The role of patient activation in improving blood pressure outcomes in Black patients receiving home care

Association between patient activation level and functional outcomes in older adults with hip fractures

BACKGROUND

Hip fractures can significantly impact older adults' mobility and function. Effective rehabilitation is crucial to help them regain independence and quality of life. However, little is known about the association between patient activation and hip fracture rehabilitation. This study aims to assess the association between the PAM-13 scores and the level of physical function, mobility, and activities of daily living in older adults following a hip fracture rehabilitation program.

METHOD

An exploratory outcome study from a cluster-randomized stepped-wedge clinical controlled trial. Two hundred thirty-nine patients were classified into four Patient Activation Measure-Levels (PAM-13) according to their PAM-13 scores, reflecting their confidence and preparedness to manage their health. Level 1 represents the lowest level of confidence. The patient's mobility, function, and daily activities were evaluated at discharge and after 12 and 24 weeks.

RESULTS

The cohort had a median age of 78; 67% were female, and 50% lived alone. There were no significant differences in demographics between the PAM-Levels. PAM-Level 1 patients had longer hospital stays and lower mobility scores than PAM-Level 4 patients. However, all patients improved over time, and higher initial PAM levels resulted in better outcomes. PAM-Level 1 patients improved in Time Up and Go score from a median score of 54 seconds to 14 seconds at 24 weeks, while PAM-Level 4 patients improved from 26 to 9 seconds.

CONCLUSION

Our study found an association between PAM levels and functional outcomes in hip fracture rehabilitation. Patients with higher activation levels had better mobility and functional outcomes.

Factors associated with patient activation among patients with diabetes on hemodialysis: a multicenter cross-sectional study from a developing country

BACKGROUND

Diabetes mellitus (DM) is a major public health concern with considerable morbidity and mortality. DM affects patients' quality of life and can lead to multiple complications, including chronic kidney disease (CKD) and the need for dialysis. Higher patient activation can improve health outcomes in hemodialysis patients with DM. This study aimed to explore the factors associated with higher patient activation and health-related quality of life (HRQoL) among hemodialysis patients with DM.

METHODS

This was a cross-sectional, questionnaire-based study conducted on hemodialysis patients with DM in Palestine. The quota sampling method was utilized to draw samples from six dialysis centers. The questionnaire consists of three sections. The first section includes demographic, socioeconomic and clinical questions. The second section utilizes the patient activation measure-13 (PAM-13) to measure patient activation, while the third section assesses HRQoL using the EQ-5D-5 L tool and the visual analog scale (VAS). Mann‒Whitney and Kruskal‒Wallis tests were employed to examine the relationships between variables at the bivariate level, and multiple regression analysis was employed at the multivariate level.

RESULTS

Of the 200 patients who were approached, 158 were included. The median PAM, EQ-5D index, and VAS score were low at 51.0, 0.58, and 60.0, respectively. A higher PAM score was independently associated with a higher household income level and taking medications independently. A higher EQ-5D index was associated with taking more than eight medications, taking medications independently, living with fewer than three comorbid conditions, and having a higher PAM. A higher VAS score was associated with being married, and receiving less than 3.5 hours of hemodialysis.

CONCLUSIONS

A higher patient activation level was associated with a higher income level and independence in taking medications. Interventions designed to improve patient activation, such as medication management programs, should address these factors among the target population. Longitudinal studies are needed to assess the time effect and direction of causation between health status and patient activation.

Effectiveness of a two-component nutritional strategy for blood pressure control in individuals with hypertension users of a public health system: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effectiveness of a nutritional strategy based on two components and adapted for the public health system on blood pressure, cardiometabolic features, self-care, qualify of life and diet quality in individuals with hypertension.

METHODS

NUPRESS was an open-label, parallel-group, superiority randomized controlled clinical trial in which participants at least 21 years with hypertension and poorly controlled blood pressure were randomly assigned (1 : 1 allocation ratio) to either an individualized dietary prescription according to nutritional guidelines (control group, n  = 205); or a two-component nutrition strategy, including a goal-directed nutritional counseling and mindfulness techniques (NUPRESS [intervention] group, n  = 205). Primary outcomes were SBP (mmHg) after 24 weeks of follow up and blood pressure control, defined as either having SBP more than 140 mmHg at baseline and achieving 140 mmHg or less after follow-up or having SBP 140 mmHg or less at baseline and reducing the frequency of antihypertensive drugs in use after follow-up.

