Is Patient Activation Associated with
Future Glycemic Control and Utilization
Outcomes for Adults with Diabetes?
Advancing
Know ledge to
Im prove H ealth
David M
M. Mosen
Mosen, PhD
PhD, MPH
Carol L. Remmers, PhD, MPH
Judy Hibbard,
Hibbard PhD
© 2010, Kaiser Permanente Center for Health Research
B k
Background
d
• Patient Activation refers to an individual’s:
• Skills and abilities to manage their own health
• Ability to engage health providers in shared decisiondecision
making practices
• Increased levels of patient activation may improve
patient outcomes
• Some evidence to suggest that Patient Activation
Measure (PAM) is associated with improved
outcomes
• Further work needed to understand association with
future glycemic control and utilization measures
© 2010, Kaiser Permanente Center for Health Research
Preliminary Results: Logistic and OLS Regression ResultsAssociation of PAM1 with Significant
g
Non Disease-Specific
p
Outcome Measures: DM Population*
PAM
Stage
Use of > 1 SM
Resources
OR
Stage 3-41
1Reference
95% CI
1.48* 1.15-1.91*
No Missed
Medications in
Past 7 Days
OR
95% CI
1.51*
1.15-1.98*
SM
Behavior
Index
Beta Coeff
PCS
Beta Coeff
MCS
Beta Coeff
+0.29***
+0.09**
+0.08*
group = PAM Stage 1-2.
* p < .05
** p < .01
001
*** p < .001
*Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is Patient
Activation Association with Outcomes of Care for Adults with Chronic Conditions? J
Ambulatory Care Manage. Vol 30, No 1, pgs 21-29.
© 2010, Kaiser Permanente Center for Health Research
St d Obj
Study
Objectives
ti
• Among adults with Diabetes Mellitus
(DM), identify the association of PAM
with:
• Glycemic control
• All-cause inpatient admissions
• DM-specific
DM
ifi inpatient
i
ti t admissions
d i i
• Acute myocardial infarction (AMI)specific inpatient admissions
© 2010, Kaiser Permanente Center for Health Research
2004 CMI Self-care/
Sh d Decision-making
Shared
D i i
ki Survey
S
• Survey assessed several domains across five chronic condition
cohorts:
•
•
•
•
•
•
•
Patient activation
System support for shared decision-making
Medication adherence
Use of self-management services
Performance of self-management behaviors
Functional status
Patient satisfaction
• Information intended to be used for quality improvement
purposes
• Seven of eight KP Regions participated
• Group Model Health Maintenance Organization (HMO) serves 8.7
million members across United States
• Survey funded by KP’s Care Management Institute (CMI)
• Development process guided by experts in the field (e.g., Judy
Hibb d K
Hibbard,
Kate
t L
Lorig,
i R
Russ Gl
Glasgow))
© 2010, Kaiser Permanente Center for Health Research
Overview of KP’s Care
M
Management
t Institute
I tit t (CMI)
Mission:
• Improve quality and efficacy of care delivered to members
with specific health conditions, including asthma and
di b t
diabetes
Goals:
• Ensure that effective care processes are uniformly and
consistently delivered to KP members
• Improve knowledge inside and outside of KP about
effective health-care delivery, including new approaches
to physician and staff learning
• Advance understanding of how patient-provider
interactions impact quality of care and outcomes
• C
Collect
ll t h
health-related
lth l t d quality
lit off life
lif (HRQOL) iinformation
f
ti on
patients with chronic conditions
© 2010, Kaiser Permanente Center for Health Research
M th d
Methods
• Survey of 1
1,180
180 persons with diabetes completed
in fall 2004 / early winter 2005
• Mode of administration = mail/telephone survey
• Survey sample identified using CMI diabetes inclusion
criteria:
• 1/96 through 12/03
•
•
•
•
> 1 DM drug dispensing
> 1 DM-related hospital admission
> 2 DM
