# Presentation: 283537

## Patient Perspective of Health Status and Medication Adherence in Urban Primary Care Practices

- Finie Richardson, MPH, Richard Levinson, MD, DPA, Charles Mouton, MD, MS

- Presented by Finie Richardson
- DC PrimCaRe Coordinator
- Department of Community and Family Medicine
- Howard University College of Medicine
- Washington, DC

- AHRQ 2007 PBRN Conference, Bethesda, MD

## EDUCATIONAL OBJECTIVES

- Explore associations between health status and medication adherence
- Determine significance of cognitive function and health literacy on quality of life indicators and medication adherence
- Examine strengths and weaknesses of measuring self-report outcomes

## INTRODUCTION

- _Patient-based outcomes:_
- Health status indicators **(Miilunpalo et al., 1997)**
-  Health care experience **(Raizi, 2002)**
-  Value to the patient **(Goertz, 1994)**
-  Differ from clinical outcomes **(Kroenke et al., 2006)**

## BACKGROUND

- Health Literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
- Ninety million people in the U.S have difficulty understanding and using health information.

**(Healthy People 2010, November, 2000)**

**(IOM, 2006)**

## LOW HEALTH LITERACY AND HEALTH STATUS

- Enter health care system sicker **(Bennet, 1998) **
- Poor physical and psychological health
**	****(Weiss et al., 1992)**
- Poor self-reported health status **(Baker, 1997)**
- Stronger predictor of health status than age, income, employment status, education level and race **(AMA, 1999)**

## ADHERENCE AND HEALTH

- Only 50% patients take medications as directed **(Center for Health Strategies, 1997)**
- Improved adherence is associated with better health outcomes (i.e. health status) quality of life (Park, 1996)
- Predicted by measures of cognition
- Executive function and working memory
- 	(Morrell et al., 1997; Park et al., 1994)

## MILD COGNITIVE IMPAIRMENT AND HEALTH STATUS

- Clinical state between elderly normal cognition and dementia (Chertkow, 2002)
- Does not interfere notably with activities of daily life. (Gauthier, 2006)
- Predictor of mortality (Royal, 2006)
- Clock drawing test can discriminate between healthy and demented patients. (Tuokko, 1992)

## STATEMENT OF PROBLEM

- Age-related cognitive decline and low health literacy affects day-to-day functional abilities, namely medication adherence and are linked to poor health outcomes.
- The impact of medication adherence on various measures of health status are not clearly understood.

## OBJECTIVE

- To determine the relationship between health status and medication adherence in patients evaluated for mild cognitive impairment and low health literacy.

## METHODS

- Design: 	Cross-Sectional Study
- Setting: 	22 clinical sites city-wide in the DC PrimCaRe PBRN
- Participants:
- 389 outpatients
- ≥50 years of age
- interviewed between January 2006 and September 2006
- Exclusion Criteria:
- visual impairment
- non-English speaking patients
- motor coordination disability

## OUTCOMES

- _Medication Adherence Report Scale_
- Measures 5 non-adherence behaviors
- Forget to take
- Take less
- Alter dose
- Miss dose
- Stop taking
- 5 point Likert Scale with reverse scoring
- Scores: 5-25
- Cut off point: 20

- _Medical Outcomes Study SF-36_
- 8 Quality of Life Domain Subscales
- Physical functioning
- Role physical
- Role emotional
- Social functioning
- Mental health
- Energy/vitality
- Pain
- General Health
- Physical Component Score
- Mental Component Score
- Scores: 0-100

## HYPOTHESIS

- H1: Adherent patients will have better  health status
- H2: Patients with low health literacy or cognitive impairment will have low adherence and poor health status

## STATISTICAL ANALYSIS

- Descriptive statistics
- Demographic data
- T-test
- Independent: Compare health status outcomes between adherent and non adherent groups
- Backward Regression
- Predict PCS and MCS
- Predict Adherence

## DEMOGRAPHICS

| Variables | N(%) |
| --- | --- |
| Education                               |  |
| 8th grade or less | 38(10.2) |
| Some high school | 64(17.2) |
| High school graduate | 102(27.3) |
| Some college or greater | 169(45.3) |
| Marital Status  |  |
| Single | 79(21.1) |
| Married | 133(35.5) |
| Widowed | 98(26.1) |
| Separated/Divorced | 65(17.3) |
| Income  |  |
| $10,000 or less | 140(37.4) |
| $10,001-$30,000 | 105(28.0) |
| $30,001-$50,000 | 61(16.3) |
| $50,000 or greater | 69(18.4) |

| Variables | N(%) |
| --- | --- |
| Gender |  |
| Male | 142(37.3) |
| Female | 239(62.7) |
| Age |  |
| 50-55 | 95(25.0) |
| 56-60 | 71(18.7) |
| 61-65 | 65(17.1) |
| 66-70 | 47(12.4) |
| 71-75 | 41(10.8) |
| 76 or greater | 61(16.1) |
| Race |  |
| Black | 356 (91.8) |
| Non Black | 32(8.2) |
| Born in U.S. |  |
| Yes | 323(85.2) |
| No | 56(14.4) |