RESULTS

In total, 410 participants were randomized and submitted to an intention-to-treat analysis regarding primary outcomes. Both groups decreased blood pressure, but after adjusting for baseline values, there was no significant difference between them on SBP [intervention-control difference: -0.03 (-3.01; 2.94); P  = 0.98] nor blood pressure control [odds ratio 1.27 (0.82; 1.97); P  = 0.28]. No differences between groups were also detected regarding secondary and tertiary outcomes.

CONCLUSION

There was no difference between a two-component nutritional strategy and an established dietary intervention on blood pressure in participants with hypertension.

Patient activation in adults with visual impairment: a study of related factors

This study aims to analyze variables related to patient activation in 78 individuals with visual impairment. The Patient Activation Measure (PAM) scores of participants showed no differences between males and females. It was found that the individuals living in urban areas, and participants with higher income and education levels had higher PAM scores. Still, the difference between the groups was statistically insignificant (p > 0.05). The PAM scores of the visually impaired individuals reflect taking action level of activation (66.51 ± 18.14-PAM level 3). There was a moderately significant relationship between PAM scores and visually impaired individuals' self-management, self-efficacy, healthy life awareness, social relations, and environment (p < 0.001). We found that the variables included in the regression model (marital status, self-management, self-efficacy, healthy life awareness, social relations, and environment) explained 72.2% of the PAM score. Individuals with visual impairment can be given training on self-management, self-efficacy, healthy life awareness, and quality of life associated with social relations and environment to develop positive health behaviors.

A codesigned integrated kidney and diabetes model of care improves patient activation among patients from culturally and linguistically diverse backgrounds

BACKGROUND

Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD.

METHODS

This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non-CALD backgrounds spoke English only as their primary language. Paired t-tests compared baseline and 12-month patient activation scores by CALD status.

RESULTS

Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non-CALD backgrounds (58.5 ± 14.6) at baseline. Within-group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow-up (52.1 ± 17.6-59.4 ± 14.7), and no significant change was observed for those from non-CALD backgrounds (58.5 ± 14.6-58.8 ± 13.6).

CONCLUSIONS

Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi-structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

Patient activation, adherence to hypertension treatment plans and blood pressure control in Saudi Arabia: a cross-sectional study

OBJECTIVES

To explore the relationship between patient activation, adherence to hypertension treatment plans, blood pressure control and other important demographic factors.

DESIGN

A cross-sectional study.

SETTING

Primary healthcare centres in Riyadh province, Saudi Arabia.

PARTICIPANTS

A total of 114 adults with hypertension, including 68 men and 46 women.

OUTCOME MEASUREMENTS

Blood pressure control is achieved if (a) patients under 80 years of age with treated hypertension have blood pressure under 140/90 mm Hg or (b) patients aged 80 years or over with treated hypertension have blood pressure under 150/90 mm Hg. Secondary outcomes included patient activation, adherence to hypertension treatment plans and demographic factors (age, gender, education, income and comorbidity). Data were analysed using Pearson's correlation and multiple regression models.

RESULTS

57% (n=66) of participants did not achieve the ideal blood pressure target. Perfect adherence to hypertension treatment plans was significantly associated with lower systolic (r=-0.38, p<0.01) and diastolic blood pressure (r=-0.50, p<0.01). Age was significantly correlated with patient activation (r=-0.20, p<0.05) and diastolic blood pressure (r=-0.33, p<0.01). There was no statistically significant association between Patient Activation Measure, systolic blood pressure and diastolic blood pressure. In the hierarchical regression analysis, adherence to hypertension treatment plans was found to be a significant predictor and explained 15% of the variance in systolic blood pressure (β=-0.36, p<0.001) and 26% of the variance in diastolic blood pressure (β=-0.51, p<0.001).

CONCLUSION

The individual and family self-management theory can serve as an effective theory for understanding the key factors in achieving ideal blood pressure target. The majority of patients with hypertension reported lower levels of activation and poor blood pressure control. Inadequate adherence to treatment plans was related to poor blood pressure control. This work is pivotal in devising self-management interventions to assist patients in the management of hypertension disease, especially in Saudi Arabia.

