Abstract

Summary:Objective: The objectives of this research were to: (1) explore the role of communication in the safe delivery of medications, and (2) provide recommendations to healthcare leaders and executives to enhance communication between physicians and adults living with chronic illness related to safe medication use.
Methods: Two data sets were used for this secondary analysis. The first data source was the Commonwealth Fund’s 2009 International Health Policy Survey. It included responses from primary care physicians in Canada. The second data set consisted of adults with chronic illness from the Commonwealth Fund’s 2008 International Health Policy Survey.
Key Findings: The key findings from this study demonstrate that there are opportunities for improvement in terms of the review that clients receive pertaining to their medications, the level of communication between physicians and clients, the access clients have to physicians and the use of technology related to providing a port for communication.
Conclusion: Effective communication between healthcare providers and clients is crucial in preventing medication errors, critical incidents and near misses. Adults with chronic illness are even more vulnerable to the ill effects of poor communication. It has been shown that physicians need to improve their systems of communication, however; the onus to improve communication related to safe medication delivery for chronically ill clients rests with both the physician and the client. Several strategies exist to enhance patient-provider communication.
Keywords: Communication, medication errors, medication, practice, physician, client, adverse event, quality, safety, client centered care.
Citation: Sears K, Bishop A, MacKinnon NJ. Do you hear what i hear? communication practices about medications between physicians and clients with chronic illness in Canada. J Participat Med. 2014 Jan 15; 6:e2.
Published: January 15, 2014.
Competing Interests: The authors have declared that no competing interests exist.

Introduction

In Canada, health care leaders are attempting to balance quality of care with increasingly high health care costs.[1] Client safety issues contribute significantly to preventable costs in health care. For example, the cost of preventable drug-related morbidity and mortality in older adults was estimated to be C$11 billion in Canada.[2]

Medication errors, many of which are preventable by effective communication, cost both the clients and the health care system dearly.[3] Effective communication between providers and clients is essential to the delivery of high quality care.[4] It has been demonstrated that a key aspect of delivering client centred care is clear and effective communication about the client’s health-related beliefs and values.[5] It is not until the physician knows how the client conceptualizes health care, medication use, alternative therapies, and the physician and client role in caring for the client’s health, can he/she effectively treat the client. The amount of information provided to the client positively correlates with the amount of respect that the physician feels towards them[6] and the relationship that exists between them.[7] Gender is another factor affecting communication. A 2009 study looked at 100 physicians and internists and concluded that the female client-female physician relationship utilized the most client centred care communication techniques.[8]

Ineffective or insufficient communication is also a contributing factor to adverse events.[9][10] In fact, Doherty and Stavropoulou’s 2012 study of clients’ willingness to actively participate in their appointments to reduce clinical error discovered that many believed that by passively accepting physician advice or acting deferentially, they were actively participating in their safety by avoiding a negative or “difficult” label.[11] It has been established that clear and effective communication between clients and health care providers prevents adverse events, and helps to mitigate consequences after an incident has taken place.[3] Moreover, in an analysis of 2,455 reported sentinal events, the Joint Commission found the primary cause to be communication issues more than 70% of the time.[12] As such, improved communication could significantly reduce error and increase positive outcomes. However, saying communication must be improved is far easier than achieving this goal.

A study published in 2009 hypothesized that physicians would be more effective fostering positive relationships with clients, leading to clearer communication, if they used first person plural statements.[13] However, it has been suggested that the client/physician relationship is the most positive not when based on communication techniques, but rather when based on the client’s perceptions of how similar they are to the physician’s personal values, beliefs and ways of communicating. Clients who reported feeling high levels of concordance with their physician were more likely to feel satisfaction and had an increased likelihood to adhere to recommendations.[14] Furthermore, clients who reported a great level of social concordance (having similarities between the client and physician such as class, education, social convictions, culture, etc.) were more likely to express positive affect with the visit, suggest their physician to a friend and express satisfaction with their appointment.[15] While one should be careful to not simplify the issues of identity in clients and physicians, it is clear that how clients and physicians perceive each other is an important factor in fostering a positive relationship.

