Study Validates Strategies to Support Patient Self-management

New Scale Gauges Clinicians' Ability to Facilitate Patient Activation

September 20, 2016 02:00 pm Paula Haas

Frustrated in your efforts to motivate patients to change unhealthy habits? The results of a new research study( might help you create a more effective approach.

[Man talking to female doctor]

The study, recently published online by Healthcare, validated the results of a previous exploratory study that identified five promising strategies for supporting patient self-management.

In the previous study, researchers interviewed 20 clinicians in an accountable care organization (ACO) -- 10 who had been found to be top performers at increasing patient activation and another 10 who had been found to be low performers. Patient activation was defined as having the knowledge, skills, confidence and motivation to manage one's health and health care. It has been shown to be associated with outcomes that include better self-management and clinical indicators, fewer hospitalizations, and lower health care costs.

The 10 top-performing clinicians most frequently reported using five strategies when they worked with patients on lifestyle behavior change: emphasizing patient ownership, partnering with patients, identifying small steps toward change, scheduling frequent follow-ups, and showing care and concern.

Story highlights
  • In a study reported in Healthcare, researchers validated five promising strategies for supporting patient self-management that were identified in an earlier exploratory study.
  • The strategies are: emphasizing patient ownership, partnering with patients, identifying small steps toward change, scheduling frequent follow-ups, and showing care and concern.
  • In the study, the researchers developed and validated a scale for measuring where primary care clinicians are in terms of patient self-management support.

The new study tested whether the five strategies were, in fact, related to clinicians' support for patient self-management in a larger sample of clinicians participating in the ACO, said Jessica Greene, Ph.D., a professor at the George Washington University School of Nursing and lead researcher for both studies. Specifically, researchers surveyed 139 primary care clinicians, including family physicians (56.8 percent of respondents), internists (16.6 percent), and nurse practitioners and physician assistants (26.6 percent).

"We went back to the first study's qualitative findings to see how top-performing clinicians described using the five strategies," Greene told AAFP News. "We pulled those descriptions into nine questions for the survey used in this new study. The questions asked clinicians how frequently they used the five strategies in the last month with patients who have chronic conditions." Clinicians answered using a 5-point scale in which 1 indicated "never" and 5 indicated "very often."

Using psychometric testing, the researchers determined that the nine questions form a scale for measuring where primary care clinicians are in terms of patient self-management support (SMS). An SMS score was calculated for each surveyed clinician based on his or her answers to the nine questions.

"Clinicians varied tremendously in how often they reported engaging in the strategies," Greene said, with SMS scores ranging from a low of 2.1 (rarely engaging in SMS) to a high of 4.9 (very often engaging in it). Of note was the fact that female clinicians had significantly higher SMS scores than their male counterparts.

The researchers tested the construct validity of the new SMS measure in two ways. One way was to compare each clinician's SMS score with his or her answers to additional survey questions related to supporting patient self-management. Researchers found that the responses to these other survey questions were strongly related to the SMS score. For example, clinicians who reported spending 60 percent or more of their office visit time in counseling, educating and coaching patients had a mean SMS score of 4.0. Those who reported spending less than 30 percent of their time doing so had a mean SMS score of 3.4, or 15 percent lower.

The second way researchers tested the SMS measure's validity used patient records, identifying patients in the ACO who reported smoking in 2012 but were no longer smoking by 2014, and patients who were obese in 2012 but no longer so by 2014. The data were aggregated to the primary care clinician level. Researchers then looked for a relationship between each surveyed clinician's SMS score and the ability of that health care professional's patients to stop smoking or lose weight.

The clinicians' SMS scores exhibited "significant but modest associations with their patients' smoking cessation and weight loss (among obese patients)," said the study report.

"I found it very validating that we were able to see a relationship between these clinician-reported strategies and patients being able to make very challenging behavior changes," said Greene. "I think a lot of things go into patients being able to make those changes, so the fact that we were able to see a relationship, even though not terribly strong, was validating."

According to Greene, the SMS measure developed in the study is publicly available and can be used to assess where primary care clinicians are in terms of engaging in the strategies. (Readers unable to readily access the measure through the Healthcare article may contact Greene via email to obtain it.)

What's next for the researchers? "My colleagues and I would be very interested in developing some trainings to see how much we could influence primary care clinicians in engaging in these five strategies," said Greene. "We would look for improvements in patient outcomes when use of the strategies is increased."

They also want to investigate what other members of the health care team could do to support patient self-management. "Primary care physicians are very strapped for time," Greene said. "There likely are different ways this work could be distributed across the team."

Amy Mullins, M.D., AAFP's medical director for quality improvement, said an interesting finding from the two research studies Greene led is that physicians can have a greater impact on their patients' health by approaching them with a positive attitude and encouragement, rather than focusing on negative things that could happen if lifestyle changes aren't made.

Many family physicians already are using some of the five strategies outlined in the studies, Mullins said. For those who are not, Mullins suggested that they try adding just one strategy at a time, picking the right patients to try them on and moving forward from there.

The results of these studies also have a message for health systems that include primary care practices, Mullins said. "It takes time to provide this kind of care, and it helps to have a team. Health systems should give family physicians either more time to see each patient or more resources -- or both, ideally -- to help them provide this kind of effective care."

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Study Finds Adopting Healthy Habits Is About More Than Motivation

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