Characteristics of Older Adults Associated with Patient–Provider Communication About Health Improvement in the United States

Abstract

Shared decision making is a key part of patient-centered care and is associated with improved quality of care. The objective was to analyze associations between sociodemographic factors, health conditions, and how frequently providers ask Medicare beneficiaries about ideas to improve their own health. The 2020 Medicare Current Beneficiary Survey, a nationally representative dataset of beneficiaries aged ≥65 years, was analyzed (n = 7416). A survey-weighted multinomial logistic model was performed to analyze associations between independent variables and a three-level categorical dependent variable. Approximately 28.6%, 22.9%, and 48.5% of beneficiaries reported never (reference group), sometimes, and usually/always being asked about their own ideas for improving health, respectively. Beneficiaries aged 65–74 were more likely to usually/always or sometimes be asked for ideas about health improvement than those aged ≥75. Beneficiaries with lower than a high school education were less likely to be asked about ideas to improve their health than those with more than a high school education. Beneficiaries living alone were less likely to be asked about their health improvement ideas than those living with others. Disparities involving how often providers asked questions for shared decision making among beneficiaries were observed. Increasing provider awareness and implementation of standardized shared decision-making models may begin to mitigate these disparities.

1. Introduction

In traditional models of care, healthcare providers often direct the patient on actions and behaviors needed to be healthy [1]. On the other hand, patient-centered care strives to incorporate the individual needs, values, and desires of patients and promotes patient engagement in healthcare decisions and discussions [2]. However, only approximately 55% and 49% of adults in the United States reported their providers always involved them in healthcare decisions and spent enough time in the encounter, respectively [3]. This highlights the need for improvement in the delivery of patient-centered care. Patient empowerment is increasingly acknowledged as an essential value of patient-centered care [4].

Generally, patient empowerment refers to a patient’s ability to be involved in their care and to manage their health [4]. The focus is on fostering a less hierarchical and more collaborative partnership [5]. Examples of patient empowerment include having a voice in clinical management, mutual exchange of information about care and treatment, and being respected as an individual [5]. Previous research indicated that empowering patients equips them with the skills and knowledge to influence change, promotes overall health, and optimizes the use of resources [6]. An important aspect of patient empowerment is for providers to elicit a patient’s ideas for improving their own health because this type of patient–provider communication can engage patients in shared decision making (SDM) and guide the care plan.

SDM interventions are heterogenous in nature [7]. The initial Three-Talk Model illustrated SDM in three “speech acts” to promote collaborative deliberation, namely choice talk, option talk, and decision talk [8]. Since then, additional refinements have been made, and medical decision models for specific conditions have even been developed. For example, a tool for multiple sclerosis patients uses Multi-Criteria Decision Analysis to help patients choose disease-modifying drugs [9]. In practice, SDM promotes respect, advocacy, autonomy, and empathy. This is essential to help patients make healthcare decisions with their providers that are consistent with their values and preferences, which can be important in reducing healthcare-related disparities [7]. Therefore, SDM is not a one-size-fits-all approach, but instead, different models can be used for different patient needs and clinical environments.

Implementing patient–provider communication to elicit patients’ ideas for health improvement is complex in the context of older patients due to possible multimorbidity, polypharmacy, frailty, disability, and other factors [10]. One multi-state population model projected that the percentage of older adults aged 50 years and older with at least one chronic disease will be 35.66% by 2035 and 47.81% by 2050 [11]. Since patient empowerment can improve health outcomes [12], it is important to determine whether providers are communicating or eliciting ideas for health improvement differently with older patients based on their sociodemographic factors and health conditions.

Many previous studies tend to focus on a specific disease and the effectiveness of the patient empowering programs or interventions [6,13,14]. Fewer studies have focused on the sociodemographic characteristics of older patients in relation to this topic. A previous study demonstrated that physician communication empowering older patients aged 55 or older in Los Angeles County mitigated racial disparities in the receipt of breast-conserving surgery [13]. However, this type of study considers the therapeutic aspects of the empowerment of older patients but does not examine which populations are differentially empowered by their physicians. Another study showed that older adults in the United States aged 65 years or older with multiple chronic conditions reported lower rates of positive patient communication than those without multiple chronic conditions [15]. In the same study, non-Hispanic Blacks and Hispanics reported higher rates of positive patient communication compared to other races [15]. However, there are various other sociodemographic factors yet to be analyzed in relation to patient–provider communication. Furthermore, existing research describes the various forms of patient empowerment (e.g., health education, social support) implemented for older adults and advocates for understanding the determinants of empowerment [14].

Therefore, this study aims to analyze associations between sociodemographic factors (e.g., age, sex, race/ethnicity, income, education), health conditions (e.g., number of chronic conditions), and how frequently providers ask Medicare beneficiaries about their own ideas to improve health. Findings could increase awareness and prompt the implementation of feasible and effective interventions to reduce the potential disparities among at-risk beneficiaries.

