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Patient Activation and Improved Outcomes in HIV-Infected Patients

ABSTRACT

BACKGROUND

The Patient Activation Measure (PAM) assesses several important concepts in chronic care management, including self-efficacy for positive health behaviors. In HIV-infected populations, better self-efficacy for medication management is associated with improved adherence to antiretroviral medications (ARVs), which is critically important for controlling symptoms and slowing disease progression.

OBJECTIVE

To determine 1) characteristics associated with patient activation and 2) associations between patient activation and outcomes in HIV-infected patients.

DESIGN

Cross-sectional survey.

PARTICIPANTS

433 patients receiving care in four HIV clinics.

METHODS

An interviewer conducted face-to-face interviews with patients following their HIV clinic visit. Survey data were supplemented with medical record abstraction to obtain most recent CD4 counts, HIV viral load and antiretroviral medications.

MAIN MEASURES

Patient activation was measured using the 13-item PAM (possible range 0–100). Outcomes included CD4 cell count > 200 cells/mL3, HIV-1 RNA < 400 copies/mL (viral suppression), and patient-reported adherence.

KEY RESULTS

Overall, patient activation was high (mean PAM = 72.3 [SD 16.5, range 34.7–100]). Activation was lower among those without vs. with a high school degree (68.0 vs. 74.0, p < .001), and greater depression (77.6 lowest, 70.2 middle, 68.1 highest tertile, p < .001). There was no association between patient activation and age, race, gender, problematic alcohol use, illicit drug use, or social status. In multivariable models, every 5-point increase in PAM was associated with greater odds of CD4 count > 200 cells/mL3 (aOR 1.10 [95 % CI 1.01, 1.21]), adherence (aOR 1.18 [95 % CI 1.09, 1.29]) and viral suppression (aOR 1.08 [95 % CI 1.00, 1.17]). The association between PAM and viral suppression was mediated through adherence.

CONCULSIONS

Higher patient activation was associated with more favorable HIV outcomes. Interventions to improve patient activation should be developed and tested for their ability to improve HIV outcomes.

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REFERENCES

  1. 1.

    Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2–4.

    PubMed  CAS  Google Scholar 

  2. 2.

    Hibbard JH, et al. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Heal Serv Res. 2004;39(4 Pt 1):1005–1026.

    Article  Google Scholar 

  3. 3.

    Hibbard JH, Greene J, Tusler M. Improving the outcomes of disease management by tailoring care to the patient’s level of activation. Am J Manag Care. 2009;15(6):353–360.

    PubMed  Google Scholar 

  4. 4.

    Deen D, et al. Asking questions: the effect of a brief intervention in community health centers on patient activation. Patient Educ Couns. 2011;84(2):257–260.

    PubMed  Article  Google Scholar 

  5. 5.

    Hibbard JH, et al. Do increases in patient activation result in improved self-management behaviors? Heal Serv Res. 2007;42(4):1443–1463.

    Article  Google Scholar 

  6. 6.

    Mosen DM, et al. Is patient activation associated with outcomes of care for adults with chronic conditions? J Ambul Care Manag. 2007;30(1):21–29.

    Google Scholar 

  7. 7.

    Schackman BR, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care. 2006;44(11):990–997.

    PubMed  Article  Google Scholar 

  8. 8.

    Gifford AL, Groessl EJ. Chronic disease self-management and adherence to HIV medications. J Acquir Immune Defic Syndr. 2002;31(Suppl 3):S163–S166.

    PubMed  Article  Google Scholar 

  9. 9.

    Gifford AL, et al. Pilot randomized trial of education to improve self-management skills of men with symptomatic HIV/AIDS. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(2):136–144.

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Yeni PG, et al. Antiretroviral treatment for adult HIV infection in 2002: updated recommendations of the International AIDS Society-USA Panel.[see comment][erratum appears in JAMA. 2003 Jan-Feb;11(1):32]. JAMA. 2002;288(2):222–235.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Haubrich RH, et al. The value of patient-reported adherence to antiretroviral therapy in predicting virologic and immunologic response. California Collaborative Treatment Group. AIDS. 1999;13(9):1099–1107.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Muma RD, et al. Zidovudine adherence among individuals with HIV infection. AIDS Care. 1995;7(4):439–447.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Rodriguez-Rosado R, et al. Virological failure and adherence to antiretroviral therapy in HIV-infected patients. AIDS. 1998;12(9):1112–1113.

    PubMed  CAS  Google Scholar 

  14. 14.

    Ironson G, et al. The impact of improved self-efficacy on HIV viral load and distress in culturally diverse women living with AIDS: the SMART/EST Women’s Project. AIDS Care. 2005;17(2):222–236.

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Gebo KA, Moore RD, Fleishman JA. The HIV Research Network: a unique opportunity for real time clinical utilization analysis in HIV. Hopkins HIV Rep. 2003;15(6):5–6.

    PubMed  Google Scholar 

  16. 16.

    Hibbard JH, et al. Development and testing of a short form of the patient activation measure. Heal Serv Res. 2005;40(6 Pt 1):1918–1930.

    Article  Google Scholar 

  17. 17.

    Skolasky RL, et al. Psychometric properties of the patient activation measure among multimorbid older adults. Heal Serv Res. 2011;46(2):457–478.

    Article  Google Scholar 

  18. 18.

    Skolasky RL, et al. Psychometric properties of the Patient Activation Measure among individuals presenting for elective lumbar spine surgery. Qual Life Res. 2009;18(10):1357–1366.

    PubMed  Article  Google Scholar 

  19. 19.

    Stepleman L, et al. Validation of the patient activation measure in a multiple sclerosis clinic sample and implications for care. Disabil Rehabil. 2010;32(19):1558–1567.

    PubMed  Article  Google Scholar 

  20. 20.

