The International Society for the Study of Women's Sexual Health Process of Care for the Identification of Sexual Concerns and Problems in Women.

Sexual problems are common in women of all ages. Despite their frequency and impact, female sexual dysfunctions (FSDs) are often unrecognized and untreated in clinical settings. In response, the International Society for the Study of Women's Sexual Health convened a multidisciplinary, international expert panel to develop a process of care (POC) that outlines recommendations for identification of sexual problems in women. This POC describes core and advanced competencies in FSD for clinicians who are not sexual medicine specialists and serve as caregivers of women and, therefore, is useful for clinicians with any level of competence in sexual medicine. The POC begins with the expectation of universal screening for sexual concerns, proceeds with a 4-step model (eliciting the story, naming/reframing attention to the problem, empathic witnessing of the patient's distress and the problem's impact, and referral or assessment and treatment) that accommodates all levels of engagement, and delineates a process for referral when patients' needs exceed clinician expertise. Distressing problems related to desire, arousal, and orgasm affect 12% of women across the lifespan. Low desire is the most common sexual problem, but sexual pain and other less common disorders of arousal and orgasm are also seen in clinical practice. Screening is best initiated by a ubiquity statement that assures the patient that sexual concerns are common and can be revealed. Patient-centered communication skills facilitate and optimize the discussion. The goal of the POC is to provide guidance to clinicians regarding screening, education, management, and referral for women with sexual problems.

Physician-patient communication about overactive bladder: Results of an observational sociolinguistic study.

INTRODUCTION: Overactive bladder (OAB) and urinary incontinence are common problems that have significant impact on quality of life (QOL). Less than half of sufferers seek help from their physicians; many who do are dissatisfied with treatment and their physicians' understanding of their problems. Little is known about the sociolinguistic characteristics of physician-patient communication about OAB in community practice. METHODS: An IRB-approved observational sociolinguistic study of dialogues between patients with OAB and treating physicians was conducted. Study design included semi-structured post-visit interviews, post-visit questionnaires, and follow-up phone calls. Conversations were analyzed using techniques from interactional sociolinguistics. RESULTS: Communication was physician- rather than patient-centered. Physicians spoke the majority of words and 83% of questions were closed-ended. The impact of OAB on QOL and concerns about and adherence to treatment were infrequently addressed by physicians, who were poorly aligned with patients in their understanding. These topics were addressed more frequently when open-ended questions successfully eliciting elaborated responses were used in ask-tell-ask or ask-tell sequences. DISCUSSION: Clinical dialogue around OAB is physician-centered; topics critical to managing OAB are infrequently and inadequately addressed. The use of patient-centered communication is correlated with more discussion of critical topics, and thus, more effective management of OAB.

Recommendations for the medical management of chronic venous disease: The role of Micronized Purified Flavanoid Fraction (MPFF).

Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index < .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.

Hypoactive Sexual Desire Disorder: A Review of Epidemiology, Biopsychology, Diagnosis, and Treatment.

INTRODUCTION: Hypoactive Sexual Desire Disorder (HSDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM-IV-TR) as persistent deficient sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), HSDD has been subsumed by Female Sexual Interest/Arousal Disorder. However, decades of research based on DSM-IV-TR HSDD criteria form the foundation of our understanding of the essential symptom of distressing low sexual desire, its epidemiology, clinical management, and treatment. AIM: This publication reviews the state of knowledge about HSDD. METHODS: A literature search was performed using terms HSDD and female sexual dysfunction (FSD). MAIN OUTCOME MEASURES: Physicians acknowledge that FSD is common and distressing; however, they infrequently address it, citing low confidence, time constraints, and lack of treatment as barriers. RESULTS: HSDD is present in 8.9% of women ages 18 to 44, 12.3% ages 45 to 64, and 7.4% over 65. Although low sexual desire increases with age, distress decreases; so prevalence of HSDD remains relatively constant across age. HSDD is associated with lower health-related quality of life; lower general happiness and satisfaction with partners; and more frequent negative emotional states. HSDD is underdetected and undertreated. Less than half of patients with sexual problems seek help from or initiate discussions with physicians. Patients are inhibited by fear of embarrassing physicians and believe that physicians should initiate discussions. The Decreased Sexual Desire Screener, a tool for detecting and diagnosing HSDD, is validated for use in general practice. CONCLUSION: Women can benefit from intervention in primary care, behavioral health and sexual medicine settings. Psychotherapeutic and pharmacological interventions aim to enhance sexual excitatory process and decrease inhibitory processes. Flibanserin, the first centrally acting daily medication for HSDD, was recently approved in the US for premenopausal women.

