ArticlePDF AvailableLiterature Review

What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs

Authors:

Abstract

Patient engagement is an increasingly important component of strategies to reform health care. In this article we review the available evidence of the contribution that patient activation-the skills and confidence that equip patients to become actively engaged in their health care-makes to health outcomes, costs, and patient experience. There is a growing body of evidence showing that patients who are more activated have better health outcomes and care experiences, but there is limited evidence to date about the impact on costs. Emerging evidence indicates that interventions that tailor support to the individual's level of activation, and that build skills and confidence, are effective in increasing patient activation. Furthermore, patients who start at the lowest activation levels tend to increase the most. We conclude that policies and interventions aimed at strengthening patients' role in managing their health care can contribute to improved outcomes and that patient activation can-and should-be measured as an intermediate outcome of care that is linked to improved outcomes.
At the Intersection of Health, Health Care and Policy
doi: 10.1377/hlthaff.2012.1061
, 32, no.2 (2013):207-214Health Affairs
Care Experiences; Fewer Data On Costs
What The Evidence Shows About Patient Activation: Better Health Outcomes And
Judith H. Hibbard and Jessica Greene
Cite this article as:
http://content.healthaffairs.org/content/32/2/207.full.html
available at:
The online version of this article, along with updated information and services, is
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php http://content.healthaffairs.org/subscriptions/etoc.dtlE-mail Alerts : http://content.healthaffairs.org/subscriptions/online.shtmlTo Subscribe:
written permission from the Publisher. All rights reserved.
mechanical, including photocopying or by information storage or retrieval systems, without prior
may be reproduced, displayed, or transmitted in any form or by any means, electronic orAffairs HealthFoundation. As provided by United States copyright law (Title 17, U.S. Code), no part of
by Project HOPE - The People-to-People Health2013Bethesda, MD 20814-6133. Copyright ©
is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600,Health Affairs
Not for commercial use or unauthorized distribution
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
By Judith H. Hibbard and Jessica Greene
What The Evidence Shows About
Patient Activation: Better Health
Outcomes And Care Experiences;
Fewer Data On Costs
ABSTRACT
Patient engagement is an increasingly important component of
strategies to reform health care. In this article we review the available
evidence of the contribution that patient activationthe skills and
confidence that equip patients to become actively engaged in their health
caremakes to health outcomes, costs, and patient experience. There is a
growing body of evidence showing that patients who are more activated
have better health outcomes and care experiences, but there is limited
evidence to date about the impact on costs. Emerging evidence indicates
that interventions that tailor support to the individuals level of
activation, and that build skills and confidence, are effective in increasing
patient activation. Furthermore, patients who start at the lowest
activation levels tend to increase the most. We conclude that policies and
interventions aimed at strengthening patientsrole in managing their
health care can contribute to improved outcomes and that patient
activation canand shouldbe measured as an intermediate outcome of
care that is linked to improved outcomes.
The Affordable Care Act recognizes
that engaging patients in their own
care is a cornerstone of successful
health system reform and is critical
to the success of accountable care
organizations and patient-centered medical
homes. A growing body of evidence links pa-
tientsactivation levels to their health and cost
outcomes. In this article we review evidence of
the contribution that patient activation makes to
health outcomes, costs, and patientsexperienc-
es of care.
The terms patient engagement and patient acti-
vation are often used interchangeably. The terms
are also frequently used to convey different
meanings or are poorly defined.
Patient activation emphasizes patientswilling-
ness and ability to take independent actions to
manage their health and care. We use the defi-
nition developed by an author of this article,
Judith Hibbard, and colleagues. This definition
equates patient activation with understanding
ones role in the care process and having the
knowledge, skill, and confidence to manage
ones health and health care.1Activation differs
from compliance, in which the emphasis is on
getting patients to follow medical advice.
We use patient engagement to denote a broader
concept that includes activation; the interven-
tions designed to increase activation; and pa-
tientsresulting behavior, such as obtaining pre-
ventive care or engaging in regular physical
exercise. The focus on activation and engage-
ment rather than compliance recognizes that
patients manage their health on their own the
vast majority of the time, making decisions daily
that affect their health and costs.
The evidence linking patient activation with
health outcomes, patient experience, and costs
has grown substantially over the past decade.
Besides reviewing the strength of that evidence,
we identify important research gaps and address
doi: 10.1377/hlthaff.2012.1061
HEALTH AFFAIRS 32,
NO. 2 (2013): 207214
©2013 Project HOPE
The People-to-People Health
Foundation, Inc.
Judith H. Hibbard (jhibbard@
uoregon.edu) is a senior
researcher at the Health
Policy Research Group,
Institute for Sustainable
Environments, and a professor
emerita in the Department of
Planning, Public Policy, and
Management, all at the
University of Oregon, in
Eugene.
Jessica Greene is a professor
and director of research at
theGeorgeWashington
University School of Nursing,
in Washington, D.C.
FEBRUARY 2013 32:2 Health Affairs 207
Evidence
&
Potential
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
two key policy questions: What are effective strat-
egies for activating patients? And can patients
who are disengaged and not activated become
activated?
In this review we include studies that quantify
patient activation using the Patient Activation
Measure and that link activation levels to health
outcomes, costs, and patientsexperiences of
care. The Patient Activation Measure is a so-
called latent constructa variable that cantbe
measured directly but instead is assessed
through a series of answers to questionsthat
gauges a persons self-concept as a manager of
his or her health and health care. The measure is
scored on a 0100 scale, and people are catego-
rized into four levels of activation, with level 1
the least activated and level 4 the most activated.
The score incorporates responses to thirteen
statements about beliefs, confidence in manag-
ing health-related tasks, and self-assessed
knowledge. Examples include the following: I
am confident that I can tell whether I need to
go to the doctor or whether I can take care of a
health problem myself;I know what treat-
ments are available for my health problems;
and I am confident that I can tell a doctor
my concerns, even when he or she does not
ask.Responses are degrees of agreement or
disagreement.
The measure has been proved to be reliable
and valid across different languages, cultures,
demographic groups, and health statuses.17
Evidence Of Better Health Outcomes
Multiple domestic and international studies
have empirically demonstrated that people
who score higher on the Patient Activation
Measure are significantly more likely than peo-
ple who score lower to engage in preventive
behavior such as having regular check-ups,
screenings, and immunizations. More highly
activated people are also significantly more
likely to engage in healthy behavior such as eat-
ing a healthy diet and getting regular exercise.
Moreover, those who score higher are more
likely to avoid health-damaging behavior such
as smoking and illegal drug use.1,2,815
Less activated patients are also three times as
likely to have unmet medical needs and twice as
likely to delay medical care, compared with more
activated patients.13 Highly activated patients are
two or more times as likely as those with low
activation levels to prepare questions for a visit
to the doctor; to know about treatment guide-
lines for their condition; and to seek out health
information, including comparisons of the qual-
ity of health care providers.10,16
Chronically ill patients with higher activation
levels are more likely than those with lower levels
to adhere to treatment; perform regular self-
monitoring at home; and obtain regular chronic
care, such as foot exams for diabetes.2,8,9,11,12,1725
These findings stem from studies of patients
with a range of conditions and economic
backgrounds.
