factors (Street, 2003; Street et al., 2005). Personal factors could be the patient’s gender, race, age, health literacy (Street et al., 2005); physician factors could be age, gender, race; and contextual or situational factors could be if the physician asks the patient whether they have questions during the visit or it could be whether the visit is a follow-up or initial visit (Street, 2003; Street et al., 2005).
Downloaded by [ECU Libraries] at 22:19 24 April 2015
662
SLEATH ET AL.
Empirical research has provided support for Street’s model by documenting that personal, physician, and contextual factors all affect patient–provider communication. Regarding personal characteristics, non-White, workingclass, less educated, and low-literacy patients are all less likely to participate in the medical visit (Brody, 1989; Davis et al., 1993; Eggly et al., 2011; Street, Voigt, Geyer, Manning, & Swanson, 1995; Street et al., 2005; Waitzkin, 1985). Studies have found contradictory results in terms of how patient age impacts question-asking (Kidd, Marteau, Robinson, Ukoumunne, & Tydeman, 2004; Maly, Umezawa, Leake, & Silliman, 2004; Sleath, Roter, Chewning, & Svarstad, 1999; Sleath, Rubin, & Huston, 2003; Street et al., 1995). Regarding physician factors, patients seeing older physicians are significantly more likely to ask a question during medical visits (Aboumatar, Carson, Beach, Roter, & Cooper, 2013; Sleath et al., 1999; Sleath, Rubin, Campbell, Gwyther, & Clark, 2001; Sleath et al., 2003). In terms of situational factors, patients started on new medications are more likely to ask questions during medical visits (Sleath et al., 1999; Sleath et al., 2003). Therefore, the purpose of this study was to apply the ecologic model of communication in medical consultations (Street, 2003; Street et al., 2005) to examine how patient (age, gender, race, literacy, years of education), physician (age, gender, race), and situational (whether the physician asks the patient if they have questions during the visit, whether glaucoma medications are prescribed for the first time) factors are associated with whether patients ask one or more questions about glaucoma and one or more questions about glaucoma medications. METHODS Procedure English-speaking adult glaucoma patients were enrolled between 2009 and 2012 at six geographically distinct ophthalmology clinics located in four states. Two sites were private offices and four were affiliated with academic ophthalmology departments. At each site, clinic staff referred eligible patients to research assistants who were based at the clinics. Written patient and provider consent was obtained. Providers completed a short demographic questionnaire after providing consent. The patient’s medical visit was video-taped. Videotapes were kept if they fit into one of two criteria: (a) the patient was diagnosed with glaucoma and glaucoma medications were prescribed for the first time or (b) patients were already on glaucoma medications. Patients were interviewed after their medical visits. The study was approved by the University of North Carolina Institutional Review Board and was Health Insurance Portability and Accountability Act (HIPAA) compliant.
Measurement Sociodemographic characteristics. Patient age, race, gender, years of education, and whether the patient was prescribed a glaucoma medication for the first time were assessed. Additionally, each subject completed the Rapid Estimate of Adult Literacy in Medicine (REALM). This is a validated, rapid screening instrument designed to identify patients who have difficulty reading common medical and lay terms that are routinely used in patient education materials (Davis et al., 1993). We choose the REALM because it has high face validity and high criterion validity, it has been well received by patients, and it only takes 2 to 3 minutes to administer and score (Davis et al., 1993). Patient scores on the REALM correspond to reading levels (score of 0–60 = eighth grade and below, 61–66 = ninth grade and above). Physician age, gender, and race were measured. Communication measures. All of the medical visit videotapes were transcribed verbatim. A detailed transcript coding tool was developed over a 1-year period for the study using input from the communication experts and ophthalmologists on the study team. Using a detailed coding tool and coding rules for the transcribed medical visits, three research assistants (who were not the same research assistants who recruited the patients at the clinics) recorded whether patients asked one or more questions about glaucoma medications and whether they asked one or more questions about glaucoma. The coders also wrote down all of the actual questions that patients asked. The coders also noted whether the doctor asked whether the patient had any questions. The glaucoma and glaucoma medication question-asking coding categories were developed using the patient questionasking literature (Kidd et al., 2004; Maly et al., 2004; Sleath et al., 1999; Sleath et al., 2003; Street et al., 1995) and input received from the ophthlamologists on the study team. After the original categories were developed and defined, the patient questions were reviewed and the categories were further refined with input from the principal investigator and the research team. The questions were then classified into the categories described in Table 1. Patient questions about glaucoma medications were classified into five main areas: (a) information about glaucoma medications, including the name, strength, and side effects of the medication; (b) information about the medication regimen, such as dose, which eye(s) to instill the medication in, and frequency of use; (c) how to administer the medication, which includes questions about how to instill eye drops and about how long to wait between instilling two different eye drops; (d) cost or supply of the medication; and (e) information about the purpose or importance of using glaucoma medications and adherence strategies. If a question was asked that did not fit into these five categories, it was classified as an “other question about glaucoma medications.”
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
663
TABLE 1 Description of the Types of Patient Questions About Glaucoma Medications and Glaucoma Glaucoma Medication Question Category How to administer the glaucoma medication Medication regimen
Cost or supply
More detailed information about glaucoma medications Adherence strategies, purpose of using, and the importance of using glaucoma medications Other
Downloaded by [ECU Libraries] at 22:19 24 April 2015
Glaucoma Question Category More detailed information about glaucoma
Treatment of glaucoma, excluding questions about medications
Intraocular pressure (IOP) Other
Similarly, questions asked by patients about glaucoma were classified into three main areas: (a) information about the disease, including diagnosis and prognosis; (b) treatment options for glaucoma, such as whether to treat or to watch and wait, information about surgery versus medications, and the duration of glaucoma treatment; and (c) information about intraocular pressure (IOP), including the definition of it as well as what was the current IOP reading. If a patient question did not fit into the three main categories, it was categorized as an “other question about glaucoma.” The three research assistants coded 25 of the same transcripts throughout the study period. After the coders were trained using the coding rules and sheets, they met monthly to discuss discrepancies in coding to prevent coder decay. Intercoder reliability was calculated using Cohen’s kappa. Cohen’s kappa was 0.78 for whether the patient asked a question about glaucoma medications, 0.84 for whether the patient asked one or more questions about glaucoma, and 1.0 for whether the doctor asked if the patient had any questions. Analysis We set the a priori level of statistical significance to p < .05. First, we presented descriptive statistics. Second, we examined the bivariate relationships among the independent
Description Includes questions about the amount of time to wait between administering two eye medications and about the nasolacrimal occlusion Includes questions about the dose, frequency, which eye in which to instill the eye drop, whether to continue the current medication regimen, and the possibility of long-term use of glaucoma medications Includes various topics such as the cost of the medication, generic formulations, the need for refills, and how long a bottle of medication should last before needing a refill Includes questions such as the about the possible side effects of the medication and about the name of the medication Includes topics such as why glaucoma medications were prescribed and how to remember to take the medications consistently Includes various unusual topics such as patient concerns or barriers with using glaucoma medication, how well the glaucoma medication was working, and the use of nonglaucoma medications Description Includes questions about the diagnosis or prognosis of the patient’s glaucoma, and whether other health conditions, such as high blood pressure or diabetes, interfere with glaucoma Includes questions about the goals of treatment, the likelihood of long-term therapy, ways to manage glaucoma with surgery, and ways to manage glaucoma with lifestyle changes Includes questions about the current IOP measurement and how IOP relates to glaucoma Includes various unusual questions about the physical or emotional changes that occur with glaucoma
variables and between the independent and dependent variables using Pearson correlation coefficients, chi-squared statistics, and t-tests. We ran generalized estimating equations (GEE) to examine how patient age, patient gender, patient race, patient years of education, patient health literacy, whether the patient was newly prescribed glaucoma medication on the day of the medical visit, and physician age and gender were associated with (a) whether the patient asked one or more questions about glaucoma medications and (b) whether the patient asked one or more questions about glaucoma. Physician race could not be included in the multivariable analysis because there was only one non-White physician.