Teaching and assessing residents' skills in managing heroin addiction with objective structured clinical examinations (OSCEs).

BACKGROUND: Heroin-abusing patients present a significant challenge. Objective Structured Clinical Examinations (OSCEs) allow evaluation of residents' clinical skills. The objective of this study was to examine residents' OSCE performance assessing and managing heroin abuse. METHODS: Evaluation and comparison of heroin-specific communication, assessment, and management skills in a 5-station postgraduate year 3 (PGY3) substance abuse OSCE. Faculty used a 4-point Likert scale to assess residents' skills; standardized patients provided written comments. RESULTS: Two hundred sixty-five internal and family medicine residents in an urban university hospital participated over 5 years. In the heroin station, residents' skills were better (P < .001 for both comparisons) in communication (mean overall score: 316 ± 0.51) than in either assessment (mean overall score: 2.66 ± 0.60) or management (mean overall score: 2.50 ± 0.73). The mean score for assessing specific high-risk behaviors was lower than the mean overall assessment score (222 ± 1.01 vs. 2.74 ± .59; P < .0001), and the mean score for recommending appropriate harm reduction management strategies was lower than the mean overall management score (2.39 ± .89 vs. 2.54 ± .74; P < .005). Standardized patients' comments reflected similar weaknessess in residents' skills. CONCLUSIONS: Assessment and management of heroin abuse were more challenging for residents than general communication. Additional training is required for residents to assess and counsel patients about high-risk behaviors.

Memory Impairment and Executive Dysfunction are Associated with Inadequately Controlled Diabetes in Older Adults.

OBJECTIVE: To assess the cross-sectional relationship of glycemic control to memory impairment and executive dysfunction in older adults with diabetes treated at an urban primary care center. PARTICIPANTS AND METHODS: As part of a primary care-based cognitive screening program, we identified adults age 65 or older with a diagnosis of diabetes. Glycosylated hemoglobin level (HbA1c) was used to define diabetes as controlled (HbA1c <7) or inadequately controlled(HbA1c ≥ 7). Episodic memory was measured by quartile of free recall scores on the Free and Cued Selective Reminding Test. Executive function was measured using an ordinal composite score derived from animal fluency and months backward. These were the main predictors of diabetic control. RESULTS: The 169 participants with diabetes had a median age of 74. The sample was 38% African American and 42% Latino. One hundred four (61%) had inadequately controlled diabetes. Memory impairment and executive dysfunction were independent predictors of diabetic control after adjusting for age and education. Binary logistic regression models indicated that the odds of inadequately controlled diabetes was higher for patients in the worst quartile of memory functioning compared to patients in higher quartiles of memory functioning (odds ratio = 6.4; 95% confidence interval: 2.3, 17.6). Any level of executive dysfunction increased the odds of inadequately controlled diabetes compared to patients in the best quintile of executive functioning (odds ratio = 3.6; 95% confidence interval: 1.58, 8.35). CONCLUSIONS: Memory impairment and executive dysfunction were associated with inadequately controlled diabetes. Though causal inferences are not robust in a cross-sectional study, we suggest that cognitive dysfunction may interfere with diabetes management and that inadequate diabetic control may contribute to cognitive dysfunction.

Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma.

