Association Between Patient-Clinician Relationships and Adherence to Antihypertensive Medications Among Black Adults: An Observational Study Design

Abstract

Background We assessed the associations between patient-clinician relationships (communication and involvement in shared decision-making [SDM]) and adherence to antihypertensive medications. Methods and Results The 2010 to 2017 Medical Expenditure Panel Survey (MEPS) data were analyzed. A retrospective cohort study design was used to create a cohort of prevalent and new users of antihypertensive medications. We defined constructs of patient-clinician communication and involvement in SDM from patient responses to the standard questionnaires about satisfaction and access to care during the first year of surveys. Verified self-reported medication refill information collected during the second year of surveys was used to calculate medication refill adherence; adherence was defined as medication refill adherence ≥80%. Survey-weighted multivariable-adjusted logistic regression models were used to measure the odds ratio (OR) and 95% CI for the association between both patient-clinician constructs and adherence. Our analysis involved 2571 Black adult patients with hypertension (mean age of 58 years; SD, 14 years) who were either persistent (n=1788) or new users (n=783) of antihypertensive medications. Forty-five percent (n=1145) and 43% (n=1016) of the sample reported having high levels of communication and involvement in SDM, respectively. High, versus low, patient-clinician communication (OR, 1.38; 95% CI, 1.14-1.67) and involvement in SDM (OR, 1.32; 95% CI, 1.08-1.61) were both associated with adherence to antihypertensives after adjusting for multiple covariates. These associations persisted among a subgroup of new users of antihypertensive medications. Conclusions Patient-clinician communication and involvement in SDM are important predictors of optimal adherence to antihypertensive medication and should be targeted for improving adherence among Black adults with hypertension.

Keywords: adherence; antihypertensive medication; black adults; communication; hypertension; patient‐clinician relationships; shared decision‐making.

Figure 1. Study design.

In this illustration, 2 years of data from 5 rounds of surveys are combined to create a cohort of participants who filled at least 1 prescription of antihypertensive medication. Data collected from rounds 1 through 3 in 2015 are used to define patient‐provider engagement factors (shared decision‐making, communication, and trust) and all covariates (individual characteristics and provider characteristics). On the other hand, the 2016 data are used to define medication refill adherence based on medication refill and the days' supply of filled drugs. MEPS indicates Medical Expenditure Panel Survey.

Figure 2. Participant selection.

Black adults were identified from the 2010 to 2017 MEPS (Medical Expenditure Panel Survey) data. The year 1 data were used for identifying Black patients with a hypertension diagnosis and antihypertensive medication (AHM) use. Persistent use, discontinuation, and new use of AHMs were assessed from the year 2 data. *Sample for measuring associations between patient‐clinician communication and adherence to AHMs. ^†Sample for measuring associations between patient involvement in shared decision‐making and adherence to AHM. AHM users (n=217) were excluded if they lacked access to a usual source of care provider. CAHPS indicates Consumer Assessment of Healthcare Providers and Systems.

Figure 3. Directed acyclic graph (DAG).

This DAG was used for identifying potential confounders of the associations between patient‐clinician relationships and adherence to antihypertensive medications. The direct paths from each set of confounders (patient characteristics, provider characteristics, and healthcare system factors) to the primary exposure (patient‐clinician relationships) and outcome (adherence) were modeled. Solid lines represent direct paths; dashed lines represent indirect paths or feedback loops.