RESULTS Fifteen physicians who cared for glaucoma patients agreed to participate in the study; one physician refused to participate for a participation rate of 94%. Fourteen physicians were White and one was African American. Ten physicians were male (66.7%). The age of the physicians ranged from 26 to 66 years (M = 40.8 years, SD = 11.7 years). Eighty-six percent of eligible patients participated in the study. Table 2 presents the patient demographics. Patients asked one or more questions about glaucoma medications
664
SLEATH ET AL. TABLE 2 Subject Characteristics (N = 279) Percent (n)
Downloaded by [ECU Libraries] at 22:19 24 April 2015
Gender Male Female Race African American Non-African American Newly prescribed glaucoma medications at visit or was on glaucoma medications before visit Newly prescribed at visit Was on glaucoma medications before visit Rapid Estimate of Adult Literacy in Medicine (REALM) Eighth grade or lower Ninth grade or higher Age Years of education
40.9 (114) 59.1 (165) 35.5 (99) 64.2 (179)
18.3 (51) 81.7 (228)
14.0 (39) 84.2 (235) Range; M (SD) 21 to 93; 65.8 (12.8) 5 to 26; 15.1 (3.5)
during 59% of the visits. Eighty percent of patients who were newly started on a glaucoma medication asked one or more questions, compared to 55% of those who were already on glaucoma medications. The number of questions about glaucoma medications that patients asked during their medical visit ranged from 0 to 16 (M = 1.7, SD = 2.4). Table 3 presents the types of glaucoma medication questions asked by patients who were newly prescribed glaucoma medications at the medical visit compared to those already taking a glaucoma medication. Twenty-three percent of new users compared to 8% of continued users asked one or more questions about how to administer their glaucoma medications (Pearson χ 2 = 9.7, p = .002). Thirty-seven
percent of new users compared to 14% of continued users asked for more information on the glaucoma medications such as the name of the medication or what the side effects are (Pearson χ 2 = 15.9, p = .000). Fifty-five percent of new users compared to 29% of continued users asked one or more questions about the glaucoma medication regimen, such as which eye to use the medication in or how many drops to use each time (Pearson χ 2 = 12.6, p = .000). Seventeen percent of new users asked about adherence, the purpose of the medication, or the importance of using glaucoma medications compared to 6% of continued users (Pearson χ 2 = 8.2, p = .0004). Patients asked one or more questions about glaucoma in 48% of visits. Sixty-nine percent of patients who were newly prescribed glaucoma medications asked a question about glaucoma compared to 45% who were on continued medications. The number of questions about glaucoma asked by the patients during their medical visit ranged from 0 to 17 (M = 1.3, SD = 2.0). Table 3 presents the types of glaucoma questions asked by patients who were newly prescribed glaucoma medications versus those already taking a glaucoma medication. Thirtyseven percent of new users compared to 8% of continued users asked one or more questions requesting more detailed information on glaucoma (Pearson χ 2 = 32.9, p = .000). Providers asked if the patients had questions during 51% of the videotaped medical visits. This was not associated with patients asking at least one question about glaucoma medications (Pearson χ 2 = 2.114; p = .146), or with patients asking at least one question about glaucoma (Pearson χ 2 = 2.679; p = .102). Table 4 presents the GEE results predicting whether patients asked one or more questions about glaucoma
TABLE 3 Categorization of Patient Questions That Were Asked About Glaucoma Medications and Glaucoma During the Medical Office Visit (N = 279) Patients Prescribed Glaucoma Medications for First Time During the Medical Visit (n = 51) Percent (n) of Patients Who Asked a Question Glaucoma medication question category How to administer glaucoma medications Glaucoma medication regimen Cost or supply of glaucoma medications More detailed information about glaucoma medications Adherence, purpose, or the importance of using glaucoma medications Glaucoma question category Treatment of glaucoma excluding glaucoma medications More detailed information about glaucoma Intraocular pressure ∗∗ Significant
at p < .01, Pearson χ 2 . at p < .001, Pearson χ 2 .
∗∗∗ Significant
Patients on Glaucoma Medications Before the Medical Visit (n = 228)
Number of Questions Asked
Percent (n) of Patients Who Asked a Question
Number of Questions Asked
23.5 (12) 54.9 (28) 21.6 (11) 37.3 (19) 17.6 (9)
16 49 20 31 16
8.3 (19)∗∗ 28.9 (66)∗∗∗ 12.3 (28) 13.6 (31)∗∗∗ 5.7 (13)∗∗∗
27 104 45 32 16
15.7 (8)
15
13.2 (30)
40
37.3 (19) 23.5 (12)
68 18
7.5 (17)∗∗∗ 25.9 (59)
84 87
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
665
TABLE 4 Generalized Estimating Equation Results Predicting Whether Patient Asked One or More Questions About Glaucoma or Glaucoma Medications (N = 279) Independent Variable Patient age Patient gender, female Patient race, African American Patient, years of education REALM, reads at eighth grade level or less Newly prescribed glaucoma medications versus already on glaucoma medications Physician age Physician gender, female Physician asking whether patient had any questions during medical visit ∗ Significant
Glaucoma Medications, OR (95% CI)
Glaucoma, OR (95% CI)
1.01 (0.99 − 1.04) 1.29 (0.71 − 2.33) 0.76 (0.44 − 1.32) 1.04 (0.96 − 1.14) 0.85 (0.46 − 1.57) 3.21 (1.68 − 6.12)∗∗ 1.03 (1.01 − 1.06)∗ 1.99 (0.83 − 4.79) 1.01 (0.65 − 1.57)
1.00 (0.99 − 1.02) 1.51 (0.84 − 2.71) 0.69 (0.45 − 1.07) 1.06 (0.97 − 1.17) 1.44 (0.75 − 2.76) 2.46 (1.58 − 3.82)∗∗ 1.02 (0.99 − 1.04) 2.85 (1.75 − 4.65)∗∗ 0.98 (0.64 − 1.48)
at p < .05. at p < .01.
Downloaded by [ECU Libraries] at 22:19 24 April 2015
∗∗ Significant
medications and one or more questions about glaucoma. None of the patient personal factors were associated with patient question-asking about glaucoma medications or glaucoma. In terms of provider factors, patients were significantly more likely to ask questions about glaucoma medications to older physicians (OR: 1.03, 95% CI: 1.01–1.06), and they were significantly more likely to ask questions about glaucoma to female physicians (OR: 2.85, 95% CI: 1.75–4.65). In terms of contextual factors, those who were newly prescribed glaucoma medications were significantly more likely to ask questions about glaucoma medications (OR: 3.21, 95% CI: 1.68–6.12) and glaucoma (OR: 2.46, 95% CI 1.58–3.82). However, the other contextual factor we examined, whether the physician asked the patients whether they had any questions, was not significantly associated with patient question-asking.
DISCUSSION As predicted by the ecological model of communication (Street et al., 2003; Street et al., 2005), we found that a contextual factor (a patient being prescribed a glaucoma medication for the first time versus being a continued user) was significantly associated with patient question-asking about glaucoma and glaucoma medications. Specifically, patients who were newly prescribed glaucoma medications during the visit were more than twice as likely to ask questions about glaucoma than patients on continued medications. This is in contrast to Cegala (2011), who found that patient status (new vs. returning patient) was not significantly associated with patient participation during visits. Cegala (2011) posits that they did not have enough new patients in their sample to see a difference by patient status. We did have enough patients new to glaucoma medications to see a significant effect. Surprisingly, the contextual factor of whether providers asked patients whether they had questions was not significantly associated with patient question-asking. It makes sense that patients prescribed a new glaucoma medication would be more likely to ask one or more
questions about glaucoma because they want to learn more about the disease. However, it is also important to encourage all patients to ask questions during glaucoma visits so that they can better understand their disease and increase their confidence or self-efficacy in managing their glaucoma (Sleath et al., 1999; Sleath et al., 2006; Sleath et al., 2009; Sleath, Blalock, Stone, et al., 2012). In addition, a previous study found that patients who reported being more likely to ask questions during glaucoma visits also reported being more adherent to their glaucoma medications (Stryker et al., 2010), further supporting the importance of encouraging patients to ask questions. Similar to previous studies (Sleath et al., 1999; Sleath et al., 2003), patients who were newly prescribed glaucoma medications were three times more likely to ask one or more questions about glaucoma medications. It is important for providers to encourage patients on continued medications to ask questions because they may have experienced side effects or difficulties adhering to the medication. If so, the provider can then help the patient address these issues by giving advice or recommendations. Provider advice on side effects may be particularly salient for patients, since prior research has shown that patients realize when they are experiencing adverse events associated with glaucoma medications, such as sedation, asthma, elevation of plasma levels, or systemic hypotension (Derick et al., 1997; Freedman et al., 1993; Lee, Wang, Kifley, & Mitchell, 2006). Provider advice on adherence may also be useful to patients since prior research has documented that patients on continued medications have adherence problems and they report difficulties in using their medications (Muir et al., 2006; Sleath et al., 2006; Sleath et al., 2009). Providers could ask patient questions like “What problems are you having in using your medications?” or “How are you doing with using your eye drops?” to encourage patients to ask questions. Providers could also ask patients to demonstrate how they use their eye drops and correct and educate the patients on how to improve any mistakes the patients make. Prior work has found that patient administration of eye drops is poor (Robin et al., 2007; Sleath, Blalock, Stone, et al., 2012).
Downloaded by [ECU Libraries] at 22:19 24 April 2015
666
SLEATH ET AL.