PURPOSE: To assess communication about adherence and to determine the impact of communication skills training on physicians' approach to nonadherence. DESIGN: Sociolinguistic analysis of videotaped community ophthalmologists' encounters with patients with glaucoma before and after training. Patients in both phases and physicians in phase I knew communication was being studied but not what the focus of the study was. In phase II, physicians knew the targeted communication behaviors. PARTICIPANTS: Twenty-three ophthalmologists and 100 regularly scheduled patients with glaucoma (50 per phase). METHODS: An educational program with videotaped vignettes of simulated patient encounters using audience response and role play to teach patient-centered communication skills, including a 4-step adherence assessment and the use of open-ended questions in ask-tell-ask sequences. MAIN OUTCOME MEASURES: Physician eliciting an acknowledgment of nonadherence during a clinical encounter compared with acknowledgment of nonadherence during a postvisit research interview (primary outcome), and performance of targeted communication and substantive discussion of adherence. RESULTS: After intervention, physicians increased the proportion of open-ended questions (15% vs 6%; P = 0.001) and specifically about medication taking (82% compared with 18% of encounters; P<0.001). Compared with the absence of ask-tell-ask communication, 32% of phase II encounters included a complete ask-tell-ask sequence, 78% included an ask-tell sequence, and 32% a tell-ask sequence (P<0.001). Three of 4 steps for assessment of adherence were more common in phase II, and substantial discussions of adherence occurred in 86% versus 30% of encounters (P<0.001). In phase II, physicians elicited acknowledgment of nonadherence in 78% (7/9) of those who acknowledged nonadherence in the postvisit interview compared with 25% in phase I (3/12; P = 0.03). CONCLUSIONS: This study demonstrates that experienced community physicians significantly improved their communication strategies and ability to detect and address nonadherence after a 3-hour educational program. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Physicians' treatment decisions, patient persistence, and interruptions in the continuous use of prostaglandin therapy in glaucoma.

BACKGROUND: Uninterrupted use of ocular hypotensive medication by glaucoma patients is important to prevent vision loss, but medication persistence is poor. Efficacy and tolerability influence physicians' decisions and patient persistence, and differences between medications may impact persistence. OBJECTIVE: To examine differences in physician's decisions to continue, switch, or discontinue therapy across three prostaglandin analogs (PGAs) latanoprost, bimatoprost, and travoprost using claims data supplemented by evaluation of physicians' charted therapeutic decisions. METHODS: A year of pharmacy claims data for 6271 patients with a first (index) fill between 5/1/2001 and 11/30/2004 for PGA monotherapy were classified as 'persistent', 'switched', 'restarted', or 'discontinued' with initial PGA use. An analysis of index therapy continuation during the first 2 years reflected chart reviews for 223 patients with PGA monotherapy as the index prescription. RESULTS: Ten percent of patients had uninterrupted use of the initial PGA alone or in combination for a year. More than half (56%) stopped and then restarted, 16% switched, and 19% discontinued the initial PGA. Patients using latanoprost were more likely to be persistent (11%) compared to bimatoprost (9%) or travoprost (5%; p < 0.0001 overall comparison). Overall, 68% of patients on latanoprost persisted or restarted after a gap compared to 61% for bimatoprost and 58% for travoprost (p < 0.0001). Patient charts demonstrated a parallel pattern in physicians' decisions to continue latanoprost (56%), bimatoprost (45%), and travoprost (40%). Study limitations included the inability to establish causal links between variables, to account for sample use, or to document reasons for patient-driven changes in therapy. The study should be replicated in a more recent database including a larger population. CONCLUSIONS: Uninterrupted use of ocular hypotensive therapy for a full year is relatively rare. Differences in physicians' decisions to continue, switch, or discontinue PGAs were observed in claims data, and parallel trends were observed in patient medical records.

Patient-centered communication to assess and enhance patient adherence to glaucoma medication.

