Enhancing Veteran engagement with health care is the foundation for VHA's strategic goal to "advance health care that is personalized, proactive, and patient-driven. " Evidence shows that patients differ in the aptitude and motivation to engage with health care. This is often conceptualized as the degree of patient activation, describing an active role orientation to health care. High patient activation characterizes individuals who seek health information, self-manage chronic conditions, and express preferences in health care encounters. Effective interventions have increased activation levels and improved health outcomes among individuals with chronic conditions and with mental health conditions. Such interventions are promising approaches to promoting health equity among Veterans Health Administration (VHA) users. However, a critical barrier to implementing such interventions is the absence of a reliable and valid measure of activation that reflects the needs of Veterans and is sufficiently brief for integration into routine clinical practice.
The broad objectives of this program of research are to develop a brief measure of patient activation for use in VHA. Specific aims of this pilot project were to: a) Refine the operational definition of patient activation based on Veteran input; and b) Conduct cognitive testing of items that correspond to the construct definition. Completed objectives will result in an item pool to measure of patient activation that is suitable for quantitative psychometric analysis in a subsequent study.
The study methods were guided by the National Institutes of Health Patient-Reported Outcome Measurement Information System (PROMIS) instrument maturity model. Stage 1 of the PROMIS model provides guidelines for defining a construct and deriving a corresponding pool of items using qualitative methods. First, a preliminary operational definition was created based on a review of the literature, and a theoretical framework was identified. This definition was reviewed by a panel of experts. To refine the definition, individual, semi-structured interviews were conducted with 26 Veterans receiving treatment for mental health conditions or chronic medical conditions. Themes from qualitative data were coded using framework analysis. Next, psychometric measures of related constructs were reviewed, and relevant items were mapped to the construct definition. New items were developed to address gaps in construct coverage. Items were reviewed by investigators or content experts. Items were evaluated by cognitive testing interviews with 34 Veterans, and revised for relevance and comprehension.
Qualitative results mapped well to the theoretical framework for patient engagement. Based on these results, the construct name and definition were refined to focus on the propensity to engage with care. Descriptions of an active role orientation were common, but inconsistently included content referring to engagement behaviors, suggesting that the patient activation construct may not be a useful proxy for patient engagement among Veterans. The definition for engagement was comprised of the following categories of behaviors: self-management; shared decision-making; health literacy behaviors; and healthcare navigation. Emergent themes of barriers and facilitators were also integrated into the construct definition. Individuals with a high propensity to engage are better able to both overcome personal and systems barriers and to make use of social and instrumental resources that facilitate engagement. Veteran identity was referenced in descriptions of several barriers and facilitators. New items were added to the item pool to address engagement behaviors not represented on other scales and to incorporate barriers and facilitators. Cognitive testing led to several important modifications in item wording and response options. After the successful completion of study objectives, a total of 75 items that map to the construct definition of Veteran engagement are ready for quantitative psychometric evaluation in the next stage of this research.
This study established a construct definition of Veteran engagement and drafted an item pool that will lead to a brief patient-reported measure of the propensity to engage with health care. The anticipated impact of this measure is to help Veterans achieve maximum benefit from health care services. The VHA population has a high burden of chronic illness. The demands of treatment for chronic conditions can be substantial for Veterans, and account for disproportionate amounts of VHA health care costs. A patient-reported measure of the propensity to engage has potential to enhance population health management. This information can be used to target and tailor coaching, decision support, and patient-facing messaging. This work will catalyze efforts to promote engagement with care by developing flexible and practical assessment tools that are applicable to Veterans with a range of chronic conditions.
- Javorka M, Wong AC, Lewis ET, Zulman DM, Kimerling R. Differences in engagement in VA health care among Veterans with and without Posttraumatic Stress Disorder. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2016 Nov 10; Dallas, TX.
- Kimerling R, Lewis ET, Wong AC, Javorka M, Zulman DM. The rules of engagement: veteran interactions with healthcare. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Sep 19; Boston, MA.
- Kimerling R. Access and engagement panel. Poster session presented at: VA HSR&D Field-Based Optimizing Evidence-Based Treatments for PTSD Meeting; 2016 Jun 27; Chaska, MN.
- Bergman AA, Hamilton AB, Chrystal JG, Kimerling R, Bean-Mayberry BA, Strauss J, Yano E. Primary Care Provider Experiences Delivering Care to Women Veterans with Histories of Military Sexual Trauma. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.