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Evaluating Implementation of an HIV Adherence Informatics Intervention
Barbara G. Bokhour, PhD
VA Bedford HealthCare System, Bedford, MA
Funding Period: January 2011 - July 2012
Adherence to antiretroviral therapy is critical in HIV-infected individuals. One way to improve adherence is through the use of informatics-based interventions. Medications for Chronic HIV: Education and Collaboration (MedCHEC), is a VA-based, NIH-funded randomized implementation trial of a multimodal intervention designed to improve the quality of adherence-related care, and thus improve HIV medication adherence. MedCHEC uses a tablet-computer pre-visit clinical assessment, plus tailored adherence support, to improve HIV medication adherence. One mechanism through which such interventions may have an effect on outcomes is through its effect on the patient-physician clinical encounter. High quality communication and good patient-physician relationships are related to better HIV adherence and clinical outcomes.
The goals of this study were to evaluate the impact of the MedCHEC tablet-computer pre-visit clinical assessment on the actual communication between patients and physicians in HIV-related clinical encounters. The objectives were: 1) to evaluate "fidelity" to the intervention: that is, whether and how physicians and patients use the output of the MedCHEC intervention in their conversation about HIV medications; and 2) to evaluate the impact of the MedCHEC informatics intervention on patterns of communication between physicians and patients about adherence to HIV antiretroviral medications.
We audio-recorded and analyzed a sample of 42 patient-physician clinical visits with 12 physicians in the MedCHEC study at two VA HIV clinics. Half of the patients in the encounters received the MedCHEC intervention, while the other half remained in the control group, and received usual care. Nearly all the physicians participated in interactions with both control and intervention patients. Audio-recorded visits were transcribed verbatim and uploaded into NVivo 10, a coding software program. We conducted quantitative and qualitative analyses of the transcripts. We coded interactions for specific reference to the output of the MedChec tablet intervention, different types of adherence talk and the speech acts associated with the adherence talk that were present. We then compared the proportion of types of talk for patients in the intervention vs. control groups. For the qualitative analysis we examined portions of transcripts in which there was discussion of nonadherence to HIV medications, to identify whether physicians or patients initiated such discussions and the extent to which physicians inquired about the reasons for nonadherence and/or engaged in problem-solving with patients about nonadherence.
When comparing intervention and control interactions, physicians in the intervention group more frequently engaged in some types of "adherence talk", including inquiring about adherence, non-adherence problem-solving, and medication side effects. Of the 21 interactions in the control group, only 16 included talk about adherence. In 2 cases, where there was no reference to ART medication-taking at all; more urgent medical issues addressed in the interactions were being addressed. In the 21 interactions of patients in the intervention group, all entailed some talk about medication adherence. Although 14 of the 21 tablet reports in the intervention group indicated ART adherence problems, these were referred to in only 3 interactions. In both intervention and control interactions, when engaged in adherence talk, physicians most frequently use closed questions (questions with "yes" or "no" answers) and the expression of factual information (for example, explaining the importance of ART adherence); physicians in the intervention group did so more often. Reference to patients' being adherent (by either patient or physician) occurred in 8 (intervention) vs. 4 (control) interactions. Adherence problem-solving, in which patient and physician attempted to address barriers to adherence occurred in 7 (intervention) vs. 5(control) interactions. Talk about side effects of medications occurred in 4 (intervention) vs. 2 (control) interactions. There was no difference between groups in talk about non-adherence (i.e. patients not taking medications as prescribed), or describing the medication regimen. Through qualitative analysis, we identified patterns of conversations about non-adherence. In 12 interactions, equally distributed across groups, physicians did not explore reasons for non-adherence or engage in non-adherence problem-solving, despite indications by patients that they were non-adherent. In 5 interactions (4 intervention, 1 control) where patients indicated a history of non-adherence, there was subsequent conversation about the reasons for, and/or problem solving about, non-adherence. The initiation of this conversation occurred only once by a physician with an intervention patient; the rest were initiated by patients..
Although physicians referenced the tablet report in only three interactions, the intervention was not necessarily ineffective. Indeed, physicians in the intervention group exhibited more adherence talk, which might be due to having been exposed to tablet reports. However, because physicians used language forms not conducive to encouraging patients to elaborate on non-adherence, and because some physicians did not explore non-adherence with patients who raised the topic, our findings suggest that doctors could benefit from interventions geared toward how to engage in discussions about, and find solutions to, improve patient adherence to ART. Given that in most cases in our study physicians inquired about reasons for nonadherence and/or engaged in problem-solving when patients raised the topic of nonadherence, future interventions might consider enhancing the MedCHEC intervention with teaching patients how to utilize them effectively in raising adherence problems in their clinical encounters. These interventions are important for addressing patient non-adherence to ART by helping patients and providers more effectively communicate not only about the fact of non-adherence, but about the difficulties patients face in adhering to these regimens.
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DRA: Infectious Diseases
DRE: Technology Development and Assessment
Keywords: Adherence, Communication -- doctor-patient, HIV/AIDS
MeSH Terms: none