The American Journal of Managed Care April 2016
Patient Perceptions of Clinician Self-Management Support for Chronic Conditions
Objectives: This study investigates the extent to which patients with chronic conditions perceive that they are receiving clinician self-management support for their conditions, and whether this perceived support is associated with self-management behaviors, such as exercise and taking medications for chronic conditions.
Study Design: A survey of a representative sample of current and retired autoworkers and their spouses, all younger than 65 years, who are or were employed by the 3 major US automobile manufacturing companies.
Methods: An index of self-management support was constructed from 3 survey questions that asked respondents with chronic conditions about their perceived level of self-management support from clinicians. Multivariate regression analysis examined: a) the extent to which perceived self-management support was influenced by patient engagement and other patient factors, and b) whether self-management support and patient engagement were associated with self-management behaviors, including exercise, use of certain preventive care services, and taking medications for specific chronic conditions.
Results: Most patients with chronic conditions reported that their clinicians provide some degree of self-management support of their chronic conditions. The extent to which a patient is engaged with their medical care—such as taking notes or bringing along friends or relatives to ask questions—is strongly associated with perceptions that they receive self-management support from their clinicians. Receiving clinician self-management support was modestly associated with most self-management behaviors.
Conclusions: Receiving self-management support from clinicians can positively influence patient self-management of chronic conditions, but patient engagement with their own healthcare is crucial to whether patients perceive they are receiving such support. Moreover, while patient engagement may influence whether self-management support is given, the study results suggest that self-management support may be just as effective with patients who are less engaged with their healthcare.
Am J Manag Care. 2016;22(4):e125-e133
- Most patients with chronic conditions receive some self-management support from clinicians, although a substantial minority does not.
- Self-management support from clinicians is moderately associated with actual self-management behaviors.
- Patient engagement is strongly correlated with receiving self-management support from clinicians, although patient engagement is less strongly associated with self-management behaviors.
- Encouraging clinicians to provide self-management support to their patients with chronic conditions is effective, although clinicians inconsistently provide such support.
Growing literature shows that implementation of self-management support and education by clinicians improves patient management of their conditions, including increased medication adherence, symptom control, and healthy behavior factors like exercise and diet.2-6 However, most studies of the effects of self-management support tend to be limited to single diseases—especially diabetes—or evaluations of individual physician practices that have implemented a self-management support program.3,7-9 Although some studies have examined self-management among low-income and racially diverse populations,8,10-12 relatively few have examined the prevalence of self-management support among more diverse patient populations with a broad range of chronic diseases.13,14
In addition, very little research has examined the inter-relationship between patients’ engagement with their own healthcare and clinician self-management support. Patient engagement is defined as “actions individuals must take to obtain the greatest benefit from the healthcare services available to them.”15 Patient engagement differs from patient activation—which refers to the “skills and confidence that equip patients to become more engaged in their healthcare”16—because patient engagement relates more directly to actions that patients take during, or in preparation for, the medical encounter.
What is less well-understood is how patient engagement and clinician self-management support work together, or separately, in influencing patients’ actual self-management behaviors. The objective of this study was to examine the extent to which patients with chronic illnesses perceive that they are being provided with clinician self-management support. Additionally, the analysis examines whether receiving self-management support is associated with disease and age-specific health behaviors, such as physical exercise, colorectal cancer screening among individuals 50 years or older, and taking prescription medications for hypertension, diabetes, and high cholesterol.
A key aspect of the analysis is the role of patient engagement with their care, both in terms of how it influences the level of perceived self-management support that patients receive from healthcare providers, and in how it is associated with health behaviors, either independently or jointly with self-management support. Conceptually, the analysis views patient engagement as a set of actions by patients during the medical encounter that were most likely planned in preparation for the visit, rather than in response to what occurs during a medical encounter. The study hypothesizes that patients at higher levels of engagement are more likely to perceive receiving self-management support from physicians, both because physicians are likely to be more responsive to patients who demonstrate a high level of interest in their healthcare, and because highly engaged patients are more likely to directly request such support.
In this view, patient engagement may influence self-management behaviors in 3 ways: a) directly and independently of the degree of self-management support, b) indirectly by influencing the amount of self-management support that patients receive, and c) interacting with self-management support so that greater patient engagement increases the effectiveness of self-management support in influencing behaviors.
