Our study demonstrates that the essence of patient-centeredness—the patient's perception of being known “as a person”—is significantly and independently associated with receiving HAART, adhering to HAART, and having undetectable serum HIV RNA. These associations persist even after controlling for multiple potential confounders, and confirms the findings of 2 previous studies 16, 22
that the quality of patient-provider relationship is significantly associated with adherence to HAART.
This study adds to our current knowledge in several important ways. First, in addition to the association between patient-provider relationship quality and adherence to HAART (among those for whom HAART was prescribed), we found an association between patient-provider relationship quality and the appropriate receipt of HAART in the first place. This association remained significant even after controlling for the length of time the patient was followed in the clinic (suggesting that it is not just that the physician has not found the time to prescribe HAART), the patient's health beliefs (suggesting that it is not just that the patient doesn't accept that HAART is useful), and other patient features that the clinician might use to decide whether the patient was a candidate for HAART (such as CD4 count or active substance abuse).
In addition, we found that the quality of the patient-provider relationship is associated with having an undetectable serum HIV-1 RNA which is a strong clinical predictor of future health for patients with HIV. The association between patients' reports of being known “as a person” and suppression of HIV-1 RNA was no longer significant after adjusting for HAART receipt, indicating that it is the receipt of HAART that is the primary mediator for the association with a suppressed HIV-1 RNA. Nevertheless, the fact that patients who are known “as a person” are also more likely to adhere to HAART when prescribed suggests a second mechanism through which higher quality patient-provider relationships may impact patient health.
One important issue that our study raises is the feasibility of improving patient experience of care in general, and the ability to improve upon the health professional's ability to make a patient feel known “as a person” in particular. Are interpersonal aspects of care modifiable? Two recent systematic reviews evaluating the effectiveness of interventions designed to promote patient-centered medicine and cultural competence have confirmed that such interventions can improve provider behavior. 23, 24
Thus, we have reason to be encouraged that educational interventions targeted at health professionals can improve patient experience. However, it would be useful for further research to explore how best to improve interpersonal aspects of care for patients with HIV and their providers.
It is worth noting that, although our independent variable—being known “as a person”—captures the essence of patient-centeredness, it is also a fairly nonspecific measure. Further research is needed to determine exactly what patients were thinking when reporting that their provider knows or does not know them “as a person.” Our own qualitative work has begun to explore this concept through in-depth interviews with a sample of 28 primary care patients. Preliminary analysis suggests that there are modifiable factors—such as remembering a patient's name, establishing good rapport, listening carefully, asking questions to learn about their lives and later remembering and following up on this information with patients—that might be useful to providers interested in improving their relationships with patients. In addition to uncovering specific physician behaviors that allow patients to feel known as a person, further research might also investigate the most effective means to increase the patients' perception of being known as a person. For example, it is unknown whether it is more effective to teach physicians a set of specific behaviors, or simply to give physicians a goal—that patients ought to feel known as a person—and then allow each physician to use his/her own communication repertoire to meet this goal.
Several limitations are also worth noting. First, as with any observational study, there is the potential for unmeasured confounding. For example, it may be that patient ratings of their relationship with their doctor and self-reported adherence are both part of some global trait such as a positive outlook. However, the fact that our findings persist even after controlling for many other variables, such as self-reported quality-of-life, which may also be thought of as part of a positive outlook, is an indication that we are indeed measuring 2 different concepts.
Second, as with any cross-sectional analysis, causality cannot be determined. Although we believe that it is more likely that effective patient-physician relationships are the cause of patient adherence, the reverse is possible. It is conceivable that physicians of patients who are adherent feel and act more positively towards those patients. Further longitudinal research is needed to determine the direction of causality. Finally, we conducted our study at just one clinic, and so there is uncertain generalizability of our results to other settings.
Adherence to HAART is one of the most challenging issues facing patients with HIV and their providers. Our study suggests that the essence of patient-centeredness—the patient's perception that they are known “as a person”—may be one important aspect of patient adherence and may directly influence the health of patients with HIV. Efforts to improve health care quality, adherence, and health of persons with HIV should focus on improving the patient-provider relationship. Further research is needed to determine how this is best accomplished.