For example, Kimberly Rask and colleagues
followed patients with diabetes from an inner-
city public hospital clinic over a six-month
period and found that patients with higher acti-
vation scores were more likely to perform foot
checks, obtain eye examinations, and exercise
regularly, compared to patients who scored
lower on this measure.19 In a study of patients
with serious mental illnesses, Michelle Salyers
and colleagues found that higher Patient
Activation Measure scores were positively re-
lated to patientsmanagement of their own ill-
ness and were negatively related to substance
abuse.15
Two studies tracked how changes in Patient
Activation Measure scores over time were related
to subsequent behavior changes. First, Hibbard
and coauthors followed patients with one or
more chronic diseases over a six-month period.9
Increases in Patient Activation Measure scores
were linked to improvements in eleven of eight-
een actions, including regular exercising and
keeping a blood glucose diary. Lisa Harvey and
colleagues reported similar results among em-
ployees: When Patient Activation Measure scores
increased, multiple behaviors improved, regard-
less of the employeesactivation level at
baseline.26
In addition to the documented linkages be-
tween activation and healthy behavior, activa-
tion has been shown to be associated with better
health outcomes. Several studies have reported
that patients with higher activation scores are
more likely than patients with lower scores to
have biometrics such as body mass index, hemo-
globin A1c, blood pressure, and cholesterol in
the normal range.8,17,25,27,28
These findings, from both cross-sectional and
prospective studies, were significant even after
sociodemographic factors, disease severity, and
insurance status were controlled for. Moreover,
many of these findings have been reported
within disadvantaged, ethnically diverse, and
medically indigent populations.19,2933
Patient activation has also been linked to out-
comes among patients with many different types
of health conditions.11,14,15,31,3440 In addition,
many of the findings have been replicated in
studies conducted in different countries, includ-
ing Denmark, Germany, the United Kingdom,
Japan, Norway, Canada, the Netherlands, and
Australia.37,20,36
Evidence
&
Potential
208 Health Affairs FEBRUARY 2013 32:2
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
Evidence Of Better Health Care
Experiences
Several studies have documented that more
highly activated patients consistently report
more positive care experiences.1,11,4144 Jeffrey
Alexander and colleagues found that patients
reports of higher-quality interpersonal ex-
changes with physicians, greater fairness, and
more out-of-office contact with physicians
were associated with higher patient activation
scores.41 Daniel Maeng and coauthors found that
patients with higher scores and one or more
chronic disease reported fewer problems with
care coordination than did patients with lower
scores.42
Most of the studies looking at patient activa-
tion and patient experience are cross-sectional,
which makes it impossible to know the direction
of causality. However, new evidence suggests
that highly activated patients report better care
experiences from a given provider than do less
activated patients who see the same provider.44
Highly activated patients may have the skills and
confidence to elicit what they need from their
providers.
These findings suggest that patient expe-
rience scores, such as those on the Consumer
Assessment of Healthcare Providers and Systems
survey, may be a reflection of a transaction that is
shaped by both the clinician and the patient and
is not just a measure of provider performance.44
Evidence Of Lower Health Care Costs
Several studies have reported that after disease
severity and demographic characteristics were
controlled for, highly activated patients had
lower rates of costly use such as hospitalizations
and emergency department visits, compared to
less activated patients.8,25,36,45 In a study of more
than 25,000 patients in a large delivery system
in Minnesota, we found that for every additional
ten points on a Patient Activation Measure score,
the predicted probability of having an emergency
department visit was one percentage point
lower.8The study controlled for health and dem-
ographic factors.
In this monthsHealth Affairs, we and Valerie
Overton publish the first study that specifically
examined patient activation and cost of care.46
We found that Patient Activation Measure scores
were predictive of the same years and the next
years billed costs of care, with less activated
patients having significantly higher costs than
more activated patients.
Evidence Of The Ability To Increase
Activation Levels
Evaluations of interventions to increase patient
activation have been carried out in a variety of
settings: the workplace,29 hospitals,47 disease
management programs,48 the community,22,4951
and primary care.29,52 These studies include
publicly and privately insured populations and
patients with various health conditions.
Interventions ranged in duration from just one
visit to periods of six months.
All of these studies have documented improve-
ments in activation scores as a result of the in-
tervention being tested. On average, improve-
ments ranged from 2.5 to 6.5 points on the
100-point activation scale. Concurrent with the
increases in activation, several of the studies
have shown improvements in health outcomes,
including health-related quality of life; clinical
indicators, such as low-density lipoprotein and
blood pressure; adherence to treatment; im-
proved health-related behavior; increased par-
ticipation in care; and reduced symptoms, hos-
pital readmissions, overnight hospital stays, and
use of the emergency department.22,28,29,4752
The studies vary in their sample sizes and de-
gree of rigor. However, collectively they help
identify the types of interventions that yield in-
creases in activation.
Interventions shown to increase activation
have one or more of the following focuses.
Skill Development, Problem Solving, And
Peer Support A good example of this type of
intervention is Kate Lorigs diabetes self-man-
agement program, which uses trained lay leaders
in community settings to facilitate workshops
aimed at helping chronically ill patients handle
problems better, engage in appropriate exercise,
and communicate with providers. The program
is community based and is typically not linked
to any delivery system. Participants have
demonstrated increases in activation that have
been sustained for up to twelve months after
participation.50
Benjamin Druss and colleagues adapted the
self-management program to patients with seri-
ous mental illnesses and tested it in a controlled
trial.22 At the six-month follow-up, participants
in the intervention group had significantly
greater improvements in patient activation than
those in usual care, along with greater improve-
ments in adherence, physical activity, and qual-
ity of life.
Two studies carried out in safety-net clinics
that focused on skills development, such as
question formulation, have been shown to in-
crease patientsskills, participation in care,
and activation levels.29,52
A quasi-experimental study conducted in
FEBRUARY 2013 32:2 Health Affairs 209
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
senior centers evaluated an intervention that fo-
cused on peer support and the development of
self-management skills such as condition mon-
itoring and increasing physical activity.51 The
intervention focused on the importance of tak-
ing an active role in managing ones conditions
and offered specific strategies for doing so.
ParticipantsPatient Activation Measure scores
and physical activity increased, and their quality-
of-life scores and health status had improved at a
six-month follow-up.
Michael Parchman and colleagues showed
that the baseline Patient Activation Measure
scores of patients with diabetes had improved
at a one-year follow-up, when the patients en-
gaged in participatory decision making with pro-
viders.53 Further Patient Activation Measure
score improvements were associated with in-
creases in medication adherence and levels of
HbA1c and low-density lipoprotein cholesterol.
Changing The Social Environment These
interventions seek to change the social environ-
ment to facilitate peoples changes in beliefs,
social norms, skills, and opportunities to engage
in healthy behavior. In an experiment involving
two large companies, employees were randomly
assigned to a control group or to a group receiv-
ing one of two different workplace interventions
focusing on wellness or being an informed
health care consumer. Although the two inter-
vention arms emphasized different issues, both
included health classes, environmental changes
such as posters and information campaigns, and
personal coaching for high-risk employees. The
findings showed that people receiving either of
the interventions significantly increased their
activation, by an average of five points.28
Tailoring Support To The Persons
Activation Level The goal of tailored coaching
is to encourage people to take actions at which
they are likely to succeed. Participants who are
less activated are encouraged to take small, man-
ageable steps; those who are more activated are
encouraged to make more substantial behavioral
changes.
In a small study, Martha Shively and col-
leagues randomly assigned patients with heart
failure to a group receiving usual care only or a
group given tailored coaching along with their
medical care.45 The coaching was designed to
help patients develop self-management skills,
with the level of intensity tailored to the patients
level of activation. The researchers found greater
increases in activation scores and greater corre-
sponding decreases in hospitalization for the
intervention group, compared to the group re-
ceiving usual care alone. Notably, the decreases
in hospitalization among the intervention group
were observed whether participantsbaseline
activation scores were high or low.
In a quasi-experimental study conducted in a
disease management program, coaches tailored
support to the patientsPatient Activation
Measure scores.48 Coaches encouraged patients
to make changes that they were likely to succeed
at, starting the less activated patients with
smaller steps. The findings showed significant
improvements over the course of six months in
activation scores; adherence to treatment; clini-
cal indicators, such as blood pressure and low-
density lipoprotein levels; and reductions in
emergency department use and hospitaliza-
tions, compared to patients in the control group
who received usual coaching, with no tailoring
according to patientsactivation level.
One interesting finding from the intervention
studies was that patients who started at the low-
est activation levels tended to increase their
Patient Activation Measure scores the most.
This result may partly be a ceiling effectthat
is, the patients who began with high scores had
less room to improvebut it is encouraging that
an effective intervention can activate patients
who were previously passive.48,51,52
Overall, interventions that tailor support to
the persons level of activation, build skills and
confidence, use peer support, and change the
social environment have a positive impact on
activation as well as other outcomes.
