Article Figures & Data
Figures
- Figure 1.
Theoretical model relating aspects of clinician and patient language to medication adherence. PDC, proportion of days covered over 180 days of observation.
- Figure 2.
Patient flow diagram. *Prescription not picked up.
Tables
- Table 1. Characteristics of Participants and Comparison of Participants to the General Population of Adults Attending the Health System
Characteristics Study Participants General Population Clinicians (n = 20) Female sex 13 (65.0) Age, mean years 46.1 (7.2) Ethnicity Non-Hispanic white 17 (85.0) Hispanic 3 (15.0) Specialty Internal medicine 5 (25.0) Family medicine 10 (50.0) Nurse practitioner 2 (10.0) Physician assistant 3 (15.0) Patients (n = 63) 2011 Community Health Adults (n = 67,256)* Sociodemographic Female sex 46 (73.0) 41,990 (62.4) Age, mean years ± SD (range) 50.0 ± 13.6 (19.7–73.4) 42.4* Ethnicity African American 20 (31.7) 11,539 (17.2) Non-Hispanic white 12 (19.0) 19,885 (29.6) Hispanic 25 (39.7) 32,116 (47.8) American Indian 3 (4.8) 3716 (5.5)† Multiethnic (non-Hispanic) 3 (4.8) Insurance (n = 62) 36 (58.1) 27,319 (40.6) Public 1 (1.6) 8,006 (11.9) Private 25 (40.3) 31,928 (47.5) No insurance English-speaking (%) 100 70.9 Physical/mental health Baseline PHQ-9 score (severity) 17.5 ± 3.9 (moderately severe) Physical comorbidity categories, mean ± SD (range)‡ 2.3 ± 1.6 (0–7) Treatment factors Unique medications, mean ± SD (range) 3.8 ± 2.6 (0–11) Previous antidepressant use 27 (42.9) Antidepressant adherence Obtained initial fill 56 (88.6) PDC, mean ± SD (range) 45.2 ± 33.6 (0–100) Patient-clinician relationship Helping Alliance Questionnaire§ 95.1 ± 16.1 (41–109) Change/sustain talk, mean ± SD (range) Mean change talk statements per encounter‖ 1.1 ± 1.0 (0–4) Mean sustain talk statements per encounter‖ 0.7 ± 1.2 (0–5) Values are n (%) unless otherwise indicated.
↵* Mean age estimated from percentage of adults in age groups (19–34, 3549, 5060, and ≥65 years); overall adult data for the complete system excludes those aged 18 years.
↵† Categorized as “Other.”
↵‡ Physical comorbidities assessed with a count of up to 8 categories (arthritis, asthma, congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, hypertension, and lower back pain).
↵§ Helping Alliance Questionnaire assesses the patient's perception of participating in a collaborative relationship with the primary care clinician. A score of <89 is considered poor.
↵‖ Of 63 patients, 48 (76.2%) voiced any change talk, whereas 22 (34.9%) made any sustain talk. The mean scores are for all 63 patients and were calculated including those with no change or sustain talk statements.
SD, standard deviation; PDC, proportion of days covered. PHQ-9, patient health questionnaire.
- Table 2. Associations Between Number of Change Talk Statements and Proportion of Days Covered (PDC) Estimates
Change Talk Statements n Mean PDC SD 0 17 0.39 0.32 1 25 0.35 0.32 2 15 0.62 0.33 3 5 0.65 0.29 4 1 0.67 NA NA, not applicable; SD, standard deviation.
Variable Estimate Standard Error t Value P Intercept 0.28 0.12 2.32 .024 Patient change talk 0.19 0.09 2.24 .029 Clinician empathy 0.10 0.04 2.27 .027 Clinician MI-adherent statements −0.03 0.01 −2.22 .03 Previous antidepressant use −0.12 0.08 −1.39 .17 African American (non-Hispanic) −0.16 0.08 −1.87 .07 R2 = 27.6% (n = 63). MI, motivational interviewing.
- Motivational Interviewing (MI) Treatment Integrity Code
Code Categories Components Definition Examples Rating Scheme MI-adherent statements Affirm, emphasize autonomy, ask before giving advice, support It takes courage to come in and talk about depression. (Affirm) May I share some information about antidepressant medications? (Ask permission) Simple reflections Reflect basic understanding of what patient has said You are determined to start an antidepressant medication. Complex reflections Add substantial meaning to what patient has said On the one hand you perceive potential benefit from the medicine, and on the other hand you are terrified of getting addicted. MI-consistent language MI-adherent statements + reflections + open questions MI spirit Average of global scores of evocation, collaboration, and autonomy/support Empathy Global score: the extent to which the clinician understands or makes an effort to grasp the client's perspective and feelings. Reflective listening is an important part of this characteristic, but this global rating is intended to capture all efforts that the clinician makes to understand the client's perspective and convey that understanding to the client. Empathy is evident when providers show an active interest in understanding what the client is saying. It can also be apparent when the clinician accurately follows or perceives a complex story or statement by the client or probes gently to gain clarity. Clinicians with low empathy show little effort to gain a deeper understanding of complex events and emotions, and questions asked reflect shallowness or impatience. MI nonadherent statements Advising, directing, confronting I would strongly recommend that you start the antidepressant medication now. (Advise) You're letting your family down if you don't take the antidepressant. (Confront) - Intraclass Correlation Coefficients (ICCs) for Behavior Counts
Measure ICC Give information 0.42 Closed questions 0.69 Open questions 0.76 Complex reflections 0.18 Simple reflections 0.58 Total reflections 0.54 MI-adherent statements 0.34 MI-nonadherent statements 0.45 Total statements consistent with MI 0.52 MI spirit 0.32 MI, motivational interviewing.
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