Patient Perceptions of Clinician Self-Management Support for Chronic Conditions

ABSTRACT

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

Take-Away Points

Patient self-management of chronic conditions is considered crucial for improving clinical outcomes, functional status, and decreasing the costs of care, but the role of clinicians in promoting self-management support of patients is not well understood. The results of this study show that:

• 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.

Self-management support and education for patients with chronic diseases are crucial for improving clinical outcomes and functional status, as well as for decreasing the use of high-cost health services, such as inpatient hospital stays.¹ The traditional view of patients with chronic illness as “passive” participants in the clinician-patient relationship is giving way to a paradigm that views patients as their own primary caregivers, with support and education—such as assistance with a patient-generated action plan—being provided by healthcare professionals.

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.

METHODS

Data

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.

Self-Management Behaviors

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

Statistical Analysis

Table 1

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 . 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.

The second part of the analysis examines the associations among perceived self-management support, patient engagement, and health behaviors, as defined previously. For this analysis, separate logistic regression analyses are used to estimate the likelihood of engaging in specific health behaviors, which are all measured as discrete binary variables. Because many of these behaviors are relevant only for specific groups based on age or condition, different samples are used for each of the regressions. For all models, independent variables include the self-management support summary measure and the patient engagement index, as well as all other independent variables used in the first part of the analysis. To facilitate interpretation of the results for clinician self-management support and patient engagement, the regression results are used to compute predicted probabilities for engaging in health behaviors at the 25th, 50th, and 75th percentiles of the clinician self-management support summary measure, holding all other variables in the regression constant.

To determine whether patient engagement and self-management support are directly and independently associated with health behaviors, regression models are estimated with both measures included. Separate regression models were also tested that included an interaction term for patient engagement and perceived self-management support in order to examine the hypothesis that the association of self-management support with health behaviors is stronger for more highly engaged patients. However, the results of these models showed that the interaction terms for all models were not statistically significant. Therefore, only the results showing the main effects for patient engagement and self-management support are presented.

All estimates were weighted to produce representative estimates of active and retired autoworkers and their spouses and to account for survey nonresponse based on information from health plan eligibility files, such as age, gender, and whether the spouse is enrolled in a company-sponsored plan. Standard errors reflect the complex sample design, primarily due to the oversampling of active workers and the clustering of the sample within families (ie, the worker and their spouse).

RESULTS

Characteristics of Study Population

Table 1 shows the characteristics of the study population. The sample tended to be older (most were aged 50 years or more) and retired. Most do not have college degrees and about half have annual family incomes of less than $50,000. Chronic conditions with especially high prevalence include hypertension (63%), arthritis (52.9%), high cholesterol (63.6%), diabetes (39.7%), and depression (37.7%). Most of the sample with chronic conditions has multiple chronic conditions, half are obese, and one-third reports their health as fair or poor.

Perceptions of Self-Management Support From Healthcare Providers

Table 2

More than half of the autoworkers with chronic conditions reported that healthcare providers frequently showed them that what they did to take care of themselves influenced their condition, including 43.8% and 24.7% who said “all of the time” and “most of the time,” respectively (). Similarly, most autoworkers with chronic conditions reported that their healthcare providers helped them make a treatment plan for their daily life, including 43.1% and 23.7% who said “all of the time” and “most of the time,” respectively. Fewer autoworkers reported that their healthcare providers contacted them after a visit to see how things were going—21.9% and 14.7% reported healthcare providers did this “all of the time” and “most of the time,” respectively. The average score on the summary measure of the 3 self-management support items was 10.3 (range between 3 and 15, with higher scores indicating greater self-management), with a standard deviation of 3.7.

Table 3

Patient engagement was strongly associated with perceived self-management support. Individuals with low patient engagement in their medical care reported lower self-management support from healthcare providers than did those with high patient engagement (—1.20; P <.001) (). The number of chronic conditions a patient had also was strongly associated with self-management support: those with 4 or more chronic conditions reported stronger self-management support compared with those with only a single chronic condition (1.05; P <.001). However, individuals who reported their physical health as “fair or poor” reported lower self-management support compared with those who reported their health as excellent or good (—0.56; P <.001). Females also reported lower self-management support compared with males (—0.49; P <.001). There were no statistically significant differences in perceived self-management support by age, worker status, race/ethnicity, education, family income, or body mass index.

Perceived Self-Management Support, Patient Engagement, and Self-Management Behaviors

Table 4

eAppendix

summarizes the results of the logistic regression analysis for the association among perceived self-management support, patient engagement, and health behaviors. Only the coefficients for the self-management support summary measure and patient engagement are shown. Full regression results are available in the (available at www.ajmc.com). In addition, predicted probabilities for each of the health behaviors are computed for the 25th, 50th, and 75th percentile scores for the self-management index (ie, scores of 8, 11, and 13).

In general, the results show that greater perceived self-management support by clinicians is positively associated with healthier behaviors. Higher self-management support was associated with a greater likelihood of exercising 5 or more days per week for all autoworkers with chronic conditions (0.05; P <.01), as well as separately for those with diabetes, high cholesterol, and hypertension. Among all autoworkers with chronic conditions, the predicted probability of exercising 5 days a week or more was 13.1% for those at the 25th percentile of self-management support, and 16% for those at the 75th percentile.