Although there is a growing body of interven-
tion studies investigating different population
groups and conditions, many limitations and
gaps remain. There is a need to expand the evi-
dence base about the efficacy of different strat-
egies in different settings. And although it
appears that several different types of interven-
tions are effective, there is no indication which
are most effective or which will work best with
specific patient populations. More controlled tri-
als are needed to develop this evidence base.
Studies are starting to emerge that look at the
impact of web-based interventions or portals on
patient activation. The results are encouraging,
but more research is needed in this area.5457 Also,
although less activated people appear to benefit
from interventions, they are less likely than
others to participate in them in the first place.57
Research is needed to identify strategies that
increase the participation of less activated
patients.
The Patient Activation Measure
In Innovative Delivery Systems
Innovative delivery systems are measuring acti-
vation to improve and individualize patient care
and to strengthen the patients role in improving
outcomes. They are improving care principally
Evidence
&
Potential
210 Health Affairs FEBRUARY 2013 32:2
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
by tailoring coaching, education, and care pro-
tocols to patients at different levels of activation.
Delivery systems are also making more efficient
use of their resources by providing more support
to patients who have a heavy disease burden and
limited self-management skills (less activated
patients), and less support to patients with
greater skills.
For example, Fairview Health Services in
Minnesotaa large not-for-profit health care
system with forty-one primary care clinics, spe-
cialty care clinics, and hospitalsroutinely col-
lects Patient Activation Measure data as part of
primary care. Fairview is also participating in the
Centers for Medicare and Medicaid Services
Pioneer Accountable Care Organization model.
The patient activation data are collected by
Fairviews front-office staff in the waiting room
or by medical assistants in the exam room. The
resulting activation score is then entered into the
patients electronic health record. Fairview is
also laying the groundwork for collecting
Patient Activation Measure data online via the
patient portal, known as MyChart, in the EPIC
electronic health record system.
Within Fairview, the Patient Activation
Measure is increasingly viewed as a vital sign
that is key to individualizing patientscare
plans. Fairviews clinicians are being trained to
use motivational interviewing to help match
patientscare plans to activation levels.
Additionally, Fairview is using the Patient
Activation Measure score to reduce hospital re-
admissions. The health system also uses the
score when patients are discharged to tailor
the type and amount of support provided to pa-
tients at that stage. By targeting extra support to
people with the weakest self-management skills,
and providing less support to those with ad-
equate self-management skills, the Fairview staff
is seeking to reduce readmissions with fewer
resources.
Another example is the Courage Center in
Minnesota, the recent winner of an innovation
grant from the Centers for Medicare and
Medicaid Services. The Courage Center provides
a patient-centered medical home for patients
many of them eligible for both Medicare and
Medicaidwith complex chronic illnesses or dis-
abilities. The patients have high rates of expen-
sive utilization, averaging 10.8 hospital days per
year. With careful management and responsive
clinicians, the center has been able to increase
Patient Activation Measure scores seven points
on average, over roughly twelve months. It
has also reduced hospital days by 71 percent,
to 3.1 days per yeara significant change. By
helping patients prevent crises, the center gives
patients a greater sense of control over their
situation.
One strategy the center uses is to have the
Patient Activation Measure score drive care pro-
tocols. For example, when a patient with a low
activation score calls the center, the staff ad-
dresses the patients needs by marshaling the
necessary resources, including medications or
medical advice, before the call concludes. This
strategy is based on the assumption that less
activated patients are less likely than others to
call back and follow up on additional unresolved
problems that could lead to hospitalizations
(Nancy Flinn, Courage Center, personal commu-
nication, October 3, 2012).
And in the Pacific Northwest, the PeaceHealth
systems patient-centered medical homes use
Patient Activation Measure scores in combina-
tion with information on disease burden to
match care to patientsneeds.58 This approach
takes into account patientsclinical profiles as
well as their ability to manage their health.
Patients with greater disease burden and lower
Patient Activation Measure scores are matched
with more highly skilled clinical team members.
For example, a patient with the lowest level of
activation and the highest disease burden would
be matched with a physician and a registered
nurse. A patient with the highest level of activa-
tion and the lowest disease burden would be
matched with a peer support group.
Fairview Health Services, the Courage Center,
and PeaceHealth are examples of innovative or-
ganizations that are using their existing quality
improvement infrastructureelectronic health
records and information systems, team-based
care, and population-based carein a more tar-
geted way to support patients and personalize
care. These organizations believe that their in-
vestment in patient engagement will pay off in
better health outcomes, better experiences for
patients, and lower costs. The extent to which
these approaches can be adapted to other care
settings will depend, in part, on health care or-
ganizationsexisting infrastructure and their
ability to capitalize on that infrastructure.
Discussion
The research shows that more activated patients
have better health outcomes and better care
experiences than patients who are less acti-
vated.2527 Studies also show that activation can
be modified and increased over timeand that
certain interventions are effective in increasing
activation.45,4853 This has been shown with med-
ically indigent patients, different racial and eth-
nic groups, and patients with multiple chronic
conditions.
These findings highlight the contribution that
FEBRUARY 2013 32:2 Health Affairs 211
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
patient activation makes to health outcomes and
patientsexperiences with care. More research is
needed to understand the contribution that it
may make in terms of health care costs.
Results suggest that increasing patient engage-
ment may be an important element in strategies
designed to reach the so-called Triple Aim59 of
health care reform: better individual and popu-
lation health and lower costs.
The results also point to the need for a system-
atic approach in encouraging patients to play a
more active role. It is important to integrate pa-
tient engagement strategies into all efforts to
improve the effectiveness and efficiency of care.
Innovative delivery systems, such as those de-
scribed above, are including patients as part of
the solution, recognizing that high-quality care
should help patients gain the skills, confidence,
and knowledge they need to manage their health.
The emerging evidence suggests a potentially
new quality goal: increasing patient activation
as an intermediate outcome of care that is meas-
urable and linked with improved outcomes.
Quality improvement efforts that systematically
work to expand the patients (and the familys)
ability to participate in care are a pathway toward
improving outcomes. Such an approach is both
necessary and achievable.
Judith Hibbard is an equity stakeholder
in and consultant to Insignia Health.
NOTES
1Hibbard JH, Stockard J, Mahoney
ER, Tusler M. Development of the
Patient Activation Measure (PAM):
conceptualizing and measuring ac-
tivation in patients and consumers.
Health Serv Res. 2004;39(4 Pt 1):
100526.
2Hibbard JH, Mahoney ER, Stockard
J, Tusler M. Development and test-
ing of a short form of the patient
activation measure. Health Serv Res.
2005;40(6 Pt 1):191830.
3Rademakers J, Nijman J, van der
Hoek L, Heijmans M, Rijken M.
Measuring patient activation in the
Netherlands: translation and valida-
tion of the American short form
Patient Activation Measure
(PAM13). BMC Public Health. 2012;
12:577.
4Herrmann W, Brenk-Franz K,
Hibbard JH, Freund T, Djalali S,
Steurer-Stey C, et al. Evaluation of
the German version of the Patient
Activation Measure (PAM-13D) in
the primary care setting. Paper pre-
sented at: World Organization of
National Colleges, Academies, and
Academic Associations of General
Practitioners/Family Physicians
conference; 2012 Jul; Vienna.
5Fujita E, Kuno E, Kato D, Kokochi M,
Uehara K, Hirayasu Y. Development
and validation of the Japanese
version of the Patient Activation
Measure 13 for mental health.
Seishingaku. 2010;52:76572.
Japanese.
6Maindal HT, Sokolowski I, Vedsted
P. Translation, adaptation and vali-
dation of the American short form
Patient Activation Measure (PAM13)
in a Danish version. BMC Public
Health. 2009;9:209.
7Steinsbekk A. Norwegian version of
the Patient Activation Measure.
Tidsskr Nor Laegeforen. 2008;
128(20):23168. Norwegian.
