Patients, Physicians Don't Always Agree on Key Health Concerns, Says Survey

A survey conducted by researchers at the University of Michigan Medical School, Ann Arbor, reveals that a sizable proportion of patients with diabetes and hypertension did not agree with their primary care health professionals on the most important health issues to address during office visits. The gap widened further when patients described their overall health as poor or when they reported having nonhealth-related competing demands.

These findings, say the study researchers, suggest a need for health care professionals to improve their recognition of multimorbid patients' concerns about symptomatic conditions, as well as better understand patients' nonhealth competing demands.

For the study "Patient-Provider Concordance in the Prioritization of Health Conditions Among Hypertensive Diabetes Patients," which was published online Feb. 2 by the Journal of General Internal Medicine, researchers surveyed 92 primary care professionals (physicians, nurse practitioners and physician assistants) and 1,200 of their patients with diabetes and hypertension. Patients were asked to list, in rank order, their top three health concerns; their health care professionals also were asked to rank the three most important conditions likely to affect each patient's health outcomes.

Of the 714 provider-patient pairs, in 72 percent of cases, health care professionals included the patient's most important health concern among what the clinician considered to be the top three most pressing health issues. Although both patients and clinicians most frequently ranked diabetes and hypertension as being among their top three concerns, 38 percent of providers marked hypertension as the most important, while only 18 percent of patients agreed.

Overall, patients were more far likely than their primary care providers to prioritize symptomatic conditions, such as chronic pain or depression. In addition, the predicted probability of patient-provider concordance decreased considerably when a patient reported having poor health status or nonhealth competing demands, such as stressors at home or work.

Michael Parchman, M.D., M.P.H., who is the Mario E. Ramirez Endowed Distinguished Professor in the department of family and community medicine at the University of Texas Health Science Center, San Antonio, said that when a patient with diabetes visits his or her physician, the patient often will complain of chronic pain and/or acute problems that are lowering his or her quality of life. Family physicians often are most concerned with high blood pressure because it has long been called the "silent killer," he told AAFP News Now.

"My observation is that visits with patients who have diabetes are often too 'gluco-centric,'" said Parchman, who also is the AAFP representative to the National Diabetes Education Program convened by NIH's National Institute of Diabetes and Digestive and Kidney Diseases and the CDC. "That is, too much time is spent discussing blood sugar control and not enough is devoted to discussing blood pressure."

Adults with diabetes often have many other chronic health conditions, meaning that their physicians face the challenge of addressing multiple complex issues in one single visit.

"What often happens is that the patient has an agenda when they come to see their physician," Parchman said. "Studies of primary care visits show that the first few minutes of the visit are often spent negotiating and setting the agenda so that both physician and patient come to some agreement about what will be taken care of today. But patients do not know that their blood pressure is too high, so, of course, it is not on their agenda."

Martin Schwarzenberger, a 57-year-old patient who has suffered from diabetes for 47 years, said that he would consider his blood sugar level, neuropathy and retinopathy to be his top three concerns. He told AAFP News Now that high blood pressure is not in his top three -- not because he doesn't care about it, but because his blood pressure reads 118/70 on a regular basis, which he believes to be pretty great.

"If I had high blood pressure, it would be my No. 1 concern. Right now, it is not at the bottom, but is maybe number three or four," Schwarzenberger said. "I guess you could say it is a concern to a point. I check it at the grocery, or wherever there is a machine that reads blood pressure."

Schwarzenberger said that when he enters his physician's office, the first thing they check is his blood pressure. He said that the nurse will first take his blood pressure, and then the doctor will come in and check it two or three times. After that, he said, his physician uses Doppler testing to check the circulation in his feet. Schwarzenberger says that although one of his main issues is retinopathy, it may not always be his physician's No. 1 priority.

"Of course my eyesight is one of my biggest concerns" Schwarzenberger said, "I can't imagine living in a world where I was unable to see."

Regardless, Schwarzenberger said that he and his physician have a great relationship.

"We go back and forth with my concerns. If my blood sugar is higher than it should be, than I will agree with my doctors that that should be our No. 1 concern," Schwarzenberger said.

To achieve the goal of maintaining a close physician-patient relationship, Parchman urges primary care physicians to encourage their patients to be actively involved in both setting the agenda for each visit and providing input into how their care is managed. Appropriately managing the negotiation that goes on between patients and physicians when coming to agreement on the agenda for that day's visit is essential to providing "patient-centered care," he said.

According to Parchman, a key advantage of being a family physician is the long-term, continuing relationships FPs have with their patients. This continuity translates into patients being willing to return for a subsequent office visit sooner rather than later to address additional concerns they may have.