We found that another contextual factor, providers asking patients “if they had any questions,” was not significantly associated with patients asking questions. Providers asking patients whether they have questions could be considered a proxy measure of whether the provider was patient-centered. Thus, our finding that eliciting patient questions (i.e., provider patient-centeredness) was unrelated to patient participation (i.e., patient question-asking) runs counter to Street’s model, including previous studies that have linked provider patient-centeredness to patient participation (Cegala, 2011). We argue that simply asking patients if they have questions is not patient-centered enough, which may be why this provider behavior was not associated with greater patient question-asking. Patients may have difficulty thinking of questions they want to ask during the medical encounter, so additional prompting by the provider could help patients think of the questions they want to ask. For example, providers could instead say something like “Many people with glaucoma tell me they have trouble using their eye drops. Do you have any questions about using your eye drops?” or “People with glaucoma often have trouble understanding what intraocular pressure is. Do you have any questions about glaucoma or intraocular pressure?” Abraham, Naik, and Street (2012) suggest that one partnership-building way to request patient questions is to say “Tell me more about that.” Providers could ask patients to tell them more about specific topics, such as administering and adhering to eye drops, to provide additional patient-centered probes and encourage patient participation. In further support of the ecological model of health communication, we did find that provider factors significantly influenced patient question-asking (Street et al., 2005). Glaucoma patients were significantly more likely to ask older providers about glaucoma medications than younger providers. This finding is similar to the findings of other researchers (Aboumatar et al., 2013; Sleath et al., 1999; Sleath et al., 2001; Sleath et al., 2003). More work is needed to better understand why patients are more likely to ask older providers questions. Is it because older physicians are doing something different during the visits (either verbally or nonverbally) that causes patients to feel more comfortable asking questions? Or is it because patients perceive older physicians differently than younger physicians and this makes patients feel more comfortable asking older physicians questions? Future work applying the ecological model of communication should also assess how patient perceptions of physicians influence whether patients ask questions during medical visits. Patients were also significantly more likely to ask female providers about glaucoma than male providers. This is contrary to prior work that found that patients were significantly more likely to ask male physicians questions about over-thecounter medications (Sleath et al., 2001). Studies conducted by Cegala (2011) and Street (2005) did not find that provider gender was significantly associated with patient participation
during visits, and Cegala (2011) attributes this to the fact that both studies included patient centeredness as a predictor variable. It could be that in our study female providers had a more patient-centered communication style with patients or they were perceived as less threatening by patients who wanted to ask questions. Future research should examine whether female and male physicians differ in other aspects of patient-centered communication, because we only assessed whether providers asked patients if they had any questions. In addition, future research should also examine whether patient perceptions of female versus male providers are different and whether this influences patient question-asking. We did not find that any patient factors significantly influenced patient question-asking. Unlike prior research (Aboumatar et al., 2013; Eggly et al., 2011; Sleath et al., 2001; Street et al., 1995; Street et al., 2005; Waitzkin, 1985), we did not find that health literacy, race, or years of education were significantly associated with patients asking one or more questions about glaucoma or glaucoma medications. Therefore, our study did not find support for the part of the ecological model of communication that posits that patient factors such as race and literacy can influence patient participation during visits (Street et al., 2003; Street et al., 2005). Our finding that patient race was not associated with patient question-asking is similar to what other researchers have found when applying the ecological model (Cegala, 2011; Street et al., 2005). We may not have found an association between literacy and patient question-asking because only 14% of our sample read at the eighth-grade level or below according to the REALM. Future work should include more patients with limited health literacy in their samples. Our research provides support for the relevance of applying the ecologic model of communication in specialty settings like ophthalmology clinics. Our finding that being newly prescribed a glaucoma medication influenced patient question-asking about both glaucoma and glaucoma medications is important because it illustrates patient willingness to ask questions when starting a new treatment. However, it is important to make sure that patients ask questions they might have at any point when using medications because research has found that approximately 50% of individuals who start on glaucoma medications discontinue them within 6 months (Nordstrom, Friedman, Mozaffari, Quigley, & Walker, 2005; Schwartz, Platt, Reardon, & Mychaskiw, 2007) and that patient performance when administering eye drops is poor (Stone, Robin, Novack, Covert, & Cagle, 2009; Sleath, Blalock, Stone, et al., 2012). Future research should examine what questions patients might have about their disease and its treatment and compare it to the actual questions that patients ask their providers. In addition, we found that physician age and gender influenced patient question-asking during glaucoma visits. This indicates that more work is needed to better understand how physician characteristics influence patient questionasking during medical visits. Do physician characteristics
Downloaded by [ECU Libraries] at 22:19 24 April 2015
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
influence patient perceptions of their physicians and therefore their question-asking behavior or do certain physician verbal or nonverbal behaviors facilitate or inhibit patient question-asking? More research is needed. A systematic review of trials to improve provider– patient communication during medical visits found that simple approaches to increasing patient participation during visits, such as providing doctors a note from patients about their concerns before visits, showed promise at increasing patient involvement (Griffin et al., 2004). There have been two prior intervention studies conducted in ophthalmology that successfully improved the communication skills of ophthalmologists to be more patient-centered (Hahn et al., 2010; Vegni, 2004). Future research in the glaucoma area should design interventions focused on the patient that encourage patients to ask questions and be more actively involved during the visits. This study has several limitations. Providers and patients both knew the visit was being recorded but they did not know the study hypotheses. Selection bias could be another limitation, since the ancillary staff did not track the characteristics of the few patients who declined to speak with the research assistant to learn more about the study. Despite these limitations, the study presents important new information on what patient, physician, and contextual factors were associated with patient question-asking about glaucoma and glaucoma medications. When applying the ecologic model of communication, we found that patients were significantly more likely to ask questions about glaucoma and glaucoma medications when newly prescribed glaucoma medications. Eye care providers should encourage glaucoma patients to ask questions during all types of visits because patients on continued medications might have questions about barriers to using eye drops. Additionally, we found that patients were significantly more likely to ask older providers about glaucoma medications and female providers about glaucoma. Future research should explore in more detail how provider characteristics influence patient question-asking.
FUNDING This work was supported by grant EY018400 from the National Eye Institute and by grant UL 1RR02574 7 from the National Center of Research Resources, National Institutes of Health (NIH). NIH had no role in the design or conduct of this research. REFERENCES Aboumatar, H. J., Carson, K. A., Beach, M. C., Roter, D. L., & Cooper, L. A. (2013). The impact of health literacy on desire of participation in healthcare, medical visit communication, and patient reported outcomes among patients with hypertension. Journal of General Internal Medicine, 11, 1469–1476.
667
Abraham, N. S., Naik, A. D., & Street, R. L. (2012). Shared decision making in GI clinic to improve patient adherence. Clinical Gastroenterology Hematology, 10, 825–827. Brody, D. S. (1989). Patient perception of involvement in medical care: Relationship to illness attitudes and outcomes. Journal of General Internal Medicine, 4, 506–511. Cegala, D. J. (2011). An exploration of factors promoting patient participation in primary care medical interviews. Health Communication, 26, 427–436. Cegala, D. J., Street, R. L., & Clinch, C. R. (2007). The impact of patient participation on physicians’ information provision during a primary care medical interview. Health Communication, 2, 177–185. Davis, T. C., Long, S. W., Jackson, R. H., Mayeaux, E. J., George, R. B., Murphy, P. W., & Crouch, M. A. (1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25, 391–395. Derick, R. J., Robin, A. L., Walters, T. R., Barnebey, H. S., Choplin, N., Schuman, J., . . . Stoecker, J. F. (1997). Brimonidine tartrate: A one-month dose response study. Ophthalmology, 104, 131–136. Eggly, S., Harper, J. W. K., Penner, L. A., Gleason, M. J., Foster, T., & Albrecht, T. L. (2011). Variation in question-asking during cancer clinical interactions: A potential source of disparities in access to information. Patient Education and Counseling, 82, 63–68. Freedman, S. F., Freedman, N. J., Shields, M. B., Lobaugh, B., Samsa, G. P., Keates, E. U., & Ollie, A. (1993). Effects of ocular carteolol and timolol on plasma high-density lipoprotein cholesterol level. American Journal of Ophthalmology, 116, 600–611. Friedman, D. S., Hahn, S. R., Quigley, H. A., Kotak, S., Kim, E., Onofrey, M., . . . Mardekian, J. (2009). Doctor-patient communication in glaucoma care: Analysis of video-taped encounters in community-based office practice. Ophthalmology, 116, 2277–2285. Glaucoma Research Foundation. (2010). Glaucoma facts and stats. Retrieved from http://www.glaucoma.org/learn/glaucoma-facts-andstats.php Greenfield, S., Kaplan, S. H., Ware, J. E., Yano, E. M., & Frank, H. J. (1988). Patients’ participation in medical care: Effects on blood sugar control and quality of life in diabetes. Journal of General Internal Medicine, 3, 448– 457. Griffin, S. J., Kinmonth, A. L., Veltman, M. W. M., Gillard, S., Grant, J., & Stewart, M. (2004). Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: A systematic review of trials. Annals of Family Medicine, 2, 595–607. Hahn, S. R., Friedman, D. S., Quigley, H. A., Kotak, S., Kim, E., Onofrey, M., . . . Mardekian, J. (2010). Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma. Ophthalmology, 117, 1339–1347. Harrington, J., Noble, L. M., & Newman, S. P. (2004). Improving patients’ communication with doctors: A systematic review of intervention studies. Patient Education and Counseling, 52, 7–16. Katz, M. G., Jacobson, T. A., Veledar, E., & Kripalani, S. (2007). Patient literacy and question-asking behavior during the medical encounter: A mixed-methods analysis. Society of General Internal Medicine, 22, 782– 786. Kidd, J., Marteau, T. M., Robinson, S., Ukoumunne, O. C., & Tydeman, C. (2004). Promoting patient participation in consultations: A randomized controlled trial to evaluate the effectiveness of three patient-focused interventions. Patient Education and Counseling, 52, 107–112. Lee, A. J., Wang, J. J., Kifley, A., & Mitchell, P. (2006). Open-angle glaucoma and cardiovascular mortality: The Blue Mountains Eye Study. Ophthalmology, 113, 1069–1076. Maly, R. C., Umezawa, Y., Leake, B., & Silliman, R. A. (2004). Determinants of participation in treatment decision-making by older breast cancer patients. Breast Cancer Research Treatment, 85, 207–209. Muir, K. W., Santiago-Turla, C., Stinnett, S. S., Herndon, L. W., Allingham, R. R., Challa, P., & Lee, P. P. (2006). Health literacy and adherence to glaucoma therapy. American Journal of Ophthalmology, 142, 223–226.
