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Original Research

Patient–provider communication, self-reported medication adherence, and race in a postmyocardial infarction population

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Pages 311-318 | Published online: 19 Feb 2015

Abstract

Objectives

Our objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients’ race.

Methods

We conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors.

Results

Overall, 298 patients (74%) reported never leaving their doctor’s office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor’s office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19–3.92) and those of minority race (OR: 1.19; 95% CI: 0.54–2.66), the overall interaction effect was not statistically significant (P=0.24).

Conclusion

The quality of patient–provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients’ race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.

Introduction

Medication nonadherence is a common and expensive problem in the United States. Only 50% of patients report taking medications for cardiovascular disease (CVD) as prescribed.Citation1 Patients may be particularly susceptible to medication nonadherence during the period following a myocardial infarction (MI). During this time, patients often require multiple medications to lower their future cardiac risk requiring intensive self-management, which may place them at increased risk for medication nonadherence.Citation2

Although there is no clear risk profile, many factors influence medication nonadherence including both patient- and provider-driven factors.Citation3 Patient–provider interactions appear to be a major determinant of medication nonadherence, particularly as it pertains to CVD risk factor reduction. Poor physician communication alone has been associated with an up to 19% higher risk of medication nonadherence.Citation4Citation6 Conversely, high-quality communication may improve adherence. Providing tailored information, patient satisfaction with the communication received, and beliefs about medication are connected and can lead to improved medication adherence.Citation7 Part of patient-reported communication quality may be based on the communication style used during the clinical encounter – instrumental (ie, explicit, direct) or affective (ie, implicit, indirect). An affective communication style, including social talk, rapport building, and asking questions, may be associated with identifying more psychosocial and behavioral problems such as medication adherence.Citation8 Tailored communication matching patients’ preferred typology of communication may improve perceived barriers to medication adherence.Citation9

Physician communication behaviors may have a varying effect on patient trust, depending on the patient’s race,Citation10 and patients of minority race are more likely to be nonadherent with their medications.Citation11,Citation12 Race may have a stronger association with patient–provider rapport building and the quality of patient–physician communication than do certain clinical factors, such as blood pressure (BP) control.Citation13 Moreover, racial concordance between a patient and provider has been associated with adherence to CVD medications.Citation14 Elderly African Americans reported that they followed physician instructions on how to take medications less frequently than did elderly white patients, even after adjusting for potentially confounding differences such as health literacy and other sociodemographic characteristics.Citation11

Racial differences in expectations of medical interactions and in medication adherence are known.Citation10Citation12 Compared to white patients, those of African American race have reported lower levels of trust of physicians and fewer informational encounters.Citation15 Collins et alCitation16 demonstrated that while both white and African American patients wanted more informational clarity about cardiac testing, African American patients valued building trust with their providers to a higher degree than their white counterparts.

While patient–provider communication and CVD-related medication nonadherence are associated,Citation17 it is not known whether a previous history of MI impacts this relationship, nor is it known whether a patient’s race may influence communication quality among post-MI patients. We considered this issue in the context of the Expectancy Violations theoretical framework.Citation18 This theoretical framework depicts communication as an exchange of information that encompasses relational content. Those communicating have expectations for their informational exchange. When there is inconsistency in expectations and what occurs in the interaction, there may be dissatisfaction with the communication and resulting negative outcomes.Citation18,Citation19 For example, in the context of adherence to an exercise program, when patients’ expectations were violated, there was a greater degree of nonadherence.Citation20 Conversely, meeting patients’ expectations has been associated with increased adherence.Citation19,Citation21 We were interested in patients’ expectations of their doctors in medical interactions, specifically the expectations that doctors address all of a patient’s concerns and answer their questions, and how that affected medication adherence.

Because post-MI patients are at an especially high risk for future cardiovascular morbidity and mortality, and race has been found to be a significant moderator of patient/provider communication,Citation22Citation24 a better understanding of the impact of patient–provider communication on medication nonadherence in the post-MI period is essential. Thus, the objective of our analysis was twofold. First, we aimed to describe patient-reported aspects of communication with their provider(s) and differences in perceptions of racially diverse adherent versus nonadherent patients. Second, we sought to examine whether the association between leaving a provider’s office with unanswered questions and medication nonadherence varied as a function of patients’ race. Given the briefness of the items, if associated, the issue of unanswered questions could be used as a screening measure for potential poor quality communication.