Changes in patient activation in people starting dialysis: A prospective longitudinal, observational study

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.

Effectiveness of health literacy- and patient activation-targeted interventions on chronic disease self-management outcomes in outpatient settings: a systematic review

Chronic diseases are the leading causes of morbidity and mortality and account for approximately 60% of all deaths worldwide. Self-management is a key strategy to manage chronic diseases, and there is emerging evidence recommending targeting both health literacy (HL) and patient activation (PA) to improve chronic disease self-management outcomes. The aim of this systematic review is to summarise the current evidence on the impact of HL- and PA-led interventions on self-management outcomes using randomised control trials (RCTs). Six well known databases (MEDLINE, Web of Science, Scopus, Science Citation Index, EMBASE and Academic Search Complete) were searched for RCTs of chronic disease self-management interventions targeting both HL and PA and published between 2004 and June 2021. The search terms included chronic disease, self-management, patient activation/engagement and health literacy/education. Ten studies were eligible for inclusion. We found that patients with low HL and PA levels are most likely to benefit from the interventions. The moderate improvements in PA and HL in the reviewed studies were translated into some improvements in physical activity and mental health outcomes but failed to improve patients' quality of life and healthcare utilisation outcomes. Patients with low HL were more likely to have higher PA levels after the interventions. This review suggests that both HL and PA are essential pillars for improving chronic disease self-management outcomes. However, more studies are needed to explore the long-term impacts of a combination of HL and PA on chronic disease self-management outcomes.

Impact of Behavioral Interventions on Patient Activation in Adults with Hypertension: A Systematic Review and Meta-Analysis

Introduction: Behavioral interventions assist patients in maintaining optimal self-management of their health, especially in those at risk of certain conditions. Little is known about the effects of self-management interventions on patient activation in adults with hypertension. Therefore, this systematic review and meta-analysis aimed to evaluate how self-management strategies affect changes in activation levels in adults with hypertension. Methods: We searched online databases: PubMed, CINAHL, and Cochrane Central Register of Controlled Trials for studies published between January 2004 and May 2021. We included randomized controlled trials that assessed the effects of self-management interventions on patient activation in adults with hypertension and reported patient activation using the patient activation measure (PAM). Results: 4 Four studies (N = 1415 participants) met the inclusion criteria. In adults with hypertension, self-management interventions improved patient activation with moderate strength of evidence. A community-based self-management program, motivational interviewing strategies, and home-based patient-activated care were associated with better PAM scores than usual care. Conclusion: Our findings reinforce the need for healthcare providers to incorporate these interventions into primary care to support the adoption of recommended hypertension self-management behaviors. Future studies must focus on tailoring support to the patient’s level of activation in hypertension self-management.

Intervention Based on Integration of Health Literacy and Health Outcomes in Hypertension “A Systematic Review”

BACKGROUND: Hypertensive patients with low health literacy rarely visit health services, therefore, they have more chances of being hospitalized in comparison with those having a more adequate health literacy. AIM: This article aims to identify intervention based on integration of health literacy and its outcome in hypertensive patients. METHODS: Articles were searched using four bibliographic databases, namely, ProQuest, Science Direct, PubMed, and Google Scholar. PRISMA 2015 is used as a guideline for determining which articles are selected, one of the criteria being published on 2011–2021. RESULTS: A total of 25,264 articles were obtained from the four databases. Seven articles were selected after the extraction and incorporation of the inclusion criteria. The health outcomes of hypertension sufferers after receiving intervention based on integration of health literacy were divided into three groups; medical health outcomes, health literacy skills, and hypertension self-management behavioral. CONCLUSION: An intervention integrated with health literacy and considering the hypertensive patient health literacy in its own will increase the health outcomes of hypertensive patient.

Patient-reported barriers and outcomes associated with poor glycaemic and blood pressure control in co-morbid diabetes and chronic kidney disease

AIMS

In patients with comorbid diabetes and chronic kidney disease, the extent to which patient-reported barriers to health-care and patient reported outcomes influence the quality of health care is not well established. This study explored the association between patient-reported barriers to health-care, patient activation, quality of life and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets.

