Sunday, January 3, 2016

Patient Engagement Perils
For health care professionals, patient engagement is the holy grail of health care.  It is the key to patient adherence – a prerequisite to achieving better outcomes, fewer ER visits and hospitalizations and more satisfied patients.  It is easy to recognize an engaged patient – they do what their health care providers recommend.

Steven Wilkins, MPH,  Patent Engagement,  January 27, 2012,  Kevin Pho website
Patient engagement is the rage these days.  It sounds so beguilingly simple – engage patients in their own health care,  and you will achieve the “triple aim” of improving  outcomes, bettering care, and lowering costs.
In the early 1990’s,  I learned the hard way that patient engagement  was not so simple.

My idea was simple.   Use an algorithm to gauge  patient’s state of health,  their “Health IQ” I called it,  by  recording  and combining their own  weight,  blood pressure, waist size, family history of heart disease,   cholesterol and its subunits (HDL and LDL), and blood sugar  and then sending patients a confidential personal letter telling  them  of their relative state of health compared to an ideal normal state of health.   The patient was then advised of what to do if their Health IQ were high, normal, or low.  Those with low values were advised to see their doctor.
The results and consequences were not so simple.    The study involved 4000 patients working for state government.   About one-third has low health IQs, mostly due to diabetes,  hypertension, and abnormal  cholesterol values.   The patients ,  their doctors, and their employer not so happy.  Many patients thought  their privacy had been invaded by their employer,  some doctors felt their  autonomy had been compromised,  and the employer was alarmed by the costs of follow-up.
In retrospect,  I should not have  been surprised.  Among Americans,    10% - 20% of Americans are diabetic or pre-diabetic,   25% -33% are hypertensive,  40% to 50% are obese, and  another  20% or so have abnormal  lipid values.   And the fact that government workers tend to have sedentary office jobs  made some of these numbers worse.
The lessons here are:
One, consider the number of likely abnormals in the population you are studying.
Two,  anticipate reactions, costs, and consequences   of your wellness evaluation among the parties involved.
Three,  nothing is simple when you are trying to improve peoples’ health, especially when it entails changing their behavior, altering their health habits,  deciding how health care should be paid for,  who to employ and how much they should be rewarded  or docked for their ill or good health.
It may be worthwhile to study the successes of some well-known  “wellness” programs,  although they are not labeled as such.
Weight Watchers,  which succeeds by focusing on one health problem,  obesity, then following up with regular group therapy sessions highlighted by group applause for weight-losers.
Alcoholic Anonymous,   with its focuses on addiction,   a 12 step quasi-religious  program featuring self-confessions,  mutual support, and regular meetings to quell  relapses.
These organizations address  one big health  problem at a time, rather than many problems at once, even though they may be interrelated,   and they address groups rather than individuals, as I tried to do.  Changing  habits  that may lead to chronic disease or poor health,  does not change human nature.  Perhaps  modern technologies,  with the iphone and self-monitoring  devices like  the Apple Watch or wearable apps,  will promote self-help health.

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