DM-related
l t d outpatient
t ti t visits
i it in
i 24-month
24
th period
i d
HgbA1c value > 8%
• 1/01 through 1/03, either test result:
• Fasting blood sugar > 125 mg/dl
• Random blood sugar > 200 mg/dl
• Survey data linked with 2006 administrative data
• Glycemic control and utilization measures obtained from CMI’s
CMI s
Clinical Outcomes, Reporting and Evaluation (CORE) Database
• Measures routinely used for performance reporting
© 2010, Kaiser Permanente Center for Health Research
S
Survey
Process
P
Fl
Flow
Initial sample
N = 3,000
Contact rate
N = 2,250 (75.0%)
Response rate
N = 1,433 (63.7%)
Initial Analytic sample
N = 1,306 (91.1%)
Maintained continuous health plan coverage 36
post-surveyy
months p
N = 1,180 (90.4%)
© 2010, Kaiser Permanente Center for Health Research
Patient Activation to Perform Self-Management
Behaviors (Independent Variable)
• PAM
• Developed by Judy Hibbard (University of Oregon)
• 22 items total
• 4-item scale (1=
( disagree strongly, 4 = agree strongly))
• Scoring algorithm applied
• 0 = lowest activation
• 100 = highest activation
• Created using Rasch methodology
• 1-dimensional interval-level Guttman-like scale
© 2010, Kaiser Permanente Center for Health Research
Four Stages of PAM and
E
Example
l Items
It
from
f
Each
E h Stage
St
• Stage
St
11: N
Nott yett believing
b li i active
ti role
l iis important
i
t t
• Ex. Question: Taking an active role in my own health care is the most important
factor in determining my health and ability to function
• Score < 47.0
• Stage 2: Lacking confidence and knowledge to take action
• Ex. Question: I am confident that I can tell my health care provider concerns I
have even when he or she does not ask
• Score > 47.1 and < 55.1
• Stage
g 3: Beginning
g
g to take action
• Ex. Question: I have made the changes in my lifestyle (such as to diet and
exercise routines) that are recommended for my health condition
• Score > 55.2 and < 67.0
• Stage 4: Maintaining behaviors over time
• Ex Question: I am confident that I can maintain lifestyle changes in my diet and
exercise routines even during times of stress
• Score > 67.1
© 2010, Kaiser Permanente Center for Health Research
Utilization Outcome Measures
• 2006 and 2007 Glycemic Control Measures
• HgA1c < 8% (vs. > 8%)
• 2006 and 2007 Utilization Measures
All-cause
cause inpatient admissions ((> 1 vs.
• All
none)
• DM-specific admissions (> 1 vs.
vs none)
• AMI-specific admissions (> 1 vs. none)
© 2010, Kaiser Permanente Center for Health Research
P di t Variables
Predictor
V i bl
• Age
A (continuous)
( ti
)
• Gender (male vs. female)
• Race/ethnicity
• White vs. African-American, Hispanic-non-white, Asian-American,
Other/unknown
• Educational attainment
• LLess th
than hi
highh school
h l vs. hi
highh school
h l graduate,
d t some college/technical
ll /t h i l
school or higher, unknown
• Self-reported health status
• Fair/poor/very poor vs.
vs good/very good/excellent
• Comorbidity status
• None vs. 1 or more comorbidities
• Geographic location
• California region vs. non-California region
• 2006 Insulin or oral hypoglycemic dispensings
• 0 vs.
vs 11-5,
5 66-10,
10 11+
© 2010, Kaiser Permanente Center for Health Research
A l i
Analysis
• Descriptive statistics
• Bivariate analysis
• Logistic regression models constructed to
assess independent association of PAM with
outcome measures for significant associations
in bivariate analysis (p < .05)
05)
• predictors included in final models had significant
relationship with outcome measures (p < .10)
10)
© 2010, Kaiser Permanente Center for Health Research
D
Descriptive
i ti Statistics
St ti ti
Study Population Characteristics
Mean Age +/- S.D.