2. Materials and Methods

2.1. Data and Population

This is a cross-sectional study using secondary data to analyze the frequency healthcare providers asked Medicare beneficiaries about their own ideas for health improvement based on their sociodemographic factors and health conditions. The 2020 Medicare Current Beneficiary Survey Public Use File (MCBS PUF) was the dataset used [16]. This is a publicly available version of the Medicare Current Beneficiary Survey (MCBS). The MCBS is sponsored by the Centers for Medicare & Medicaid Services and has been continuously conducted since 1991 [16]. MCBS data collection includes in-person and phone interviewing [16]. The survey is weighted such that it allows for analysis that is nationally representative of the population of beneficiaries enrolled in Medicare during each given year [16]. This dataset was chosen because it includes information about sociodemographic factors, health conditions, and patient–provider communication related to beneficiaries who participated in the survey [16]. For more information about the MCBS PUF and its User Policy and Agreement, please visit the MCBS website [16]. The study included Medicare beneficiaries aged 65 years and older who responded to the questions related to the independent and dependent variables (n = 7416) (Figure S1). The University of Central Florida Institutional Review Board determined that this is not research involving human subjects.

2.2. Measures

The dependent variable describes the frequency of provider-initiated inquiries about patients’ ideas for improving their health. The response options were never, sometimes, usually, or always. This variable was recoded into three categories: never, sometimes, and usually/always. The original MCBS question was: “Since (TODAY’S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] ask whether [you/(sample person [SP])] had ideas about how to improve [your/his/her] health?” [16].

The independent variables include age group, sex, race/ethnicity, marital status, educational level, income level, residential area, household composition, payment/service delivery model, functional limitations, body mass index, general health status, and number of chronic conditions (Table S1). The selection of these variables was based on past research related to this topic [6,13,14,15].

2.3. Data Analysis

Proportions of provider inquiries about health improvement ideas by sociodemographic characteristics and health conditions were calculated, and differences were compared using Wald chi-squared tests. A multinomial logistic regression model was used to analyze the associations between those factors and patient–provider communication about health improvement (as a categorical dependent variable) (Table S2). Survey weights were applied to adjust for the complex survey design of MCBS. The SAS Enterprise Guide 8.3 was used for data management and data analysis.

3. Results

The survey-weighted bivariate analysis showed 28.6%, 22.9%, and 48.5% of Medicare beneficiaries were never, sometimes, and usually/always asked about their ideas for improving health, respectively. Medicare beneficiaries who were younger, non-Hispanic Black, or did not live alone reported a higher prevalence of being asked about their ideas regarding health improvement. Additionally, Medicare beneficiaries who had more than a high school education or with obesity reported being asked more often about their own ideas regarding health improvement (Figure 1 and Table S1).

From the survey-weighted multinomial logistic analysis, beneficiaries aged 65–74 were more likely to be sometimes asked about their own ideas for health improvement than those aged ≥75 (OR = 1.28; p = 0.003) (Figure 2 and Table S2). Beneficiaries who lived alone were less likely to be sometimes asked about their health improvement ideas (OR = 0.71; p = 0.012), as were beneficiaries who had less than a high school education (OR = 0.66; p = 0.009). Compared with those who were underweight/of normal weight based on their body mass index (BMI), beneficiaries who were overweight (OR = 1.28, p = 0.012) or obese (OR = 1.26; p = 0.016) were more likely to be sometimes asked about their ideas for health improvement.

Beneficiaries aged 65–74 were more likely to be usually/always asked about their own ideas for health improvement than those ≥75 years old (OR = 1.35; p < 0.001) (Figure 3 and Table S2). Non-Hispanic Blacks were more likely to be usually/always asked about their health improvement ideas compared to non-Hispanic Whites (OR = 1.89; p < 0.001), as were beneficiaries reported as “Other” race (OR = 1.63; p = 0.012). Beneficiaries who lived alone (OR = 0.78; p = 0.010) or who had less than a high school education (OR = 0.78; p = 0.045) were less likely to usually/always be asked about their health improvement ideas. Compared with those who were underweight/of normal weight, beneficiaries who were overweight (OR = 1.20, p = 0.035) or obese (OR = 1.40, p < 0.001) were more likely to usually/always be asked about their ideas for health improvement (Figure 3).

4. Discussion

It is essential to identify disparities among Medicare beneficiaries related to patient–provider communication, including the frequency of provider-initiated questions about patients’ ideas and input for improving their own health. About a third of beneficiaries (representing 10.8 million beneficiaries) reported never being asked for their own ideas about improving their health. Beneficiaries who were younger, non-Hispanic Black, or overweight/obese were more likely to be asked more frequently about their own ideas for personal health improvement than their respective reference groups. Beneficiaries living alone or with less than a high school education were less likely to be asked this question. Overall, findings suggest that disparities exist in how often providers engage in shared decision making with Medicare beneficiaries based on multiple factors. Therefore, educational awareness programs to promote patient–provider communication and interventions to reduce potential disparities among at-risk beneficiaries are needed to empower patients to be more involved in their treatment plans.