Downloaded by [ECU Libraries] at 22:19 24 April 2015
668
SLEATH ET AL.
Nordstrom, B. L., Friedman, D. S., Mozaffari, E., Quigley, H. A., & Walker, A. M. (2005). Persistence and adherence with topical glaucoma therapy. American Journal of Ophthalmology, 140, 598–606. Robin, A. L., Novack, G. D., Covert, D. W., Crockett, R. S., & Marcic, T. S. (2007). Adherence in glaucoma: Objective measurements of once-daily and adjunctive medication use. American Journal of Ophthalmology, 144, 533–540. Schwartz, G. F., Platt, R., Reardon, G., & Mychaskiw, M. A. (2007). Accounting for restart rates in evaluating persistence with ocular hypotensives. Ophthalmology, 114, 648–652. Sleath, B., Ballinger, R., Covert, D., Robin, A. L., Byrd, J. E., & Tudor, G. (2009). Self-reported prevalence and factors associated with nonadherence with glaucoma medications in veteran outpatients. American Journal of Geriatric Pharmacotherapy, 7, 67–73. Sleath, B., Blalock, S. J., Covert, D., Skinner, A. C., Muir, K., & Robin, A. L. (2012). Patient race, reported problems in using glaucoma medications, and adherence. ISRN Ophthalmology, 2012, Article 902819. Retrieved from http://www.hindawi.com/isrn/ophthalmology/ 2012/902819 Sleath, B., Blalock, S., Covert, D., Stone, J. L., Skinner, A. C., Muir, K., & Robin, A. L. (2011). The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology, 118, 2398–2402. Sleath, B., Blalock, S. J., Robin, A., Hartnett, M. E., Covert, D., DeVellis, B., & Giangiacomo, A. (2010). Development of an instrument to measure glaucoma medication self-efficacy and outcome expectations. Eye (London), 24, 624–631. Sleath, B., Blalock, S. J., Stone, J. L., Skinner, A. C., Covert, D., Muir, K., & Robin, A. L. (2012). Validation of a short version of the glaucoma medication self-efficacy questionnaire. British Journal of Ophthalmology, 96, 258–262. Sleath, B., Robin, A. L., Covert, D., Byrd, J. E., Tudor, G., & Svarstad, B. (2006). Patient-reported behavior and problems in using glaucoma medications. Ophthalmology, 113, 431–436. Sleath, B., Roter, D., Chewning, B., & Svarstad, B. (1999). Asking questions about medication: Analysis of physician-patient interactions and physician perceptions. Medical Care, 37, 1169–1173.
Sleath, B., Rubin, R. H., Campbell, W., Gwyther, L., & Clark, T. (2001). Physician-patient communication about over-the-counter medications. Social Science & Medicine, 53, 357–369. Sleath, B., Rubin, R. H., & Huston, S. A. (2003). Hispanic ethnicity, physician-patient communication, and antidepressant adherence. Comprehensive Psychiatry, 44, 198–204. Stone, J. L., Robin, A. L., Novack, G. D., Covert, D. W., & Cagle, G. D. (2009). An objective evaluation of eyedrop instillation in patients with glaucoma. Archives of Ophthalmology, 127, 732–736. Street, R. L., Jr. (2003). Communication in medical encounters: An ecological perspective. In T. Thompson, A. Dorsey, K. T. Miller, & R. Parrott (Eds.), The handbook of health communication (pp. 63–89). Mahwah, NJ: Lawrence Erlbaum Associates. Street, R. L., Gordon, H. S., Ward, M. M., Krupat, E., & Kravitz, R. L. (2005). Patient participation in medical consultations: Why some patients are more involved than others. Medical Care, 43, 960–969. Street, R. L., Voigt, B., Geyer, C., Manning, T., & Swanson, G. P. (1995). Increasing patient involvement in choosing treatment for early breast cancer. Cancer, 76, 2275–2285. Stryker, J. E., Beck, A. D., Primo, S. A., Echt, K. V., Bundy, L., Pretorius, G. C., & Glanz, K. (2010). An exploratory study of factors influencing glaucoma treatment adherence. Journal of Glaucoma, 19, 66–72. Taylor, S. A., Galbraith, S. M., & Mills, R. P. (2002). Causes of non-compliance with drug regimens in glaucoma patients: A qualitative study. Journal of Ocular Pharmacology and Therapeutics, 18, 401–409. Tsai, J. C., McClure, C. A., Ramos, S. E., Schlundt, D. G., & Pichert, J. W. (2003). Compliance barriers in glaucoma: A systematic classification. Journal of Glaucoma, 12, 393–398. Vegni, E., & Moja, E. A. (2004). Effects of a course on ophthalmologist communication skills: A pilot study. Education for Health, 17, 163–171. Venetis, M. K., Robinson, J. D., & Kearney, T. (2013). Consulting with a surgeon before breast cancer surgery: Patient question-asking and satisfaction. Journal of Health Communication, 18, 943–959. Waitzkin, H. (1985). Information giving in medical care. Journal of Health and Social Behavior, 26, 81–101.
Health Communication Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hhth20
Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits ab
a
a
a
c
Betsy Sleath , Robyn Sayner , Susan J. Blalock , Delesha M. Carpenter , Kelly W. Muir , Mary d
e
fg
h
ij
E. Hartnett , Gail Tudor , Scott Lawrence , Annette L. Giangiacomo & Alan L. Robin a
Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy b
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill c
Department of Ophthalmology, School of Medicine, Duke University and Durham VA Medical Center
Click for updates
d
Department of Ophthalmology and Visual Sciences, University of Utah
e
Department of Science and Mathematics, Husson University
f
University of North Carolina Kittner Eye Center
g
Department of Ophthalmology, University of North Carolina at Chapel Hill
h
Department of Ophthalmology, Emory University School of Medicine
i
Department of International Health, Bloomberg School of Public Health, Johns Hopkins University School of Medicine j
Department of Ophthalmology, Johns Hopkins University School of Medicine Published online: 25 Jul 2014.
To cite this article: Betsy Sleath, Robyn Sayner, Susan J. Blalock, Delesha M. Carpenter, Kelly W. Muir, Mary E. Hartnett, Gail Tudor, Scott Lawrence, Annette L. Giangiacomo & Alan L. Robin (2015) Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits, Health Communication, 30:7, 660-668, DOI: 10.1080/10410236.2014.888387 To link to this article: http://dx.doi.org/10.1080/10410236.2014.888387
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
Downloaded by [ECU Libraries] at 22:19 24 April 2015
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Health Communication, 30: 660–668, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.888387
Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits Betsy Sleath
Downloaded by [ECU Libraries] at 22:19 24 April 2015
Division of Pharmaceutical Outcomes and Policy University of North Carolina Eshelman School of Pharmacy and Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill
Robyn Sayner, Susan J. Blalock, and Delesha M. Carpenter Division of Pharmaceutical Outcomes and Policy University of North Carolina Eshelman School of Pharmacy
Kelly W. Muir Department of Ophthalmology, School of Medicine Duke University and Durham VA Medical Center
Mary E. Hartnett Department of Ophthalmology and Visual Sciences University of Utah
Gail Tudor Department of Science and Mathematics Husson University
Scott Lawrence University of North Carolina Kittner Eye Center and Department of Ophthalmology University of North Carolina at Chapel Hill
Annette L. Giangiacomo Department of Ophthalmology Emory University School of Medicine
Alan L. Robin Department of International Health Bloomberg School of Public Health and Department of Ophthalmology Johns Hopkins University School of Medicine
Correspondence should be addressed to Betsy Sleath, Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 2212 Kerr Hall CB # 7573, Chapel Hill, NC 27599-7573. E-mail: [email protected]
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
661
Downloaded by [ECU Libraries] at 22:19 24 April 2015
We applied the ecologic model of communication in medical consultations to examine how patient, physician, and situational/contextual factors are associated with whether patients ask one or more questions about glaucoma and glaucoma medications during visits to ophthalmologists. Patients with glaucoma who were newly prescribed or already on glaucoma medications were recruited at six ophthalmology clinics. Patients’ visits with their doctors were videorecorded and patients were interviewed after visits. Generalized estimating equations were used to analyze the data. Two hundred and seventy-nine patients participated. Patients asked one or more questions about glaucoma during 59% of visits and about glaucoma medications during 48% of visits. Patients who were newly prescribed glaucoma medications were significantly more likely to ask one or more questions about glaucoma and glaucoma medications. Whether providers asked patients if they had questions was not significantly associated with patient question-asking. Patients were significantly more likely to ask older providers questions about glaucoma medications and female providers questions about glaucoma. Eye care providers should encourage glaucoma patients to ask questions during their medical visits.
