Patient engagement falls short as ‘blockbuster drug’ physicians are seeking

Medical organizations across the country are trending toward patient-centered care, incorporating meaningful patient activation and engagement (PAE) into their clinical routines. But, despite a push for more personalized medicine, the majority of physicians and assistants still fail to fully understand what PAE means, and much less how to incorporate it into practice.

It’s widely accepted that patients and families who are actively engaged in their care see more favorable health outcomes, first author Manish K. Mishra, of the Geisel School of Medicine at Dartmouth, and colleagues wrote in BMJ Open. Techniques like goal-setting, motivational interviewing and shared decision-making are all regarded as successful approaches to PAE.

“If patient engagement is the new ‘blockbuster drug,’ why are we not seeing spectacular effects?” Mishra et al. wrote. “Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organizations (ACOs). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown.”

Mishra and coauthors conducted a total of 103 interviews with 68 physicians, nurses, medical assistants and administrators at DaVita HealthCare Partners in Los Angeles and Advocate Healthcare in Chicago—two ACOs with a “reputation for undertaking patient engagement activities.” The professionals were asked about their awareness of, attitudes toward and experiences with PAE, including goal-setting, motivational interviewing and shared decision-making.

Previous research has found that up to 48 percent of primary care providers at ACOs are trained in PAE and 60 percent have specifically trained in shared decision-making techniques. So it was somewhat surprising that, at the two ACOs Mishra et al. studied, understanding of PAEs was limited.

“Many interviewees described PAE techniques in ways that did not align with accepted definitions,” the authors wrote. “As an example, after a question about whether her clinic used tools or forms for goal-setting or shared decision-making, one medical assistant said, ‘I use an Accu machine to check patients’ blood sugar levels.’”

The response suggested the employee equated goal-setting with monitoring clinical indicators, which Mishra and colleagues said isn’t the case. Other common misunderstandings involved equating goal-setting to history-taking or conducting physical exams.

Interviewees told the researchers that low levels of administrative support and limited time barred them from practicing PAE. The low levels of patient activation fell in line with other evidence suggesting PAE implementation in clinical practice is somewhat rare.

“When we asked one member of the management team, for instance, if the ACO worked to prioritize collaborative goal-setting with patients, the response was, ‘No. I really—I guess I really should—it’s just that it doesn’t happen,’” Mishra et al. said. “This admission represented a widespread acknowledgement that PAE was essentially aspirational.”

For PAE to be successful, Mishra and co-authors said it will be important for clinicians to cement strong partnerships with their patients. It’s positive that healthcare is moving away from a fee-for-service model, they said, but as that transition progresses it’ll be important to turn the “rhetoric of patient-centered care into a reality.”

“There was agreement that PAE was a ‘good thing,’ but beyond superficial endorsement we found no evidence that PAE approaches were being adopted into routine care,” the authors wrote of their study. “In fact, we found evidence that PAE techniques were often understood as expedient ways to meet externally driven, biomedical targets.

“If healthcare organizations wish to optimize patient-centered care, we suggest they move beyond a superficial understanding of PAE.”