8Greene J, Hibbard JH. Why does
patient activation matter? An
examination of the relationships
between patient activation and
health-related outcomes. J Gen
Intern Med. 2012;27(5):5206.
9Hibbard JH, Mahoney ER, Stock R,
Tusler M. Do increases in patient
activation result in improved self-
management behaviors? Health Serv
Res. 2007;42(4):144363.
10 Fowles JB, Terry P, Xi M, Hibbard J,
Bloom CT, Harvey L. Measuring self-
management of patientsand em-
ployeeshealth: further validation of
the Patient Activation Measure
(PAM) based on its relation to em-
ployee characteristics. Patient Educ
Couns. 2009;77(1):11622.
11 Mosen DM, 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. 2007;30(1):219.
12 Becker ER, Roblin DW. Translating
primary care practice climate into
patient activation: the role of patient
trust in physician. Med Care. 2008;
46(8):795805.
13 Hibbard JH, Cunningham PJ. How
engaged are consumers in their
health and health care, and why does
it matter? Res Briefs. 2008;(8):19.
14 Tabrizi JS, Wilson AJ, ORourke PK.
Customer quality and type 2 diabetes
from the patientsperspective: a
cross-sectional study. J Res Health
Sci. 2010;10(2):6976.
15 Salyers MP, Matthias MS, Spann CL,
Lydick JM, Rollins AL, Frankel RM.
The role of patient activation in
psychiatric visits. Psychiatr Serv.
2009;60(11):15359.
16 Hibbard JH. Using systematic
measurement to target consumer
activation strategies. Med Care Res
Rev. 2009;66(1 Suppl):9S27S.
17 Rogvi S, Tapager I, Almdal TP,
Schiøtz ML, Willaing I. Patient fac-
tors and glycaemic controlassoci-
ations and explanatory power.
Diabet Med. 2012;29(10):e3829.
18 Lorig K, Ritter PL, Laurent DD, Plant
K, Green M, Jernigan VB, et al.
Online diabetes self-management
program: a randomized study.
Diabetes Care. 2010;33(6):127581.
19 Rask KJ, Ziemer DC, Kohler SA,
Hawley JN, Arinde FJ, Barnes CS.
Patient activation is associated with
healthy behaviors and ease in man-
aging diabetes in an indigent popu-
lation. Diabetes Educ. 2009;35(4):
62230.
20 Ellins J, Coulter A. Measuring pa-
tient activation: validating a tool for
improving quality of care in the UK.
Oxford: Picker Institute Europe;
2005.
21 Wolever RQ, Webber DM, Meunier
JP, Greeson JM, Lausier ER, Gaudet
TW. Modifiable disease risk, readi-
ness to change, and psychosocial
functioning improve with integra-
tive medicine immersion model.
Altern Ther Health Med. 2011;17(4):
3847.
22 Druss BG, Zhao L, von Esenwein SA,
Bona JR, Fricks L, Jenkins-Tucker S,
et al. The Health and Recovery Peer
(HARP) Program: a peer-led inter-
vention to improve medical self-
management for persons with seri-
ous mental illness. Schizophr Res.
2010;118(13):26470.
23 Schiøtz ML, Bøgelund M, Almdal T,
Jensen BB, Willaing I. Social support
and self-management behaviour
among patients with type 2 diabetes.
Diabet Med. 2012;29(5):65461.
24 Hibbard JH, Tusler M. Assessing
activation stage and employing a
next stepsapproach to supporting
patient self-management. J Ambul
Care Manage. 2007;30(1):28.
Evidence
&
Potential
212 Health Affairs FEBRUARY 2013 32:2
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
25 Remmers C, Hibbard J, Mosen DM,
Wagenfield M, Hoye RE, Jones C. Is
patient activation associated with
future health outcomes and health-
care utilization among patients with
diabetes? J Ambul Care Manage.
2009;32(4):3207.
26 Harvey L, Fowles JB, Xi M, Terry P.
When activation changes, what else
changes? The relationship between
change in patient activation measure
(PAM) and employeeshealth status
and health behaviors. Patient Educ
Couns. 2012;88(2):33843.
27 Skolasky RL, Mackenzie EJ, Wegener
ST, Riley LH. Patient activation and
functional recovery in persons
undergoing spine surgery.
Orthopedics. 2011;34(11):888.
28 Terry PE, Fowles JB, Xi M, Harvey L.
The ACTIVATE study: results from a
group-randomized controlled trial
comparing a traditional worksite
health promotion program with an
activated consumer program. Am J
Health Promot. 2011;26(2):e6473.
29 Alegría M, Sribney W, Perez D,
Laderman M, Keefe K. The role of
patient activation on patient-
provider communication and quality
of care for US and foreign born
Latino patients. J Gen Intern Med.
2009;24(Suppl 3):53441.
30 Hibbard JH, Greene J, Becker ER,
Roblin D, Painter MW, Perez DJ,
et al. Racial/ethnic disparities and
consumer activation in health.
Health Aff (Millwood). 2008;27(5):
144253.
31 Gerber LM, Barrón Y, Mongoven J,
McDonald M, Henriquez E,
Andreopoulos E, et al. Activation
among chronically ill older adults
with complex medical needs: chal-
lenges to supporting effective self-
management. J Ambul Care Manage.
2011;34(3):292303.
32 Lubetkin EI, Lu WH, Gold MR.
Levels and correlates of patient ac-
tivation in health center settings:
building strategies for improving
health outcomes. J Health Care Poor
Underserved. 2010;21(3):796808.
33 Kansagara D, Ramsay RS, Labby D,
Saha S. Post-discharge intervention
in vulnerable, chronically ill pa-
tients. J Hosp Med. 2012;7(2):
12430.
34 Green CA, Perrin NA, Polen MR, Leo
MC, Hibbard JH, Tusler M.
Development of the Patient
Activation Measure for mental
health. Adm Policy Ment Health.
2010;37(4):32733.
35 Munson GW, Wallston KA, Dittus
RS, Speroff T, Roumie CL. Activation
and perceived expectancies: correla-
tions with health outcomes among
veterans with inflammatory bowel
disease. J Gen Intern Med. 2009;
24(7):80915.
36 Begum N, Donald M, Ozolins IZ,
Dower J. Hospital admissions,
emergency department utilisation
and patient activation for self-man-
agement among people with diabe-
tes. Diabetes Res Clin Pract. 2011;
93(2):2607.
37 Saft HL, Kilaru S, Moore E, Enriquez
M, Gross R. The impact of a patient
activation measure on asthma out-
comes: a pilot study. Chest. 2008;
134(4_MeetingAbstracts):
s2004s2004.
38 Stepleman L, Rutter MC, Hibbard J,
Johns L, Wright D, Hughes M.
Validation of the patient activation
measure in a multiple sclerosis clinic
sample and implications for care.
Disabil Rehabil. 2010;32(19):
155867.
39 Skolasky RL, Green AF, Scharfstein
D, Boult C, Reider L, Wegener ST.
Psychometric properties of the pa-
tient activation measure among
multimorbid older adults. Health
Serv Res. 2011;46(2):45778.
40 AARP Public Policy Institute.
Chronic care: a call to action for
healthcare reform [Internet].
Washington (DC): AARP; 2009 Apr
[cited 2013 Jan 10]. Available from:
http://assets.aarp.org/rgcenter/
health/beyond_50_hcr.pdf
41 Alexander JA, Hearld LR, Mittler JN,
Harvey J. Patient-physician role re-
lationships and patient activation
among individuals with chronic ill-
ness. Health Serv Res. 2012;
47(3 Pt 1):120123.
42 Maeng DD, Martsolf GR, Scanlon
DP, Christianson JB. Care co-
ordination for the chronically ill:
understanding the patients per-
spective. Health Serv Res. 2012;
47(5):196079.
43 Glasgow RE, Wagner EH, Schaefer J,
Mahoney LD, Reid RJ, Greene SM.