Methods

Data source

Data were obtained from a trial to improve post-MI management called the Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) study (clinicaltrials.gov resistry number: NCT00901277). The methods of the SPRITE study have been previously described in detail.Citation25 In brief, SPRITE is a three-arm randomized controlled trial using the following two electronic self-management tools: HealthVault, a Web-based communication tool created by Microsoft Corporation (Redmond, WA, USA), with Heart360, the American Heart Association’s (Dallas, TX, USA) Web-based heart health tracker; and a portable electronic BP cuff. To be eligible for the study, patients had to have a current hypertension diagnosis (by the International Classification of Diseases 9 diagnosis code or elevated BP on two consecutive clinic visits) and a history of MI within the 3 years prior to enrollment. Patients (total number [N]=406) were enrolled and randomized to one of three arms: either 1) home BP monitoring plus a nurse-delivered, telephone-based tailored patient education intervention, and enrollment in HealthVault and Heart360; 2) home BP monitoring plus a tailored, Web-based patient education intervention, and enrollment in HealthVault and Heart360; or 3) usual care.

A survey assessing patients’ perceptions of communication with their physicians and self-reported medication nonadherence, among other factors, was administered at enrollment. We used this baseline survey data to evaluate associations between self-reported medication nonadherence and items reflecting patient–provider communication.

Outcome measure: self-reported medication nonadherence

Self-reported medication nonadherence

A modified Morisky Medication-Taking Scale was used to assess self-reported medication nonadherence. To ease respondent burden, we used a validated, four-item measure rather than the lengthier eight-item measure.Citation26Citation28 Patients were asked whether four statements about CVD medication-taking behaviors were true for them over the previous 30 days: 1) “I sometimes forget to take my medicine”; 2) “I am sometimes careless about taking my medicine”; 3) “when I feel better, I sometimes stop taking my medicine”; and 4) “if I feel worse when I take the medicine, sometimes I stop taking it”. Each of the medication adherence items could be answered on a four-point Likert scale with responses ranging from “strongly agree” to “strongly disagree”. Consistent with prior research,Citation29 patients were dichotomized into either the “adherent” or “nonadherent” group. Individuals were classified as nonadherent if they responded affirmatively, “don’t know”, or “refused” to any of the four statements; otherwise, patients were classified as adherent. Patients with missing data on any of these four items were excluded from the analysis. The Cronbach’s alpha (α=0.80) for the Morisky medication adherence items indicated a good degree of internal consistency.

Primary independent variables: patient-reported communication and race

Patient-reported communication

The SPRITE baseline survey contained survey items extracted from the Primary Care Assessment Survey (PCAS),Citation30 which was designed as a patient-completed questionnaire operationalizing the Institute of Medicine’s concept of primary care. The SPRITE baseline survey contained three of six items from the communication subdomain of the PCAS. We selected these items based on face validity and expected relevance to the post-MI patient population.

Communication questions included on the baseline survey were: “How often do you leave your doctor’s office with unanswered questions?”; “In the last 12 months, how often did your personal doctor explain things in a way that was easy to understand?”; and, “In the last 12 months, how often did your personal doctor listen carefully to you?” Response options for the “unanswered questions” item were on a four-point Likert scale. In addition to examining each communication item descriptively, a binary measure was created for the “unanswered questions” item for use in the analyses (“at least some of the time” versus another nonmissing response).

Race

As previously described, race impacts medication adherence and perceived communication.Citation31 Race was based on patients’ self-reported race during the baseline survey. Possible response options included: “White or Caucasian”; “Black or African American”; “Asian”; “American Indian/Alaska Native”; “Native Hawaiian or Other Pacific Islander”; as well as “other”, “don’t know”, or “refused”. Because there were few non-African American minorities (sample number [n]=20), we created a binary measure of the race variable (minority versus all nonminority races).

Covariates: sociodemographic factors

As a proxy measure for social support, marital status was included. Married people tend to engage in healthier behaviors, including medication adherence, compared to those who are unmarried.Citation32 This analysis included a binary measure for those who were partnered (married or living with a partner versus other). People with less than a high school education and/or who are unemployed are at increased risk for medication nonadherence.Citation33Citation35

Low health literacy has been suggested to correspond with medication nonadherence and to also negatively influence communication between patients and their providers.Citation4 Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM) test.Citation36 Low health literacy was a dichotomous variable defined as a REALM score of up to and including the eighth grade (≤60 score) versus the ninth grade or higher (>61 score).Citation37

We included a binary measure of employment (employed part time or full time versus not employed). A dichotomized measure of patient-reported educational attainment was also included in the analysis (less than high school education versus high school or greater education). Patients were asked to describe their household’s current financial situation. Possible response options included: “after paying the bills, you still have enough money for special things that you want”; “you have enough money to pay the bills, but little spare money to buy extra or special things”; “you have money to pay the bills, but only because you have to cut back on things”; or “you are having difficulty paying the bills no matter what you do”. Patients who reported the latter two categories (eg, cutting back on things or difficulty paying bills) were considered to have an inadequate financial status.