TOPIC: Using an understanding of a patient's difficulty in revealing nonadherence and patient-centered communication skills to identify and address barriers to adherence to glaucoma medication regimens. CLINICAL RELEVANCE: In addition to cost and logistical difficulties with obtaining and administering medicine, a patient's adherence to medication is influenced by the balance between the perceived need for medication and concerns about taking medication. METHODS: This article is based on both the author's clinical experience and peer-reviewed research on effective doctor-patient communication and assessment and management of nonadherence. RESULTS: Three strategies have been identified that help physicians to detect and address problems with adherence: (1) a 4-step adherence assessment interview designed to detect nonadherence that decreases patient resistance to revealing nonadherence by applying a shared decision-making process and mitigating social undesirability; (2) asking open-ended questions in ask-tell-ask sequences; and (3) tailoring interventions to the patient's stage of readiness for change. CONCLUSIONS: Patients conceal nonadherence because they want to be thought of by their physicians as good patients. They are driven to nonadherence by an imbalance between their perceived need for medication and their concerns about taking it. Patient-centered communication techniques can engage the patient in shared decision making about medication, thereby redefining the good patient as someone who works with his or her health care provider to address adherence barriers. Those barriers can be explored with open-ended questions designed to elicit the patient's understanding and concerns, to provide information, and to assess change in the patient's understanding and attitudes. Communication will be more effective if it is based on the patient's stage of readiness to adopt adherent self-management practices. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Doctor-patient communication in glaucoma care: analysis of videotaped encounters in community-based office practice.

PURPOSE: To assess doctor-patient communication in patients with glaucoma. DESIGN: Observational cohort study. PARTICIPANTS: Twenty-three ophthalmologists and 50 patients with glaucoma. METHODS: Doctor-patient encounters were audio- and videotaped and analyzed using validated sociolinguistic approaches. After the visit, the doctor and the patient completed questionnaires, and patients were interviewed using a semistructured, patient-centered protocol. MAIN OUTCOME MEASURES: Summary statistics about doctor-patient encounters, assessment of alignment of attitudes between patients and doctors, and patient admission to missing doses. RESULTS: Physicians spent an average of 8.0 (standard deviation [SD], 3.1; median, 7.8) minutes in the room with the patient and an average of 5.8 (SD, 2.4; median, 7.5) minutes talking with the patient, delivering 70% of all spoken words and asking two thirds of all questions. Glaucoma-related discussion occupied 50% of talk time and was focused primarily on examinations and treatment (25%). One third of discussions addressed ocular issues other than glaucoma. Virtually all physician questions (94%) were closed ended. Most patient questions were about intraocular pressure (20% of visits), details of the medication regimen (20%), disease status (14%), and testing (12%). Although physicians and patients were aligned in believing that the physician should control the visit agenda, physicians tended to support greater physician control of decision making than did patients. Physicians failed to identify most patients who admitted to missing doses, a surrogate for nonadherence, stating that 10 of 13 in this category were taking drops "all" or "most" of the time. Physician interviews detected 3 of the 11 patients whose postvisit questionnaire indicated missing a dose in the last week compared with 11 of the 11 detected by the postvisit research interview. Patients who stated they had missed doses recently reported being less satisfied with the doctor-patient encounter than those who did not. CONCLUSIONS: Doctor-patient dialogue was universally physician centered; physicians spoke 70% of the words and asked closed-ended questions that restricted the patient's contribution to "yes/no" or brief responses. A minority of physicians ever asked patients if they had questions. In contrast with the patient-centered research interview, doctors' physician-centered communication failed to identify most patients who had missed doses.

The impact of ocular adverse effects in patients treated with topical prostaglandin analogs: changes in prescription patterns and patient persistence.

PURPOSE: To document patient/physician perceptions of adverse effects and their relationship to medication changes among patients prescribed prostaglandin analogs. METHODS: Medical/pharmacy claims (private U.S. health network) identified patients filling initial topical ocular hypotensive prescriptions from 2001 to 2004; 300 open-angle glaucoma patients prescribed a prostaglandin analog and 103 ophthalmologists were selected by algorithm for telephone interviews. Medical charts for 225/300 interviewed and 75 non-interviewed patients were abstracted. Medication patterns were assessed in pharmacy claims data. Frequency of adverse effects noted by physicians and associations with medication change decisions were examined in charted data. Patients' experiences with adverse effects were compiled from surveys. RESULTS: In patients treated with latanoprost (N = 4,071), bimatoprost (N = 1,199), or travoprost (N = 1,001), continuous refill of medication through 1 year was seen in 11%, 9%, and 5% of patients, respectively (P = 0.0001; retrospective pharmacy claims). Adverse effects were the second most common reasons noted by physicians for switching medications after lack of efficacy (19% vs. 43%, respectively). Adverse effects were noted in 65% of patient charts. Hyperemia was the most common adverse effect occurring with at least one other adverse effect in 48% of patients with the condition. CONCLUSIONS: Ocular adverse effects, particularly hyperemia, negatively affect patient continuation with therapy and switching.