METHODS

This cross-sectional study recruited adults with diabetes and CKD (eGFR 20 to <60 ml/min/1.73m²) across four hospitals. We combined clinical data with results from a questionnaire comprising measures of patient-identified barriers to care, the Patient Activation Measure (PAM), 12-Item Short Form Survey (SF-12), and the Summary of Diabetes Self-Care Activity (SDSCA).

RESULTS

199 patients, mean age 68.7 (SD 9.6), 70.4% male and 90.0% with type 2 diabetes were studied. Poor glycaemic control was associated with increased odds of patient reported "poor family support" (OR 4.90; 95% CI 1.80 to 13.32, p < 0.002). Poor BP control was associated with increased odds of patient reported, "not having a good primary care physician" (OR 6.01; 2.42 to 14.95, p < 0.001). The number of barriers was not associated with increased odds of poor control (all p > 0.05).

CONCLUSIONS

Specific patient-reported barriers, lack of patient perceived family and primary care physician support, are associated with increased odds of poor glycaemic and blood pressure control respectively. Interventions addressing these barriers may improve treatment target attainment.

Effects of a Community Population Health Initiative on Blood Pressure Control in Latinos

Background

Hypertension remains one of the most important, modifiable cardiovascular risk factors. Yet, the largest minority ethnic group (Hispanics/Latinos) often have different health outcomes and behavior, making hypertension management more difficult. We explored the effects of an American Heart Association–sponsored population health intervention aimed at modifying behavior of Latinos living in Texas.

Methods and Results

We enrolled 8071 patients, and 5714 (65.7%) completed the 90‐day program (58.5 years ±11.7; 59% female) from July 2016 to June 2018. Navigators identified patients with risk factors; initial and final blood pressure (BP) readings were performed in the physician's office; and interim home measurements were recorded telephonically. The intervention incorporated home BP monitoring, fitness and nutritional counseling, and regular follow‐up. Primary outcomes were change in systolic BP and health‐related quality of life. Using a univariate paired‐samples pre–post design, we found an average 5.5% (7.6‐mm Hg) improvement in systolic BP (139.1 versus 131.5, t=10.32, P<0.001). Quality of life measured by the European quality of life 5‐dimension visual analog scale improved from 0.79 to 0.82 (t=31.03, P<0.001). After multivariate regression analyses, improvements in quality of life and overall body mass index were significantly associated with reductions in systolic BP.

Conclusions

A noninvasive, population health initiative that encourages routine engagement in patients’ own BP control was associated with improvements in systolic BP and quality of life for this largely Latino community.

Patient and treatment characteristics associated with patient activation in patients undergoing hemodialysis: a cross-sectional study

Background

Patient activation is associated with better outcomes and lower costs. Although the concept is widely investigated, little attention was given to patient activation and its predictors in patients undergoing hemodialysis. Hence, we aimed to investigate the level of patient activation and aimed to determine patient- and treatment-related predictors of activation in patients undergoing hemodialysis.

Methods

This cross-sectional observational study recruited patients undergoing hemodialysis in three Flemish hospitals. Participants were questioned about patient characteristics (i.e., age, sex, education, employment, children, social support, leisure-time, living condition, and care at home), treatment- and health-related characteristics (i.e., hospital, time since first dialysis, transplantation, self-reported health (EQ-VAS) and depressive symptoms (PHQ-2)), and patient activation (PAM-13). Univariate and multiple linear regression analyses with dummy variables were conducted to investigate the associations between the independent variables and patient activation.

Results

The average patient activation-score was 51. Of 192 patients, 44% patients did not believe they had an important role regarding their health. Multiple linear regression showed that older patients, who reported being in bad health, treated in a particular hospital, without leisure-time activities, and living in a residential care home, had lower patient activation. These variables explained 31% of the variance in patient activation. Based on literature, we found that activation of patients on hemodialysis is low, compared to that of other chronic patient groups.

Conclusion

It could be useful to implement patient activation monitoring, since the level of activation is low in patients undergoing hemodialysis. Older patients, who reported being in bad health, treated in a particular hospital, without leisure-time activities, living in a residential care home, are at higher risk for lower activation.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0917-2) contains supplementary material, which is available to authorized users.

