Asthma Patients and the Patient-Practitioner Relationship: A Qualitative Study of Continuity of Care Margaret M. Love, PhD Family Practice and Community Medicine University of Kentucky (UK)

Co-investigators Sarah B. Wackerbarth, PhD, University of Kentucky Arch G. Mainous, III, PhD, Medical University of South Carolina Renee V. Girdler, MD, University of Louisville Dennis E. Doherty, MD, University of Kentucky

Funding UK NIH K30 Therapeutics and Translational Research Training Program Agency for Healthcare Research and Quality (AHRQ)

Background Asthma –Chronic respiratory disease characterized by episodes or attacks of inflammation and narrowing of small airways in response to asthma ‘triggers.’ NCHS

Background U.S. asthma statistics 2002 –14 million (6.8%) noninstitutionalized adults diagnosed and still have asthma –12.6 million asthma-related visits to office- based physicians –1.9 million hospital emergency dept visits NCHS

Background Continuity of care –Ongoing relationship with the same health care practitioner over time

Background Continuity of care is associated with positive health-related outcomes –Higher patient satisfaction –Greater medication adherence –Reduced health services utilization –Decreased likelihood of emergency dept (ED) use and future hospitalization

Background An ongoing relationship with the same physician is highly valued by patients… especially by asthma patients. –Love & Mainous. J Fam Pract; –Love, Mainous, Talbert, & Hager. J Fam Pract; 2000.

Research Objective To better understand the physician- patient relationship from the perspective of persons with asthma, through the application of qualitative research methods

Study Design Qualitative, focus group study –Six focus groups held in 2004 –3 - 7 patients per group –Audiotaped, prompted discussion

Study Design Adult asthma patients (age>18 years) –UK Family Medical Center –UK Pulmonary & Critical Care Medicine –Lexington community –Word of mouth

Study Design Examples of focus group prompts: –Why would a relationship over time with the same health care professional be especially important to people who have asthma? –What if you can’t see your regular doctor…? –What else is important in your relationships with health care professionals?

Analysis Thematic analysis of transcripts –What do patients like about their health care professional or their care? –2 investigators reviewed independently, identified themes, discussed, combined –“Open” coding –Saturation reached after 6 focus groups

Participants 26 participants –20 female –22 white –20 aged years –18 group or private insurance –14 college educated –15 from UK Family Medical Center

Results Quality / healthcare outcomes Interpersonal process / interaction Relationship qualities / shared history

Quality / Outcomes Discovered diagnosis –Figured it out –Finally one day a doctor told me, ‘No, you have mild asthma.’

Quality / Outcomes Successful treatment –Finally got help. –They’ve tried something new on me and it’s worked for me. –I appreciate my doctor helping me get to the point that we handled the balance of medications.

Quality / Outcomes Reliable / assumes responsibility for care –There constantly. –Will take care of me. –I pick up the telephone and call my doctor and he’ll meet me at the hospital.

Quality / Outcomes Tailors care –I feel like I just have to stand up and say, ‘Look. That just doesn’t go for me. This is what works.’ (-) –He came in and treated me with a preconceived notion. (-)

Interpersonal Interaction Straightforward communication –I appreciate the doctor being up front with me. Explains –He explains things in a way that even I can understand.

Interpersonal Interaction Talking and listening –He would sit there and talk to me, ask me what was going on. –And I don’t know that I feel that I’ve been heard yet. (-)

Interpersonal Interaction Respect and responsiveness –Condescending. (-) –And it’s real dismissive. (-) –…respect my pain, treat me as an adult…

Interpersonal Interaction Comfortable –Feel at ease with him –Concerned –Caring –Compassionate

Relationship / History “Knows” patient –... knows my history… knows what things trigger with me and what doesn’t trigger. –… knows me… knows how to handle me. –They know I don’t call unless I’m pretty well down.

Relationship / History Mutual trust –I trust her. –If Doctor X tells me something, or advises me, I’ve taken that to heart. –Mutual trust that I am not going to bother them just for the little bitty things.

Relationship / History Continuity avoids starting over –It takes time away from your visit… (-) –… and you know what does work, and they want to try something new… (-)

Limitations Small number of participants Kentucky only Self-reported outcomes

Implications and Next Steps How to meet asthma patients’ concerns? –When patients seek care at multiple locations (PCP, specialists, UTCs, EDs) –When continuity of care with individual clinicians difficult to maintain Future research… –Does addressing their concerns improve health outcomes?