3005 — Explanatory Models and Daily Lived Experience in Patient-Provider Communication about Hypertension
Bokhour BG (Center for Health Quality, Outcomes, & Economic Research), Solomon JL
(Center for Health Quality, Outcomes & Economic Research), Fix GM
(Center for Health Quality, Outcomes & Economic Research), Cohn EC
(Boston University), Cortes DE
(Harvard Medical School, Cambridge Hospital), Haidet P
(Pennyslvania State University College of Medicine), Katz L
(VA New York Harbor Healthcare System), Mueller N
(Harvard Medical School), Elwy AR
(Center for Health Quality, Outcomes & Economic Research), Kressin NR
(VA New England Healthcare System)
Uncontrolled hypertension (HTN) remains a pervasive health problem despite the availability of effective treatment. Our previous work shows that patients’ explanatory models (EMs) and daily lived experienced (DLEs) affect the ways in which patients manage their HTN. EMs are beliefs that individuals have regarding the cause, mechanisms and course of illness, and effects of treatment; while DLE refers to patients’ contexts, routines, and other health problems that affect hypertension management. We sought to understand how patients and providers communicate about explanatory models and patients’ daily lived experiences in relationship to HTN management.
We audio-recorded clinical encounters between 53 patients with uncontrolled HTN and 12 primary care providers at two urban VA medical centers. We coded verbatim transcripts for segments in which patients’ and/or providers’ explanatory models, or patients’ daily lived experiences were discussed. We also conducted discourse analysis to examine provider communication that facilitated or hindered discussions of each construct.
In most encounters, discussions of HTN management focused on confirmation of HTN medications prescribed. In 52% of the encounters, patients discussed their explanatory models. In 67% of encounters, patients discussed daily lived experience and these primarily focused on routines for medication taking and avoiding salt. In 79% of encounters, providers discussed their biomedical explanatory models. Facilitators of discussions of patient EMs and DLEs included provider open-ended questions of patients’ understandings and patients’ daily lives. Closed-ended questions of patient adherence or directives regarding medication management hindered discussion.
Most providers did not seek to elicit patients’ perspectives on HTN or its treatment. By not doing so, providers may be missing key opportunities to influence patients’ behaviors, thereby making “contextual errors” hindering improved HTN control.
Our findings indicate that despite the importance of patients’ explanatory models and daily lived experience in managing their HTN, providers frequently do not address these in clinical encounters. Given the limited time that providers have with patients, collaborative care models in which patient coaches or navigators address EMs and DLEs with patients may be most effective. Such models could be integrated into the patient aligned care teams in the VA.