Health Services Research & Development

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Patient Engagement and Diabetes Self-Management

At any given time, over 1 million Veterans receive health care services for diabetes, and many suffer adverse vascular outcomes, such as myocardial infarction, blindness, and peripheral artery disease. Glycemic control, as measured by hemoglobin (Hb) A1c, is associated with lower morbidity and mortality. Given that diabetes is a self-managed condition, achieving diabetes control requires patient involvement in most aspects of treatment planning and management.

Patient-reported measures, such as functional health literacy (FHL) and patient activation, play critical roles in achieving diabetes control through enhanced diabetes self-management. 1, 2 Thus, identifying these characteristics and incorporating information on these characteristics into routine self-management and collaborative goal setting may lead to better patient outcomes. The ability to integrate information about FHL and patient activation into the context of traditional primary care encounters is, however, limited. Nonetheless, VA's transition to Patient Aligned Care Teams (PACT) provides an opportunity for developing and implementing patient-centered, personalized approaches to diabetes care that are aligned with patient preferences.

While the independent effects of FHL and patient activation on diabetes control are well documented, their combined effect is less clear. Using brief, validated screening measures, we explored the relationship between/among FHL, patient activation, and glycemic control in a cohort of multimorbid, diabetic Veterans receiving care within VA PACTs.

Using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnoses codes and relevant ICD-9-CM and Current Procedural Terminology procedure codes, we identified Veterans who had coexisting hypertension, diabetes, and ischemic heart disease and were receiving primary care between November and December 2010. We excluded patients with limited life expectancy and those who died during the study period. We mailed to eligible participants a self-administered questionnaire with brief measures of FHL and patient activation and then collected laboratory, demographic, and clinical data from the medical records of the patients who returned surveys. Using validated scoring for the Single Item Literacy Screener and the Patient Activation Measure, we classified patients based on their level of health literacy and patient activation into four categories. 3 We based these categories on combined high versus low levels of FHL and patient activation, e.g. high FHL/high activation. Subsequently, we examined the relationship between/among patients' self-reported FHL, patient activation, and mean HbA1c levels.

We received surveys from 195 individuals (50 percent response rate). Of those, we studied 183 individuals (94 percent) with complete data for all variables in the analyses. The mean age of the study cohort was 68 years. We found a normal distribution for FHL and patient activation, with approximately 50 percent of participants reporting high FHL and 45 percent reporting high patient activation. Patients identified with both high FHL and patient activation (i.e., high FHL/high activation) had significantly lower HbA1c levels compared to those with low levels of both FHL and patient activation.

Providing high-quality care to patients with diabetes can pose significant challenges. However, VA's transformation to the PACT model of care offers the ideal setting in which to meet these challenges. One approach to providing more personalized care is to incorporate into routine PACT care patient self-reported measures (e.g., FHL and patient activation) that have been shown to influence diabetes outcomes. We demonstrated that brief, validated measures of FHL and patient activation may be feasibly obtained among multimorbid Veterans within the context of primary care encounters. Further, we found that the combined effects of FHL and patient activation are associated with better glycemic levels. Thus, understanding patients' FHL and activation levels may result in more personalized care and a greater likelihood of diabetes control.

Future research is needed to inform how measures of FHL and patient activation can be efficiently integrated into routine discussions between patients and their clinicians. Interventions that incorporate information about patients' FHL and activation levels hold promise for providing collaborative care that is personalized to patients' desired level of engagement and understanding of diabetes self-management.

  1. Schillinger, D. et al. "Association of Health Literacy with Diabetes Outcomes," The Journal of the American Medical Association 2002; 288:475-82.
  2. Remmers, C. et al. "Is Patient Activation Associated with Future Health Outcomes and Healthcare Utilization among Patients with Diabetes?" The Journal of Ambulatory Care Management 2009; 32:320-7.
  3. Morris, N.S. et al. "The Single Item Literacy Screener: Evaluation of a Brief Instrument to Identify Limited Reading Ability," BMC Family Practice 2006; 7:21.