Between 9 and 12% of all blindness in the United States is attributed to glaucoma (Glaucoma Research Foundation, 2010). The absence of symptoms in glaucoma patients increases the risk of regimen nonadherence among these patients. Approximately 50% of individuals who start on glaucoma medications discontinue them within 6 months (Nordstrom, Friedman, Mozaffari, Quigley, & Walker, 2005; Schwartz, Platt, Reardon, & Mychaskiw, 2007). Also, research has shown that continued users of glaucoma medications are nonadherent (Friedman et al., 2009; Muir et al., 2006; Sleath et al., 2006; Sleath, Blalock, Stone, et al., 2012). Further, even when patients attempt to adhere to their eye drop medications, research has shown that patient performance during eye drop administration is poor (Sleath, Blalock, Stone, et al., 2012; Stone, Robin, Novack, Covert, & Cagle, 2009). In a recent study where 140 experienced glaucoma patients were videotaped while instilling their eye drops, 18% of patients missed their eye when administering their drops, only 60% of patients correctly instilled the correct number of drops, and 65% of patients contaminated the bottle by touching it to the eye (Stone et al., 2008). Research has also shown that 60% or more of glaucoma patients express problems in using their glaucoma medications as prescribed (Sleath et al., 2006; Sleath et al., 2009; Sleath, Blalock, Covert, et al., 2012), including, paying for the medication, difficulty getting the drops in the eyes, reading the print on the bottle, and remembering to take the medication (Sleath et al., 2006; Sleath et al., 2009; Sleath, Blalock, Covert, et al., 2012). This suggests that many patients might have reasons to ask their ophthalmologists questions about their glaucoma and how to correctly use prescribed glaucoma medications, yet little is known about ophthalmologist–patient communication during glaucoma visits. Two qualitative studies found that glaucoma patients reported poor communication with their providers as negatively impacting adherence (Taylor et al., 2002; Tsai et al., 2003). Unfortunately, these studies did not investigate actual communication (Taylor et al., 2002; Tsai et al., 2003). Another prior study found that patients who reported being less likely to ask their eye doctor
questions during visits also reported being less adherent to their glaucoma medications (Stryker et al., 2010). One prior study that did examine ophthalmologist and patient communication during 51 videotaped glaucoma visits found that patients asked questions about the following topics most often during visits: intraocular pressure (20%), details about the medication regimen (20%), and disease status (14%) (Friedman et al., 2009). However, the study did not describe the types of questions asked in any detail, nor did it try to examine what factors predicted patient question-asking (Friedman et al., 2009). Patient question-asking is important because it is a form of active patient participation during medical visits where patients can ask for more information (Cegala, Street, & Clinch, 2007; Street, Gordon, Ward, Krupat, & Kravitz, 2005). Patient question-asking can potentially improve patient self-efficacy in managing glaucoma, because if patients ask questions about how to correctly use eye drops or resolve problems in using glaucoma medications, they can receive information from the doctor and gain more confidence in managing their glaucoma (Sleath et al., 2010; Sleath et al., 2011; Sleath, Blalock, Covert, et al., 2012). Patient activation has been found to increase patient satisfaction, perceived health, and adherence; decrease anxiety levels; and improve diabetes and hypertension management (Greenfield, Kaplan, Ware, Yano, & Frank, 1988; Harrington, Noble, & Newman, 2004; Katz, Jacobson, Veledar, & Kripalani 2007; Venetis, 2013). The theoretical rationale for this study is the ecologic model of communication in medical consultations (Street, 2003; Street et al., 2005). This model hypothesizes that the way patients communicate with physicians is influenced by personal, physician, and contextual factors (Street, 2003; Street et al., 2005). Personal factors could be the patient’s gender, race, age, health literacy (Street et al., 2005); physician factors could be age, gender, race; and contextual or situational factors could be if the physician asks the patient whether they have questions during the visit or it could be whether the visit is a follow-up or initial visit (Street, 2003; Street et al., 2005).
Downloaded by [ECU Libraries] at 22:19 24 April 2015
662
SLEATH ET AL.
Empirical research has provided support for Street’s model by documenting that personal, physician, and contextual factors all affect patient–provider communication. Regarding personal characteristics, non-White, workingclass, less educated, and low-literacy patients are all less likely to participate in the medical visit (Brody, 1989; Davis et al., 1993; Eggly et al., 2011; Street, Voigt, Geyer, Manning, & Swanson, 1995; Street et al., 2005; Waitzkin, 1985). Studies have found contradictory results in terms of how patient age impacts question-asking (Kidd, Marteau, Robinson, Ukoumunne, & Tydeman, 2004; Maly, Umezawa, Leake, & Silliman, 2004; Sleath, Roter, Chewning, & Svarstad, 1999; Sleath, Rubin, & Huston, 2003; Street et al., 1995). Regarding physician factors, patients seeing older physicians are significantly more likely to ask a question during medical visits (Aboumatar, Carson, Beach, Roter, & Cooper, 2013; Sleath et al., 1999; Sleath, Rubin, Campbell, Gwyther, & Clark, 2001; Sleath et al., 2003). In terms of situational factors, patients started on new medications are more likely to ask questions during medical visits (Sleath et al., 1999; Sleath et al., 2003). Therefore, the purpose of this study was to apply the ecologic model of communication in medical consultations (Street, 2003; Street et al., 2005) to examine how patient (age, gender, race, literacy, years of education), physician (age, gender, race), and situational (whether the physician asks the patient if they have questions during the visit, whether glaucoma medications are prescribed for the first time) factors are associated with whether patients ask one or more questions about glaucoma and one or more questions about glaucoma medications. METHODS Procedure English-speaking adult glaucoma patients were enrolled between 2009 and 2012 at six geographically distinct ophthalmology clinics located in four states. Two sites were private offices and four were affiliated with academic ophthalmology departments. At each site, clinic staff referred eligible patients to research assistants who were based at the clinics. Written patient and provider consent was obtained. Providers completed a short demographic questionnaire after providing consent. The patient’s medical visit was video-taped. Videotapes were kept if they fit into one of two criteria: (a) the patient was diagnosed with glaucoma and glaucoma medications were prescribed for the first time or (b) patients were already on glaucoma medications. Patients were interviewed after their medical visits. The study was approved by the University of North Carolina Institutional Review Board and was Health Insurance Portability and Accountability Act (HIPAA) compliant.
Measurement Sociodemographic characteristics. Patient age, race, gender, years of education, and whether the patient was prescribed a glaucoma medication for the first time were assessed. Additionally, each subject completed the Rapid Estimate of Adult Literacy in Medicine (REALM). This is a validated, rapid screening instrument designed to identify patients who have difficulty reading common medical and lay terms that are routinely used in patient education materials (Davis et al., 1993). We choose the REALM because it has high face validity and high criterion validity, it has been well received by patients, and it only takes 2 to 3 minutes to administer and score (Davis et al., 1993). Patient scores on the REALM correspond to reading levels (score of 0–60 = eighth grade and below, 61–66 = ninth grade and above). Physician age, gender, and race were measured. Communication measures. All of the medical visit videotapes were transcribed verbatim. A detailed transcript coding tool was developed over a 1-year period for the study using input from the communication experts and ophthalmologists on the study team. Using a detailed coding tool and coding rules for the transcribed medical visits, three research assistants (who were not the same research assistants who recruited the patients at the clinics) recorded whether patients asked one or more questions about glaucoma medications and whether they asked one or more questions about glaucoma. The coders also wrote down all of the actual questions that patients asked. The coders also noted whether the doctor asked whether the patient had any questions. The glaucoma and glaucoma medication question-asking coding categories were developed using the patient questionasking literature (Kidd et al., 2004; Maly et al., 2004; Sleath et al., 1999; Sleath et al., 2003; Street et al., 1995) and input received from the ophthlamologists on the study team. After the original categories were developed and defined, the patient questions were reviewed and the categories were further refined with input from the principal investigator and the research team. The questions were then classified into the categories described in Table 1. Patient questions about glaucoma medications were classified into five main areas: (a) information about glaucoma medications, including the name, strength, and side effects of the medication; (b) information about the medication regimen, such as dose, which eye(s) to instill the medication in, and frequency of use; (c) how to administer the medication, which includes questions about how to instill eye drops and about how long to wait between instilling two different eye drops; (d) cost or supply of the medication; and (e) information about the purpose or importance of using glaucoma medications and adherence strategies. If a question was asked that did not fit into these five categories, it was classified as an “other question about glaucoma medications.”