Physician beliefs and behaviors related to glaucoma treatment adherence: the Glaucoma Adherence and Persistency Study.

PURPOSE: Patient adherence with topical glaucoma therapy is recognized as suboptimal. Though some studies have associated physician/patient interaction with adherence, little systematic research has explored the ophthalmologist's perspective of this interaction. Telephone interviews with physicians treating glaucoma were conducted to ascertain the extent to which multivariate analysis of physician demographics, beliefs, and behaviors could reveal differences potentially relevant to future adherence with topical glaucoma therapy for primary open-angle glaucoma, in conjunction with other phases of the Glaucoma Adherence and Persistency Study (GAPS). METHODS: Structured interviews were conducted with 103 ophthalmologists treating significant numbers of primary open-angle glaucoma patients in a national managed care network. To the maximum extent possible, eligible patients of physicians interviewed were included in the other GAPS phases (claims analysis, patient surveys, and medical chart reviews). RESULTS: Physicians reported a wide range of beliefs and behaviors regarding patients' medication adherence, but beliefs and behaviors were linked. The segmentation analysis yielded 3 clusters of physicians, which we have described on the basis of their predominant beliefs as "reactives," "skeptics," and "idealists." The "idealists," though the smallest group, more often reported beliefs and behaviors that may be more positively associated with patient adherence, especially in the context of other GAPS findings. CONCLUSIONS: Physician vigilance for opportunities to detect and address nonadherence is suggested, as is interventional research on the basis of the constructs identified.

Development of the ASK-20 adherence barrier survey.

OBJECTIVE: Poor medication adherence is widespread among patients with chronic conditions requiring long-term drug therapy. Medication adherence is determined by multiple patient-, context-, and therapy-dependent factors. This paper describes the development and initial validation of the ASK-20 survey, created to identify actionable risk factors for medication nonadherence and to improve communication about adherence. METHODS: A pool of 30 items was generated through comprehensive literature review. Items were refined and the item pool was expanded through an expert panel review and patient focus groups to yield 47 candidate items, each with five response options ranging from either Strongly Agree to Strongly Disagree or from In the Last Week to Never. The pool of 47 candidate items was administered to a web-based sample of 605 patients taking medications and reporting a diagnosis of asthma, diabetes, or depression for psychometric testing and item reduction. RESULTS: Eleven multi-item factor groupings with two additional unique items were identified on the basis of principal components analysis and interpretability. Twenty (20) items representing ten factor groupings were selected for the final instrument. Each of the final items was dichotomized as positive - indicating a barrier, or negative. Two summary scores - the sum of all positive barriers or Total Barrier Count (TBC) and the sum of raw item scores, the ASK-20 score - were calculated. Concurrent validity of the dichotomously scored individual items, the TBC and ASK-20 scores in relation to self-reported adherence was generally good. Cronbach's alpha coefficient was 0.77 for the TBC and 0.85 for the ASK-20 score. CONCLUSIONS: ASK-20 consists of 20 clinically actionable items representing multiple factors that affect medication adherence. The ASK-20 survey demonstrated satisfactory validity and internal consistency and may be used to identify actionable barriers to adherence across a spectrum of chronic diseases. Future research using more objective measures of adherence is warranted to confirm the exploratory validity and reliability of ASK-20 reported in this study.

In-office discussions of migraine: results from the American Migraine Communication Study.

