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Patient engagement: the critical catalyst to health reform in the USA

2012; Future Medicine; Volume: 1; Issue: 3 Linguagem: Inglês

10.2217/cer.12.15

2042-6313

Joseph Couto, Dominique Comer,

Health Systems, Economic Evaluations, Quality of Life

Journal of Comparative Effectiveness ResearchVol. 1, No. 3 EditorialFree AccessPatient engagement: the critical catalyst to health reform in the USAJoseph E Couto & Dominique M ComerJoseph E Couto* Author for correspondenceThomas Jefferson University School of Population Health, Philadelphia, PA, USA. Search for more papers by this authorEmail the corresponding author at joseph.couto@jefferson.edu & Dominique M ComerThomas Jefferson University School of Population Health, Philadelphia, PA, USASearch for more papers by this authorPublished Online:18 May 2012https://doi.org/10.2217/cer.12.15AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: healthcare reformpatient activation measurepatient contractspatient engagementOne of the hot topic issues during the 2012 Presidential campaign in the USA will surely be the Patient Protection and Affordable Care Act of 2010 (PPACA). This act, which has brought significant changes to healthcare with respect to access and quality, has become a symbol of the growing divide between Democrats and Republicans in the USA. The PPACA implements a number of programs, such as a Patient’s Bill of Rights and state Consumer Assistance Programs geared towards solving health insurance issues. While these options allow patients to become involved with the quality of and access to necessary healthcare, they appear to do little to motivate and engage patients in this process. In 2014, states will be required to create Health Insurance Exchanges, which will standardize the purchase of health insurance and will allow individuals to compare insurers with ease. These exchanges will be available for individual purchasers and small employers, and will eventually allow for the choice of Medicaid and Children’s Health Insurance Program benefits. A recent Altarum Institute consumer survey found that those surveyed on average spend less time researching prospective health plans than they do purchasing a new appliance or automobile [101]. Thus, while these exchanges will create a marketplace to easily shop across insurers as if you were shopping for a television, will it create engaged shoppers?Engaging patients will be a unique yet imperative challenge that the Patient Centered Outcomes Research Institute (PCORI) must face as it begins to produce and disseminate results. Part of PCORI’s mission is that results generated from studies it funds will be disseminated in a format that is appropriate for both patients and healthcare providers. PCORI is already engaging patients through its use of public forums and comment periods to help guide its priorities and agendas. In both the Health Insurance Exchanges and PCORI examples, the patient is set up as an active stakeholder, yet without the proper motivation and action from the informed patient, neither will realize their full potential as outlined in PPACA.What exactly does an engaged patient look like? While there is no universal definition, research in this area seems to point to four areas of competence for engaged patients; health literacy, clinical decision-making, self-care and patient safety [102]. While somewhat difficult to quantify, outcomes of interest associated with engaged patients are patient knowledge, patient experience, the use of services and cost of care, and healthy behaviors and overall health status.One of the most widely cited methods to measure and quantify whether a patient is engaged was developed by Judith Hibbard and colleagues at the University of Oregon (OR, USA). Hibbard and colleagues created the Patient Activation Measure (PAM), which recognizes that an ‘activated’ patient is an engaged patient who demonstrates an understanding that actions determine health outcomes and that they have the confidence to institute change. The PAM is a valid and highly reliable survey tool that assesses patient activation and places patients into one of four stages of activation. Stages 1–4 build in patient engagement and activation, ranging from simply believing that an active role in care is important (stage 1) up to maintaining appropriate healthcare behaviors under stress (stage 4) [1]. High scoring patients are significantly more likely to perform self-management behaviors, use self-management services and report high medication adherence [2,3].Several large studies using the PAM have helped to identify which patients are more likely to be engaged in the USA. Mosen and colleagues in 2004 had over 4000 Kaiser Permanente Medical Care program members respond to a survey that included the PAM to assess the members’ level of activation. Individuals were enrolled in Kaiser Permanente’s asthma, diabetes, heart failure, coronary artery disease, chronic pain, or diabetes and coronary artery disease program. The authors reported that only approximately 37% of these individuals were in activation stages 3 or 4, which are the stages where patients are most likely to have ideal outcomes and adequate management of chronic disease. With each increase in PAM stage, the change was associated with an increase in performance of self-management behaviors, medication adherence, satisfaction with services, self-reported quality of life and functional status [2]. The Center for Studying Healthcare Change periodically conducts a national Health Tracking Household Survey, and in 2007 embedded the PAM survey into its survey, to which they received over 6500 responses. They reported that those at a higher activation level (activation stages 3 or 4) tended to be younger, have a higher education and income, have private insurance, were white, and reported no chronic conditions. Amongst those with chronic conditions, patients with asthma, cancer and diabetes tended to have higher engagement. Those with multiple chronic conditions, depression, heart disease, arthritis, obesity and hypertension reported lower levels of activation [4]. It is important to note that both of these studies primarily surveyed commercially insured populations, and in both cases participation was voluntary. These studies do validate the notion that many patients suffering from chronic disease are not highly engaged or activated patients, thus there exists ample room for improvement. Also, we believe that the model of empowerment and self-efficacy surrounding cancer treatment in the USA results in highly activated patients, and should be adopted by organizations and providers that serve conditions more likely to be associated with lower engagement patients.An emerging