Epstein et al's Exploring and Validating Patient Concerns-Relation to Prescribing for Depression

ANNALS OF FAMILY MEDICINE
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WWW.ANNFAMMED.ORG
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VOL. 5, NO. 1
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JANUARY/FEBRUARY 2007
21
Exploring and Validating Patient Concerns:
Relation to Prescribing for Depression
ABSTRACT
PURPOSE
This study examined moderating effects of physician communication
behaviors on relationships between patient requests for antidepressant medica-
tions and subsequent prescribing.
METHODS We conducted a secondary analysis of a randomized trial. Primary
care physicians (N = 152) each had 1 or 2 unannounced visits from standardized
patients portraying the role of major depression or adjustment disorder. Each
standardized patient made brand-specific, general, or no requests for antidepres-
sants. We coded covert visit audio recordings for physicians’ exploration and
validation of patient concerns (EVC). Effects of communication on prescribing
(the main outcome) were evaluated using logistic regression analysis, accounting
for clustering and for site, physician, and visit characteristics, and stratified by
request type and standardized patient role.
RESULTS In the absence of requests, high-EVC visits were associated with higher
rates of prescribing of antidepressants for major depression. In low-EVC visits,
prescribing was driven by patient requests (adjusted odds ratio [AOR] for request
vs no request = 43.54, 95% confidence interval [CI], 1.69-1,120.87; P ≤.005),
not clinical indications (AOR for depression vs adjustment disorder = 1.82;
95% CI, 0.33-9.89; P = NS). In contrast, in high-EVC visits, prescribing was
driven equally by requests (AOR = 4.02; 95% CI, 1.67-9.68; P ≤.005) and clini-
cal indications (AOR = 4.70; 95% CI, 2.18-10.16; P ≤.005). More thorough his-
tory taking of depression symptoms did not mediate these results.
CONCLUSIONS Quality of care for depression is improved when patients partici-
pate more actively in the encounter and when physicians explore and validate
patient concerns. Communication interventions to improve quality of care should
target both physician and patient communication behaviors. Cognitive mecha-
nisms that link patient requests and EVC to quality of care warrant further study.
Ann Fam Med 2007;5:21-28. DOI: 10.1370/afm.621.
INTRODUCTION
I
n primary care settings, some patients with major depression who
would benefit from antidepressants do not receive medications,
whereas others with questionable indications do. 1 We recently reported
that when patients request an antidepressant medication, prescribing
increases regardless of clinical indications. 1 Because depression is com-
mon
2
and associated with considerable morbidity and cost,
3-6
and because
treatment is effective,
7,8
these findings have important health and quality
of care implications. Patterns of underuse and overuse of medical interven-
tions have been noted for other conditions as well.
9-12
Poorly understood communication factors appear to underlie the vari-
ability in use of antidepressants. We undertook this analysis to gain under-
standing of the relationship between patient-physician communication and
concurrent prescribing decisions. In particular, we were interested in the
process of communication, rather than just the content. One feature of