Development and validation of the
Patient Assessment of Chronic
Illness Care (PACIC). Med Care.
2005;43(5):43644.
44 Greene J, Hibbard JH, Sacks RM,
Overton V. Understanding the rela-
tionship between patient engage-
ment and patient experiences of
care. Unpublished paper.
45 Shively MJ, Gardetto NJ, Kodiath
MF, Kelly A, Smith TL, Stepnowsky
C, et al. Effect of patient activation
on self-management in patients with
heart failure. J Cardiovasc Nurs.
2013;28(1):2034.
46 Hibbard JH, Greene J, Overton V.
Patients with lower activation asso-
ciated with higher costs; delivery
systems should know their patients
scores.Health Aff (Millwood).
2013;32(2):21622.
47 Richmond DR, Bell-Johnson E,
Richetto P, Gadson S, Li J.
Complementary use of care transi-
tion intervention and Patient
Activation Measure to reduce 30-day
re-hospitalization in the elderly.
Paper presented at: QualityNet
Conference; 2010; Baltimore, MD.
48 Hibbard JH, Greene J, Tusler M.
Improving the outcomes of disease
management by tailoring care to the
patients level of activation. Am J
Manag Care. 2009;15(6):35360.
49 Washington State Department of
Social and Health Services. Chronic
care management project evaluation
report [Internet]. Olympia (WA):
The Department; [cited 2013 Jan 10].
Available from: http://www.adsa
.dshs.wa.gov/professional/
hcs/CCM/
50 Lorig K, Alvarez S. Re: community-
based diabetes education for Latinos.
Diabetes Educ. 2011;37(1):128.
51 Frosch DL, Rincon D, Ochoa S,
Mangione CM. Activating seniors to
improve chronic disease care: results
from a pilot intervention study. J Am
Geriatr Soc. 2010;58(8):1496503.
52 Deen D, Lu WH, Rothstein D,
Santana L, Gold MR. Asking ques-
tions: the effect of a brief interven-
tion in community health centers on
patient activation. Patient Educ
Couns. 2011;84(2):25760.
53 Parchman ML, Zeber JE, Palmer RF.
Participatory decision making,
patient activation, medication ad-
herence, and intermediate clinical
outcomes in type 2 diabetes: a
STARNet study. Ann Fam Med.
2010;8(5):4107.
54 Solomon M, Wagner SL, Goes J.
Effects of a Web-based intervention
for adults with chronic conditions on
patient activation: online random-
ized controlled trial. J Med Internet
Res. 2012;14(1):e32.
55 Nagykaldi Z, Aspy CB, Chou A, Mold
JW. Impact of a Wellness Portal on
the delivery of patient-centered pre-
ventive care. J Am Board Fam Med.
2012;25(2):15867.
56 Wagner P, Sodomka P, Dias J,
Kintziger K, Seol Y-H, Howard S,
et al. Using an electronic personal
health record to empower patients
with hypertension. Rockville (MD):
Agency for Healthcare Research and
Quality; 2011.
57 Hibbard JH, Green J. Who are we
reaching through the patient portal:
engaging the already engaged? Int J
Pers Cent Med. 2011;1(4):78893.
58 Blash L, Dower C, Chapman S.
PeaceHealths Team Fillingame uses
Patient Activation Measure to cus-
tomize the medical home [Internet].
San Francisco (CA): University of
California, San Francisco, Center for
the Health Professions; 2011 May 1
[cited 2012 Dec 19]. Available from:
http://www.futurehealth.ucsf.edu/
Content/11660/2011_05_Peace
Health's_Team%20Fillingame_
Uses_Patient_Activation_
Measures_to_Customize_the_
Medical_Home.pdf
59 Berwick DM, Nolan TW, Whittington
J. The Triple Aim: care, health, and
cost. Health Aff (Millwood). 2008;
27(3):75969.
FEBRUARY 2013 32:2 Health Affairs 213
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
ABOUT THE AUTHORS: JUDITH H. HIBBARD
&
JESSICA GREENE
Judith H. Hibbard is
a professor emerita
at the University of
Oregon.
In this monthsHealth Affairs,
Judith Hibbard and Jessica Greene
assess the evidence on the effects
of patient activation”—the skills
and confidence that equip patients
to become actively engaged in their
health care. The authors cite a
growing body of evidence showing
that patients who are more
activated have better health
outcomes and care experiences, but
they also find that there is limited
evidence to date about the impact
on costs. Arguing for more
research to buttress this evidence,
they recommend that patient
activation be broadly assessed as
an intermediate outcome linked to
improved health outcomes over
time.
Hibbard is a professor emerita in
the Department of Planning, Public
Policy, and Management and a
senior researcher at the Health
Policy Research Group, Institute
for Sustainable Environments, all
at the University of Oregon. Over
thepasttwenty-eightyears,
Hibbard has focused her research
on consumer choices and behavior,
with a particular emphasis on
testing approaches that give
consumers and patients more
knowledge and control over their
health and health care. Hibbards
studies examine such topics as how
consumers understand and use
health care information, how
health literacy affects choices, and
assessments of patient
engagement.
Hibbard holds a mastersdegree
in public health from the
University of California, Los
Angeles, and a doctorate in social
and administrative health sciences
from the University of California,
Berkeley.
Jessica Greene is a
professor and
director of research
at the George
Washington
University School
of Nursing.
Greene is a professor and
director of research at the George
Washington University School of
Nursing. She focuses on evaluating
health policies and strategies for
improving quality of care. Greene
also serves as principal investigator
in a studyfunded by the
Commonwealth Fundof how a
health system uses an innovative
physician compensation model to
drive improvements in care
delivery, and as coprincipal
investigator of another study
funded by the Gordon and Betty
Moore Foundationof changes in
patient activation over time.
In addition, Greene serves as an
advisory board member for Medical
Care Research and Review. She holds
masters degrees in public health
and international affairs from
Columbia University and earned a
doctorate in public administration
from New York University.
Evidence
&
Potential
214 Health Affairs FEBRUARY 2013 32:2
by JUDITH HIBBARD on February 4, 2013Health Affairs by content.healthaffairs.orgDownloaded from
... Patient activation, a measure of patients' knowledge, skills, and confidence to enact relevant health behaviors, plays a critical role in the self-management of chronic disease. 1 Those with high levels of patient activation are more likely to have their healthcare needs met, receive timely care, and gain support from healthcare providers; this in turn improves both their satisfaction with and outcomes of healthcare. 2 While the link between patient activation and health outcomes has been established, increasing attention is being paid to the link between patient activation and psychological factors. Importantly, depressive symptoms are the most frequently assessed and are strongly associated with patient activation. ...
... Analyses were based on 200 primary care patients (age = 47.72 ± 11.56 years; 60.0% male) at primary care clinics who had at least 1 risk factor for either CVD or type 2 diabetes, defined in the inclusion criteria as follows: (1) age 18 to 65 years; (2) presence of at least one of the following risk factors: body mass index ≥ 25 kg/m 2 , fasting blood glucose > 100 and ≤ 125 mg/dL, HbA1c > 5.7% ≤ 6.4%, systolic blood pressure ≥ 130 mmHg, total cholesterol ≥ 200 mg/dL, triglyceride ≥ 150 mg/dL, and low-density lipoprotein ≥ 129 mg/dL; (3) regularly take at least one medication for these risk factors; (4) have an active email address and internet access; (5) able to speak, write, and understand English; and (6) able and willing to give informed consent. ...
... 2.9 ± .67 PAM-10 I have been able to maintain lifestyle changes, like eating right or exercising (1)(2)(3)(4) 2.9 ± .69 PAM-11 I know how to prevent problems with my health (1)(2)(3)(4) 2.9 ± .58 ...
