Impact of group medical visits on patient engagement and quality of life

BACKGROUND

Group medical visits (GMV) effectively improve patient care and outcomes through interactive education, increased patient contact, and facilitated social support. This quality improvement research examined if patient activation and quality of life correlate with weight, blood pressure (BP), and hemoglobin A1c (A1C) through GMV interventions.

METHODS

Participants were enrolled in GMV Lighten Up for weight management or GMV Diabetes. At pre- and post-intervention, patients completed the Patient Activation Measure (PAM) and the health-related quality of life measure, the SF-12; and were assessed for weight, blood pressure (BP), and hemoglobin A1c (A1C).

RESULTS

Weight and PAM scores significantly improved regardless of group. For patients in GMV Diabetes, A1C significantly decreased. GMV Lighten Up participants had statistically significant declines in diastolic BP. Both groups improved patient activation, but statistically significantly so only in GMV Diabetes participants. SF-12 scores did not statistically significantly improve. There were no predictors of A1C and PAM score change for the Diabetes GMV. However, age, SBP and SF-12 scores predicted PAM score changes in GMV Lighten up participants.

CONCLUSIONS

Participants in this study showed overall improvement in biomarkers and patient activation. Thus, GMV continue to be a viable method for healthcare delivery.

Does Patient-Reported Outcome Measures Use at New Foot and Ankle Patient Clinic Visits Improve Patient Activation, Experience, and Satisfaction?

BACKGROUND

Patient-reported outcome measures (PROMs) can help predict clinical outcomes and improve shared clinical decision-making discussions. There remains a paucity of research assessing how the use of PROMs may drive improved patient experience and patient activation.

METHODS

New foot and ankle patients completed PROMIS physical function (PF), pain interference (PI), and depression assessments. Patients were then randomized to viewing and discussing their PROMIS scores with their surgeon or not. Following the clinic visit, patients completed a series of Clinician & Group Survey-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions and the Patient Activation Measure (PAM). Responses to the CG-CAHPS questions and PAM were compared between the 2 groups and after clustering on surgeon. Potential interaction effects by social deprivation were also explored.

RESULTS

After enrolling patients but removing those lost to follow-up or with missing data, 97 and 116 patients remained in the intervention control cohorts, respectively. No difference was found in CG-CAHPS responses nor PAM scores between the 2 groups (P > .05). All surgeons were highly rated by all patients. When clustered by surgeon, intervention subjects were less likely to indicate "top box" scores for the understanding domain of the CG-CAHPS question (OR 0.51, P < .001) and had decreased odds of high patient activation compared to control subjects (OR 0.67; P = .005). Among the most socially disadvantaged patients, there was no difference in control and intervention subjects in their likelihood of having high patient activation (P = .09).

CONCLUSION

Highly rated foot and ankle surgeons who show and discuss PROM results may not improve patient experience or activation and may, in fact, decrease understanding or patient activation in select populations. Future work is needed to determine when PROM discussions are most beneficial and how best to present PROMs data, as we suspect that how the information was presented-and not the use of PROMs-resulted in our findings. Health literacy tools and/or communication training may better engage different patient groups regarding PROMs.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

The Patient Activation Measure (PAM) and the pandemic: Predictors of patient activation among Australian health consumers during the COVID-19 pandemic

BACKGROUND

Preventative healthcare is crucial for improving individual patient outcomes and is integral to sustainable health systems. The effectiveness of prevention programs is enhanced by activated populations who are capable of managing their own health and are proactive to keep themselves well. However, little is known about the level of activation among people drawn from general populations. We used the Patient Activation Measure (PAM) to address this knowledge gap.

METHODS

A representative, population-based survey of Australian adults was conducted in October 2021 during the Delta strain outbreak of the COVID-19 pandemic. Comprehensive demographic information was collected, and the participants completed the Kessler-6 psychological distress scale (K6) and PAM. Multinomial and binomial logistic regression analyses were performed to determine the effect of demographic factors on PAM scores, which are categorised into four levels: 1-participants disengaged with their health; 2-becoming aware of how to manage their health; 3-acting on their health; and 4-engaging with preventative healthcare and advocating for themselves.

