Identifying Patients' Health Self-Management Skills

Patients who do not feel capable of managing their own health or navigating the healthcare system are more likely to develop a new chronic disease over a 3-year period than patients with good health self-management skills, a new study in Health Services Research suggests. These patients who feel incapable are also more likely to be hospitalized and visit the emergency department (ED) for avoidable conditions than patients with good self-management skills.

Judith H. Hibbard, PhD, MPH, of the Health Policy Research Group at the University of Oregon, and colleagues concluded that understanding patients’ capability for self-management is a key part of understanding the risk of health declines and avoidable utilization.

The study explored whether considering a patient’s self-management skills and confidence, predicted by the Patient Activation Measure (PAM), might help healthcare delivery systems identify high-risk patients who could benefit from supportive interventions. The PAM, which was developed in 2004 by Hibbard and colleagues and is commercially available, assigns patients a score of 0 to 100, and groups them into 4 “activation levels,” with level 1 (low patient-activation) representing patients with the most limited self-management skills.

The study retrospectively examined 98,142 patients at Minnesota’s Fairview Health Services who had a PAM score recorded in the electronic health record in 2011 and then visited a primary care clinic at least once in 2012, 2013, and 2014. Researchers evaluated the potential of the PAM in determining future chronic disease burden and ambulatory care-sensitive hospitalizations or ED visits.

At baseline, poorer patient self-management (demonstrated by lower patient activation scores) was associated with a higher prevalence of chronic conditions, including depression and hypertension, more ED visits, and more hospital admissions related to those conditions. After controlling for demographic characteristics and baseline chronic conditions, the researchers found that patients at the lowest activation level at baseline were 25% more likely to develop a new chronic disease in the upcoming calendar year compared with patients at the highest activation level. Two years after baseline, the analysis showed a 31% difference between the lowest and highest activation groups; and 3 years after baseline, the difference was 21%. The study authors said that their findings suggest the enduring predictive value of PAM scores.

Patients with the lowest activation scores at baseline had a 62% greater likelihood of having an avoidable hospitalization compared with the most activated group 1 year later. Two years later the difference between the least and most activated groups was 40%, and 3 years later the difference was still 30%.

The authors said the big picture that their findings suggest is that a patient’s activation score (self-management skill level) helps predict future risk of developing a chronic disease and using costly and avoidable medical care. They believe it is possible to increase patients’ activation levels and help them become better at managing their health and healthcare.

“When working with patients with low activation levels, healthcare providers should recommend small steps to achieve behavioral changes,” and not overwhelm them with too much information or too many changes at once the authors wrote.

Healthcare delivery systems can stratify populations by patient activation scores and thus identify and help those patients with limited self-management skills to prevent poor outcomes and unnecessary costs.