Article
Full-text available
Background Network analysis provides a new method for conceptualizing interconnections among psychological and behavioral constructs. Objective We used network analysis to investigate the complex associations between depressive symptoms and patient activation dimensions among patients at elevated risk of cardiovascular disease. Methods This secondary analysis included 200 patients seen in primary care clinics. Depressive symptoms were assessed using the 21-item Beck Depression Inventory. Patient activation was measured using the 13-item Patient Activation Measure. Glasso networks were constructed to identify symptoms/traits that bridge depressive symptoms and patient activation and those that are central within the network. Results “Self-dislike” and “confidence to maintain lifestyle changes during times of stress” were identified as important bridge pathways. In addition, depressive symptoms such as “punishment feelings,” “loss of satisfaction,” “self-dislike,” and “loss of interest in people” were central in the depressive symptom–patient activation network, meaning that they were most strongly connected to all other symptoms. Conclusions Bridge pathways identified in the network may be reasonable targets for clinical intervention aimed at disrupting the association between depressive symptoms and patient activation. Further research is warranted to assess whether targeting interventions to these central symptoms may help resolve other symptoms within the network.
... The benefits of pre-operative interventions, such as stopping alcohol and smoking habits before surgery, are associated with improved post-operative outcomes (Egholm et al., 2018;Gaskill et al., 2017;Levett et al., 2016). Pre-operative education and counselling can be completed in person, through printed material or new online tools (Hibbard & Greene, 2013). The explanations and goals are provided to improve patient care, to encourage patients to perform exercise, to increase knowledge, to decrease fear and to enhance recovery and early discharge (Hibbard & Greene, 2013;Emanuel, 2013). ...
... Pre-operative education and counselling can be completed in person, through printed material or new online tools (Hibbard & Greene, 2013). The explanations and goals are provided to improve patient care, to encourage patients to perform exercise, to increase knowledge, to decrease fear and to enhance recovery and early discharge (Hibbard & Greene, 2013;Emanuel, 2013). Pre-habilitation improves patients' functional capacity, readiness to surgery both physically and psychologically, and post-operative outcomes such as hospital length of stay (Sawatzky et al., 2014). ...
Article
Full-text available
Aims: The purpose of this research was to identify the needs of older persons waiting for elective open-heart surgery. Design: A qualitative exploratory design methodology, using Focus Groups. Methods: A purposive sampling technique was used. Three interviews were conducted with experienced nurses, individuals waiting for open-heart surgery (≥65years) and individuals having had open-heart surgery (≥65years); enrolling up to 17 participants from October 2019 to January 2020. Qualitative data analysis was conducted using the iteractive model and MaxQDA® software, and EQUATOR COREQ guidelines were followed. Results: Three themes were identified from the analysis of all three Focus Groups: (i) Needing health information; (ii) Needing emotional support; and (iii) Needing access to care.
... Increasing patient engagement has been suggested to improve surgical outcomes and patient satisfaction after orthopedic surgical procedures [1][2][3]. It has been shown that more preoperative patient activation, or a patient's willingness to engage in adaptive health behaviors, is related to better overall pain scores and greater satisfaction after total joint arthroplasty [4]. ...
Article
Full-text available
Background Digital technology has emerged as a useful tool for preoperative and postoperative patient engagement and for remote patient monitoring. Smartphones are equipped with motion-sensing technology, and apps can be designed which use these features to create a simple method for measuring range of motion. The purpose of this study was to determine the accuracy of digital technology in assessing knee range of motion using a smartphone app, compared to traditional goniometric measurements in an office setting. Methods Fifty-three (53) patients in a clinical practice were enrolled between October 2019 and March 2020. Three separate measurements were taken during the patient encounter: (1) the surgeon, (2) the app, and (3) the physical therapist. Intraclass correlations were computed to assess the agreement between (1) the surgeon and app and (2) that between the physical therapist and surgeon. Results When measuring flexion, the correlation between either the surgeon or therapist with the app was good, whereas the comparison between the surgeon and therapist was moderate. All extension measurement comparisons, between the app, surgeon, and therapist, showed moderate correlation. Limits of agreements showed that 80% of the difference between surgeon and app is within 10 degrees for extension and 11 degrees for flexion. Body mass index did not affect the accuracy of the measurements. Conclusion Digital app measurements were comparable to measurements made by either a surgeon or physical therapist with a manual goniometer in the clinical setting and may be beneficial for measuring and monitoring patients’ range of motion remotely.
... 17,18 The health intervention through smart phones, smart devices, therefore, prove to be beneficial, similar to previous studies. 19,20 There are existing reminder systems already set up and in use for several treatment strategies for some diseases, and immunization. The reminder systems notify the patients about their appointments, and the recall system contacts those who have missed their appointments and encourage them to reschedule. ...
Article
Full-text available
BACKGROUND Diabetes, one of the most common non-communicable diseases, poses a serious threat due to its increasing incidence, prevalence, and mortality. The prevalence of diabetes globally was estimated to be 9.3% (463 million people), and one in every two people with diabetes are not aware of their condition. 1 The prevalence of diabetes in India has a wide regional variation and varies from state to state from 4.3% in Bihar to 13.6% in Chandigarh. 2 A study conducted in India revealed that the prevalence of diabetes in India is at 11.8% (12% in males and 11.6% in females), with the highest prevalence observed in the 70+ age group. Deaths due to diabetes rose from 0.98% of all deaths in 1990 to 3.1% of all deaths in India in 2016. Diabetes and hypergly-cemia accounted for about 2.75 crores disability-adjusted life years. 3 The significant growth in the number of cases is more likely due to India's unprecedented rates of urbanization resulting in rapid environmental and lifestyle changes. 4 The average annual direct and indirect cost of diabetes treatment was found to be Rs 8,822 and Rs 3,949, respectively, and ABSTRACT Background: Effective delivery of health education is critical to achieving the goal of controlled diabetes. The objective was to assess the impact of health education among patients with Type 2 Diabetes mellitus.
... These brochures provide detailed information about the medication, allow patients to test their knowledge of the medication and indications for use, reflect on their own experiences with potential side effects, discuss alternative therapies (medication and non-pharmacologic options), and include a vignette of a patient who successfully discontinued the medicine. These decision aids were written at a 6 th grade reading level and were based upon theories of patient activation (e.g., skills and confidence to enable patient engagement), adult learning (e.g., knowledge acquisition is immediately applicable), and cognitive dissonance (i.e., contradictory behaviors and/or beliefs) [25,[35][36][37]. The brochures repeatedly emphasize that patients should not make any medication changes without first consulting with their health care provider. ...
Article
Full-text available
Background Deprescribing, or the intentional discontinuation or dose-reduction of medications, is an approach to reduce harms associated with inappropriate medication use. We sought to determine how direct-to-patient educational materials impacted patient-provider discussion about and deprescribing of potentially inappropriate medications. Methods We conducted a pre-post pilot trial, using an historical control group, at an urban VA medical center. We included patients in one of two cohorts: 1) chronic proton pump inhibitor users (PPI), defined as use of any dose for 90 consecutive days, or 2) patients at hypoglycemia risk, defined by diabetes diagnosis; prescription for insulin or sulfonylurea; hemoglobin A1c < 7%; and age ≥ 65 years, renal insufficiency, or cognitive impairment. The intervention consisted of mailing medication-specific patient-centered EMPOWER (Eliminating Medications Through Patient Ownership of End Results) brochures, adapted to a Veteran patient population, two weeks prior to scheduled primary care appointments. Our primary outcome – deprescribing – was defined as clinical documentation of target medication discontinuation or dose-reduction. Our secondary outcome was documentation of a discussion about the target medication (yes/possible vs. no/absent). Covariates included age, sex, race, specified comorbidities, medications, and utilization. We used chi-square tests to examine the association of receiving brochures with each outcome. Results The 348 subjects (253 intervention, 95 historical control) were primarily age ≥ 65 years, white, and male. Compared to control subjects, intervention subjects were more likely to have deprescribing (36 [14.2%] vs. 4 [4.2%], p = 0.009) and discussions about the target medication (31 [12.3%] vs. 1 [1.1%], p = 0.001). Conclusions Targeted mailings of EMPOWER brochures temporally linked to a scheduled visit in primary care clinics are a low-cost, low-technology method associated with increases in both deprescribing and documentation of patient-provider medication discussions in a Veteran population. Leveraging the potential for patients to initiate deprescribing discussions within clinical encounters is a promising strategy to reduce drug burden and decrease adverse drug effects and harms.