Greater perceived self-management support also was associated with a greater likelihood of cholesterol screening, including those who had been told by a physician that they had high cholesterol (0.11; P <.001). Among those 50 years or older with chronic conditions, greater self-management support was associated with a greater likelihood of having a recent colorectal cancer screening (0.04; P <.01). The predicted probabilities show that 62% received this service at the 25th percentile of self-management support, compared with 66% at the 75th percentile.

In addition to more frequent exercise participation, individuals with diabetes, hypertension, and high cholesterol were also more likely to be taking medication for their condition if they received greater self-management support, although the association between self-management support and taking medication for hypertension was statistically significant only at the P <.10 level.

In contrast to the measure of perceived self-management support, patient engagement with their healthcare was independently associated with only the 2 preventive health measures. Higher patient engagement was associated with a greater likelihood of all individuals with chronic conditions having a cholesterol test in the past year (0.06; P <.01) and having a recent colon cancer test (0.07; P <.001). For all other health behaviors in Table 4, the association with patient engagement was not statistically significant.

DISCUSSION

Both self-management support and patient engagement separately have been found to be associated with self-management behaviors among individuals with chronic illnesses, but very little is known about how they work together in influencing patient behavior. The results from this study suggest that while engaged patients report much more self-management support from their clinicians, the association with self-management behaviors is likely more indirect, and self-management support is more directly associated with influencing actual self-management behaviors. Moreover, the analysis did not find that the association of self-management support with health behaviors was stronger at higher levels of patient engagement than at lower levels. For clinicians implementing patient-centered approaches for managing chronic conditions, identifying patients who are most likely to benefit from such approaches is often challenging—not just in terms of their conditions and symptoms that need to be managed, but whether the patients themselves would be receptive to such coaching from clinicians.^5,6 For self-management support, a crucial question that clinicians must address is whether it is more efficient and effective to direct such counseling to more highly engaged patients than less-engaged patients, or whether increasing patient engagement should also be a goal of a patient-centered approach to chronic illness care. Although patient engagement may influence whether self-management support is given, the results suggest that self-management support may be just as effective with patients who are less engaged with their healthcare.

Self-management support for chronic conditions may be provided in different ways, including through individual clinicians and practices, traditional disease management programs, and new forms of care delivery, such as patient-centered medical homes (PCMHs) and high-intensity primary care, also known as ambulatory intensive care units (AICUs). Although individual physician practices have shown such methods to be effective in improving quality and reducing costs, a key question is how to increase mainstream implementation of self-management support programs. Reviews of AICUs and PCMHs have noted barriers, such as the need to change the structure and workflow of physician practices, insufficient information technology to identify high-risk patients and those most likely to benefit from self-management support and counseling, and insufficient time and financial incentives.²⁰ In the long run, the effectiveness of such programs will depend not just on whether individual models or practices can achieve results, but whether they can achieve enough critical mass to benefit most patients with chronic conditions.

Limitations

Several limitations should be noted. First, the cross-sectional nature of the survey data means that firm causal connections among clinician self-management support, patient engagement, and self-management behaviors cannot be determined with certainty. Patients who are more inclined to engage in self-management behaviors may be more selective of physicians and other healthcare providers who support such behaviors. Controlling for patient engagement in the analysis partially, but not completely, addresses this limitation.

In addition, the survey questions are based on patient perceptions of self-management support, and whether such self-management support was actually provided, was not ascertained. Patients’ perceptions may be influenced by—among other factors&mdash;their receptivity to such support, as reflected by their self-reported level of engagement with medical care. Again, controlling for patient engagement in the analysis partially, but not completely, resolves this limitation.

Also, the measures of self-management support were general and not specific to a patient’s condition or treatment regimen. The general nature of the questions may explain why the associations with self-management behavior, while statistically significant, were modest in magnitude. More focused questions on the types of self-management support patients were receiving might lead to findings of larger magnitude.

Finally, although the sample includes a number of different chronic conditions, and individuals with varied sociodemographic and economic backgrounds, the results are not nationally representative. Nevertheless, the results are more generalizable than those of much of the prior research on this topic that tended to focus on a single disease or individual physician practices.

CONCLUSIONS

Among a population of autoworkers with chronic conditions, most report that their clinicians are providing some degree of self-management support for their chronic conditions— such as helping them to make treatment plans. The extent to which a patient is engaged with their medical care is strongly associated with perceptions that they receive clinician self-management support, which may reflect that clinicians are more responsive to highly engaged patients, or that engaged patients request such support from their clinicians. Receiving self-management support from clinicians was modestly associated with self-management behaviors, such as exercise, use of preventive services, and taking medications for chronic conditions. However, self-management support was more consistently associated with self-management behaviors than with patient engagement. These results suggest that the association of patient engagement with preventive and self-management behaviors is more indirect, by influencing the amount of self-management support they receive from clinicians.

Author Affiliation: Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA.

Source of Funding: National Institute for Health Care Reform.

Author Disclosures: The survey was designed and conducted by Mathematica Policy Research, Inc, where Dr Cunningham was employed at the time that the survey was conducted. He was the Principal Investigator for the survey, and led the design of the questionnaire and sample. The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis; provision of patients or study materials; obtaining funding; administrative, technical, or logistic support; and supervision.

Address correspondence to: Peter Cunningham, PhD, Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, 830 East Main St, 4th Fl, Richmond, VA 23298. E-mail: peter.cunningham@vcuhealth.org

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