Jane McCredie: Active engagement

A SYDNEY GP has been ordered to pay $364 000 to a morbidly obese patient because he had failed to refer the man to a weight loss clinic or for laparoscopic surgery.

The patient argued the GP was legally responsible for the progression of his pre-existing liver disease to cirrhosis, liver failure and eventually terminal cancer of the liver, according to a report in the medical press.

The court agreed, finding the doctor should have been more proactive in treating the early liver disease by “emphatically addressing the problem of [the patient’s] morbid obesity”.

Without wishing to make any assessment of the rights or wrongs of that case — which is likely to be appealed — the report did make me wonder, not for the first time, about how we define the responsibilities of doctor and patient when it comes to health care.

A series of papers in Health Affairs this month casts an interesting light on the issue, suggesting an individual patient’s engagement in managing their own health could be “the blockbuster drug of the century”.

Patients who are actively involved in their health and health care have better outcomes and incur lower costs, the journal says.

That might sound like a statement of the bleeding obvious, but the argument is not simply that patients need to take more responsibility for their own health. What emerges from many studies is that engagement is not just a question of motivation, but also of knowledge, skills and confidence — things many people find hard to achieve on their own, particularly when faced with complex medical information and an often bewildering health system.

Patient education has become a routine part of clinical management in many areas, particularly in chronic disease, but this research suggests we might need to go further.

Studies have shown that improving patient engagement is associated with better clinical outcomes in conditions ranging from heart failure to mental illness.

One diabetes study, for example, found improvements in patients’ confidence and ability to manage their own health were associated with increased medication adherence and better HbA1c and LDL cholesterol levels.

That study used a commercially available tool — the Patient Activation Measure — which categorises patients based on their responses to statements such as: “I know what treatments are available for my health problems” and “I am confident that I can tell a doctor my concerns, even when he or she does not ask”.

I’m not seeking to spruik any particular tool, but it does seem this kind of formal assessment could help clinicians to build patient engagement and to target their approach to an individual patient’s needs.

Professor Judith Hibbard, who led development of the Patient Activation Measure at the University of Oregon, writes in Health Affairs about Fairview Health Services, a large Minnesota not-for-profit provider that routinely collects this data in its primary care clinics and enters it into patients’ electronic health records.

At Fairview, the measure is “increasingly viewed as a vital sign that is key to individualizing patients’ care plans”, the article says. The score is also used to help tailor the type and amount of support provided to patients on discharge from the organisation’s specialist clinics and hospitals.

Targeting care and support in recognition of a patient’s individual needs and capacities is not new, but this sort of formalised, consistent approach takes the principle a step further.

Given the benefits patient engagement can bring, should clinicians be measuring and seeking to improve it in much the same way they might address clinical indicators such as blood pressure or body mass index?

Jane McCredie is a Sydney-based science and medicine writer.

Posted 11 February 2013

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