RESULTS

Of 5100 participants, 7.8% scored at PAM level 1; 13.7% level 2, 45.3% level 3, and 33.2% level 4. The mean score was 66.1, corresponding to PAM level 3. More than half of the participants (59.2%) reported having one or more chronic conditions. Respondents aged 18 to 24 years old were twice as likely to score PAM level 1 compared with people aged 25-44 (p < .001) or people aged over 65 years (p < .05). Speaking a language other than English at home was significantly associated with having low PAM (p < .05). Greater psychological distress scores (K6) were significantly predictive of low PAM scores (p < .001).

CONCLUSION

Overall, Australian adults showed high levels of patient activation in 2021. People with lower incomes, of younger age, and those experiencing psychological distress were more likely to have low activation. Understanding the level of activation enables targeting sociodemographic groups for extra support to increase the capacity to engage in prevention activities. Conducted during the COVID-19 pandemic, our study provides a baseline for comparison as we move out of the pandemic and associated restrictions and lockdowns.

PATIENT OR PUBLIC CONTRIBUTION

The study and survey questions were co-designed with consumer researchers from the Consumers Health Forum of Australia (CHF) as equal partners. Researchers from CHF were involved in the analysis of data and production of all publications using data from the consumer sentiment survey.

Factor structure and internal consistency of the parent patient activation measure (P-PAM) in parents of children with ADHD in norwegian paediatric mental health

BACKGROUND

This study aimed to explore the internal consistency and factor validity of the 13-item self-report questionnaire Parent-Patient Activation Measure (P-PAM) in a sample of parents of children with Attention-deficit/hyperactivity disorder.

METHODS

In a cross-sectional study, 239 parents were recruited from four outpatient clinics of the Child and Adolescent Mental Health Services and completed the P-PAM along with demographic variables. The factor structure of the P-PAM was examined through exploratory factor analysis, and internal consistency was estimated with the use of both Cronbach's alpha and McDonald's omega. A confirmatory factor analysis was used to estimate and test individual parameters.

RESULTS

The fit indices suggest an acceptable two-factor model of P-PAM and show high internal consistency and reliability for both factors, indicating that the scale measures two concepts.

CONCLUSIONS

Our findings provide evidence for an acceptable factor structure and a high reliability of P-PAM as a measure of parent activation, suggesting that the theoretical factors reflect the construct of parent activation as intuitively compiled into an inner cognitive factor and an outer behavioral factor, which are related.

Employee and Employer Benefits From a Migraine Management Program: Disease Outcomes and Cost Analysis

OBJECTIVE

To assess the impact of a migraine management program offered as a complimentary service by a company within its corporate well-being program.

BACKGROUND

Migraine imposes a substantial burden on patients, families, employers, and societies. As migraine primarily affects working-age adults, this has important implications for both employees and employers. Workplace educational and well-being programs positively contribute to employees' productivity, reduce costs related to absenteeism, and improve the quality of life of the employees living with migraine.

METHODS

This was a non-interventional cohort study, which followed employees and their family members over time. Participants received 1 telemedicine consultation to determine migraine diagnosis or a high probability of having migraine and 6 sessions of individualized telecoaching from a specialized nurse via a specially developed smartphone application to optimize their migraine management leveraging all appropriate medical and lifestyle options. Participants were evaluated during the program and at 3 months after completion through a series of validated questionnaires including Migraine Disability Assessment (MIDAS), Patient Activation Measure (PAM), and satisfaction with the services offered. A cost analysis was also performed to determine the economic benefit of the program considering the number of completers, dropouts, their associated program costs, MIDAS data, average salary of a Swiss employee in the pharma sector, and working days per year.

RESULTS

Of the 141 participants enrolled in the program, 79 completed 6-month and 42 completed 9-month assessments. The total MIDAS scores (mean, standard deviation [SD]) significantly improved from baseline by 54% at Month 6 (15.0 [13.6] vs 6.9 [8.2]; mean [SD] reduction: 8.1 [12.9], 95% confidence interval [CI]: 5.6-10.6; P < .0001) and by 64% at Month 9 (15.4 [14.7] vs 5.6 [6.0]; mean [SD] reduction: 9.8 [14.0], 95% CI: 6.6-13.0; P < .0001). The PAM scores also significantly improved from baseline by 8% at Month 6 (63.8 [10.9] vs 69.6 [12.8]; mean [SD] increase: 5.8 [12.8], 95% CI: 3.2-8.4; P = .003) and 11% at Month 9 (63.5 [10.7] vs 71.3 [12.2]; mean [SD] increase: 7.8 [11.0], 95% CI: 4.3-11.2; P = .003). At Month 6, common coaching lessons and respective action plans focused on progressive muscle relaxation, sleep, hydration, nutrition, general disease education, and stress management. The exit survey showed that the majority of the participants who completed the program had a meaningful and sustained improvement in their overall health and reported a high level of satisfaction with the program. The cost analysis revealed that on average participants gained 10.8 (95% CI: 9.3-12.3) working days/year that were previously lost due to migraine, resulting in a positive return on investment (ROI) of 490% (95% CI: 410%-570%), indicating a higher magnitude of savings that could be achieved by the implementation of such program. In addition to ROI and work productivity gained, participants also gained on average 13.6 (95% CI: 9.9-17.3) migraine-free days/year for their private and social life.