Clients also have the ability to shape the kinds of interactions between themselves and the physician. A 2008 study which reported on the interactions of 25 physicians and their clients, revealed that clients who engaged in highly participatory behavior were more likely to elicit client centered care communication from their physicians, both in terms of illness investigation and general interest in understanding the client as a person.[16] Indeed, in a cross-sectional survey and medical record review of over 2,000 diabetes clients, it was reported that clients who preferred participatory decision-making were given different tests.[17]

Effective communication between physicians and adults living with chronic illness is central to the delivery of quality care.[18] A full detailed communication dialogue between physicians and clients regarding their medication management reduces potential adverse effects and increases compliance with the treatment regime.[19] In 2007, the Canadian Institute for Health Information reported that 1 in 10 ill adults received the wrong medication or dosage. One of the primary contributing factors for medication errors are clients’ lack of access to drug information from physicians.[20]

Many reported adverse drug events are attributed to the physician’s failure to respond to medication-related symptoms and to the chronically ill adult’s failure to inform the physician of symptoms.[21] Adverse events related to medications are common in primary care, and many are preventable.[22] Improving communication is not only considered essential to reducing medication-related issues,[23] it also has been shown to have an effect on client and system outcomes.[24] A literature review containing articles from 1966 to 2001 revealed as many as 28% of all emergency department visits were medication-related.[25] Of these, 70% were preventable, and as many as 24% resulted in hospital admission. Furthermore, documentation and communication have been identified as part of the eight essential elements of a safe and effective medication-use system.[26]

To explore the role of communication in ensuring safe medication use, communication between primary care physicians and adults with chronic illness was examined. The objectives of this research were to: (1) explore the role of communication in the safe delivery of medications, and (2) provide recommendations to health care leaders and executives to enhance communication between physicians and adults living with chronic illness related to safe medication use.

Methods

Two data sets were used. The first data source was the Commonwealth Fund’s 2009 International Health Policy Survey. Our analysis included responses from primary care physicians in Canada. Harris Interactive Inc. collected the data used in this survey, and its collection and sample procedures are detailed in full elsewhere.[27] The survey canvassed primary care physicians in Canada via mail, telephone, and the Internet between February and July 2009. Gender, age, and province were items used to weight the data in order to reflect the distribution in the 2007 National Physician Survey.[27] Variables that were included from this study focused on four themes namely; medication review, communication at transitions to care, access to physicians and technology to aid communication.

The second data set consisted of adults with chronic illness from the Commonwealth Fund’s 2008 International Health Policy Survey.[28] As with the 2009 data, only responses from Canadian respondents were used in our analysis. Respondents were randomly selected through a process of random digit dialing. Eligibility required participants be age 18 and older, and self-reporting at least one of the following criteria: poor/fair health, illness, disability, hospitalization, or major surgery in the past two years. Harris Interactive Inc. collected the data used in this survey, and its collection and sample procedures are detailed in full elsewhere.[27][28] Survey data were weighted by age, sex, region and education to reflect the demographic composition provided in the 2001 Canadian census. The same variables were explored in this survey: medication review, communication at transitions to care, access to physicians and technology to aid communication. Specifically, frequencies were run including means and percentages. Permission was received from the Commonwealth Fund to use the raw survey data for the purpose of this paper.

Results

There were 1,401 physician respondents to the 2009 Commonwealth Fund International Health Policy Survey. Overall, the majority of physician respondents (855) were male (61%), and ages 35-64 (76%) (Table 1). There were 2,635 respondents for the 2008 International Health Policy Survey of Sicker Adults. Of these, 1,344 (51%) were female, and the largest age group was between 35-65+ years old (Table 1). In total, 74.2% of participants identified that they had a chronic illness. The data identified that of the 7,675 participants taking medications, 5,764 were taking 1-5 medications (75.1%), 1,399 were taking 6-10 medications (18.2%) and 512 were taking more than 10 medications (6.7%).

Table 1. Demographic characteristics of physician and adults with chronic illness study populations.

Main Findings

Medication Review

When asked if they had had their medications reviewed and discussed by a physician or pharmacist within the last two years, 783 (29.7%) of client respondents had always had this done, 359 (13.6%) had often had this done, 289 (11%) had sometimes had this done, and 508 (19.3%) had rarely or never had this done. When asked if they had been told by a pharmacist that their prescription may be harmful in combination with another medication they were already taking, 431 (16.4%) of clients responded yes (Table 2). When physicians were asked if they provide clients with a written list of medications they are taking, 15% said yes, routinely and 37% said yes, occasionally while 44% said never (Table 3).