## DEMOGRAPHIC CHARACTERISTICS BY GENDER

| Variables | Males | Females | p |
| --- | --- | --- | --- |
| Age  
Mean (SD) | 
62(8.8) | 
65(10.9) | .000 |
| Education  
≤12 years
HS graduate
≥ College  | N=140
44(31.4%)
29(20.7%)
67(50.0%) | N=276
102(25%)
73(31.5%)
101(43.5%) | 1.43 |
| Income
≤$10,000
$10,001-$30,000
$30,001-$50,000
≥ $50,001 | N=141
36(25.6%)
39(27.7%)
26(18.4%)
40(28.4%) | N=233
103(44.2%)
66(28.3%)
35(15.0%)
29(12.4%) | 
.000 |
| Marital Status
Single
Married
Widowed
Separated/Divorced | 
32(22.9%)
77(55.0%)
12(8.6%)
19(13.6%) | N=234
46(19.7%)
56(23.9%)
86(36.8%)
46(19.7%) | 
.000 |

## GENDER AND HEATH STATUS

|  | Males
Mean (SD) | Females
Mean (SD) | P value |
| --- | --- | --- | --- |
| PCS | 53.8(5.7) | 55.2(6.0) | .065 |
| MCS | 60.0(10.9) | 55.8(12.8) | .008 |
| Physical Functioning | 21.6(25.0) | 33.5(28.8) | .014 |
| Role-Physical | 65.1(41.7) | 58.2(41.6) | .213 |
| Role-Emotional | 83.8(31.2) | 73.0(36.1) | .014 |
| Vitality | 65.8(22.0) | 55.6(24.5) | .001 |
| General Health | 65.2(23.0) | 65.6(22.4) | .884 |
| Mental Health | 84.4(15.3) | 81.2(19.3) | .168 |
| Social Functioning | 77.4(26.1) | 75.6(28.1) | .594 |
| Bodily Pain | 69.5(20.4) | 67.0(22.4) | .375 |

## ADHERENCE AND HEATH STATUS

| Variable | MARS Score |  |  |
| --- | --- | --- | --- |
|  | Adherent
Mean (SD) | Nonadherent
Mean (SD) | P value |
| PCS | 55.0(5.8) | 52.3(6.5) | .019* |
| MCS | 57.4(12.3) | 54.3(13.5) | .238 |
| Physical Functioning | 26.6(26.4) | 33.5(28.8) | .214 |
| Role-Physical | 62.4(41.3) | 42.7(41.9) | .014* |
| Role-Emotional | 77.3(34.9) | 68.3(40.4) | .185 |
| Vitality | 60.2(24.2) | 52.6(22.5) | .091 |
| General Health | 66.7(22.4) | 54.(22.2) | .008* |
| Mental Health | 82.1(18.3) | 80.0(19.4) | .550 |
| Social Functioning | 76.3(28.2) | 66.5(26.3) | .062 |
| Bodily Pain | 68.0(23.1) | 61.2(20.4) | .098 |

- * p= .05

## HEALTH STATUS HEALTH LITERACY AND COGNITION

| Variables | REALM
r (p value) | CLOX1
r (p value) | CLOX2 
r (p value) |
| --- | --- | --- | --- |
| PCS Score | .043(.433) | .090(.096) | .029(.588) |
| MCS Score | .118 (.032) | .058(.282) | .113 (.035) |
| Physical Functioning | -0.46(.401) | -.049(.359) | -.101(.057) |
| Role-Physical | .145 (.008) | .123 (.020) | .090(.093) |
| Role-Emotional | .181 (.001) | .058(.277) | .079(.141) |
| Vitality | .027(.617) | .060(.258) | .157(.003) |
| General Health | .102(.064) | .123 (.021) | .154 (.004) |
| Mental Health | .040(.467) | -.001(.978) | .043(.428) |
| Social Functioning | .133 (.014) | .061(.249) | .069(.194) |
| Bodily Pain | .013(.809) | .002(.972) | .025(.636) |
| MARS score | .320 (.000) | .076(.222) | .097(.119) |

## REGRESSION MODEL TO PREDICT ADHERENCE

| Model 
 | R square | Adjusted
R square | P value |
| --- | --- | --- | --- |
| REALM, bodily pain and gender | .099 | .086 | .000 |

- Variables excluded: Number of medications, income, age, race, born in US, education, CLOX1, CLOX2

## REGRESSION MODEL TO PREDICT MCS

| Model 
 | R square | Adjusted
R square | P value |
| --- | --- | --- | --- |
| Number of medications, gender, income, medication adherence | .186 | .171 | .012 |

- Variables excluded: age, race, born in US, education, CLOX1, CLOX2, PCS

## REGRESSION MODEL TO PREDICT PCS

| Model 
 | R square | Adjusted
R square | P value |
| --- | --- | --- | --- |
| REALM, CLOX2, gender, income, education | .089 | .050 | .000 |