Statistical analysis

Data were analyzed in Stata version 12.1 (StataCorp LP, College Station, TX, USA) and SAS version 9.2 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were used to summarize baseline patient characteristics and patient-reported communication by nonadherence status and race. Multivariable logistic regression was used to examine whether the association between medication nonadherence and communication (ie, unanswered questions) varied as a function of patients’ race. The model included an interaction term for unanswered questions by race and was adjusted for covariates that were selected a priori based on factors previously shown to impact medication nonadherence.Citation31Citation35,Citation38Citation41 Model results are presented as odds ratios (OR), 95% confidence intervals (CI), and P-values. The impact of the interaction term is reported by providing the interaction P-value and ORs for the simple main effects of unanswered questions conditional on level of race.

Results

Study population

The total number of patients examined was 405. One patient was omitted from the analysis because of missing medication nonadherence information. More than half of the patients reported being adherent (n=232; 57%). Most patients were male (n=292; 72%) and married or living with a partner (n=269; 66%). A minority of patients had less than a high school education (n=53; 13%), low health literacy (n=68; 17%), were employed (n=149; 37%), or reported inadequate financial status (n=92; 23%). A full description of the patients’ baseline characteristics by adherence status and race is provided in .

Table 1 Baseline characteristics overall and by adherence/race groups (n=405Table Footnote*)

Communication

Few patients reported always leaving their doctor’s office with unanswered questions (n=8; 2%). Overall, 298 patients (74%) reported never leaving their doctor’s office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor’s office with unanswered questions. Similarly, most patients reported that their personal doctor always explained things in a way that was easy to understand (n=293; 72%). Among adherent patients, 181 (78%) reported always having things well explained by their doctor; among nonadherent patients, 112 (65%) reported always having things well explained by their doctor. The majority of patients (n=282; 70%) reported that their doctors always listened carefully. Additional information regarding individual communication items by adherence status and race are provided in .

Table 2 Communication items overall and by adherence/race

Medication nonadherence

presents results from the multivariable logistic regression model. The OR and 95% CI estimates are from the full model, which included the interaction term (ie, minority race by unanswered questions). Although the simple effects of the interaction term were different for patients of nonminority race (OR: 2.16; 95% CI: 1.19–3.92) and those of minority race (OR: 1.19; 95% CI: 0.54–2.66), the overall interaction effect was not statistically significant (P=0.24). Additionally, none of the a priori covariates including male sex (OR: 1.07; 95% CI: 0.65–1.76), married/living with a partner (OR: 0.92; 95% CI: 0.58–1.48), employed (OR: 1.18; 95% CI: 0.76–1.84), less than a high school education (OR: 1.43; 95% CI: 0.72–2.83), inadequate financial status (OR: 1.55; 95% CI: 0.94–2.56), and low health literacy (OR: 0.98; 95% CI: 0.52–1.85) were significantly associated with medication nonadherence.

Table 3 Multivariable logistic regression showing the association between CVD-related medication nonadherence and leaving the doctor’s office with unanswered questionsTable Footnote§ (n=390)

Discussion

Productive interactions between informed patients and proactive providers are a critical element in the management of chronic disease.Citation42 Despite the importance of communication, patients both in our study and in other studiesCitation43,Citation44 have reported leaving their doctor’s office with unaddressed questions. We report two primary findings. First, consistent with existing literature, we found that nonwhite patients were more likely to be nonadherent than white patients.Citation45,Citation46 Second, we determined that factors associated with nonadherence did not differ as a function of patients’ race. We found that leaving with unanswered questions after a doctor’s visit was not associated with medication nonadherence as a function of race. These results differ from previously published studies.Citation10Citation13 This may be because our study relied on subjective measures that were self-reported by patients. Differences in patients’ expectations as a function of their race and how violations of these expectations may influence their adherence behaviors are not known. For example, did patients’ expectations of whether or not doctors would or should address all of their questions vary by race? This was not addressed in the current study. Further, an association between financial burden and nonadherence is known,Citation47,Citation48 and while the estimated odds ratio for patient-reported inadequate financial status (OR: 1.55) was suggestive of an association with medication nonadherence, this was not significant (P=0.09) in the adjusted model.