Article
Purpose: To assess the association between vulnerable populations and nursing care needs, using NANDA-I diagnostics, in the population of the Canary Islands, Spain. Methods: Nursing social epidemiology study. Cross Mapping of Medical Records to NANDA-I to Identify Nursing Diagnoses in a Population usinga medical, epidemiological follow-up study of a cohort of 7,190 people. The level of vulnerability of the participants was assigned, among those who were also assigned nursing diagnoses, using the "ICE index" to calculate the expected associations. Findings: The most prevalent nursing diagnosis in our sample was Sedentary lifestyle (60.5%), followed by Ineffective health self-management (33.8%) and Risk-prone health behaviour (28.7%). Significant differences were found by sex, age group and social class, with the nursing diagnoses included in the study being more prevalent among the most socio-economically disadvantaged social class. Conclusions: The cross-mapping method is useful to generate diagnostic information in terms of care needs, using the NANDA-I classification. The expected associations between high social vulnerability and care needs have been verified in a comprehensive and representative sample of the Canarian population (Spain). Implications for nursing practice: From an epidemiological perspective, identifying nursing diagnoses at the population level allows us to find the most prevalent needs in the different community groups and to focus appropriate nursing interventions for their implementation and impact assessment.
Article
Introduction: Increased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end-stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis. Methods: Prospective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in-center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13-item Patient Activation Measure (PAM-13) survey at baseline (month 1 after commencement of dialysis) and follow-up (month 4). The survey yields a score (0-100) that corresponds to four levels (1-4), with higher scores or levels indicating higher activation. Findings: One hundred eighty-two participants (139 center, 43 home) completed both baseline and follow-up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM-13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow-up, respectively; mean intraindividual change: -0.3 ± 17.3. The proportions of patients at levels 1-4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow-up, 50%, 64%, 52%, and 37% of participants at levels 1-4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in-center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11-11.37 and 9.02, 95% CI: 3.03-15.02, at baseline and follow-up, respectively). Discussion: Although aggregated group scores and levels remained stable, intra-individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.
Article
As we navigate to provide the best patient care and outcomes, the patient experience has shown to be a driver that improves quality. Patient experience surveys are the primary means of measuring the perception of the care received. Positive patient experience has been linked to better patient compliance, decreased health care costs, decreased liability, and improved outcomes. Physician wellbeing and improved job satisfaction is a recognized additional benefit. Strategies have been developed to achieve these goals, enhance our practice and improve our work satisfaction and the patient experience.
Article
Background Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context. Methods This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics. Results Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM. Conclusions A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.
Article
Full-text available
Patient activation is a term that describes the skills and confidence that equip patients to become actively engaged in their health care. Health care delivery systems are turning to patient activation as yet another tool to help them and their patients improve outcomes and influence costs. In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What's more, patient activation was a significant predictor of cost even after adjustment for a commonly used "risk score" specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients' ability and willingness to manage their health will be a relevant piece of information integral to health care providers' ability to improve outcomes and lower costs.
Article
Full-text available
Background The American short form Patient Activation Measure (PAM) is a 13-item instrument which assesses patient (or consumer) self-reported knowledge, skills and confidence for self-management of one’s health or chronic condition. In this study the PAM was translated into a Dutch version; psychometric properties of the Dutch version were established and the instrument was validated in a panel of chronically ill patients. Methods The translation was done according to WHO guidelines. The PAM 13-Dutch was sent to 4178 members of the Dutch National Panel of people with Chronic illness or Disability (NPCD) in April 2010 (study A) and again to a sub sample of this group (N = 973) in June 2010 (study B). Internal consistency, test-retest reliability and cross-validation with the SBSQ-D (a measure for Health literacy) were computed. The Dutch results were compared to similar Danish and American data. Results The psychometric properties of the PAM 13-Dutch were generally good. The level of internal consistency is good (α = 0.88) and item-rest correlations are moderate to strong. The Dutch mean PAM score (61.3) is comparable to the American (61.9) and lower than the Danish (64.2). The test-retest reliability was moderate. The association with Health literacy was weak to moderate. Conclusions The PAM-13 Dutch is a reliable instrument to measure patient activation. More research is needed into the validity of the Patient Activation Measure, especially with respect to a more comprehensive measure of Health literacy.
Article
Full-text available
With almost one-half of Americans projected to have at least one chronic condition before 2020, a vital role of the health care system is to develop informed, engaged individuals who are effective self-managers of their health. Self-management interventions (SMIs) delivered face-to-face or by telephone (traditional SMIs) are associated with improved self-management knowledge, skills, and self-efficacy, which are expressed by the composite construct of patient activation, a predictor of health outcomes. Web-based interventions to support self-management across the spectrum of chronic diseases have the potential to reach a broader population of patients for extended periods than do traditional SMIs. However, evidence of the effectiveness of Web-based interventions on patient activation is sparse. High-quality studies featuring controlled comparisons of patients with different chronic conditions are needed to explore the interaction of Web-based interventions and patient activation. To explore the effect of a Web-based intervention on the patient activation levels of patients with chronic health conditions, measured as attitudes toward knowledge, skills, and confidence in self-managing health. For this 12-week study, prospective participants were selected from the patient panel of a regional health care system in the United States. The 201 eligible participants were randomly assigned to two groups. Intervention group participants had access to MyHealth Online, a patient portal featuring interactive health applications accessible via the Internet. Control participants had access to a health education website featuring various topics. Patient activation was assessed pre- and posttest using the 13-item patient activation measure. Parametric statistical models (t test, analysis of variance, analysis of covariance) were applied to draw inferences. The Web-based intervention demonstrated a positive and significant effect on the patient activation levels of participants in the intervention group. A significant difference in posttest patient activation scores was found between the two groups (F(1,123) = 4.438, P = .04, r = .196). Patients starting at the most advanced development of patient activation (stage 4) in the intervention group did not demonstrate significant change compared with participants beginning at earlier stages. To our knowledge, this is the first study to measure change in patient activation when a Web-based intervention is used by patients living with different chronic conditions. Results suggest that Web-based interventions increase patient activation and have the potential to enhance the self-management capabilities of the growing population of chronically ill people. Activated patients are more likely to adhere to recommended health care practices, which in turn leads to improved health outcomes. Designing Web-based interventions to target a specific stage of patient activation may optimize their effectiveness. For Web-based interventions to reach their potential as a key component of chronic disease management, evidence is needed that this technology produces benefits for a sustained period among a diverse population.
Article
BACKGROUND: Patient education is a mandatory activity for Norwegian hospitals, but its effects have not been possible to assess properly due to lack of suitable instruments in Norwegian. This article describes the work undertaken to find a suitable questionnaire, translate it to Norwegian and validate it. MATERIAL AND METHODS: The heads of centres for patient education in the hospitals in Central Norway were presented with 15 different questionnaires measuring various areas - for example quality of life and coping. They were then asked to pick out the/those instruments which in their opinion best captured the aim of patient education. The unanimously chosen questionnaire was translated from English to Norwegian and back and was then validated in two samples of patients. RESULTS: The American "Patient Activation Measure (PAM)" was chosen because it focused on the patients' own efforts, was viewed as respectful and patient-oriented and emphasised self- management skills, knowledge and ability to choose. The correlation between PAM score and a question about ability to take care of own health was good (r = 0.477, p = 0.018) and the test-retest showed good reliability. INTERPRETATION: The Norwegian version of PAM is suitable as a measure of knowledge, skills, and ability to cope with own health and use of health services. The questionnaire is suitable for evaluation of interventions aimed at activating patients' ability to take care of their own health.