- Variables excluded: Number of medications, age, race, born in US, MCS

## Summary

- For all eight subscales the means scores were higher in patients that were adherent
- Physical Component Scores significantly increase with improve adherence
- Health literacy was associated with MARS scores

## Summary

- Gender, health literacy and bodily pain are predictors of adherence
- REALM and CLOX 2 were associated with better physical component scores
- Adherence, income and number of medications taken were predictors of the mental component score

## LIMITATIONS

-  Convenience sample
-  Self-report adherence
-  Generalizability

## CLINICAL IMPLICATIONS

- Simplify regimens
- Side effects of medications
- Annual health literacy and cognition screenings

## ACKNOWLEDGEMENTS

- _Funding support_
- Health Resources and Services Administration
- American Academy of Family Physicians

## PREVALENCE of MCI and LHL

| Variable | N (%) | Mean (SD) |
| --- | --- | --- |
| CLOX 1  (N=375) |  | 9.84(3.6) |
|          Impaired | 163(43.5) |  |
|          Not Impaired | 212(56.5) |  |
| CLOX 2  (N=372) |  | 12.75(2.2) |
|          Impaired | 69(18.5) |  |
|          Not Impaired | 303(81.5) |  |
| REALM  (N=355) |  | 57.0(14.4) |
| Low | 132(37.2) |  |
|         3rd grade and below | 15(4.2) |  |
|         4th to 6th grade | 35(9.9) |  |
|         7th to 8th grade | 82(23.1) |  |
| High  | 223(62.8) |  |

- _PREVALENCE of MCI and LHL_

- * Changes in N reflect missing data

## NON ADHERENCE BEHAVIORSN=271

| Non adherent Behavior | N(%) |
| --- | --- |
| Forget to take meds | 109(40.2) |
| Stop taking meds | 64(23.7) |
| Miss dose of meds | 57(21.1) |
| Alter dose of meds | 43(15.9) |
| Takes less than instructed | 46(17.3) |

## COGNITION AND HEATH STATUS

| Variable | CLOX1 |  |  |
| --- | --- | --- | --- |
|  | Impaired
Mean (SD) | Not Impaired
Mean (SD) | P value |
| PCS | 34.7(6.4) | 35.1(5.3) | .572 |
| MCS | 55.4(12.0) | 57.3(12.9) | .157 |
| Physical Functioning | 30.1(24.6) | 25.4(27.0) | .102 |
| Role-Physical | (54.8(42.7) | 63.5(40.3) | .064 |
| Role-Emotional | 70.0(39.2) | 74.8(37.3) | .271 |
| Vitality | 57.5(21.7) | 61.5(24.1) | .122 |
| General Health | 61.8(22.8) | 67.1(22.5) | .039* |
| Mental Health | 81.3(16.6) | 81.8(18.8) | .810 |
| Social Functioning | 73.3(27.3) | 76.6(27.5) | .268 |
| Bodily Pain | 67.6(22.2) | 67.9(22.7) | .892 |

- * p= .05

## COGNITION AND HEATH STATUS

| Variable | CLOX2 |  |  |
| --- | --- | --- | --- |
|  | Impaired
Mean (SD) | Not Impaired
Mean (SD) | P value |
| PCS | 34.3(6.4) | 35.1(5.5) | .404 |
| MCS | 54.1(12.1) | 57.2(12.7) | .078 |
| Physical Functioning | 55.7(23.1) | 56.1(26.8) | .129 |
| Role-Physical | 51.1(41.0) | 62.7(41.1) | .044* |
| Role-Emotional | 66.4(36.5) | 74.9(38.0) | .107 |
| Vitality | 53.6(24.1) | 61.4(23.0) | .017* |
| General Health | 58.6(23.2) | 66.6(22.4) | .011* |
| Mental Health | 80.7(16.6) | 81.8(18.4) | .681 |
| Social Functioning | 71.6(28.3) | 76.2(27.2) | .227 |
| Bodily Pain | 67.3(21.1) | 67.9(22.9) | .851 |

## HEALTH LITERACY AND HEATH STATUS

| Variable | REALM |  |  |
| --- | --- | --- | --- |
|  | LHL
Mean (SD) | HL
Mean (SD) | P value |
| PCS | 34.8(5.2) | 35.1(5.8) | .622 |
| MCS | 55.6(12.0) | 57.4(13.2) | .230 |
| Physical Functioning | 48.1(25.4) | 46.9(27.2) | .676 |
| Role-Physical | 57.2(40.5) | 63.2(41.7) | .198 |
| Role-Emotional | 67.3(38.9) | 76.7(37.3) | .029* |
| Vitality | 60.5(21.8) | 60.5(24.3) | .976 |
| General Health | 63.8(22.5) | 66.7(22.7) | .266 |
| Mental Health | 81.2(17.7) | 82.2(18.6) | .623 |
| Social Functioning | 72.8(26.9) | 76.9(27.7) | .183 |
| Bodily Pain | 66.9(20.4) | 68.4(23.5) | .555 |