Brief provider communication skills training fails to impact patient hypertension outcomes

Highlights

• We test a provider training to improve patient hypertension outcomes.

• Training to improve communication skills related to patient-centeredness.

• The intervention did not improve counseling, adherence or blood pressure outcomes.

• It may have been too brief and lacked sufficient practice level changes.

Abstract

Objectives

Hypertension remains a prevalent risk factor for cardiovascular disease, and improved medication adherence leads to better blood pressure (BP) control. We sought to improve medication adherence and hypertension outcomes among patients with uncontrolled BP through communication skills training targeting providers.

Methods

We conducted a randomized controlled trial to assess the effects of a communication skills intervention for primary care doctors compared to usual care controls, on the outcomes of BP (systolic, diastolic), patient self-reported medication adherence, and provider counseling, assessed at baseline and post-intervention. We enrolled 379 patients with uncontrolled BP; 203 (54%) with follow-up data comprised our final sample. We performed random effects least squares regression analyses to examine whether the provider training improved outcomes, using clinics as the unit of randomization.

Results

In neither unadjusted nor multivariate analyses were significant differences in change detected from baseline to follow-up in provider counseling, medication adherence or BP, for the intervention versus control groups.

Conclusion

The intervention did not improve the outcomes; it may have been too brief and lacked sufficient practice level changes to impact counseling, adherence or BP.

Practice Implications

Future intervention efforts may require more extensive provider training, along with broader systematic changes, to improve patient outcomes.

Introduction

Hypertension remains a prevalent risk factor for cardiovascular disease and related mortality [1]. In 2010, approximately 29% of Americans aged 18 or older had been diagnosed with hypertension [2]. Data from the 2003–2010 National Health and Nutrition Examination Surveys reveal that an estimated 53.5% (35.8 million) of those diagnosed with hypertension had uncontrolled blood pressure (BP) [3]. Of those, 44.8% were pharmacologically treated for their hypertension and 39.4% were not even aware of this diagnosis [3].

The overwhelming majority of those with uncontrolled hypertension report having a usual source of care (89.4%), underscoring the opportunity for health care providers to counsel patients about pharmacologic treatment and lifestyle behaviors to improve BP [3]. Patient-provider communication is an important determinant of medication adherence [4], [5], [6]. Effective communication also can impact intermediate outcomes, such as patients’ understanding of their health, trust and commitment to treatment, which in turn can improve health behaviors and outcomes [5], [6], [7], [8], [9].

Patient-centered, culturally competent care and counseling have the potential to improve patients’ hypertension control [10]. One approach to training in such care is the “5 A's”, in which health care providers are trained to: ask the patient about a certain health issue or behavior, assess their motivation in making a behavior change to address this issue, advise the patient about addressing the issue, assist them in overcoming barriers to treatment and arrange for follow-up [11]. The 5 A's model is an evidence-based approach for behavior change counseling for a broad range of behaviors and health conditions with prior effects on smoking [12], physical activity [13], weight loss [14], and chronic illness care [15], but it has not yet been applied in the context of hypertension care.

It can be argued that patient-centered counseling is inherently culturally sensitive because it requires clinicians to understand the issues and factors surrounding medication adherence that are most meaningful to individual patients in their own cultural context. Insofar as individuals vary in their adoption of cultural beliefs or approaches to illness, the individual remains important to understand. However, it can also be argued that without an understanding of the patient's broad cultural context (e.g. norms and beliefs of one's cultural group), it may not be possible to fully understand the individual.

Patient-centered counseling can focus on a single behavior (e.g. antihypertensive medication adherence), and is designed to enhance a patients’ self-efficacy for that specific behavior by addressing logistical and practical barriers to adherence. In contrast, cultural competency enhances a clinician's ability to view the patient in his/her socio-cultural context, improving the understanding of the patient's background. Culturally competent views of patients happen when a clinician's understanding of a patient in context, and the patient's world view (regarding illness generally and hypertension specifically), are clearly understood. We posit that a better and more complete understanding of patients occur when physicians are both skilled in patient-centered counseling and are culturally competent.

We examined whether comprehensive training for clinicians to improve communication about hypertension would improve such communication, affect antihypertensive medication adherence, or BP outcomes.