While not addressed in the current study, when patients have unanswered questions, there may be uncertainty about how to properly take their medications. Patients may not speak with their doctor about important barriers to medication nonadherence, such as the cost of their medications. Atreja et alCitation49 reviewed proven interventions to increase medication adherence and summarized key points in a mnemonic device. The mnemonic is “SIMPLE”: simplifying regimen characteristics; imparting knowledge; modifying patients’ beliefs; patient communication; leaving the bias; and evaluating adherence.Citation49 The latter five elements hinge on strong communication between patients and their providers, highlighting its chief importance in improving adherence.

Because patients and providers often perceive the quality of communication differently,Citation50 routinely asking patients if they have additional questions and/or asking them to rate interactions with their doctors may be an important tool to increase medication adherence. At minimum, this would increase awareness of the importance of communication among both patients and providers. Cultivating communication skills has been the focus of much attention and is now a standard part of most medical education curricula.Citation51 While this is a critical first step, teaching providers about quality communication is only one-half of the equation for a productive interaction. Patients also must be educated. When both patients and providers are trained in effective communication, they exhibit a greater sense of control and preference for a more active role in decision making.Citation52 In a study conducted by Haskard et alCitation53 the researchers determined that when physicians were trained, patients reported increased satisfaction. When patients were trained, physicians’ satisfaction with data collection improved. If only the physician or the patient was trained (not both), then physician stress increased and satisfaction decreased.Citation53

Our study has several limitations. Because this analysis is cross-sectional, we are unable to determine the directionality of the association between poor communication and medication nonadherence; it may be that, compared to those who are nonadherent, patients who adhere have other unmeasured characteristics that would lead them to be more proactive in their medical interactions. Similarly, whether the quality of patient–doctor interactions directly caused nonadherence behavior cannot be determined from these data. There may be unmeasured confounders, such as the length of time spent in the encounter,Citation13 and/or cultural differences not assessed by race alone. We did not have information about race concordance between patients and their providers. For African American patients, race concordance between a patient and provider has been associated with adherence to CVD medications.Citation14 Moreover, African American patients with uncontrolled BP have been shown to have shorter medical visits with less rapport building than white patients with controlled BP.Citation13 At least one study concluded that patient race has a stronger association with the quality of the patient–physician communication than do certain clinical factors, such as BP control.Citation13 The small percentage of non-African American minorities precluded us from evaluating specific differences among different minority groups. Additionally, medication nonadherence was measured through three patient-reported items. While we used a validated measure of medication adherence, it is possible that patients misrepresented their actual adherence behaviors. The three included items do not address a full spectrum of communication quality indicators. Ideally, a more comprehensive measure of patient-reported communication measures would be assessed in tandem with a potentially more objective observational measurement, such as videotaping or audio taping patient–doctor interactions. Lastly, failure to detect differences between medication nonadherence and communication by race may have resulted from a lack of statistical power, as the original study was not powered specifically to detect interaction effects.

Conclusion

The quality of patient–provider communication may be an important resource for supporting CVD medication adherence. While the association between race and having unanswered questions was not statistically significant, racial differences in medication adherence were prevalent and should be addressed to ensure maximum adherence. Future studies should seek to understand the temporality between communication and medication nonadherence, as well as to identify specific strategies to improve adherence in patients of diverse backgrounds at both an individual patient–provider dyad level, as well as at a health care facility or systems level.

Practice implications

Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills.

Acknowledgments

This study was supported in part by an award from the American Heart Association Pharmaceutical Roundtable and David and Stevie Spina. Dr Zullig (CDA 13–025) and Dr Crowley (CDA 13–261) are supported by VA Health Services Research and Development Career Development Awards. Dr Bosworth was supported by a research career scientist award from VA Health Service Research and Development (VA HSR&D 08–027). This project was also supported in part by grant number U19HS021092 from the Agency for Healthcare Research and Quality.

Disclosure

SCG receives consulting fees from Gilead Sciences for serving on multiple Data and Safety Monitoring Boards (DSMBs). Although the relationship is not perceived to represent a conflict with the present work, it has been included in the spirit of full disclosure. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of Duke University, the US Department of Veterans Affairs, or the United States government. The other authors report no conflicts of interest in this work.