Communication at Transitions of Care

In total, approximately 1 in 4 clients identified that they had been given a new prescription during their most recent hospitalization (Table 2). When asked if someone discussed what to do with the other medications they were taking prior to being hospitalized, 335 (12.7%) of clients responded yes and 194 (7.4%) said no (Table 2). When physician respondents were asked if they call clients to check on medications, symptoms or to help coordinate care between visits with other staff such as nurses, nurse practitioners, or medical assistants, 37% responded they routinely do this, 44% responded they occasionally do this, 15% indicated that they never do this (Table 3).

Access to Physicians

Regarding access to their physician, 1007 (38.2%) of clients responded that they found it very easy and 814 (30.9%) of clients found it somewhat easy to contact their physician’s office by telephone during normal office hours. More than 1 in 5, 594 (22.5%) adults with chronic illness found it somewhat-to-very difficult to contact their physician’s office.

Technology to Aid Communication

Adults with chronic illness were asked if they were able to communicate with their physician by email, with only 166 (6.3%) responding yes, 1,188 (45.1%) saying no and 269 (10.2%) said not sure (Table 2). Physicians were asked if they use e-prescribing, and 25% said they did this routinely, 5% said yes, occasionally and 65% said they did not (Table 3). Furthermore, when asked if they were able to electronically transfer prescriptions to the pharmacy, the majority of physicians indicated they could not (83%) (Table 3).

Table 2. Pertinent patient data from the Commonwealth Fund’s 2008 International Health Policy Survey.

Table 3. Pertinent data from the Commonwealth Fund’s 2009 International Health Policy Survey.

Discussion

The main findings from this study demonstrate that there are opportunities for improvement in terms of the review that clients receive pertaining to their medications, the level of communication between physicians and clients, the access clients have to physicians and the use of technology related to providing a port for communication. In examining the findings, there are some limitations that are inherent in conducting a secondary analysis of pre-existing survey data. Due to the nature of the data, there was an inability to further explore the characteristics of the communities and hospitals in which the errors occurred. As well, the use of the secondary data set did not permit the opportunity to ask specific questions of interest or to clarify any findings. Another potential limitation of the study was the reliance on self-reported error reporting. Research demonstrates that medication errors are under-reported,[29] which presents a challenge as it is difficult to know the exact number of errors during this study period. Additionally, the survey asked participants to reflect retrospectively, presenting the opportunity for recall bias. Nonetheless, the survey and database provided valid, reliable and in-depth data that covered a broad geographical range and a large sample size.

The results from this study identified that many of the adults with chronic medical conditions were taking numerous medications concurrently. Previous research has identified that when clients are taking five or more medications there is an increase in the likelihood of a self-reported medication error occurrence.[30] Moreover, only 783 (29.7%) of clients identified that they always had their medications reviewed and discussed by a physician or pharmacist within the last 2 years. When physicians were asked if they provided their clients with a written list of medications they were taking, nearly half (44%) indicated they did not. Therefore, these results indicate that 24.9 % of participants are taking more than 5 medications and appear to not be receiving adequate monitoring and follow up. These results are concerning given that adults with chronic illness access the health care system frequently, have more long-term interactions with physicians and other health care professionals, tend to be on multiple medications, and tend to see a greater number of physicians, with all of these characteristics putting them at greater risk of error.

When physicians were asked if they call clients to check on medications, symptoms or help coordinate care in between visits with other staff such as nurses, nurse practitioners, medical assistants, 15% of respondents indicated they do not do this. As such, there is a need to foster improved communication amongst team members.[31][32] Furthermore, the client needs to be seen as an integral team member.

[32] Although communication is an area that is taught in most medical programs, discussing medications with clients is an area that needs to be emphasized and frequently revisited during physician/client encounters.[33]

There is a greater risk of experiencing a medication error at points in transition of care.[34] This is especially true for clients who have a chronic disease.[35] In this study, 637 (24.2%) clients leaving the hospital identified they had been given a new prescription and 194 (7.4%) said that no one had discussed what to do with other medications they were taking prior to being hospitalized. There is a lack of standardization regarding transfer of accountability in Canadian hospitals, with the risk of miscommunication increasing when a person is transitioning between care providers.[36] Clients should be encouraged to keep a list of their medications with them, including name, strength, dose and frequency of dosage, names of all non-prescription medicines, vitamins and herbal products, known medication and food allergies, special diets, and medications previously taken and the rationale for discontinuation.[37]