CONCLUSION

The employer-sponsored disease management program provided a better understanding of migraine, promoted methods and approaches to improve management by combining medical and lifestyle options leading to significant improvements in migraine symptoms that sustained beyond the intervention, supporting prolonged effectiveness of such programs. The program also provided a high ROI to the employer, supporting that the systematic inclusion of such programs into corporate well-being initiatives can be of significant benefit not only to the impacted individuals but to the employers as well.

Activation in individuals with vision loss

Vision loss and blindness are significant causes of disability. Patient activation has been previously unstudied in individuals with vision loss. Among our 146 participants, visual acuities for 38.3 percent were better than 20/70, 43.2 percent had acuities between 20/70 and 20/400, and 12.3 percent had acuities of <20/400. Participants with lower Patient Activation Measure scores missed more clinic visits (p = 0.017); those participants with caregivers also had lower PAM scores (p = 0.002). Targeting interventions to address patient activation in patients with vision loss may increase patient involvement in their care, increase treatment protocol adherence, and improve outcomes.

The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders

OBJECTIVE

Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.

METHODS

Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).

RESULTS

While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8-5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5-5.3).

CONCLUSIONS

Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

Measuring patient activation in Chinese patients with hypertension and/or diabetes: reliability and validity of the PAM13

Objective

Patient activation is important in the management of chronic diseases (CDs), especially hypertension and diabetes. The 13-item short form Patient Activation Measure (PAM13) is widely used, but data are lacking for China. The study aim was to assess the reliability and validity of the PAM13 in Chinese patients with hypertension and/or diabetes in a community management setting.

Methods

A cross-sectional survey was conducted at four community health centres in Kunming (Yunnan province, China) Participants were patients (n = 519) with hypertension and/or type 2 diabetes mellitus being managed at the community health centres. Patient activation was measured using the Chinese version of the PAM13. Reliability and validity were tested using Cronbach’s α and confirmatory factor analysis.

Results

The male to female ratio was 1:1.65. In total, 307 (60.3%) patients had ≤9 years of education and 213 (41.8%) had a low household income (≤5000 RMB/month). Cronbach’s α was 0.920 and item–total correlations ranged from 0.535 to 0.714. Confirmatory factor analysis showed a good fit to the data.

Conclusions

The PAM13 shows good reliability and validity for measuring patient activation in Chinese patients with CDs (hypertension and/or diabetes).

How adults with cardiac conditions in Singapore understand the Patient Activation Measure (PAM-13) items: a cognitive interviewing study

PURPOSE

Validation studies of the PAM-13 have found differences in scale performance, suggesting that health beliefs embedded in different cultures and/or self-management needs of different client groups influence how people respond to the items. The purpose of this study was to examine how adults with cardiac conditions in Singapore interpreted and responded to the PAM-13, to investigate possible reasons for differences in responses and to propose solutions to overcome them.

METHODS

We conducted retrospective cognitive interviews with 13 participants in an out-patient heart center. Interviews were transcribed and analyzed based on the framework approach to qualitative analysis. The four stages from Tourangeau's cognitive model were used as a framework to index the data from each item.

RESULTS

There was variation in comprehension of questions leading to variation in responses. Comprehension issues were due to terms perceived by participants to be vague and the use of English terms uncommon in Singapore. Cultural influences impacted decision processes and problems with response processes of the self-rating Likert scale surfaced.

CONCLUSIONS

This study reinforces the need to culturally adapt the tool, even when language translation is not necessary. Providing Likert scales with a larger number of may widen the relevance of PAM-13 in Singapore. Implications for rehabilitation Need to culturally adapt assessment tool, even when language translation is not necessary. Consider using Likert scales with a larger number of categories when using in Asian countries such as Singapore. Caution must be taken when using PAM-13 levels to decide interventions for each individual.