References

  • BosworthHBHow can innovative uses of technology be harnessed to improve medication adherence?Expert Rev Pharmacoecon Outcomes Res201212213313522458612
  • JneidHAndersonJLWrightRS2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesJ Am Coll Cardiol201260764568122809746
  • van DijkLHeerdinkERSomaiDPatient risk profiles and practice variation in nonadherence to antidepressants, antihypertensives and oral hypoglycemicsBMC Health Serv Res200775117425792
  • JollesEPClarkAMBraamBGetting the message across: opportunities and obstacles in effective communication in hypertension careJ Hypertens20123081500151022635137
  • RoterDLHallJAAokiYPhysician gender effects in medical communication: a meta-analytic reviewJAMA2002288675676412169083
  • ZolnierekKBDimatteoMRPhysician communication and patient adherence to treatment: a meta-analysisMed Care200947882683419584762
  • LinnAJvan WeertJCvan DijkLHorneRSmitEGThe value of nurses’ tailored communication when discussing medicines: Exploring the relationship between satisfaction, beliefs and adherenceJ Health Psychol2014pii: 1359105314539529
  • DeveugeleMDereseADe BacquerDvan den Brink-MuinenABensingJDe MaeseneerJIs the communicative behavior of GPs during the consultation related to the diagnosis? A cross-sectional study in six European countriesPatient Educ Couns200454328328915324979
  • LinnAJvan WeertJCSchoutenBCSmitEGvan BodegravenAAvan DijkLWords that make pills easier to swallow: a communication typology to address practical and perceptual barriers to medication intake behaviorPatient Prefer Adherence2012687188523271896
  • MartinKDRoterDLBeachMCCarsonKACooperLAPhysician communication behaviors and trust among black and white patients with hypertensionMed Care201351215115723132201
  • GerberBSChoYIArozullahAMLeeSYRacial differences in medication adherence: A cross-sectional study of Medicare enrolleesAm J Geriatr Pharmacother20108213614520439063
  • RolnickSJPawloskiPAHedblomBDAscheSEBruzekRJPatient characteristics associated with medication adherenceClin Med Res2013112546523580788
  • CenéCWRoterDCarsonKAMillerER3rdCooperLAThe effect of patient race and blood pressure control on patient-physician communicationJ Gen Intern Med20092491057106419575270
  • TraylorAHSchmittdielJAUratsuCSMangioneCMSubramanianUAdherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?J Gen Intern Med201025111172117720571929
  • GordonHSStreetRLSharfBFKellyPASouchekJRacial differences in trust and lung cancer patients’ perceptions of physician communicationJ Clin Oncol200624690490916484700
  • CollinsTCClarkJAPetersenLAKressinNRRacial differences in how patients perceive physician communication regarding cardiac testingMed Care2002401 SupplI27I3411789628
  • BosworthHBGrangerBBMendysPMedication adherence: a call for actionAm Heart J2011162341242421884856
  • BurgoonJKA communication model of personal space violations: explication and an initial testHum Commun Res197842129142
  • BurgoonMBirkTSHallJRCompliance and satisfaction with physician-patient communication an expectancy theory interpretation of gender differencesHum Commun Res1991182177208
  • SearsSRStantonALExpectancy-value constructs and expectancy violation as predictors of exercise adherence in previously sedentary womenHealth Psychol200120532633311570646
  • KlingleRSBringing time into physician compliance-gaining research: toward a reinforcement expectation theory of strategy effectivenessHealth Commun199354283308
  • Burnett-ZeiglerIKimHMChiangCThe association between race and gender, treatment attitudes, and antidepressant treatment adherenceInt J Geriatr Psychiatry201429216917723801324
  • SchoenthalerAAllegranteJPChaplinWOgedegbeGThe effect of patient-provider communication on medication adherence in hypertensive black patients: does race concordance matter?Ann Behav Med201243337238222270266
  • SchoenthalerAChaplinWFAllegranteJPProvider communication effects medication adherence in hypertensive African AmericansPatient Educ Couns200975218519119013740
  • ShahBRAdamsMPetersonEDSecondary prevention risk interventions via telemedicine and tailored patient education (SPRITE): a randomized trial to improve postmyocardial infarction managementCirc Cardiovasc Qual Outcomes20114223524221406672
  • MoriskyDEGreenLWLevineDMConcurrent and predictive validity of a self-reported measure of medication adherenceMed Care198624167743945130