    Cacciola JS, et al. Initial evidence for the reliability and validity of a “Lite” version of the Addiction Severity Index. Drug Alcohol Depend. 2007;87(2–3):297–302.

    PubMed  Article  Google Scholar 

  21. 21.

    Adler NE, et al. Relationship of subjective and objective social status with psychological and physiological functioning: preliminary data in healthy white women. Heal Psychol. 2000;19(6):586–592.

    Article  CAS  Google Scholar 

  22. 22.

    Ostrove JM, et al. Objective and subjective assessments of socioeconomic status and their relationship to self-rated health in an ethnically diverse sample of pregnant women. Heal Psychol. 2000;19(6):613–618.

    Article  CAS  Google Scholar 

  23. 23.

    Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.

    Article  Google Scholar 

  24. 24.

    Lu M, et al. Optimal recall period and response task for self-reported HIV medication adherence. AIDS Behav. 2008;12(1):86–94.

    PubMed  Article  Google Scholar 

  25. 25.

    Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: Conceptual, strategic and statistical considerations. J Personal Soc Psychol. 1986;51:1173–1182.

    Article  CAS  Google Scholar 

  26. 26.

    MacKinnon DP, Fairchild AJ, Fritz MS. Mediation analysis. Annu Rev Psychol. 2007;58:593–614.

    PubMed  Article  Google Scholar 

  27. 27.

    Sobel ME, ed. Asymptotic confidence intervals for indirect effects in structural equation models. In: Leinhardt S, ed. Sociological Methodology. Washington, D.C: American Sociological Association; 1982.

  28. 28.

    Fowles JB, et al. Measuring self-management of patients’ and employees’ health: further validation of the Patient Activation Measure (PAM) based on its relation to employee characteristics. Patient Educ Couns. 2009;77(1):116–122.

    PubMed  Article  Google Scholar 

  29. 29.

    Donald M, et al. The role of patient activation in frequent attendance at primary care: a population-based study of people with chronic disease. Patient Educ Couns. 2011;83(2):217–221.

    PubMed  Article  Google Scholar 

  30. 30.

    Hibbard JH, et al. Assessing activation stage and employing a “next steps” approach to supporting patient self-management. J Ambul Care Manag. 2007;30(1):2–8.

    Google Scholar 

  31. 31.

    Wong ST, Peterson S, Black C. Patient activation in primary healthcare: a comparison between healthier individuals and those with a chronic illness. Med Care. 2011;49(5):469–479.

    PubMed  Article  Google Scholar 

  32. 32.

    Lubetkin EI, Lu WH, Gold MR. Levels and correlates of patient activation in health center settings: building strategies for improving health outcomes. J Health Care Poor Underserved. 2010;21(3):796–808.

    PubMed  Article  Google Scholar 

  33. 33.

    Hibbard JH, et al. How engaged are consumers in their health and health care, and why does it matter? Res Briefs. 2008;8:1–9.

    Google Scholar 

  34. 34.

    Green CA, et al. Development of the Patient Activation Measure for mental health. Adm Policy Ment Health. 2010;37(4):327–333.

    PubMed  Article  Google Scholar 

  35. 35.

    Grenard JL, et al. Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis. J Gen Intern Med. 2011;26(10):1175–1182.

    PubMed  Article  Google Scholar 

  36. 36.

    van Servellen G, et al. Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women. AIDS Patient Care Stds. 2002;16(6):269–281.

    PubMed  Article  Google Scholar 

  37. 37.

    Angelino AF, Treisman GJ. Management of psychiatric disorders in patients infected with human immunodeficiency virus. Clin Infect Dis. 2001;33(6):847–856.

    PubMed  Article  CAS  Google Scholar 

  38. 38.

    Florence E, et al. Factors associated with a reduced CD4 lymphocyte count response to HAART despite full viral suppression in the EuroSIDA study. HIV Med. 2003;4(3):255–262.

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Gifford AL, et al. Predictors of self-reported adherence and plasma HIV concentrations in patients on multidrug antiretroviral regimens. J Acquir Immune Defic Syndr. 2000;23(5):386–395.

    PubMed  CAS  Google Scholar 

  40. 40.

    Simoni JM, et al. Efficacy of interventions in improving highly active antiretroviral therapy adherence and HIV-1 RNA viral load. A meta-analytic review of randomized controlled trials. J Acquir Immune Defic Syndr. 2006;43(Suppl 1):S23–S35.

    PubMed  Article  Google Scholar 

  41. 41.

    Arnsten JH, et al. Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring. Clin Infect Dis. 2001;33(8):1417–1423.

    PubMed  Article  CAS  Google Scholar 

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Acknowledgements

Contributors

All authors who contributed to the manuscript meet the criteria for authorship.

Funders

This research was supported by a contract from the Health Resources Service Administration and the Agency for Healthcare Research and Quality (AHRQ 290-01-0012). Dr. Korthuis’ time was supported by the National Institutes of Health, National Institute on Drug Abuse (K23DA019809). Dr. Beach was supported by the Agency for Healthcare Research and Quality (K08 HS013903-05), and both Dr. Beach and Dr. Saha were supported by Robert Wood Johnson Generalist Physician Faculty Scholars Awards. Dr. Saha is supported by the Department of Veterans Affairs. The contents of the publication are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies or the U.S. government.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

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Correspondence to P. Todd Korthuis MD, MPH.

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Marshall, R., Beach, M.C., Saha, S. et al. Patient Activation and Improved Outcomes in HIV-Infected Patients. J GEN INTERN MED 28, 668–674 (2013). https://doi.org/10.1007/s11606-012-2307-y

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KEY WORDS

  • patient activation
  • HIV
  • self-efficacy
  • medication adherence
  • patient outcomes