Validation of the Patient Activation Measure (PAM-13) among adults with cardiac conditions in Singapore

PURPOSE

The Patient Activation Measure (PAM-13) measures patients' knowledge, skill, and confidence in chronic condition self-management. The purpose of this study was to assess the validity of PAM-13 (English version) among English-speaking adults with cardiac conditions in Singapore.

METHODS

A cross-sectional study was conducted in a convenient sample of 270 heart clinic patients. Using the unitary concept of validity, evidence of (1) internal structure via data quality, unidimensionality, differential item functioning, and internal consistency, (2) response process through item difficulty and item fit using Rasch modeling, and (3) relationship to other variables via correlations with depression and self-efficacy were examined.

RESULTS

The item response was high with only one missing answer. All items had a small floor effect, but nine out of 13 items had a ceiling effect larger than 15 %. Cronbach's α was 0.86, and average inter-item correlations was 0.324. Results suggested unidimensionality; however, differences in item difficulty ranking were found. A low, negative correlation was found with depression, while a moderate, positive correlation was found with self-efficacy.

CONCLUSION

Evidence in all three areas of validity were mixed. Caution should be exercised when using categorical activation "level" to inform clinical decisions.

Psychometric properties of the Patient Activation Measure-13 among out-patients waiting for mental health treatment: A validation study in Norway

OBJECTIVE

The Patient Activation Measure-13 (PAM-13) has been found useful for assessing patient knowledge, skills and confidence in management of chronic conditions, but the empirical evidence from mental health is sparse. The psychometric properties of PAM in out-patients waiting for treatment in community mental health centers (CMHC) have therefore been examined.

METHODS

A total of 290 adults from two CMHC completed PAM. An exploratory factor analysis was conducted with 273 patients. Data at baseline and after 4 weeks were used to analyze test-retest reliability (n=60) and to analyze the sensitivity to change (n=51).

RESULTS

The exploratory factor analysis revealed a fit for a two-factor model (Cronbach's α was 0.86 and 0.67), and was assessed for a one-factor model (α=0.87). The test-retest intraclass correlation coefficient was 0.76. Sensitivity to change was good with a statistically significant activation improvement (p<0.001) on patients receiving a peer co-led-educational intervention (Cohen's d was 0.85).

CONCLUSION

PAM has appropriate and acceptable psychometric properties in mental health settings.

PRACTICE IMPLICATIONS

Assessing activation before treatment might be useful for scheduling the delivery of mental health services as well as evaluating educational interventions aimed at improving patient engagement in mental health.

The impact of Telephonic Health Coaching on Health Outcomes in a High-risk Population

Background:

Health coaching is a client-centric process to increase motivation and self-efficacy that supports sustainable lifestyle behavior changes and active management of health conditions. This study describes an intervention offered as a benefit to health plan members and examines health and behavioral outcomes of participants.

Methods:

High-risk health plan enrollees were invited to participate in a telephonic health coaching intervention addressing the whole person and focusing on motivating health behavior changes. Outcomes of self-reported lifestyle behaviors, perceived health, stress levels, quality of life, readiness to make changes, and patient activation levels were reported at baseline and upon program completion. Retrospectively, these data were extracted from administrative and health coaching records of participants during the first 2 full years of the program.

Results:

Less than 7% of the 114 615 potential candidates self-selected to actively participate in health coaching, those with the highest chronic disease load being the most likely to participate. Of 6940 active participants, 1082 fully completed health inventories, with 570 completing Patient Activation Measure (PAM). The conditions most often represented in the active participants were depression, congestive heart failure, diabetes, hyperlipidemia, hypertension, osteoporosis, asthma, and low back pain. In 6 months or less, 89% of participants met at least one goal. Significant improvements occurred in stress levels, healthy eating, exercise levels, and physical and emotional health, as well as in readiness to make change and PAM scores.

Discussion:

The types of client-selected goals most often met were physical activity, eating habits, stress management, emotional health, sleep, and pain management, resulting in improved overall quality of life regardless of condition. Positive shifts in activation levels and readiness to change suggest that health coaching is an intervention deserving of future prospective research studies to assess the utilization, efficacy, and potential cost-effectiveness of health coaching programs for a range of populations.