ORIGINAL ARTICLE
The Active Patient Role and Asthma Outcomes in an Underserved Rural Community Henry N. Young, PhD;1 Tonja L. Larson, PharmD;2 Elizabeth D. Cox, MD, PhD;3 Megan A. Moreno, MD;4 Joshua M. Thorpe, PhD;5 & Neil J. MacKinnon, PhD6 1 Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin, Madison, Wisconsin 2 Department of Clinical Pharmacy Services, Marshfield Clinic, Marshfield, Wisconsin 3 Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 4 Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Research and Foundation, Seattle, Washington 5 Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 6 Center for Rural Health, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
Abstract Purpose: Patient activation, an individual’s knowledge, skills, and confidence The project described was supported by the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011, and now by the National Center for Advancing Translational Sciences (NCATS), grant 9U54TR000021. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have no conflicts of interest to disclose. For further information, contact: Henry N. Young, PhD, 777 Highland Avenue, Madison, WI 53705; e-mail: [email protected]. doi: 10.1111/jrh.12031
for managing their own health and health care, can play an important role in the management of chronic conditions. However, few studies have examined patient activation in underserved rural communities. The purpose of this study was to describe patient activation and examine how patient activation is associated with adherence to asthma maintenance medication and disease control in a low-income rural population with asthma. Methods: We conducted a cross-sectional telephone survey with 98 adults. Patient activation was assessed with the Patient Activation Measure. Adherence to long-term controller (LTC) medications and asthma control were examined using the Morisky Medication Adherence Scale (MMAS) and Asthma Control Test (ACT). Multivariate regression analyses were used to assess the associations between patient activation and: (1) adherence to LTC medications and (2) asthma control. Findings: The majority of participants (50%) were classified in the highest level of patient activation. The least activated participants had lower mean MMAS and ACT scores in comparison to participants who were classified in higher patient activation levels. Multivariate analyses found significant positive associations between patient activation and adherence and asthma control. Conclusions: Patient activation may be instrumental in low-income rural patients’ use of asthma medication and disease control. Study results inform interventions to help patients use asthma medications appropriately and achieve better asthma control. In addition to increasing access to health care services in rural communities, health care professionals also may develop and implement strategies to positively impact rural patients’ involvement in care.
Key words asthma, patient activation, rural, self-management, underserved.
Asthma is a costly chronic condition that is associated with morbidity, mortality, and diminished quality of life.1-4 Significant disparities exist in asthma prevalence and control. Individuals with family incomes below the federal poverty level have higher prevalence of asthma than those at or above the poverty level.4 Although the
c 2013 National Rural Health Association The Journal of Rural Health 30 (2014) 121–127
prevalence of asthma is similar in metropolitan (7.8%) and nonmetropolitan areas (7.9% to 8.6%), limited data suggest that rural patients receive inferior asthma care.5-7 More specifically, researchers have found that rural patients have more emergency department visits and hospitalizations per 100,000 persons per year than urban
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patients, which may indicate difficulties with primary care.8,9 National guidelines stress the importance of disease control as a key therapeutic goal.10 However, many patients (20% to 85%) are not well-controlled or are very poorly controlled.11,12 Poor adherence to long-term controller (LTC) medications (eg, inhaled corticosteroids, long-acting beta agonists, and leukotriene receptor antagonists) is a contributing factor to diminished asthma control.13,14 Up to 80% of patients with asthma have problems adhering to prescribed treatment regimens.15 Researchers have found that knowledge about asthma, positive attitudes about asthma care, and greater self-efficacy regarding self-management are associated with improved medication use, quality of life, and health care utilization, which may be indicative of better asthma control.16-21 The 2005 IOM Report, Quality Through Collaboration: The Future of Rural Health Care, stresses the importance of rural residents’ self-management of chronic conditions (eg, adherence to medication regimens).22 Given the role of medications in controlling asthma, patient activation may be a potential target for improving asthma management among underserved populations. Hibbard and associates conceptualize patient activation as individuals’ knowledge, skills, and confidence for managing their own health and health care.17 They describe 4 levels of patient activation reflecting: (1) peoples’ beliefs about the importance of the patient role; (2) confidence and knowledge necessary to take action; (3) enacting health behaviors (eg, maintaining lifestyle changes, preventing problems, handling symptoms on one’s own); and (4) behavior maintenance even when under stress.17 Recent literature highlights the importance of patient activation in an effort to improve the quality and safety of care.23,24 Patients with low activation are typically passive recipients of care and do not believe in an active patient role, while those with high activation are proactive participants in the care process and actively engage in healthy behaviors.24 Previous studies have found positive associations between patient activation, self-management behaviors, and outcomes. Mosen and associates found that respondents with higher patient activation were more likely to perform self-management behaviors and report greater adherence to medication regimens as well as higher quality of life.21 Hibbard and associates found positive relationships between increases in patient activation and positive changes in medication management behaviors such as asking a physician or pharmacist about medication side effects and how to avoid them.25 Scant research has examined patient activation in disadvantaged and/or rural populations. Lubetkin and associates assessed patient activation in those who received care from inner-city low-income health centers
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and found more patients were characterized as having low activation in comparison to the general population.26 However, the consequences of poverty likely differ in rural and inner-city populations, as low-income rural individuals report worse perceived health than low-income urban individuals.27 Thus, the objectives of this study conducted in a low-income rural population with asthma were: (1) to describe patient activation and (2) to examine how patient activation is associated with adherence to asthma maintenance medication and asthma control.
Methods Population We conducted a cross-sectional telephone survey in a low-income rural population. Patients with asthma who received their medications from the Family Health Center of Marshfield Inc. (FHC), a Federally Qualified Health Center, 340B mail-order pharmacy, were invited to participate. During this study, the FHC service area included an 11-county region in north central Wisconsin and comprised 254 municipalities, 78% of which were populated by less than 1,000 people. The FHC is based in Wood County, which has been designated as a nonmetro county by the Office of Rural Health Policy (Health Resources and Services Administration).28 The FHC targets all individuals living at or below 200% of the federal poverty level who experience barriers to health and dental care. The majority of the service area population (86%) resides in communities that have been designated by the federal government as medically underserved areas and/or a medical, dental, or mental health professional shortage area. This study was approved by the Marshfield Clinic Research Foundation Institutional Review Board and the Health Sciences Institutional Review Board at the University of Wisconsin-Madison. Enrollment criteria included age ≥19 years, Englishspeaking, receipt of ≥1 asthma medication(s) dispensed in the 6-month period ending June 31, 2009, and a diagnosis of asthma. Potential participants were identified by reviewing electronic health records. A total of 576 individuals met the enrollment criteria; 25% were randomly selected to be targeted for the recruitment effort with the intention of enrolling 100 participants. Research assistants mailed letters to prospective participants to introduce the study. Approximately 5 days after the mailing, research assistants contacted prospective participants to determine their willingness to participate in the study. If an individual was interested, the research assistant obtained oral consent and conducted the telephone survey. Prospective participants were contacted until approximately 100 individuals agreed to participate. The
c 2013 National Rural Health Association The Journal of Rural Health 30 (2014) 121–127
Active Patient Role in Rural Asthma Patients
Young et al.
telephone surveys were conducted from January to March 2010.