Medicare beneficiaries aged 65–74 were more likely to be asked more often about their own ideas for health improvement than those aged ≥75. Previous research found that the patient’s cognitive state can hinder or promote empowerment [17]. As people age, there is a greater likelihood of cognitive decline [18]. Furthermore, many people often stereotype aging as being linked to weakness, unproductivity, and dependency [19]. It is possible that physicians perceived the beneficiaries aged ≥75 to have less cognitive function and, therefore, did not often encourage them to share their own ideas for health improvement. However, it may be more important for providers to engage in shared decision making with those aged ≥75 years because allostatic load, a measure of physiological wear and tear, accumulates in a linear fashion as people age [20]. Thus, they have a higher risk of morbidity and frailty, which makes patient-centered or individualized care involving shared decision making especially beneficial with older populations.

Non-Hispanic Blacks were more likely to be asked about their health improvement ideas than non-Hispanic Whites. This finding is consistent with previous research showing that non-Hispanic Black and Hispanic patients reported higher rates of positive communication with physicians than other races [15]. The data analyzed in this study were collected during the coronavirus disease 2019 (COVID-19) pandemic. It was widely reported that the COVID-19 mortality rate and hospitalization rate for older Black Americans were significantly greater than those of White Americans [21,22]. At the height of COVID-19 and with the awareness of these disparities, it is possible that providers were motivated to be more proactive in initiating discussions with older Black Americans by inquiring about their ideas for health improvement. However, post-pandemic monitoring of this trend should be continued.

Compared to beneficiaries who were underweight/of normal weight, those who were overweight or obese were more likely to be asked with greater frequency about ideas to improve their own health. This finding is inconsistent with previous research that reported no significant differences in patient-centered communication across BMI categories [23]. This inconsistency may be due to differences in study population characteristics. As the study focused on adults aged ≥18 years [23], some participants might not have health insurance coverage and/or a regular provider, which could affect the results. With approximately 96% of Medicare beneficiaries having a usual source of care and obesity being associated with very detrimental health effects and serious comorbidities [24,25], it is understandable that providers are soliciting beneficiaries’ ideas that are relevant and realistic for improving their health. This may help patients with overweight or obesity formulate individualized, attainable plans to help manage their weight and health.

Beneficiaries living alone were less likely to be asked for their health improvement ideas. Previous research demonstrated that older adults living alone reported worse care in terms of physician communication compared to those who lived with others [26]. It is possible that there is a stigma associated with living alone, and providers may unknowingly communicate differently with those who live alone. Empowering older adults living alone is especially important because they are at higher risk for poor health outcomes [27].

Similarly, beneficiaries with less than a high school education were less likely to be asked about their ideas for health improvement. Prior studies found that less appointment time was spent on ascertaining health knowledge, answering questions, and negotiating options among patients with lower educational levels [28]. However, patients of all educational levels should have the opportunity to play an active role in their healthcare encounters and decisions. Since education is a social determinant of health, it is important that providers are mindful of the intersection between education and healthcare and take steps to understand the perspectives and individualized needs of all their patients.

These findings indicate a need for interventions to increase awareness and abilities among healthcare providers to integrate SDM in caring for older patients with various characteristics and backgrounds. For example, role-playing exercises could simulate conversations with patients from diverse backgrounds and help providers practice SDM. Moreover, evidence-based, standardized decision aids could be integrated into electronic health records to prompt providers to use these tools during patient visits.

A limitation of this study is the inability to evaluate causality due to the cross-sectional study design. Another limitation is self-report bias in that some Medicare beneficiaries may not have answered questions accurately because they forgot how often their provider asked them about their ideas for health improvement and answered the survey based on potentially inaccurate recollections. In addition, only community-dwelling beneficiaries were included in the MCBS PUF. Therefore, the results cannot be extrapolated to other populations. Because this is a secondary data analysis, the validity and use of the questionnaire to measure the dependent variable is based on what is available in MCBS. More specific or different measurements may yield different results. Furthermore, subgroup analyses, particularly with respect to race/ethnicity, education, and different age groups, are warranted, and may provide additional insight.

5. Conclusions

In conclusion, there are disparities in how providers share decision making with Medicare beneficiaries based on factors related to sociodemographic characteristics and health status, namely the patient’s age group, race/ethnicity, education level, household composition, and BMI. All patients should be empowered to share their own ideas for improving their health because patient empowerment is associated with many health benefits. Interventions that promote provider awareness of disparities and offer practical tools to improve patient–provider communication could be the next step in mitigating these disparities. A multifaceted approach could include simulated patient interactions and incorporating standardized decision aids into electronic health records.