What are the contents of patient engagement interventions for older adults? A systematic review of randomized controlled trials

OBJECTIVE

To describe the contents of interventions reported in RCTs focusing on patient engagement of older adults.

METHODS

A systematic literature review based on a search for "patient engagement/activation/empowerment/involvement/participation". Interventions were classified according to: (i) specific components (micro level), (ii) single/multiple dimensions (educational, behavioral, affective) (meso level), and (iii) the studies' main educational, behavioral or affective dimension (macro level).

RESULTS

After screening 2749 articles, 35 were included. 20 unique components were identified, mostly behavioral or educational (45.5% each) (e.g., goal setting or written informational materials). Most interventions with a single-focus were classified as educational (31%), one was solely affective (3%). Half of the interventions covered more than one dimension, with four (11%) combining all three dimensions. Studies mainly focusing on the affective dimension included older participants (72 vs. 67 years), had a higher proportion of females (71% vs. 44%), and included other dimensions more frequently (67% vs. 31%) than did studies with a main focus on the educational dimension.

CONCLUSION

The contents of the interventions that focused on patient engagement of older adults tend to focus more on behavioral and educational dimensions than the affective dimension.

PRACTICE IMPLICATIONS

The possibility of adding the affective dimension into behavioral and/or educational interventions should be explored.

Telephone-Based Intervention to Improve Rehabilitation Engagement After Spinal Stenosis Surgery: A Prospective Lagged Controlled Trial

BACKGROUND

Spine surgery outcomes are variable. Patients who participate in and take responsibility for their recovery have improved health outcomes. Interventions to increase patient involvement in their care may improve health outcomes after a surgical procedure. We conducted a prospective interventional trial to compare the effectiveness of health behavior change counseling with usual care to improve health outcomes after lumbar spine surgical procedures.

METHODS

In this study, 122 patients with lumbar spinal stenosis undergoing a decompression surgical procedure from December 2009 through August 2012 were enrolled. Participants were assigned, according to enrollment date, to health behavior change counseling or usual care. Health behavior change counseling is a brief, telephone-based intervention intended to increase rehabilitation engagement through motivational interviewing strategies that elicit and strengthen motivation for change. Health behavior change counseling was designed to identify patients with low patient activation, to maximize postoperative rehabilitation engagement, to decrease pain and disability, and to improve functional recovery. Participants were assessed before the surgical procedure and for 3 years after the surgical procedure for pain intensity (Brief Pain Inventory), disability (Oswestry Disability Index), and physical health (12-Item Short-Form Health Survey, version 2). Differences in changes in health outcomes after the surgical procedure were compared between the health behavior change counseling group and the usual care group.

RESULTS

By 12 months, health behavior change counseling participants reported significantly greater reductions in pain intensity (p = 0.008) and disability (p = 0.028) and significantly greater improvement in physical health compared with usual care participants (p = 0.025). These differences were attenuated by 24 and 36 months after the surgical procedure. Early improvements in health outcomes were mediated by improvements in physical therapist-rated engagement and self-reported attendance at physical therapy sessions in the health behavior change counseling group.

CONCLUSIONS

Health behavior change counseling improved health outcomes during the first 12 months after the surgical procedure through changes in rehabilitation engagement. Wider use of health behavior change counseling may lead to improved outcomes not only after lumbar spine surgery but also in other conditions for which rehabilitation is key to recovery.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Spotlight on the Patient Health Engagement model (PHE model): a psychosocial theory to understand people's meaningful engagement in their own health care

The concept of patient engagement in health care is gaining more and more attention not only in the scientific literature, but also as a requirement in the everyday practices of health care organizations. In general terms, the growing body of literature devoted to patient engagement is mainly inspired by the sociological and public health perspectives, which have generated various theories and models trying to explain how people become active agents in their health and care management. However, theories focusing on the psychosocial dimensions intervening in the patient engagement experience are still limited. This paper proposes a psychosocial perspective on patient engagement and discusses the Patient Health Engagement model, which is an evidence-based psychological theory built on extensive qualitative narrative research and literature analysis aimed at explaining patient engagement and its development in the patients' perspective. The model has been applied to orient patient and professional educational interventions and has contributed to the generation of the first scientific measure of the psychological experience of patients' engagement in their own care (Patient Health Engagement scale). According to this theory, patient engagement is a developmental process that involves the recovered patients' ability to have a life projectuality and goal directedness - even if living with a disease. The paper will also discuss the theoretical origins of this model and will conduct a critical comparison of the theory with the Transtheoretical Model of Change developed by Prochaska and the five-stage grief theory by Kubler-Ross.