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
663
TABLE 1 Description of the Types of Patient Questions About Glaucoma Medications and Glaucoma Glaucoma Medication Question Category How to administer the glaucoma medication Medication regimen
Cost or supply
More detailed information about glaucoma medications Adherence strategies, purpose of using, and the importance of using glaucoma medications Other
Downloaded by [ECU Libraries] at 22:19 24 April 2015
Glaucoma Question Category More detailed information about glaucoma
Treatment of glaucoma, excluding questions about medications
Intraocular pressure (IOP) Other
Similarly, questions asked by patients about glaucoma were classified into three main areas: (a) information about the disease, including diagnosis and prognosis; (b) treatment options for glaucoma, such as whether to treat or to watch and wait, information about surgery versus medications, and the duration of glaucoma treatment; and (c) information about intraocular pressure (IOP), including the definition of it as well as what was the current IOP reading. If a patient question did not fit into the three main categories, it was categorized as an “other question about glaucoma.” The three research assistants coded 25 of the same transcripts throughout the study period. After the coders were trained using the coding rules and sheets, they met monthly to discuss discrepancies in coding to prevent coder decay. Intercoder reliability was calculated using Cohen’s kappa. Cohen’s kappa was 0.78 for whether the patient asked a question about glaucoma medications, 0.84 for whether the patient asked one or more questions about glaucoma, and 1.0 for whether the doctor asked if the patient had any questions. Analysis We set the a priori level of statistical significance to p < .05. First, we presented descriptive statistics. Second, we examined the bivariate relationships among the independent
Description Includes questions about the amount of time to wait between administering two eye medications and about the nasolacrimal occlusion Includes questions about the dose, frequency, which eye in which to instill the eye drop, whether to continue the current medication regimen, and the possibility of long-term use of glaucoma medications Includes various topics such as the cost of the medication, generic formulations, the need for refills, and how long a bottle of medication should last before needing a refill Includes questions such as the about the possible side effects of the medication and about the name of the medication Includes topics such as why glaucoma medications were prescribed and how to remember to take the medications consistently Includes various unusual topics such as patient concerns or barriers with using glaucoma medication, how well the glaucoma medication was working, and the use of nonglaucoma medications Description Includes questions about the diagnosis or prognosis of the patient’s glaucoma, and whether other health conditions, such as high blood pressure or diabetes, interfere with glaucoma Includes questions about the goals of treatment, the likelihood of long-term therapy, ways to manage glaucoma with surgery, and ways to manage glaucoma with lifestyle changes Includes questions about the current IOP measurement and how IOP relates to glaucoma Includes various unusual questions about the physical or emotional changes that occur with glaucoma
variables and between the independent and dependent variables using Pearson correlation coefficients, chi-squared statistics, and t-tests. We ran generalized estimating equations (GEE) to examine how patient age, patient gender, patient race, patient years of education, patient health literacy, whether the patient was newly prescribed glaucoma medication on the day of the medical visit, and physician age and gender were associated with (a) whether the patient asked one or more questions about glaucoma medications and (b) whether the patient asked one or more questions about glaucoma. Physician race could not be included in the multivariable analysis because there was only one non-White physician.
RESULTS Fifteen physicians who cared for glaucoma patients agreed to participate in the study; one physician refused to participate for a participation rate of 94%. Fourteen physicians were White and one was African American. Ten physicians were male (66.7%). The age of the physicians ranged from 26 to 66 years (M = 40.8 years, SD = 11.7 years). Eighty-six percent of eligible patients participated in the study. Table 2 presents the patient demographics. Patients asked one or more questions about glaucoma medications
664
SLEATH ET AL. TABLE 2 Subject Characteristics (N = 279) Percent (n)
Downloaded by [ECU Libraries] at 22:19 24 April 2015
Gender Male Female Race African American Non-African American Newly prescribed glaucoma medications at visit or was on glaucoma medications before visit Newly prescribed at visit Was on glaucoma medications before visit Rapid Estimate of Adult Literacy in Medicine (REALM) Eighth grade or lower Ninth grade or higher Age Years of education
40.9 (114) 59.1 (165) 35.5 (99) 64.2 (179)
18.3 (51) 81.7 (228)
14.0 (39) 84.2 (235) Range; M (SD) 21 to 93; 65.8 (12.8) 5 to 26; 15.1 (3.5)
during 59% of the visits. Eighty percent of patients who were newly started on a glaucoma medication asked one or more questions, compared to 55% of those who were already on glaucoma medications. The number of questions about glaucoma medications that patients asked during their medical visit ranged from 0 to 16 (M = 1.7, SD = 2.4). Table 3 presents the types of glaucoma medication questions asked by patients who were newly prescribed glaucoma medications at the medical visit compared to those already taking a glaucoma medication. Twenty-three percent of new users compared to 8% of continued users asked one or more questions about how to administer their glaucoma medications (Pearson χ 2 = 9.7, p = .002). Thirty-seven
percent of new users compared to 14% of continued users asked for more information on the glaucoma medications such as the name of the medication or what the side effects are (Pearson χ 2 = 15.9, p = .000). Fifty-five percent of new users compared to 29% of continued users asked one or more questions about the glaucoma medication regimen, such as which eye to use the medication in or how many drops to use each time (Pearson χ 2 = 12.6, p = .000). Seventeen percent of new users asked about adherence, the purpose of the medication, or the importance of using glaucoma medications compared to 6% of continued users (Pearson χ 2 = 8.2, p = .0004). Patients asked one or more questions about glaucoma in 48% of visits. Sixty-nine percent of patients who were newly prescribed glaucoma medications asked a question about glaucoma compared to 45% who were on continued medications. The number of questions about glaucoma asked by the patients during their medical visit ranged from 0 to 17 (M = 1.3, SD = 2.0). Table 3 presents the types of glaucoma questions asked by patients who were newly prescribed glaucoma medications versus those already taking a glaucoma medication. Thirtyseven percent of new users compared to 8% of continued users asked one or more questions requesting more detailed information on glaucoma (Pearson χ 2 = 32.9, p = .000). Providers asked if the patients had questions during 51% of the videotaped medical visits. This was not associated with patients asking at least one question about glaucoma medications (Pearson χ 2 = 2.114; p = .146), or with patients asking at least one question about glaucoma (Pearson χ 2 = 2.679; p = .102). Table 4 presents the GEE results predicting whether patients asked one or more questions about glaucoma
TABLE 3 Categorization of Patient Questions That Were Asked About Glaucoma Medications and Glaucoma During the Medical Office Visit (N = 279) Patients Prescribed Glaucoma Medications for First Time During the Medical Visit (n = 51) Percent (n) of Patients Who Asked a Question Glaucoma medication question category How to administer glaucoma medications Glaucoma medication regimen Cost or supply of glaucoma medications More detailed information about glaucoma medications Adherence, purpose, or the importance of using glaucoma medications Glaucoma question category Treatment of glaucoma excluding glaucoma medications More detailed information about glaucoma Intraocular pressure ∗∗ Significant
at p < .01, Pearson χ 2 . at p < .001, Pearson χ 2 .
∗∗∗ Significant
Patients on Glaucoma Medications Before the Medical Visit (n = 228)
Number of Questions Asked
Percent (n) of Patients Who Asked a Question
Number of Questions Asked
23.5 (12) 54.9 (28) 21.6 (11) 37.3 (19) 17.6 (9)
16 49 20 31 16
8.3 (19)∗∗ 28.9 (66)∗∗∗ 12.3 (28) 13.6 (31)∗∗∗ 5.7 (13)∗∗∗
27 104 45 32 16
15.7 (8)
15
13.2 (30)
40
37.3 (19) 23.5 (12)
68 18
7.5 (17)∗∗∗ 25.9 (59)
84 87
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
665
TABLE 4 Generalized Estimating Equation Results Predicting Whether Patient Asked One or More Questions About Glaucoma or Glaucoma Medications (N = 279) Independent Variable Patient age Patient gender, female Patient race, African American Patient, years of education REALM, reads at eighth grade level or less Newly prescribed glaucoma medications versus already on glaucoma medications Physician age Physician gender, female Physician asking whether patient had any questions during medical visit ∗ Significant
Glaucoma Medications, OR (95% CI)
Glaucoma, OR (95% CI)
1.01 (0.99 − 1.04) 1.29 (0.71 − 2.33) 0.76 (0.44 − 1.32) 1.04 (0.96 − 1.14) 0.85 (0.46 − 1.57) 3.21 (1.68 − 6.12)∗∗ 1.03 (1.01 − 1.06)∗ 1.99 (0.83 − 4.79) 1.01 (0.65 − 1.57)
1.00 (0.99 − 1.02) 1.51 (0.84 − 2.71) 0.69 (0.45 − 1.07) 1.06 (0.97 − 1.17) 1.44 (0.75 − 2.76) 2.46 (1.58 − 3.82)∗∗ 1.02 (0.99 − 1.04) 2.85 (1.75 − 4.65)∗∗ 0.98 (0.64 − 1.48)
at p < .05. at p < .01.
Downloaded by [ECU Libraries] at 22:19 24 April 2015
∗∗ Significant
medications and one or more questions about glaucoma. None of the patient personal factors were associated with patient question-asking about glaucoma medications or glaucoma. In terms of provider factors, patients were significantly more likely to ask questions about glaucoma medications to older physicians (OR: 1.03, 95% CI: 1.01–1.06), and they were significantly more likely to ask questions about glaucoma to female physicians (OR: 2.85, 95% CI: 1.75–4.65). In terms of contextual factors, those who were newly prescribed glaucoma medications were significantly more likely to ask questions about glaucoma medications (OR: 3.21, 95% CI: 1.68–6.12) and glaucoma (OR: 2.46, 95% CI 1.58–3.82). However, the other contextual factor we examined, whether the physician asked the patients whether they had any questions, was not significantly associated with patient question-asking.