trend in the development of engaged patients is the creation and utilization of patient contracts that represent an agreement between the patient and the provider. Currently, such contracts are often seen as a part of the chronic pain treatment model. The contract defines the expectations and responsibilities of each party, and each party signs it as if it were a legally binding agreement. The contract engages the patient and the provider on elements of safety, self-care and chronic disease management, and sends the message that both parties play an active role in the treatment of a patient. Example responsibilities include patients being required to account for all medical encounters between clinician visits and ask questions about treatments and alternative options, with clinicians providing a confidential environment for appointments, asking specific questions, and explaining the risks and benefits of the patient’s treatment options. This concept has been endorsed by the Patient Centered Primary Care Collaborative [103] for all primary care patients and will likely become more popular as providers see more of their income being based on the outcomes of their patients.While patient contracts represent a very low technological method to engage and activate patients, many engagement tools being developed utilize technology extensively. The Institute for Interactive Patient Care (IIPC) is an organization devoted to research that examines patient outcomes in patients that have been engaged through interactive technologies [104]. The Thomas Jefferson School of Population Health has collaborated on two studies with the IIPC that engaged patients in the hospital who were at risk for falling and patients who suffer from heart failure [5,6]. While technology can play a crucial role in engaging patients, nothing can replace the interactions between patients and providers, and as such providers should always be integrated somehow with technologies that engage and activate patients.The PPACA and the current push to reform healthcare in the USA largely ignore the true importance of engaged and activated patients in our healthcare system. The legislation places a great emphasis on improving patient outcomes through technology, access, communication, coordination of care and provider incentives; yet without a significant focus on health literacy and creating engaged patients, some of these efforts are likely to have little impact on chronic disease. Currently the availability of public report cards for hospitals and healthcare providers is widespread, yet research shows that these efforts to improve healthcare quality have largely fallen on deaf ears. Frequently, such report cards are unknown to their targeted population and are not used to affect change in practice [7,8]. These report cards serve as a reminder of the old saying that ‘you can lead a horse to water, but you can’t make it drink’. As the changes and innovations put forth in the PPACA legislation begin to be fully realized in the coming years, we will need engaged patients ready to make choices about their own health and wellness that will drive desperately needed reforms into our healthcare system.Financial & competing interests disclosureThe Thomas Jefferson School of Population Health receives research grants and consulting fees from the Institute for Interactive Patient Care. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.References1 Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv. Res.39(4 Pt 1),1005–1026 (2004).Crossref, Medline, Google Scholar2 Mosen D, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is patient activation associated with outcomes of care for adults with chronic conditions? J. Ambul. Care Manage.30(1),21–29 (2007).Crossref, Medline, Google Scholar3 Hibbard JH, Mahoney ER, Stock R, Tusler M. Do increases in patient activation result in improved self-management behaviors? Health Serv. Res.42(4),1443–1463 (2007).Crossref, Medline, Google Scholar4 Hibbard JH, Cunningham PJ. How engaged are consumers in their health and health care, and why does it matter? Res. Briefs8,1–9 (2008).Google Scholar5 Comer D, Wright D, Southerton J, Couto J. Impact of an interactive care plan on patient activation in heart failure inpatients. [Abstract]. Presented at: ISPOR 2012 Annual Meeting. Washington, DC, USA, 2–6 June 2012.Google Scholar6 Comer D, Wright D, Southerton J, Zanke A, Couto J. Patient engagement on fall reduction using an interactive educational intervention. [Abstract]. IHI 2011 Annual Meeting. Orlando, FL, USA, 6–8 December 2011.Google Scholar7 Bentley JM, Nash DB. How Pennsylvania hospitals have responded to publicly released reports on coronary artery bypass graft (CABG) surgery: a pilot project. Jt Comm. J. Qual. Improv.23,40–49 (1998).Google Scholar8 Rainwater JA, Romano PS, Antonius DM. The California hospital outcomes project: how useful is California’s report card for quality improvement? Jt Comm. J. Qual. Improv.23,31–39 (1998).Google Scholar101 Altarum Institute Center for Consumer Choice in Health Care. Fall 2011 Altarum Survey of Consumer Health Care Opinions. Ann Arbor, MI, USA. Altarum Institute (2011). www.altarum.org/files/imce/Consumer-Choice_Fall-2011-Findings_121211.pdf (Accessed 5 March 2012) Google Scholar102 Coulter A, Ellins J. Patient-focused interventions: a review of the evidence. Health Foundation, London, UK (2006). www.health.org.uk/public/cms/75/76/313/526/Patient%20focused%20interventions.pdf?realName=juNCmR.pdf (Accessed 5 March 2012)Google Scholar103 Patient-Centered Primary Care Collaborative. www.pcpcc.netGoogle Scholar104 Institute for Interactive Patient Care. www.instituteipc.orgGoogle ScholarFiguresReferencesRelatedDetailsCited ByItalian Consensus Statement on Patient Engagement in Chronic Care: Process and Outcomes11 June 2020 | International Journal of Environmental Research and Public Health, Vol. 17, No. 11The refluxing anterior accessory saphenous vein demonstrates similar clinical severity when compared to the refluxing great saphenous vein10 July 2016 | Phlebology: The Journal of Venous Disease, Vol. 31, No. 9Health literacy-listening skill and patient questions following cancer prevention and screening discussions22 July 2015 | Health Expectations, Vol. 19, No. 4 Vol. 1, No. 3 Follow us on social media for the latest updates Metrics History Published online 18 May 2012 Published in print May 2012 Information© Future Medicine LtdKeywordshealthcare reformpatient activation measurepatient contractspatient engagementFinancial & competing interests disclosureThe Thomas Jefferson School of Population Health receives research grants and consulting fees from the Institute for Interactive Patient Care. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download