Article
PURPOSE:Although a number of risk factors and severity scores exist for asthma outcomes, few measures include the ability to self manage disease, or “patient activation.” The Patient Activation Measure (PAM-13),¹ measures the degree of patient responsibility, confidence, knowledge and skill in self management of disease. It is not clear whether the PAM-13 correlates with asthma outcomes.To assess whether the PAM-13 and perceived cost-related access to medications affect asthma outcomes. METHODS:Physicians in the Internal Medicine and Pulmonary clinics were educated regarding asthma severity classification per the NHLBI 1997 Asthma Guidelines.² Surveys of patients aged 18–60 with a history of asthma were then collected from October 2006-January 2008. Variables included demographics, asthma education, severity and control scores, and the PAM-13. Pearson’s correlation coefficient and multivariate regression analyses were performed to assess whether these variables affected asthma outcomes. RESULTS:Sixty eight surveys were collected. Mean patient age was 43; 76% were female. Although most asthma was classified as mild-moderate persistent, only 39% patients were well-controlled. The mean PAM-13 score was 64 (0–100) and correlated with asthma control (r = -0.27, CI - 0.5 to -.01, p<0.015), but not with hospitalizations or ED visits. Costs prohibiting access to medications was a strong risk factor for ED visits (r = 0.88, CI 0.58–1.2, p<0.001), hospitalizations (r= 0.51, CI 0.34–0.69, p<0.01), and missed days of work (r= 36.9, CI 29.0- 45.3, p<0.01). Previous asthma education did not predict outcomes. CONCLUSION:The PAM-13 may correlate with asthma control and has the potential to identify interventions that improve asthma management. A prospective study with a larger sample size is required to assess the effect on ED visits and hospitalizations. Perceived prohibitive medication cost correlates with poor outcomes. CLINICAL IMPLICATIONS:The PAM-13 may be a useful tool to target individualized interventions in asthma care, providing a patient-centered approach to asthma education. Improving access to medications would improve asthma outcomes. 1.Hibbard, JH, et. al. 2005. Health Serv Res 40: 1918–30. 2. Expert Panel Report 2. NHLBIJuly 2007. NIH Publication #97–4051. DISCLOSURE:Silpa Kilaru, No Financial Disclosure Information; No Product/Research Disclosure Information
Article
To identify factors associated with perception of care coordination problems among chronically ill patients. Patient-level data were obtained from a random-digit dial telephone survey of adults with chronic conditions. The survey measured respondents' self-report of care coordination problems and level of patient activation, using the Patient Activation Measure (PAM-13). Logistic regression was used to assess association between respondents' self-report of care coordination problems and a set of patient characteristics. Respondents in the highest activation stage had roughly 30-40 percent lower odds of reporting care coordination problems compared to those in the lowest stage (p < .01). Respondents with multiple chronic conditions were significantly more likely to report coordination problems than those with hypertension only. Respondents' race/ethnicity, employment, insurance status, income, and length of illness were not significantly associated with self-reported care coordination problems. We conclude that patient activation and complexity of chronic illness are strongly associated with patients' self-report of care coordination problems. Developing targeted strategies to improve care coordination around these patient characteristics may be an effective way to address the issue.
Article
Background: Quality in health care can be seen as having three principal dimensions: service, technical and customer quality. This study aimed to measure Customer Quality in relation to self-management of Type 2 diabetes. Methods: A cross-sectional survey of 577 Type 2 diabetes people was carried out in Australia. The 13-item Patient Activation Measure was used to evaluate Customer Quality based on self-reported knowledge, skills and confidence in four stages of self-management. All statistical analyses were conducted using SPSS 13.0. Results: All participants achieved scores at the level of stage 1, but ten percent did not achieve score levels consistent with stage 2 and a further 16% did not reach the actual action stage. Seventy-four percent reported capacity for taking action for self-management and 38% reported the highest Customer Quality score and ability to change the action by changing health and environment. Participants with a higher education attainment, better diabetes control status and those who maintain continuity of care reported a higher Customer Quality score, reflecting higher capacity for self-management. Conclusion: Specific capacity building programs for health care providers and people with Type 2 diabetes are needed to increase their knowledge and skills; and improve their confidence to self-management, to achieve improved quality of delivered care and better health outcomes.
Article
Diabet. Med. 29, e382–e389 (2012) Aims To investigate the association between glycaemic control and patient socio-demographics, activation level, diabetes-related distress, assessment of care, knowledge of target HbA1c, and self-management behaviours, and to determine to what extent these factors explain the variance in HbA1c in a large Danish population of patients with Type 2 diabetes. Methods Cross-sectional survey and record review of 2045 patients from a specialist diabetes clinic. Validated scales measured patient activation, self-management behaviours, diabetes-related emotional distress, and perceived care. The electronic patient record provided information about HbA1c, medication, body mass index, and duration of diabetes. Data were analysed using multiple linear regression models with stepwise addition of covariates. Results The response rate was 54% (n = 1081). Good glycaemic control was significantly associated with older age, higher education, higher patient activation, lower diabetes-related emotional distress, better diet and exercise behaviours, lower body mass index, shorter duration of disease and knowledge of HbA1c targets (P < 0.05 for all). Patient socio-demographics, behaviour; perceptions of care and diabetes distress accounted for 14% of the total variance in HbA1c levels (P = 0.0134), but the variance explained was higher for respondents treated with medications other than insulin. Conclusions Our study emphasizes the complex relationships between patient activation, distress and behaviour, specific treatment modalities and glycaemic control. Knowledge of treatment goals, achieving patient activation in coping with diabetes, and lowering disease-related emotional stress are important patient education goals. However, the large unexplained component of HbA1c variance highlights the need for more research to understand the mechanisms of glycaemic control.
Article
To test whether changes in the patient activation measure (PAM) are related to changes in health status and healthy behaviors. Data for this secondary analysis were taken from a group-randomized, controlled trial comparing a traditional health promotion program for employees with an activated consumer program and a control program. The study population included 320 employees (with and without chronic disease) from two U.S. companies: a large, integrated health care system and a national airline. Survey and biometric data were collected in Spring 2005 (baseline) and Spring 2007 (follow-up). Change in PAM was associated with changes in health behaviors at every level (1-4), especially at level 4. Changes related to overall risk score and many of its components: aerobic exercise, safety, cancer risk, stress and mental health. Other changes included frequency of eating breakfast and the likelihood of knowing about health plans and how they compare. Level 4 of patient activation is not an end-point. People are capable of continuing to make significant change within this level. Interventions should be designed to encourage movement from lower to higher levels of activation. Even people at the most activated level improve health behaviors.
Article
Background/objective: Few studies have examined whether chronic heart failure (HF) outcomes can be improved by increasing patient engagement (known as activation) in care and capabilities for self-care management. The objective was to determine the efficacy of a patient activation intervention compared with usual care on activation, self-care management, hospitalizations, and emergency department visits in patients with HF. Methods: This study used a randomized, 2-group, repeated-measures design. After consent was given, 84 participants were stratified by activation level and randomly assigned to usual care (n = 41) or usual care plus the intervention (n = 43). The primary outcomes and measures were patient activation using the Patient Activation Measure (PAM), self-management using the Self-Care of Heart Failure Index (SCHFI) and the Medical Outcomes Study (MOS) Specific Adherence Scale, and hospitalizations and emergency department visits. The intervention was a 6-month program to increase activation and improve HF self-management behaviors, such as adhering to medications and implementing health behavior goals. Results: Participants were primarily male (99%), were white (77%), and had New York Heart Association III stage (52%). The mean (SD) age was 66 (11) years, and 71% reported 3 or more comorbidities. The intervention group compared with the usual care group showed a significant increase in activation/PAM scores from baseline to 6 months. No significant group-by-time interactions were found for the SCHFI scales. Although the baseline MOS Specific Adherence Scale mean was lower in the intervention group, results showed a significant group-by-time effect with the intervention group improving more over time. Participants in the intervention group had fewer hospitalizations compared with the usual care group when the baseline activation/PAM level was low or high. Conclusion: This study supports the importance of targeted interventions to improve patient activation or engagement in HF care. Further work is needed related to HF self-management measurement and outcomes.