  • ShalanskySJLevyARIgnaszewskiAPSelf-reported Morisky score for identifying nonadherence with cardiovascular medicationsAnn Pharmacother20043891363136815238622
  • MoriskyDEAngAKrousel-WoodMWardHJPredictive validity of a medication adherence measure in an outpatient settingJ Clin Hypertens (Greenwich)200810534835418453793
  • ThorpeCTBrysonCLMaciejewskiMLBosworthHBMedication acquisition and self-reported adherence in veterans with hypertensionMed Care200947447448119330891
  • SafranDGKosinskiMTarlovARThe Primary Care Assessment Survey: tests of data quality and measurement performanceMed Care19983657287399596063
  • GuQBurtVLPaulose-RamRDillonCFGender differences in hypertension treatment, drug utilization patterns, and blood pressure control among US adults with hypertension: data from the National Health and Nutrition Examination Survey 1999–2004Am J Hypertens200821778979818451806
  • TrivediRBAyotteBEdelmanDBosworthHBThe association of emotional well-being and marital status with treatment adherence among patients with hypertensionJ Behav Med200831648949718780175
  • ParkYHKimHJangSNKohCKPredictors of adherence to medication in older Korean patients with hypertensionEur J Cardiovasc Nurs2013121172421704563
  • GazmararianJAKripalaniSMillerMJEchtKVRenJRaskKFactors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacyJ Gen Intern Med200621121215122117105519
  • MochariHFerrisAAdigopulaSHenryGMoscaLCardiovascular disease knowledge, medication adherence, and barriers to preventive action in a minority populationPrev Cardiol200710419019517917515
  • DeWaltDAHinkAHealth literacy and child health outcomes: a systematic review of the literaturePediatrics2009124Suppl 3S265S27419861480
  • DewaltDABerkmanNDSheridanSLohrKNPignoneMPLiteracy and health outcomes: a systematic review of the literatureJ Gen Intern Med200419121228123915610334
  • CharlesHGoodCBHanusaBHChangCCWhittleJRacial differences in adherence to cardiac medicationsJ Natl Med Assoc2003951172712656446
  • GehiAHaasDPipkinSWhooleyMADepression and medication adherence in outpatients with coronary heart disease: findings from the Heart and Soul StudyArch Intern Med2005165212508251316314548
  • World Health OrganizationAdherence to Long-Term Therapies: Evidence for ActionGeneva, SwitzerlandWorld Health Organization2003
  • HoPMBrysonCLRumsfeldJSMedication adherence: its importance in cardiovascular outcomesCirculation2009119233028303519528344
  • WagnerEHBennettSMAustinBTGreeneSMSchaeferJKVonkorffMFinding common ground: patient-centeredness and evidence-based chronic illness careJ Altern Complement Med200511Suppl 1S7S1516332190
  • HeinrichCKarnerKWays to optimize understanding health related information: the patients’ perspectiveGeriatr Nurs2011321293821051100
  • MartinMYKohlerCKimYITaking less than prescribed: medication nonadherence and provider-patient relationships in lower-income, rural minority adults with hypertensionJ Clin Hypertens (Greenwich)201012970671320883231
  • BlackwellSABaughDKMontgomeryMACiborowskiGMWaldronCJRileyGFNoncompliance in the use of cardiovascular medications in the Medicare Part D populationMedicare Medicaid Res Rev201114
  • ZhangYBaikSHChangCCKaplanCMLaveJRDisability, race/ethnicity, and medication adherence among Medicare myocardial infarction survivorsAm Heart J20121643425 e4–433.e4.22980311
  • NekhlyudovLMaddenJGravesAJZhangFSoumeraiSBRoss-DegnanDCost-related medication nonadherence and cost-saving strategies used by elderly Medicare cancer survivorsJ Cancer Surviv20115439540421800053
  • NguyenHGChamieKNguyenKGDurbin-JohnsonBKurzrockEAOutcomes after pediatric ureteral reimplantation: a population based analysisJ Urol201118562292229721511291
  • AtrejaABellamNLevySRStrategies to enhance patient adherence: making it simpleMed Gen Med2005714
  • KennyDAVeldhuijzenWWeijdenTVInterpersonal perception in the context of doctor–patient relationships: a dyadic analysis of doctor–patient communicationSoc Sci Med201070576376820005618
  • American Medical AssociationInitiative to Transform Medical Education: Recommendations for Change in the System of Medical EducationChicago, ILAmerican Medical Association2007
  • HarringtonJNobleLMNewmanSPImproving patients’ communication with doctors: a systematic review of intervention studiesPatient Educ Couns200452171614729285
  • HaskardKBWilliamsSLDiMatteoMRRosenthalRWhiteMKGoldsteinMGPhysician and patient communication training in primary care: effects on participation and satisfactionHealth Psychol200827551352218823177