BACKGROUND: Research indicates that successful migraine assessment and treatment depends on information obtained during patient and healthcare professional (HCP) discussions. However, no studies outline how migraine is actually discussed during clinical encounters. OBJECTIVE: Record naturally occurring HCP-migraineur interactions, analyzing frequency and impairment assessment, and preventive treatment discussions. DESIGN: HCPs seeing high volumes of migraineurs were recruited for a communication study. Patients likely to discuss migraine were recruited immediately before their normally scheduled appointment and, once consented, were audio- and video-recorded without a researcher present. Separate post-visit interviews were conducted with patients and HCPs. All interactions were transcribed. PARTICIPANTS: Sixty patients (83% female; mean age 41.7) were analyzed. Patients were diagnosed with migraine 14 years and experienced 5 per month, on average. APPROACH: Transcripts were analyzed using sociolinguistic techniques such as number and type of questions asked and post-visit alignment on migraine frequency and impairment. American Migraine Prevalence and Prevention Study guidelines were utilized. RESULTS: Ninety-one percent of HCP-initiated, migraine-specific questions were closed-ended/short answer; assessments focused on frequency and did not focus on attention on impairment. Open-ended questions in patient post-visit interviews yielded robust impairment-related information. Post-visit, 55% of HCP-patient pairs were misaligned regarding frequency; 51% on impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention. CONCLUSIONS: Sociolinguistic analysis revealed that HCPs often used narrowly focused, closed-ended questions and were often unaware of how migraine affected patients' lives as a result. It is recommended that HCPs assess impairment using open-ended questions in combination with the ask-tell-ask technique.

Healthcare provider-patient communication and migraine assessment: results of the American Migraine Communication Study, phase II.

OBJECTIVE: The American Migraine Communication Study I (AMCS I) revealed communication deficits illustrated by differing healthcare professional (HCP) and patient reports about issues such as impairment and frequency. AMCS II was designed to assess an intervention using open-ended questions about impairment and 'ask-tell-ask' sequences to confirm headache frequency in days versus attacks. RESEARCH DESIGN AND METHODS: HCPs who participated in AMCS I completed an internet-based intervention. Researchers were sent to HCPs' offices, and patients likely to discuss migraine were recruited immediately prior to normally-scheduled appointments. Post-consent, visits were recorded without a researcher present. Separate post-visit interviews were conducted with all parties. All interactions were transcribed. MAIN OUTCOME MEASURES: Transcripts were analyzed using validated sociolinguistic techniques, and study results were compared to AMCS I. RESULTS: HCPs assessed impairment in 90% of interactions compared to 10% in AMCS I (p<0.0001) and used open-ended questions to assess impairment in 55% of visits (95% CI: 0.4261-0.6598). Impairment between attacks was discussed in 37% of visits vs. 0% in AMCS I (p<0.0001). HCPs completed full ask-tell-ask sequences in 29% of visits (95% CI: 0.1921-0.4070). AMCS II contained more discussions of migraine preventive therapy with appropriate candidates compared to AMCS I (74 vs. 50%; p=0.069) without statistically increasing median visit length (9:36 vs. 11:00; p=0.668). Post-visit, HCPs and patients were often aligned about impairment and frequency and reported high levels of satisfaction. CONCLUSIONS: Although further research with a larger sample is needed, a brief, internet-based intervention appears to promote positive communication changes not associated with increased visit length.

Doctor-patient communication, health-related beliefs, and adherence in glaucoma results from the Glaucoma Adherence and Persistency Study.

OBJECTIVE: To use multiple data sources to determine drivers of patient adherence to topical ocular hypotensive therapy. DESIGN: Retrospective database and chart reviews in combination with prospective patient surveys. Diverse medical environments where insured patients in the research database seek care. PARTICIPANTS: Three hundred patients with a new claim diagnosis for open-angle glaucoma who initially were prescribed one of three prostaglandins and 103 physicians participating in the same medical plans. METHODS: A structured interview addressing self-reported adherence, experiences with medication, communication with the physician, and health-related beliefs associated with adherence behavior was administered to surveyed patients. Phone interviews were conducted with participating ophthalmologists. MAIN OUTCOME MEASURE: Of adherence, medication possession ratio. RESULTS: Eight variables were associated independently with a lower medication possession ratio: (1) hearing all of what you know about glaucoma from your doctor (compared with some or nothing); (2) not believing that reduced vision is a risk of not taking medication as recommended; (3) having a problem paying for medications; (4) difficulty while traveling or away from home; (5) not acknowledging stinging and burning; (6) being nonwhite; (7) receiving samples; and (8) not receiving a phone call visit reminder. The multivariate model explained 21% of the variance. CONCLUSIONS: These findings indicate that doctor-patient communications and health-related beliefs of patients contribute to patient adherence. Patient learning styles that are associated with less concern about the future effects of glaucoma and the risks of not taking medications are associated with lower adherence. Specifically, knowledge about potential vision loss from glaucoma is a critical element that tends to be missed by more passive doctor-dependent patients who tend to be poorly adherent. These findings suggest that educational efforts in the office may improve patient adherence to medical therapies.

