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P E R S P E C T I V E S
V A R I A T I O N S
W E B  E X C L U S I V E   

7 October 2004  
  

Perspective: 
Moving Toward A More 
Patient-Centered 
Health Care Delivery System

Measuring patients’ engagement and activation
should be made a routine part of quality assessment.

By Judith H. Hibbard

ABSTRACT:

Quality-of-care measurement has not kept pace with the recent shift toward policy approaches that rely on patients to contain costs and improve quality. If patients are to play a critical role in care, then the degree to which providers support and improve patients’ capabilities for participation must also be part of the quality measurement picture. Quality measures that focus on intermediate patient outcomes (such as self-management ability), that follow the patient over time, and that integrate measurement into the processes of care are necessary to move toward a delivery system that is centered on patients.

Current health policy directions rely on consumers and patients to play a critical role in containing costs and improving quality. Central to this policy direction is the belief that with more financial risk sharing and access to new information sources, consumers will not only become more prudent users of care but will also become more engaged and “in charge” of their own care, accepting a higher level of responsibility and acquiring the knowledge and skills to be effective in this new role.¹ As the personal consequences of individual choices are made more clear, the stakes are being raised for individual consumers. At the same time, effective functioning of the larger delivery system is also at stake.

Quality-of-care measurement capability has not kept pace with this shift to patient-centric approaches. Despite the rhetoric about patient-centered care, few attempts have been made to measure and improve in this arena. If patients are to play a critical role in care, then the degree to which providers support and improve their capabilities for participation must also be part of quality measurement.

Karen Sepucha and colleagues and Annette O’Connor and colleagues elaborate on an approach to measuring and improving one element of patient-centered care: incorporating patients’ values into the choice of treatments.² The authors call for improving the support of patients’ decision making as a way to reduce unwarranted variations, expand patient-centered care, and improve quality. They make a case for the development of metrics of patient decision quality and suggest that those metrics be used to provide rewards and incentives to providers who perform well on them.

The patient’s role. The authors make four key points that, taken together, represent an important shift in thinking about the patient’s role in care, what constitutes high-quality care, and how it should be measured.

First, the idea of measuring the quality of patient decision making explicitly acknowledges that patients are key players in health care. It focuses measurement on the patient and on patient outcomes. What patients do makes a difference; their role in the care process is not just that of a passive recipient. Yet there are almost no quality metrics that assess, or even recognize, patients’ critical role.

Second, good care is not just providing patients with the facts associated with their conditions and treatment options; it also means assuring that they have the skills and tools to function adequately in the decisionmaker role. The authors’ focus on an intermediate patient outcome (high-quality decisions) is important. In the past, patient education, counseling, and coaching have rarely been held to this standard. Most clinicians feel that they have done an adequate job when they give patients information to make choices or manage their conditions. However, the idea of measuring intermediate outcomes suggests that it isn’t whether the patient was given the information (a process measure), but whether the patient understands adequately, can use the information in choice, and can make a good choice (an intermediate outcome). Holding providers accountable for intermediate patient outcomes is truly a sea change.

Third, Sepucha and colleagues imply that measurement should capture what happens to a patient over time. It may be necessary to measure at more than one point in time to understand how care is affecting patient’s experiences, what they value, and the consequences of their choices for their quality of life and health.

Finally, both sets of authors suggest that measurement can be integrated into care delivery and improve patient care. That is, measuring intermediate patient outcomes (patient decision quality) presents an opportunity to improve care for that patient as well as to assess quality across groups of patients making similar clinical choices.

Focus on chronic illness and beyond. The focus in these two papers is only a small slice of the patient experience. Yet patients make many more choices in their day-to-day lives that have far more impact on their health and well-being than the narrow set of clinical choices these authors discuss. Patients with chronic diseases often must follow complex treatment regimens, monitor their conditions, make lifestyle changes, and make decisions about when they need to seek care and when they can handle a problem on their own. Effectively functioning in the role of self-manager, particularly when living with one or more chronic illnesses, requires a high level of knowledge, skill, and confidence.

A growing body of evidence shows that patients who are engaged, active participants in their own care have better health outcomes and measurable cost savings.³ Training patients with chronic diseases to manage their illnesses is effective in increasing functioning, reducing pain, and reducing health care costs.⁴ Thus, if one of the aims of patient-centered care is to produce better health outcomes, then it should include an explicit focus on supporting patients in their role as self-managers.