The data for this study are based on the 2012 Autoworker Health Care Survey, a survey of active and retired hourly wage workers from Chrysler, Ford, and General Motors. The survey was sponsored by the National Institute for Health Care Reform, a nonprofit, nonpartisan organization established by the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America; Chrysler Group LLC (now FCA US LLC); Ford Motor Company; and General Motors. The total survey sample includes 8656 hourly wage workers, retirees younger than 65 years (ie, not eligible for Medicare), and their spouses (all ages). Retired autoworkers 65 years or older and their spouses were excluded from the sample.
The sample was randomly selected, with some oversampling of active workers so that the proportion of active and retired workers in the sample was about evenly split. The survey was administered by mail, with a final response rate of 64%. The study sample includes those with chronic conditions who responded to questions on perceptions of clinician self-management support of chronic conditions (n = 3005).
Perception of Clinician Self-Management Support
Sampled individuals were asked specifically about the type of help with their chronic conditions that they received from their doctor, nurse, or physician’s assistant. The 3 questions were derived from the Patient Assessment of Chronic Illness Care17:
“Over the past 12 months, when I received care for my chronic condition, I was:
- shown how what I did to take care of myself influenced my condition;
- helped to make a treatment plan that I could carry out in my daily life; and
- contacted after a visit to see how things were going.”
For all 3 questions, response categories included a) none of the time, b) a little of the time, c) some of the time, d) most of the time, or e) always. A summary measure of self-management support was constructed by summing responses to the 3 items, with a range of 3 to 15, with higher scores indicating greater self-management support.
Patient Engagement With Healthcare
Four questions on patient engagement during medical encounters were included in the survey, derived from a 2007 survey sponsored by the National Business Group on Health.18 The following questions were asked of respondents about things they might have done before or during a medical visit: “Have you ever—
- brought information you found on an Internet website to a medical visit and talked about it with your doctor?
- taken notes during a medical visit to help you remember what the doctor or nurse said?
- brought along a friend or family member to your medical visit as your advocate or to give you support?
- brought along a list of questions to ask during a medical visit?”
Responses to the questions include “never” (coded as 0), “once” (coded as 1), and “more than once” (coded as 2). An index of patient engagement was constructed by summing the responses to the 4 measures. Scores range from a high of 8 (answered “more than once” on all 4 questions) to a low of 0 (answered “never” to all 4 questions). Roughly based on percentile distributions, 3 categories were constructed from this summary, indicating high engagement (scores of 5-8; 75th percentile or higher), moderate engagement (scores of 2-4; 25th-75th percentile), and low engagement (scores of 0 or 1; between 0 and 25th percentile). Less than 1% of those sampled did not respond to these questions.
The survey included selected measures of preventive behaviors, including exercise, cholesterol testing, and colon cancer testing. For physical exercise, a survey question asked respondents how many days in a typical week they engaged in any moderate-intensity physical activity or exercise. We examined the percent who exercised 5 or more days a week for all autoworkers with chronic conditions, as well as separately for those with health conditions that can be managed in part through exercise, including individuals with diabetes, hypertension, or high cholesterol. The 3 conditions were ascertained through survey questions asking whether a doctor ever told them that they had these conditions. Follow-up questions ascertained whether survey respondents were currently taking medicine prescribed by a doctor for that condition.
Questions on preventive healthcare use included whether they had their blood cholesterol checked in the past year, and their history of colon cancer screening. For individuals 50 years or older, the survey asked about the use of colonoscopies, sigmoidoscopies, or fecal occult blood tests. Consistent with guidelines based on those of the US Preventive Services Task Force, we examined the percent that had a recent colon cancer test, defined as either a colonoscopy or sigmoidoscopy within the past 5 years or a fecal occult blood test in the past year.19
The first part of the analysis examines the prevalence of clinician self-management support, as well as patient characteristics associated with higher levels of self-management support (the dependent variable). Since the index of self-management support created by summing the 3 component variables is an interval or continuous measure, ordinary least squares (OLS) regression is used in this part of the analysis. Major independent variables include patient engagement (defined previously); worker status (retirees, recent hires, or longer-term [defined as hired before November 2007] employees); age; gender; race/ethnicity; educational attainment (years of education/attainment of degree); family income (before taxes); and measures of health status (including the number of chronic conditions, body mass index (based on self-reported height and weight), and perceived physical and mental health status). Specification of the independent variables is shown in Table 1. Only coefficients with a P value of less than .05 were considered to be statistically significant. Predicted marginals are computed based on the OLS results. These reflect predicted values of the dependent variable (the self-management support index) for each subgroup represented by the independent variables, holding all other variables constant.