Male (%)
Total Sample (N = 1,180)
61.7 +/- 9.4
55.3
Race/Ethnicity (%)
White
African-American
Hispanic non-white
A i A i
Asian-American
Other/unknown
51.4
15.7
10.2
10 8
10.8
11.9
Educational Attainment (%)
Less than high school
High school graduate
Some college or higher
Unknown
8.0
19.3
60.8
11.9
Comorbidity Status
> 1 comorbidities (%)
41.6
Self-reported health status
Fair/Poor/Very Poor (%)
Good/Very Good/Excellent (%)
34.7
65.3
© 2010, Kaiser Permanente Center for Health Research
Descriptive Statistics: Insulin Dispensings, PAM and
Outcome Measures
2006 insulin or oral hypoglycemics dispensings (%)
0
1-5
6-10
11+
Mean PAM Measure +/- S.D. (0=lowest, 100=highest)
% Stage 1
% Stage 2
% Stage 3
% Stage 4
23.2
29.8
27.5
19 5
19.5
57.1 +/- 9.9
11.7
44.4
26.5
17.4
2006 Outcome Measures (%)
HgA1c < 8%
All-cause admissions
DM-specific admissions
AMI-specific admissions
68.5
21.4
19.2
1.4
2007 Utilization (%)
HgA1c < 8%
All-cause admissions
DM-specific
DM
specific admissions
AMI-specific admissions
69.3
19.8
19.5
2.0
© 2010, Kaiser Permanente Center for Health Research
Bivariate Results: Association of
PAM with 2006 Outcome Measures
PAM Stage
HgA1c < 8
((%))
> 1 All-cause
> 1 DM
Admissions ((%)) Admissions ((%))
> 1 AMI
Admissions ((%))
Stage 1-2
64.5
25.2
21.9
1.8
Stage 3-4
72.9
17.8
17.2
1.1
p-value
.004
.004
.05
NS
© 2010, Kaiser Permanente Center for Health Research
Bivariate Results: Association of
PAM with 2007 Outcome Measures
PAM Stage
HgA1c < 8
((%))
> 1 All-Cause
> 1 DM
Admissions ((%)) Admissions ((%))
> 1 AMI
Admissions ((%))
Stage 1-2
68.8
18.8
19.5
3.0
Stage 3-4
71.3
21.8
20.7
0.9
p-value
NS
NS
NS
.03
© 2010, Kaiser Permanente Center for Health Research
Logistic Regression Results:
g
Association of PAM with Significant
2006 and 2007 Outcome Measures
PAM Stage
20061
HgA1c < 8%
OR
95% CI
20062
> 1 Hosp. Admissions
OR
95% CI
20063
> 1 DM Admissions
OR
95% CI
20074
> 1 AMI Admissions
OR
95% CI
Stage 1-2
1.00
NA
1.00
NA
1.00
NA
1.00
NA
Stage 3-4
1.50
1.16 -1.94
0.58
0.43-0.78
0.66
0.49 – 0.90
0.32
0.12 – 0.89
1 Model
adjusted for age, race/ethnicity, and geographic location
adjusted for age, gender, race/ethnicity, HgA1c value (2006), and health status
3 Model adjusted for age, gender, race/ethnicity, HgA1c value (2006), geographic location,
and health status
4 Model adjusted for geographic location and health status
2 Model
© 2010, Kaiser Permanente Center for Health Research
C l i
Conclusions
• Glycemic Control
• Higher levels of PAM (stage 3-4) independently
associated with higher HgA1c control in 2006
• Utilization outcome measures
• Higher levels of PAM (stage 3-4) independently
associated with:
• Lower all-cause hospital admissions in 2006
• Lower DM-specific hospital admissions in 2006
• Lower AMI-specific
AMI specific hospital admissions in 2007
© 2010, Kaiser Permanente Center for Health Research
Li it ti
Limitations
• Results cannot be generalized beyond
ggroup-model
p
HMO settingg
• Self-reported medication adherence
• PAM only measured during one time period
© 2010, Kaiser Permanente Center for Health Research
I li ti
Implications
ffor IInterventions
t
ti
• Implications for interventions
• Further efforts are needed to develop and implement
interventions to increase PAM scores
• Determine whether movement on PAM scores results in
improvement in quality of care/quality of life measures
© 2010, Kaiser Permanente Center for Health Research
Candidate Intervention: KPNW –
S b itt d R01 to
Submitted
t AHRQ
• Use the PAM tool and structured health coaching and
motivational interviewing (MI) among adults with diabetes
• Health interventionist would train clinical teams how to effectively use
PAM
• Health interventionist would use MI and follow up with patients
over 6-month period
• Methods
• 12 clinical teams randomized (6 intervention, 6 usual care)
• Target population:
• Persons with diabetes and poor HgA1c control (> 8%)
• Total sample size: 600-900; 300-450 each group
• Primary outcomes:
• PAM: baseline, 6 and 12 months
• Secondary outcomes (assessed baseline and 12 months)
•
•
•
•
Health-related quality of life (measured by health utilities index [HUI])
Clinical indicators (glycemic control, blood pressure, lipids, weight)
Medication adherence
Utilization (emergency department and/or hospital admissions)
© 2010, Kaiser Permanente Center for Health Research
A
Appendix:
di Demographics
D
hi andd PAM
Demographic characteristic
Gender (%)
Male
Female
Age (%)
18-44
45 64
45-64
65-74
75+
Race/Ethnicity (%)
White
African-American
Asian-American
Hispanic, non-white
Education (%)
Less than High School
High School Graduate
Some College/Tech
College Grad+
High PAM (Stage 3-4)
p value
NS
40.6
42.1
NS
36.4
42 7
42.7
41.1
38.7
NS
42.1
38.6
43.5
39.0
< 0.001
32.3
36.7
38 9
38.9
49.2
© 2010, Kaiser Permanente Center for Health Research