Sarah Kowitt, MPH

Patient engagement is a precursor to successful prevention and chronic disease self-management programs

With the understanding that patients need to be involved in the management of their health, patient engagement and patient activation have been recognized as crucial components of prevention and chronic disease self-management programs. Many new practices, such as the Patient-Centered Medical Home (PCMH) model, were developed with the patient’s perspective in mind and are encouraging greater patient participation in care. In support of these patient-focused models, research is demonstrating that increased patient engagement leads to reduced health care costs, better patient outcomes, and higher quality of care, particularly for those with chronic disease¹.

For instance, one study found that patient engagement predicted diabetic patients at risk for poorer health outcomes, such as A1C levels, cholesterol levels, and all-cause discharges among patients². Another study found that more engaged patients were more likely to use preventive care and less likely to use the emergency department or to be hospitalized, compared to less engaged patients³.

Making sense of the many ways to define and operationalize patient engagement

Interestingly, there is a lack of consensus about what patient engagement means.

To better understand how patient engagement has been defined, Barello et al. conducted a systematic review of the term in academic literature from 2002-2012⁴. They found an increasing number of publications investigating patient engagement in this time period⁴. In 2002, 74 studies were published that involved patient engagement; in 2011, there were 954⁴. However, the term was operationalized differently depending on the context and setting.

While the overall goal for patient engagement may be involvement in health programs and decision-making, in some papers, engagement was measured by the performance of a set of healthy behaviors, such as medication adherence⁴. Other authors described engagement as a cognitive factor, such as knowledge about one’s health condition, or as a relational factor, such as quality of patient-provider interactions^4,6. Finally, in some papers, engagement was an organizational feature of health care service delivery, encompassing overall quality of care and cost of health care services. The authors suggest that because patient engagement may be observed from multiple perspectives, it makes sense that it can be defined in individual, relational, and organizational dimensions⁴.

The complexity of the issue makes it difficult to compare patient engagement across settings and populations⁴. Some researchers have relied on the Patient Activation Measure (PAM) to operationalize engagement¹. Developed by Hibbard and colleagues, this 13-item scale defines engagement as patients’ knowledge, skills, and confidence to take on a greater role in their health care services¹. Higher scores indicate a higher perceived ability to manage illness and health behaviors¹. However, measuring engagement this way makes it seem quite similar to concepts such as self-efficacy or empowerment¹. Other scales conceptualize patient engagement as “interaction, communication, and involvement” with health care providers⁶; but how does this differ from patient-provider communication? Moreover, even when engagement is clearly defined, the directionality of how engagement relates to other variables of interest, such as social support, improved health outcomes, or health literacy, is often still unclear.

Peer support: A strategy for increasing patient engagement

Despite the absence of a universal definition for patient engagement, emerging research suggests that peer support is a promising strategy for increasing patient involvement in the health care system. In 2010, Druss et al. conducted a study to assess a peer-led chronic disease management intervention for persons with serious mental illness (SMI)⁵. Those in the intervention group had statistically significant patient engagement scores (using the PAM measure) and visits to a primary care provider⁵. In fact, while patient engagement scores declined by 5.7% in the usual care group, they increased by 7.7% in the intervention group⁵. Similarly, while there was a 17.1% decline in visits to a primary care provider among those receiving usual care, those receiving the peer support intervention showed an 8.3% increase in visits⁵. Moreover, the intervention appeared to be particularly beneficial among medically and socially disadvantaged subgroups⁵.

Conclusion

What should we take away from these studies? First, there is little doubt that patient engagement increases the quality of health care services and improves patient outcomes, particularly for prevention and chronic disease management. Second, peer support can improve patient engagement from any perspective, whether it’s individual, relational, or organizational, by increasing patient involvement. A unifying concept of patient engagement is needed to lay the groundwork for future studies on the relationship between peer support, patient engagement, health outcomes, and healthcare utilization, quality, and costs.

References

1. Hibbard, J. H., Greene, J., & Overton, V. (2013). Patients with lower activation associated with higher costs; delivery systems should know their Patients’‘Scores’. Health Affairs, 32(2), 216-222.
2. Remmers, C., Hibbard, J., Mosen, D. M., Wagenfield, M., Hoye, R. E., & Jones, C. (2009). Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?. The Journal of ambulatory care management, 32(4), 320-327.
3. Greene, J., & Hibbard, J. H. (2012). Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. Journal of general internal medicine, 27, 520-526.
4. Barello, S., Graffigna, G., & Vegni, E. (2012). Patient engagement as an emerging challenge for healthcare services: mapping the literature. Nursing research and practice, 2012.
5. Druss, B. G., Zhao, L., von Esenwein, S. A., Bona, J. R., Fricks, L., Jenkins-Tucker, S., … & Lorig, K. (2010). The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophrenia research, 118(1), 264-270.
6. Chen, W. T., Wantland, D., Reid, P., Corless, I. B., Eller, L. S., Iipinge, S., … & Webel, A. R. Engagement with Health Care Providers Affects Self-Efficacy, Self-Esteem, Medication Adherence and Quality of Life in People Living with HIV. Journal of AIDS & Clinical Research.