DISCUSSION As predicted by the ecological model of communication (Street et al., 2003; Street et al., 2005), we found that a contextual factor (a patient being prescribed a glaucoma medication for the first time versus being a continued user) was significantly associated with patient question-asking about glaucoma and glaucoma medications. Specifically, patients who were newly prescribed glaucoma medications during the visit were more than twice as likely to ask questions about glaucoma than patients on continued medications. This is in contrast to Cegala (2011), who found that patient status (new vs. returning patient) was not significantly associated with patient participation during visits. Cegala (2011) posits that they did not have enough new patients in their sample to see a difference by patient status. We did have enough patients new to glaucoma medications to see a significant effect. Surprisingly, the contextual factor of whether providers asked patients whether they had questions was not significantly associated with patient question-asking. It makes sense that patients prescribed a new glaucoma medication would be more likely to ask one or more
questions about glaucoma because they want to learn more about the disease. However, it is also important to encourage all patients to ask questions during glaucoma visits so that they can better understand their disease and increase their confidence or self-efficacy in managing their glaucoma (Sleath et al., 1999; Sleath et al., 2006; Sleath et al., 2009; Sleath, Blalock, Stone, et al., 2012). In addition, a previous study found that patients who reported being more likely to ask questions during glaucoma visits also reported being more adherent to their glaucoma medications (Stryker et al., 2010), further supporting the importance of encouraging patients to ask questions. Similar to previous studies (Sleath et al., 1999; Sleath et al., 2003), patients who were newly prescribed glaucoma medications were three times more likely to ask one or more questions about glaucoma medications. It is important for providers to encourage patients on continued medications to ask questions because they may have experienced side effects or difficulties adhering to the medication. If so, the provider can then help the patient address these issues by giving advice or recommendations. Provider advice on side effects may be particularly salient for patients, since prior research has shown that patients realize when they are experiencing adverse events associated with glaucoma medications, such as sedation, asthma, elevation of plasma levels, or systemic hypotension (Derick et al., 1997; Freedman et al., 1993; Lee, Wang, Kifley, & Mitchell, 2006). Provider advice on adherence may also be useful to patients since prior research has documented that patients on continued medications have adherence problems and they report difficulties in using their medications (Muir et al., 2006; Sleath et al., 2006; Sleath et al., 2009). Providers could ask patient questions like “What problems are you having in using your medications?” or “How are you doing with using your eye drops?” to encourage patients to ask questions. Providers could also ask patients to demonstrate how they use their eye drops and correct and educate the patients on how to improve any mistakes the patients make. Prior work has found that patient administration of eye drops is poor (Robin et al., 2007; Sleath, Blalock, Stone, et al., 2012).
Downloaded by [ECU Libraries] at 22:19 24 April 2015
666
SLEATH ET AL.
We found that another contextual factor, providers asking patients “if they had any questions,” was not significantly associated with patients asking questions. Providers asking patients whether they have questions could be considered a proxy measure of whether the provider was patient-centered. Thus, our finding that eliciting patient questions (i.e., provider patient-centeredness) was unrelated to patient participation (i.e., patient question-asking) runs counter to Street’s model, including previous studies that have linked provider patient-centeredness to patient participation (Cegala, 2011). We argue that simply asking patients if they have questions is not patient-centered enough, which may be why this provider behavior was not associated with greater patient question-asking. Patients may have difficulty thinking of questions they want to ask during the medical encounter, so additional prompting by the provider could help patients think of the questions they want to ask. For example, providers could instead say something like “Many people with glaucoma tell me they have trouble using their eye drops. Do you have any questions about using your eye drops?” or “People with glaucoma often have trouble understanding what intraocular pressure is. Do you have any questions about glaucoma or intraocular pressure?” Abraham, Naik, and Street (2012) suggest that one partnership-building way to request patient questions is to say “Tell me more about that.” Providers could ask patients to tell them more about specific topics, such as administering and adhering to eye drops, to provide additional patient-centered probes and encourage patient participation. In further support of the ecological model of health communication, we did find that provider factors significantly influenced patient question-asking (Street et al., 2005). Glaucoma patients were significantly more likely to ask older providers about glaucoma medications than younger providers. This finding is similar to the findings of other researchers (Aboumatar et al., 2013; Sleath et al., 1999; Sleath et al., 2001; Sleath et al., 2003). More work is needed to better understand why patients are more likely to ask older providers questions. Is it because older physicians are doing something different during the visits (either verbally or nonverbally) that causes patients to feel more comfortable asking questions? Or is it because patients perceive older physicians differently than younger physicians and this makes patients feel more comfortable asking older physicians questions? Future work applying the ecological model of communication should also assess how patient perceptions of physicians influence whether patients ask questions during medical visits. Patients were also significantly more likely to ask female providers about glaucoma than male providers. This is contrary to prior work that found that patients were significantly more likely to ask male physicians questions about over-thecounter medications (Sleath et al., 2001). Studies conducted by Cegala (2011) and Street (2005) did not find that provider gender was significantly associated with patient participation
during visits, and Cegala (2011) attributes this to the fact that both studies included patient centeredness as a predictor variable. It could be that in our study female providers had a more patient-centered communication style with patients or they were perceived as less threatening by patients who wanted to ask questions. Future research should examine whether female and male physicians differ in other aspects of patient-centered communication, because we only assessed whether providers asked patients if they had any questions. In addition, future research should also examine whether patient perceptions of female versus male providers are different and whether this influences patient question-asking. We did not find that any patient factors significantly influenced patient question-asking. Unlike prior research (Aboumatar et al., 2013; Eggly et al., 2011; Sleath et al., 2001; Street et al., 1995; Street et al., 2005; Waitzkin, 1985), we did not find that health literacy, race, or years of education were significantly associated with patients asking one or more questions about glaucoma or glaucoma medications. Therefore, our study did not find support for the part of the ecological model of communication that posits that patient factors such as race and literacy can influence patient participation during visits (Street et al., 2003; Street et al., 2005). Our finding that patient race was not associated with patient question-asking is similar to what other researchers have found when applying the ecological model (Cegala, 2011; Street et al., 2005). We may not have found an association between literacy and patient question-asking because only 14% of our sample read at the eighth-grade level or below according to the REALM. Future work should include more patients with limited health literacy in their samples. Our research provides support for the relevance of applying the ecologic model of communication in specialty settings like ophthalmology clinics. Our finding that being newly prescribed a glaucoma medication influenced patient question-asking about both glaucoma and glaucoma medications is important because it illustrates patient willingness to ask questions when starting a new treatment. However, it is important to make sure that patients ask questions they might have at any point when using medications because research has found that approximately 50% of individuals who start on glaucoma medications discontinue them within 6 months (Nordstrom, Friedman, Mozaffari, Quigley, & Walker, 2005; Schwartz, Platt, Reardon, & Mychaskiw, 2007) and that patient performance when administering eye drops is poor (Stone, Robin, Novack, Covert, & Cagle, 2009; Sleath, Blalock, Stone, et al., 2012). Future research should examine what questions patients might have about their disease and its treatment and compare it to the actual questions that patients ask their providers. In addition, we found that physician age and gender influenced patient question-asking during glaucoma visits. This indicates that more work is needed to better understand how physician characteristics influence patient questionasking during medical visits. Do physician characteristics
Downloaded by [ECU Libraries] at 22:19 24 April 2015
PATIENT QUESTION-ASKING ABOUT GLAUCOMA
influence patient perceptions of their physicians and therefore their question-asking behavior or do certain physician verbal or nonverbal behaviors facilitate or inhibit patient question-asking? More research is needed. A systematic review of trials to improve provider– patient communication during medical visits found that simple approaches to increasing patient participation during visits, such as providing doctors a note from patients about their concerns before visits, showed promise at increasing patient involvement (Griffin et al., 2004). There have been two prior intervention studies conducted in ophthalmology that successfully improved the communication skills of ophthalmologists to be more patient-centered (Hahn et al., 2010; Vegni, 2004). Future research in the glaucoma area should design interventions focused on the patient that encourage patients to ask questions and be more actively involved during the visits. This study has several limitations. Providers and patients both knew the visit was being recorded but they did not know the study hypotheses. Selection bias could be another limitation, since the ancillary staff did not track the characteristics of the few patients who declined to speak with the research assistant to learn more about the study. Despite these limitations, the study presents important new information on what patient, physician, and contextual factors were associated with patient question-asking about glaucoma and glaucoma medications. When applying the ecologic model of communication, we found that patients were significantly more likely to ask questions about glaucoma and glaucoma medications when newly prescribed glaucoma medications. Eye care providers should encourage glaucoma patients to ask questions during all types of visits because patients on continued medications might have questions about barriers to using eye drops. Additionally, we found that patients were significantly more likely to ask older providers about glaucoma medications and female providers about glaucoma. Future research should explore in more detail how provider characteristics influence patient question-asking.
FUNDING This work was supported by grant EY018400 from the National Eye Institute and by grant UL 1RR02574 7 from the National Center of Research Resources, National Institutes of Health (NIH). NIH had no role in the design or conduct of this research. REFERENCES Aboumatar, H. J., Carson, K. A., Beach, M. C., Roter, D. L., & Cooper, L. A. (2013). The impact of health literacy on desire of participation in healthcare, medical visit communication, and patient reported outcomes among patients with hypertension. Journal of General Internal Medicine, 11, 1469–1476.