Variables The Patient Activation Measure (PAM) short form was used to measure patient activation.29 The PAM contains 13 items, rated on a Guttman-like scale. PAM scores can range from 0 to 100, with higher scores indicating greater patient activation.29,30 PAM scores were categorized into 4 standard levels: Level 1 (scores 0-47.0) indicates that an individual may not believe that the patient role is important; Level 2 (scores 47.1-55.1) indicates that an individual may lack confidence and knowledge to take action; Level 3 (scores 55.2-67.0) indicates that an individual is beginning to take action; and Level 4 (scores 67.1-100) indicates an individual may have difficulty maintaining behaviors over time.24 Respondents with PAM scores of 0 or 100 were removed from the dataset due to validity concerns.17,29 Adherence to LTC medications was assessed with the Morisky Medication Adherence Scale (MMAS).31,32 The MMAS is a reliable and valid measure that contains 8 items, with a range of 0 to 8.31 A score of 0 is reflective of the lowest adherence and 8 indicates highest adherence. MMAS scores also were dichotomized, as recommended, to represent low adherers (MMAS
The Active Patient Role and Asthma Outcomes in an Underserved Rural Community Henry N. Young, PhD;1 Tonja L. Larson, PharmD;2 Elizabeth D. Cox, MD, PhD;3 Megan A. Moreno, MD;4 Joshua M. Thorpe, PhD;5 & Neil J. MacKinnon, PhD6 1 Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin, Madison, Wisconsin 2 Department of Clinical Pharmacy Services, Marshfield Clinic, Marshfield, Wisconsin 3 Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 4 Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Research and Foundation, Seattle, Washington 5 Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 6 Center for Rural Health, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
Abstract Purpose: Patient activation, an individual’s knowledge, skills, and confidence The project described was supported by the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011, and now by the National Center for Advancing Translational Sciences (NCATS), grant 9U54TR000021. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have no conflicts of interest to disclose. For further information, contact: Henry N. Young, PhD, 777 Highland Avenue, Madison, WI 53705; e-mail: [email protected]. doi: 10.1111/jrh.12031
for managing their own health and health care, can play an important role in the management of chronic conditions. However, few studies have examined patient activation in underserved rural communities. The purpose of this study was to describe patient activation and examine how patient activation is associated with adherence to asthma maintenance medication and disease control in a low-income rural population with asthma. Methods: We conducted a cross-sectional telephone survey with 98 adults. Patient activation was assessed with the Patient Activation Measure. Adherence to long-term controller (LTC) medications and asthma control were examined using the Morisky Medication Adherence Scale (MMAS) and Asthma Control Test (ACT). Multivariate regression analyses were used to assess the associations between patient activation and: (1) adherence to LTC medications and (2) asthma control. Findings: The majority of participants (50%) were classified in the highest level of patient activation. The least activated participants had lower mean MMAS and ACT scores in comparison to participants who were classified in higher patient activation levels. Multivariate analyses found significant positive associations between patient activation and adherence and asthma control. Conclusions: Patient activation may be instrumental in low-income rural patients’ use of asthma medication and disease control. Study results inform interventions to help patients use asthma medications appropriately and achieve better asthma control. In addition to increasing access to health care services in rural communities, health care professionals also may develop and implement strategies to positively impact rural patients’ involvement in care.
Key words asthma, patient activation, rural, self-management, underserved.
Asthma is a costly chronic condition that is associated with morbidity, mortality, and diminished quality of life.1-4 Significant disparities exist in asthma prevalence and control. Individuals with family incomes below the federal poverty level have higher prevalence of asthma than those at or above the poverty level.4 Although the
c 2013 National Rural Health Association The Journal of Rural Health 30 (2014) 121–127
prevalence of asthma is similar in metropolitan (7.8%) and nonmetropolitan areas (7.9% to 8.6%), limited data suggest that rural patients receive inferior asthma care.5-7 More specifically, researchers have found that rural patients have more emergency department visits and hospitalizations per 100,000 persons per year than urban
121
Active Patient Role in Rural Asthma Patients
patients, which may indicate difficulties with primary care.8,9 National guidelines stress the importance of disease control as a key therapeutic goal.10 However, many patients (20% to 85%) are not well-controlled or are very poorly controlled.11,12 Poor adherence to long-term controller (LTC) medications (eg, inhaled corticosteroids, long-acting beta agonists, and leukotriene receptor antagonists) is a contributing factor to diminished asthma control.13,14 Up to 80% of patients with asthma have problems adhering to prescribed treatment regimens.15 Researchers have found that knowledge about asthma, positive attitudes about asthma care, and greater self-efficacy regarding self-management are associated with improved medication use, quality of life, and health care utilization, which may be indicative of better asthma control.16-21 The 2005 IOM Report, Quality Through Collaboration: The Future of Rural Health Care, stresses the importance of rural residents’ self-management of chronic conditions (eg, adherence to medication regimens).22 Given the role of medications in controlling asthma, patient activation may be a potential target for improving asthma management among underserved populations. Hibbard and associates conceptualize patient activation as individuals’ knowledge, skills, and confidence for managing their own health and health care.17 They describe 4 levels of patient activation reflecting: (1) peoples’ beliefs about the importance of the patient role; (2) confidence and knowledge necessary to take action; (3) enacting health behaviors (eg, maintaining lifestyle changes, preventing problems, handling symptoms on one’s own); and (4) behavior maintenance even when under stress.17 Recent literature highlights the importance of patient activation in an effort to improve the quality and safety of care.23,24 Patients with low activation are typically passive recipients of care and do not believe in an active patient role, while those with high activation are proactive participants in the care process and actively engage in healthy behaviors.24 Previous studies have found positive associations between patient activation, self-management behaviors, and outcomes. Mosen and associates found that respondents with higher patient activation were more likely to perform self-management behaviors and report greater adherence to medication regimens as well as higher quality of life.21 Hibbard and associates found positive relationships between increases in patient activation and positive changes in medication management behaviors such as asking a physician or pharmacist about medication side effects and how to avoid them.25 Scant research has examined patient activation in disadvantaged and/or rural populations. Lubetkin and associates assessed patient activation in those who received care from inner-city low-income health centers
122
Young et al.