Measuring patients’ ability to manage their care. Supporting patients in their role is part of good care. Just as there is a need for measurement in the quality of patient decisions, there is also a need to measure patient self-management capability. If clinicians measured each patient’s level of knowledge, skill, and confidence for self-management (also referred to as “patient activation”), they could be much more targeted in how they educate and support patients and likely be more effective in promoting patient self-management.⁵

Similarly, measuring patient activation could be integrated into the processes of care; it could be one of the vital signs taken at each visit and could provide clinicians with information that is critical to informing and tailoring patient care plans. Measuring patient activation thus can be used both to improve the care of the patient being measured and for broader quality improvement efforts. Because we expect that patients receiving high-quality care should, over time, grow in their ability to self-manage, the patient activation measure could be used as a key intermediate outcome for quality improvement, accountability, and providing rewards and incentives to high-performing clinicians.

Feedback thus can be given to providers about which interventions and care processes are most effective in helping patients function in their expanded role. Further, delivery systems can stratify their enrolled patient populations not only by health risk level (level of resource consumption) but also by their activation level; this would enable early intervention with patients who lack the skills to self-manage before they inevitably move to a higher health-risk group.

Process measures. This is not to say that process measures are unimportant in patient-centered care. There is a need for evidence that the necessary processes are in place to support patients’ role in care. Process measures that assess different elements of patient-centered care are now becoming available.⁶ Among others, Hospital CAHPS (Consumer Assessment of Health Plans, HCAHPS) and Ambulatory CAHPS (ACAHPS) are soon to join the CAHPS family of measures that assess patients’ experiences in different care settings.⁷

While these two papers expand our thinking about patient-centric measures of quality, they only begin to touch on the possibilities. Measurement must be extended to assess intermediate patient outcomes in the areas where patients play a key role in determining outcomes. The likelihood that we will be able to move health care to a more patient-centric system depends, in large part, on our ability to also shift performance measurement in this direction.

The author acknowledges the helpful review comments provided by Joyce Dubow, Eldon Mahoney, and Jessica Greene and the assistance provided by Martin Tusler.

NOTES

1. J.K. Iglehart, “Changing Health Insurance Trends,” New England Journal of Medicine 347, no. 12 (2002): 956–962; and R.E. Herzlinger, “Let’s Put Consumers in Charge of Health Care,” Harvard Business Review 80, no. 7 (2002): 44–50, 52–55, 123.
2. K.R. Sepucha, F.J. Fowler Jr., and A.G. Mulley Jr., “Policy Support for Patient-Centered Care: The Need for Measurable Improvements in Decision Quality,” Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.var.54; and A.M. O’Connor, H.A. Llewellyn-Thomas, and A.B. Flood, “Modifying Unwarranted Variations in Health Care: Shared Decision Making using Patient Decision Aids,” Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.var.63.
3. See, for example, M. Von Korff et al., “A Randomized Trial of a Lay Person–Led Self-Management Group Intervention for Back Pain Patients in Primary Care,” Spine 23, no. 23 (1998): 2608–2615; T. Bodenheimer et al., “Patient Self-Management of Chronic Disease in Primary Care,” Journal of the American Medical Association 288, no. 19 (2002): 2469–2475; and R. Glasgow, “Technology and Chronic Care” (Presented at the Congress on Improving Chronic Care: Innovations in Research and Practice, Seattle, Washington, 8–10 September 2002).
4. K.R. Lorig et al., “Evidence Suggesting That a Chronic Disease Self-Management Program Can Improve Health Status while Reducing Hospitalization: A Randomized Trial,” Medical Care 37, no. 1 (1999): 5–14.
5. J.H. Hibbard et al., “Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patient and Consumers,” Health Services Research 39, no. 4 (2004): 1005–1026.
6. R.E. Glasgow et al., “Development and Validation of the Patient Assessment of Chronic Illness Care (PACIC),” Medical Care (forthcoming); E.A. Coleman, E. Mahoney, and C. Parry, “Assessing the Quality of Preparation for Post-Hospital Care from the Patient’s Perspective: The Care Transitions Measure (CTM),” Medical Care (forthcoming); E. Mahoney, “Patient-Centered Care: An Equal Interval Measure to Facilitate Improvement in the Quality of the Hospital Care Experience,” PeaceHealth Quality Improvement Research Report (Bellingham, Wash.: Peace-Health, September 2002); and D.G. Safran et al., “Measuring Patients’ Experiences with Individual Physicians,” Journal of General Internal Medicine 19 Supp. (2004): 177.
7. For more information, see the CAHPS Survey Users Network home page, www.cahps-sun.org/home/index.asp.

Judith Hibbard (Jhibbard{at}uoregon.edu) is a professor of health care policy in the Department of Planning, Public Policy, and Management, University of Oregon, in Eugene.

DOI: 10.1377/hlthaff.var.133
©2004 Project HOPE–The People-to-People Health Foundation, Inc.