667
Abraham, N. S., Naik, A. D., & Street, R. L. (2012). Shared decision making in GI clinic to improve patient adherence. Clinical Gastroenterology Hematology, 10, 825–827. Brody, D. S. (1989). Patient perception of involvement in medical care: Relationship to illness attitudes and outcomes. Journal of General Internal Medicine, 4, 506–511. Cegala, D. J. (2011). An exploration of factors promoting patient participation in primary care medical interviews. Health Communication, 26, 427–436. Cegala, D. J., Street, R. L., & Clinch, C. R. (2007). The impact of patient participation on physicians’ information provision during a primary care medical interview. Health Communication, 2, 177–185. Davis, T. C., Long, S. W., Jackson, R. H., Mayeaux, E. J., George, R. B., Murphy, P. W., & Crouch, M. A. (1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25, 391–395. Derick, R. J., Robin, A. L., Walters, T. R., Barnebey, H. S., Choplin, N., Schuman, J., . . . Stoecker, J. F. (1997). Brimonidine tartrate: A one-month dose response study. Ophthalmology, 104, 131–136. Eggly, S., Harper, J. W. K., Penner, L. A., Gleason, M. J., Foster, T., & Albrecht, T. L. (2011). Variation in question-asking during cancer clinical interactions: A potential source of disparities in access to information. Patient Education and Counseling, 82, 63–68. Freedman, S. F., Freedman, N. J., Shields, M. B., Lobaugh, B., Samsa, G. P., Keates, E. U., & Ollie, A. (1993). Effects of ocular carteolol and timolol on plasma high-density lipoprotein cholesterol level. American Journal of Ophthalmology, 116, 600–611. Friedman, D. S., Hahn, S. R., Quigley, H. A., Kotak, S., Kim, E., Onofrey, M., . . . Mardekian, J. (2009). Doctor-patient communication in glaucoma care: Analysis of video-taped encounters in community-based office practice. Ophthalmology, 116, 2277–2285. Glaucoma Research Foundation. (2010). Glaucoma facts and stats. Retrieved from http://www.glaucoma.org/learn/glaucoma-facts-andstats.php Greenfield, S., Kaplan, S. H., Ware, J. E., Yano, E. M., & Frank, H. J. (1988). Patients’ participation in medical care: Effects on blood sugar control and quality of life in diabetes. Journal of General Internal Medicine, 3, 448– 457. Griffin, S. J., Kinmonth, A. L., Veltman, M. W. M., Gillard, S., Grant, J., & Stewart, M. (2004). Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: A systematic review of trials. Annals of Family Medicine, 2, 595–607. Hahn, S. R., Friedman, D. S., Quigley, H. A., Kotak, S., Kim, E., Onofrey, M., . . . Mardekian, J. (2010). Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma. Ophthalmology, 117, 1339–1347. Harrington, J., Noble, L. M., & Newman, S. P. (2004). Improving patients’ communication with doctors: A systematic review of intervention studies. Patient Education and Counseling, 52, 7–16. Katz, M. G., Jacobson, T. A., Veledar, E., & Kripalani, S. (2007). Patient literacy and question-asking behavior during the medical encounter: A mixed-methods analysis. Society of General Internal Medicine, 22, 782– 786. Kidd, J., Marteau, T. M., Robinson, S., Ukoumunne, O. C., & Tydeman, C. (2004). Promoting patient participation in consultations: A randomized controlled trial to evaluate the effectiveness of three patient-focused interventions. Patient Education and Counseling, 52, 107–112. Lee, A. J., Wang, J. J., Kifley, A., & Mitchell, P. (2006). Open-angle glaucoma and cardiovascular mortality: The Blue Mountains Eye Study. Ophthalmology, 113, 1069–1076. Maly, R. C., Umezawa, Y., Leake, B., & Silliman, R. A. (2004). Determinants of participation in treatment decision-making by older breast cancer patients. Breast Cancer Research Treatment, 85, 207–209. Muir, K. W., Santiago-Turla, C., Stinnett, S. S., Herndon, L. W., Allingham, R. R., Challa, P., & Lee, P. P. (2006). Health literacy and adherence to glaucoma therapy. American Journal of Ophthalmology, 142, 223–226.
Downloaded by [ECU Libraries] at 22:19 24 April 2015
668
SLEATH ET AL.
Nordstrom, B. L., Friedman, D. S., Mozaffari, E., Quigley, H. A., & Walker, A. M. (2005). Persistence and adherence with topical glaucoma therapy. American Journal of Ophthalmology, 140, 598–606. Robin, A. L., Novack, G. D., Covert, D. W., Crockett, R. S., & Marcic, T. S. (2007). Adherence in glaucoma: Objective measurements of once-daily and adjunctive medication use. American Journal of Ophthalmology, 144, 533–540. Schwartz, G. F., Platt, R., Reardon, G., & Mychaskiw, M. A. (2007). Accounting for restart rates in evaluating persistence with ocular hypotensives. Ophthalmology, 114, 648–652. Sleath, B., Ballinger, R., Covert, D., Robin, A. L., Byrd, J. E., & Tudor, G. (2009). Self-reported prevalence and factors associated with nonadherence with glaucoma medications in veteran outpatients. American Journal of Geriatric Pharmacotherapy, 7, 67–73. Sleath, B., Blalock, S. J., Covert, D., Skinner, A. C., Muir, K., & Robin, A. L. (2012). Patient race, reported problems in using glaucoma medications, and adherence. ISRN Ophthalmology, 2012, Article 902819. Retrieved from http://www.hindawi.com/isrn/ophthalmology/ 2012/902819 Sleath, B., Blalock, S., Covert, D., Stone, J. L., Skinner, A. C., Muir, K., & Robin, A. L. (2011). The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology, 118, 2398–2402. Sleath, B., Blalock, S. J., Robin, A., Hartnett, M. E., Covert, D., DeVellis, B., & Giangiacomo, A. (2010). Development of an instrument to measure glaucoma medication self-efficacy and outcome expectations. Eye (London), 24, 624–631. Sleath, B., Blalock, S. J., Stone, J. L., Skinner, A. C., Covert, D., Muir, K., & Robin, A. L. (2012). Validation of a short version of the glaucoma medication self-efficacy questionnaire. British Journal of Ophthalmology, 96, 258–262. Sleath, B., Robin, A. L., Covert, D., Byrd, J. E., Tudor, G., & Svarstad, B. (2006). Patient-reported behavior and problems in using glaucoma medications. Ophthalmology, 113, 431–436. Sleath, B., Roter, D., Chewning, B., & Svarstad, B. (1999). Asking questions about medication: Analysis of physician-patient interactions and physician perceptions. Medical Care, 37, 1169–1173.
Sleath, B., Rubin, R. H., Campbell, W., Gwyther, L., & Clark, T. (2001). Physician-patient communication about over-the-counter medications. Social Science & Medicine, 53, 357–369. Sleath, B., Rubin, R. H., & Huston, S. A. (2003). Hispanic ethnicity, physician-patient communication, and antidepressant adherence. Comprehensive Psychiatry, 44, 198–204. Stone, J. L., Robin, A. L., Novack, G. D., Covert, D. W., & Cagle, G. D. (2009). An objective evaluation of eyedrop instillation in patients with glaucoma. Archives of Ophthalmology, 127, 732–736. Street, R. L., Jr. (2003). Communication in medical encounters: An ecological perspective. In T. Thompson, A. Dorsey, K. T. Miller, & R. Parrott (Eds.), The handbook of health communication (pp. 63–89). Mahwah, NJ: Lawrence Erlbaum Associates. Street, R. L., Gordon, H. S., Ward, M. M., Krupat, E., & Kravitz, R. L. (2005). Patient participation in medical consultations: Why some patients are more involved than others. Medical Care, 43, 960–969. Street, R. L., Voigt, B., Geyer, C., Manning, T., & Swanson, G. P. (1995). Increasing patient involvement in choosing treatment for early breast cancer. Cancer, 76, 2275–2285. Stryker, J. E., Beck, A. D., Primo, S. A., Echt, K. V., Bundy, L., Pretorius, G. C., & Glanz, K. (2010). An exploratory study of factors influencing glaucoma treatment adherence. Journal of Glaucoma, 19, 66–72. Taylor, S. A., Galbraith, S. M., & Mills, R. P. (2002). Causes of non-compliance with drug regimens in glaucoma patients: A qualitative study. Journal of Ocular Pharmacology and Therapeutics, 18, 401–409. Tsai, J. C., McClure, C. A., Ramos, S. E., Schlundt, D. G., & Pichert, J. W. (2003). Compliance barriers in glaucoma: A systematic classification. Journal of Glaucoma, 12, 393–398. Vegni, E., & Moja, E. A. (2004). Effects of a course on ophthalmologist communication skills: A pilot study. Education for Health, 17, 163–171. Venetis, M. K., Robinson, J. D., & Kearney, T. (2013). Consulting with a surgeon before breast cancer surgery: Patient question-asking and satisfaction. Journal of Health Communication, 18, 943–959. Waitzkin, H. (1985). Information giving in medical care. Journal of Health and Social Behavior, 26, 81–101.