Using pharmacy claims data to study adherence to glaucoma medications: methodology and findings of the Glaucoma Adherence and Persistency Study (GAPS).

PURPOSE: To develop methods for investigating adherence to glaucoma medications by using a modified claims data-based measure of adherence, validation by chart review, and patient and physician interviews. METHODS: Data from administrative claims of 13,956 subjects receiving an initial glaucoma medication, and data from overlapping samples of 300 patients' charts, 300 interviews of patients, and 103 interviews of physicians were analyzed and compared. RESULTS: The mean medication possession ratio (MPR) was 0.64 (median 0.57) for the 13,956 subjects. Although 59% potentially had an ocular hypotensive agent at 12 months, only 10% had such medication available continuously. Chart review revealed that 31% of subjects "new to therapy" in claims data had actually been previously treated; and that 90% of the 17% who had medication added to initial monotherapy were misclassified by claims-based algorithms as medication switches or no change. Twenty percent of surveyed patients received samples on a regular basis and had lower MPR than those who did not (P < 0.05). CONCLUSIONS: Large pharmacy databases offer insight into medication usage but are vulnerable to errors from sampling (since patients who receive samples will be considered to have poor adherence), misidentification of newly treated patients, and misclassification of added versus switched medications. That a large proportion of patients stop and restart medications makes MPR a robust measure of adherence over time that reflects the resumption of medication after a gap in adherence. The data confirm that adherence to treatment with glaucoma medications is poor, similar to adherence in patients with other chronic diseases.

Evaluation of practice patterns for the care of open-angle glaucoma compared with claims data: the Glaucoma Adherence and Persistency Study.

OBJECTIVE: To perform a chart review to measure the validity of large claims databases in estimating patient cooperation with eyedrop therapy and to assess physician adherence with guidelines for a preferred practice pattern (PPP) using a new metric. DESIGN: Claims database analysis, chart review, and telephone survey. PARTICIPANTS: From 10,260 persons who were recently prescribed a prostaglandin eyedrop for open-angle glaucoma (OAG), a sample of 300 charts (3650 visits) was selected for detailed abstraction. METHODS: Database review of pharmacy refill, diagnostic testing, and visit information, with chart review of a sample of patients from the database and interviews with an overlapping sample of patients and physicians. MAIN OUTCOME MEASURES: The individual patient medication possession ratio (MPR), an index estimating the proportion of time that patients have prescribed drug available for use, frequency of examination findings present in charts, and associations between MPR and physician adherence to a PPP. RESULTS: Chart data confirm that the claims database accurately identified the specific glaucoma eyedrop prescribed, but often identified long-term OAG patients as being new to treatment. Physicians frequently used billing codes for OAG in patients with normal visual field tests. Physicians varied dramatically in their adherence to the PPP, performing intraocular pressure measurements, disc evaluations and imaging, and visual field tests on 90% of OAG patients, but carrying out gonioscopy, central corneal thickness measurement, and setting of target intraocular pressure (IOP) on half of patients. CONCLUSIONS: Large claims databases permit conclusions regarding patient cooperation with glaucoma eyedrop therapy, but they should be used cautiously in imputing severity of disease and prior treatment history. Physician adherence to practice guidelines varied substantially; thus, scoring systems for physician behavior have promise in measuring outcome improvements related to better care.