and found more patients were characterized as having low activation in comparison to the general population.26 However, the consequences of poverty likely differ in rural and inner-city populations, as low-income rural individuals report worse perceived health than low-income urban individuals.27 Thus, the objectives of this study conducted in a low-income rural population with asthma were: (1) to describe patient activation and (2) to examine how patient activation is associated with adherence to asthma maintenance medication and asthma control.
Methods Population We conducted a cross-sectional telephone survey in a low-income rural population. Patients with asthma who received their medications from the Family Health Center of Marshfield Inc. (FHC), a Federally Qualified Health Center, 340B mail-order pharmacy, were invited to participate. During this study, the FHC service area included an 11-county region in north central Wisconsin and comprised 254 municipalities, 78% of which were populated by less than 1,000 people. The FHC is based in Wood County, which has been designated as a nonmetro county by the Office of Rural Health Policy (Health Resources and Services Administration).28 The FHC targets all individuals living at or below 200% of the federal poverty level who experience barriers to health and dental care. The majority of the service area population (86%) resides in communities that have been designated by the federal government as medically underserved areas and/or a medical, dental, or mental health professional shortage area. This study was approved by the Marshfield Clinic Research Foundation Institutional Review Board and the Health Sciences Institutional Review Board at the University of Wisconsin-Madison. Enrollment criteria included age ≥19 years, Englishspeaking, receipt of ≥1 asthma medication(s) dispensed in the 6-month period ending June 31, 2009, and a diagnosis of asthma. Potential participants were identified by reviewing electronic health records. A total of 576 individuals met the enrollment criteria; 25% were randomly selected to be targeted for the recruitment effort with the intention of enrolling 100 participants. Research assistants mailed letters to prospective participants to introduce the study. Approximately 5 days after the mailing, research assistants contacted prospective participants to determine their willingness to participate in the study. If an individual was interested, the research assistant obtained oral consent and conducted the telephone survey. Prospective participants were contacted until approximately 100 individuals agreed to participate. The
c 2013 National Rural Health Association The Journal of Rural Health 30 (2014) 121–127
Active Patient Role in Rural Asthma Patients
Young et al.
telephone surveys were conducted from January to March 2010.
Variables The Patient Activation Measure (PAM) short form was used to measure patient activation.29 The PAM contains 13 items, rated on a Guttman-like scale. PAM scores can range from 0 to 100, with higher scores indicating greater patient activation.29,30 PAM scores were categorized into 4 standard levels: Level 1 (scores 0-47.0) indicates that an individual may not believe that the patient role is important; Level 2 (scores 47.1-55.1) indicates that an individual may lack confidence and knowledge to take action; Level 3 (scores 55.2-67.0) indicates that an individual is beginning to take action; and Level 4 (scores 67.1-100) indicates an individual may have difficulty maintaining behaviors over time.24 Respondents with PAM scores of 0 or 100 were removed from the dataset due to validity concerns.17,29 Adherence to LTC medications was assessed with the Morisky Medication Adherence Scale (MMAS).31,32 The MMAS is a reliable and valid measure that contains 8 items, with a range of 0 to 8.31 A score of 0 is reflective of the lowest adherence and 8 indicates highest adherence. MMAS scores also were dichotomized, as recommended, to represent low adherers (MMAS