Although the majority of clients found it somewhat to very easy to contact their physician’s office, 594 (22%) indicated they found it somewhat to very difficult. Furthermore, this variable only captured the ability to contact the physician’s office, and not necessarily the physician directly. Access is a top concern of Canadians about the health care system.[38] Problems accessing their physicians are likely to send clients to seek other medical assistance. Data shows that when clients have multiple care providers and are on multiple medications, there is a higher risk for experiencing medication errors.[39] A health care poll conducted by Harris interactive found that 90% of online Americans would like to be able to access their physician by email.[40] However, the majority of physicians are not reimbursed for time and risk association with advice dispensed through email or phone.[41]

Email communication between clients and physicians was also found to be low, with only 166 (6.3%) of client indicating they communicate in this manner. Given that younger individuals are typically more technologically savvy, there is an opportunity for clients to connect with physicians via e-technology that is not currently being fully realized. In 1998, email exchange between physicians and clients was seen as an opportunity to provide improved communication and increase client involvement in their own care.[42] Given the prevalence of computer usage in physician offices, a lack of email communication is not readily understood. Many physicians may still feel uncomfortable using information technology.[21] However, effective communication has been shown to improve client satisfaction, recall of information, and medical outcomes, and can protect physicians against malpractice litigation.[27]

Beyond email, other technological advances such as e-prescribing and electronic transfer of prescriptions were not well used by physicians. Illegible handwriting has been identified as a cause of medication errors.[43] Insufficient information has been identified as a significant cause of medication errors.[21] Information technology is envisioned to be integral to advancing quality in health care.

The results from this study uphold the findings from the Institute of Medicine,[1] that identified steps to reduce medication errors, namely to encourage clients to take an active role in their health care and the greater use of technology. Therefore, there is a role for health care leaders to advocate for clients taking an increased role in their care and increased use of technology.

Recommendations to improve client safety, health care quality, and to reduce risk to patients due to poor communication from the perspective of the health care providers include: (a) Healthcare providers need to be trained to recognize how cultural differences, socio-economic factors, and personal values and beliefs can impact, both positively and negatively, effective communication; (b) Healthcare providers should be introduced to the concept of normative deviance, and how this ‘drifting into failure’ behavior may be negatively impacting their client-provider relationship; (c) Advances in communicative technology (particularly email) should be embraced and offered to clients who are technologically competent; (d) Healthcare providers should be trained on how to effectively facilitate client centered care appointments; (e) Systematic changes are needed in how high risk situations, such as transfer of care, are dealt with; and (f) Medication use and communication in the community setting needs to be thoroughly assessed and studied to provide support for all of the changes recommended above. Responsibility to improve communication rests not only with health care providers, but also with the patient. Recommendations for how patients should communicate with their health care providers include: (a) Carrying an up to date list of medications with them to all appointments; (b) Requesting an update list of medications from their health care provider at the transition in care, such as discharge from hospital; (c) Knowing the medication they are on and the rational for each medication; (d) Bringing a list of questions and concerns to all appointments; (e) Reporting any changes to their medication regime that their care provider may not be aware of (such as the use of herbal remedies); (f) Request a follow up appointment when a change in their medication regime has been made and (g) Accurately reporting the frequency of which they are taking their medications, any side effects they are experiencing and advocating and/or challenging any changes in their medication regime.

Conclusion

Effective communication between health care providers and clients is crucial in preventing medication errors, critical incidents and near misses. Adults with chronic illness and therefore complex medical histories are even more vulnerable to the ill effects of poor communication. Health care leaders are in an optimal position to advocate for clients’ role in their care and increase the use of technology within the health care system. Furthermore, clients and primary care physicians have identified areas for improvement in the communication of information across the various stages of the medication-use system. It is crucial for clients to receive detailed information in regards to their medication management to avoid potential adverse effects, especially after a medication change. Clients need clear information about the medications they are taking, the reasons they are taking them, and carry with them a complete up-to-date list of current medications. They need to have followup on their medication regime to assess progress and efficacy. Physicians should embrace technology and utilize e-prescribing as a method to reduce medication errors caused by illegible hand writing. However, it is important to note that the onus to improve communication regarding medications rests not only with physicians, but also with clients to voice concerns and engage in a dialogue about their health.

Acknowledgements

This paper conducted a secondary analysis of the data. All survey procedures including ethics approval, was coordinated by the Commonwealth Fund and Harris Interactive. The authors would like to thank Cathy Schoen, Michelle Doty, Robin Osborn, David Squires, and Kristof Stremikis from the Commonwealth Fund for the provision of the dataset and input on the research findings.

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Copyright: © 2013 Kim Sears, Andrea Bishop, Neil J. MacKinnon. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.

 

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