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.

Factors associated with patient activation in an Australian population with comorbid diabetes and chronic kidney disease: a cross-sectional study

OBJECTIVE

To evaluate the extent of patient activation and factors associated with activation in adults with comorbid diabetes and chronic kidney disease (CKD).

DESIGN

A cross-sectional study.

SETTING

Renal/diabetes clinics of four tertiary hospitals across the two largest states of Australia.

STUDY POPULATION

Adult patients (over 18 years) with comorbid diabetes and CKD (estimated glomerular filtration rate <60 mL/min/1.73 m²).

MAIN OUTCOME MEASURES

Patients completed the Patient Activation Measure, the Kidney Disease Quality of Life and demographic and clinical data survey from January to December 2014. Factors associated with patient activation were examined using χ² or t-tests and linear regression.

RESULTS

Three hundred and five patients with median age of 68 (IQR 14.8) years were studied. They were evenly distributed across socioeconomic groups, stage of kidney disease and duration of diabetes but not gender. Approximately 46% reported low activation. In patients with low activation, the symptom/problem list, burden of kidney disease subscale and mental composite subscale scores were all significantly lower (all p<0.05). On multivariable analysis, factors associated with lower activation for all patients were older age, worse self-reported health in the burden of kidney disease subscale and lower self-care scores. Additionally, in men, worse self-reported health in the mental composite subscale was associated with lower activation and in women, worse self-reported health scores in the symptom problem list and greater renal impairment were associated with lower activation.

CONCLUSION

Findings from this study suggest that levels of activation are low in patients with diabetes and CKD. Older age and worse self-reported health were associated with lower activation. This data may serve as the basis for the development of interventions needed to enhance activation and outcomes for patients with diabetes and CKD.

Impact of electronic personal health record use on engagement and intermediate health outcomes among cardiac patients: a quasi-experimental study

OBJECTIVES

To determine the impact of tethered personal health record (PHR) use on patient engagement and intermediate health outcomes among patients with coronary artery disease (CAD).

METHODS

Adult CAD patients (N = 200) were enrolled in this prospective, quasi-experimental observational study. Each patient received a PHR account and training on its use. PHRs were populated with information from patient electronic medical records, hosted by a Health Information Exchange. Intermediate health outcomes including blood pressure, body mass index, and hemoglobin A1c (HbA1c) were evaluated through electronic medical record review or laboratory tests. Trends in patient activation measure® (PAM) were determined through three surveys conducted at baseline, 6 and 12 months. Frequency of PHR use data was collected and used to classify participants into groups for analysis: Low, Active, and Super users.

RESULTS

There was no statistically significant improvement in patient engagement as measured by PAM scores during the study period. HbA1c levels improved significantly in the Active and Super user groups at 6 months; however, no other health outcome measures improved significantly. Higher PAM scores were associated with lower body mass index and lower HbA1c, but there was no association between changes in PAM scores and changes in health outcomes. Use of the PHR health diary increased significantly following PHR education offered at the 6-month study visit and an elective group refresher course.

CONCLUSIONS

The study findings show that PHR use had minimal impact on intermediate health outcomes and no significant impact on patient engagement among CAD patients.

The Influence of Wireless Self-Monitoring Program on the Relationship Between Patient Activation and Health Behaviors, Medication Adherence, and Blood Pressure Levels in Hypertensive Patients: A Substudy of a Randomized Controlled Trial

Background

Active engagement in the management of hypertension is important in improving self-management behaviors and clinical outcomes. Mobile phone technology using wireless monitoring tools are now widely available to help individuals monitor their blood pressure, but little is known about the conditions under which such technology can effect positive behavior changes or clinical outcomes.

Objective

To study the influence of wireless self-monitoring program and patient activation measures on health behaviors, medication adherence, and blood pressure levels as well as control of blood pressure in hypertensive patients.

