In this study of multimorbid diabetic patients with elevated blood pressure in primary care clinic, we found that patients’ most important health concerns frequently matched the conditions that their providers ranked as most likely to affect these patients’ health outcomes. The probability of concordance, however, was significantly lower for patients with poorer health status and those with non-health competing demands, even after controlling for the patient’s comorbidity count.
There are several possible explanations why patient-provider concordance is lower when patients have poor health or other non-health competing demands. One scenario is that this discordance reflects a breakdown in communication. For example, the provider may not fully recognize how the patient’s health conditions and non-health concerns are affecting his health and well-being, or the provider might not effectively communicate to the patient the morbidity and mortality risks of his conditions. This explanation, if true, would be troubling because several studies have demonstrated an association between effective patient-provider communication and a multitude of positive patient-centered and clinical outcomes.4,15–17
However, when we adjusted our model for the patient’s assessment of the quality of the patient-provider relationship, the association between our main independent variables and concordance remained unchanged.
A second scenario is that patients with poor health or non-health competing demands may be more likely to face functional limitations, financial stress, and other barriers to care, and are therefore more likely to prioritize a symptomatic condition that is exacerbating these existing challenges. Providers of these patients, meanwhile, may focus on the long-term health consequences of asymptomatic hypertension or uncontrolled diabetes. While both sets of priorities are valid, previous studies suggest that poor health status and non-health competing demands may interfere with self-management of diabetes as well as productive clinic-based management decisions and processes.5,6,30,47
If patients and providers disagree on the importance they ascribe to a patient’s different health conditions, this discordance may intensify barriers to self-management and clinical decision-making for that patient.
We observed several notable patterns in the patient- and provider-ranked lists. While diabetes and hypertension were ranked highly by the majority of patients and providers, providers were far more likely to rank hypertension as the most important health concern for the patient (38% vs. 18%). This is consistent with previous findings that many diabetic patients are unaware of the importance of blood pressure control despite evidence and guidelines that emphasize the critical importance of this issue.48–52
Patients, in contrast, were modestly but consistently more likely than providers to rank weight loss and symptomatic concerns such as pain, depression, and breathing problems among their top three concerns. Strikingly, very few of the patients who listed pain or depression as their top health concern had a provider who ranked these conditions as likely to affect the patient’s health outcomes (9% and 32%, respectively). This discordance is concerning, not only because it raises the possibility that providers are unaware of the extent to which these conditions affect their patients, but also because pain and depression can be barriers to effective diabetes self-management,7,8
and (in the case of depression) may worsen glycemic control and increase the risk of mortality.53,54
Therefore, it is plausible that by deemphasizing symptomatic conditions, providers are actually neglecting some of the most important medical concerns that are likely to affect health outcomes in these patients.
There are several limitations to this study that should be noted. First, we set out to measure the degree to which the patient and provider had a shared set of priorities about the most important problems facing the patient. Thus, our concordance score does not explicitly measure the somewhat different concept of which conditions providers thought the patient would have prioritized. This latter concept is also of interest and merits additional research. Second, all enrolled patients and providers were aware that this was a study of diabetic patients, and patients and providers were filling out their surveys after the patient had an elevated blood pressure in triage. Not surprisingly, a majority of both patients and providers ranked diabetes and hypertension among the top three health conditions affecting the patient. This limited our ability to fully evaluate concordance patterns among other health conditions. Finally, patients and providers ranked “other health concern” in 5% and 30% of instances, respectively. Write-in responses were assessed qualitatively to better understand the health conditions that most frequently take a patient and provider’s time and attention away from diabetes and hypertension. These responses, summarized in the Appendix
, suggest that the most common other concerns listed by providers were unlisted chronic conditions such as renal disease and cancer, and issues related to medication adherence. Only 26 write-in responses were contributed by patients (vs. 326 by providers), so we were unable to assess concordance using these data. Of the 26 write-in responses from patients, only two (cancer and memory loss) matched write-in responses of the corresponding provider. Therefore, for the purposes of our multivariate analysis, we only used the listed nine conditions to determine patient-provider matches. While this may have inflated the frequency of concordance because participants were constrained by a limited number of choices, it likely did not influence our other results because we adjusted our analyses for total number of conditions.
While previous work has focused extensively on patient-provider concordance regarding a patient’s presenting complaint,28,29,31
to our knowledge this is the first study to evaluate patient-provider concordance regarding priority given to the chronic health conditions of multimorbid patients. Although we did not assess the influence of this concordance on patient-centered and clinical outcomes, previous studies in the setting of acute conditions have found an association between higher patient-provider concordance and symptom resolution, improvement in mental health and function, and retention in outpatient care.19,20,55
Our finding that patients with poor health status are less likely to share priorities with their provider is thus concerning, as poor health status has been associated with increased risk of mortality,35,38
and this population is therefore one in which effective communication and shared understanding of priorities are likely to be critical in developing goals of care and treatment strategies.56
In conclusion, diabetes patients with multimorbidity and their primary care providers often agree on the most important health conditions affecting these patients’ health. Our findings, however, reinforce the need for heightened provider recognition of patients’ symptomatic conditions as well as their non-health competing demands. Fortunately, there is growing evidence that interventions can increase provider awareness about patient concerns and priorities,57–59
and that patient-centered approaches can improve diabetes self-management in the face of multimorbidity and other competing demands.60,61
Future research should focus on how best to encourage and implement these practices in primary care in order to optimize chronic disease management in this vulnerable population.