Methods

We examined a subset of 95 hypertensive participants from a 6-month randomized controlled trial designed to determine the utility of a wireless self-monitoring program (n=52 monitoring program, n=43 control), which consisted of a blood pressure monitoring device connected with a mobile phone, reminders for self-monitoring, a Web-based disease management program, and a mobile app for monitoring and education, compared with the control group receiving a standard disease management program. Study participants provided measures of patient activation, health behaviors including smoking, drinking, and exercise, medication adherence, and blood pressure levels. We assessed the influence of wireless self-monitoring as a moderator of the relationship between patient activation and health behaviors, medication adherence, and control of blood pressure.

Results

Improvements in patient activation were associated with improvements in cigarette smoking (beta=−0.46, P<.001) and blood pressure control (beta=0.04, P=.02). This relationship was further strengthened in reducing cigarettes (beta=−0.60, P<.001), alcohol drinking (beta=−0.26, P=.01), and systolic (beta=−0.27, P=.02) and diastolic blood pressure (beta=−0.34, P=.007) at 6 months among individuals participating in the wireless self-monitoring program. No differences were observed with respect to medication adherence.

Conclusions

Participation in a wireless self-monitoring program provides individuals motivated to improve their health management with an added benefit above and beyond that of motivation alone. Hypertensive individuals eager to change health behaviors are excellent candidates for mobile health self-monitoring..

Trial Registration

ClinicalTrials.gov NCT01975428, https://clinicaltrials.gov/ct2/show/NCT01975428 (Archived by WebCite at http://www.webcitation.org/6iSO5OgOG)

The impact of culturally responsive self-management interventions on health outcomes for minority populations: A systematic review

OBJECTIVES

The health of people from Indigenous and ethnic minorities is poorer than the remainder of the population. Frequently, Westernized health systems respond by introducing self-management interventions to improve chronic illness health outcomes. The aim of this study was to answer the research question: "Can self-management programs that have been adapted or modified still be effective for ethnic minority and Indigenous populations?"

METHODS

A systematic review across four databases was conducted.

RESULTS

Twenty-three publications met the inclusion criteria. As the studies were heterogeneous, meta-analysis was not possible. Overall, interventions resulted in more positive health outcomes than usual care, but findings were inconsistent.

DISCUSSION

We argue that rather than focusing on individual skills, knowledge, self-efficacy, and attitudes toward self-management, it may be more important to explore the structures and processes that underpin the sharing of information and skills within clinical or education encounters. Given that self-management is a Western cultural construct, creating empathic and responsive systems might be more effective for improving health of Indigenous and ethnic minority groups rather than relying predominantly on individual skill development.

The Role of Patient Activation in Contraceptive Use

PURPOSE

Many unintended pregnancies occur due to to contraceptive misuse and nonuse, which is partly due to to lack of knowledge and low self-efficacy related to contraception. We conducted an exploratory, cross-sectional study among low-income women to examine the relationship between knowledge, skills, and confidence in managing one's health, measured using the Patient Activation Measure (PAM) and factors that influence contraceptive use.

METHODS

A survey and chart review were conducted among 18- to 45-year-old women from a community health center in Chicago, Illinois, to measure the relationship between activation, self-confidence in avoiding pregnancy, contraception use, and contraceptive counseling. Associations between PAM and outcomes were evaluated using the χ(2) test and adjusted logistic regression models.

RESULTS

Among 112 participants (61% Latina, 15% Black, 14% White), we found no differences in PAM by age, race/ethnicity, or parity. Women with higher PAM were more likely to be confident they could avoid pregnancy compared with women with lower PAM (50% vs. 7%; p = .02). Higher PAM remained a significant predictor for self-confidence after risk adjustment (odds ratio, 3.13; 95% CI, 1.11-8.78; p = .031). Greater confidence in avoiding pregnancy was associated with using a moderately or highly effective contraceptive method (43% vs. 14%; p = .047). Women with lower PAM were less likely to receive contraceptive counseling in the prior month (0% vs. 57%; p < .01).

CONCLUSIONS

Patient activation may be an important construct for understanding factors that influence women's contraceptive use, including self-confidence in avoiding pregnancy until it is desired and receiving contraceptive services in primary care.