Healthcare Executives and Patient Agency
Nearly 1/5th of US GDP is dedicated to healthcare expenditures.
Healthcare spending, and its long-term affordability, drives public policy debate, with academics and government agencies annually proposing new plans as part of an agenda to control costs and improve health outcomes. The proposals fit nicely within concepts that seem to promote advantages for patients. An example is the upcoming event, Patient- and Family-Centered Care for Adults with Chronic Conditions, by the U.S. Agency of Healthcare Research and Quality.
Among the many events that seek to address the health care debate, the AHRQ is particularly promising as it examines real examples of patient experiences. However, AHRQ’s efforts could be significantly enhanced if the format and outcomes include direct conversations with healthcare executives – the officials who manage the designs of operations and organizations that affect patients.
At heart, healthcare executives have a unique role in society. They shape the organizational behavior of a diverse industry, including doctors, nurses, pharmacists, technicians, and other that we contact through our medical lives. It is an organizational behavior that informs us, the patients, what we can expect and control in clinical and overall health experiences.
That expectation and control is our “patient agency,” the ability of a patient to evaluate, decide, and act on healthcare matters according to personal preferences. It includes control over (1) visible and understandable information, (2) flexible and efficacious processes, and (3) effective and authoritative decision-making.
Patient agency is critical to the success of healthcare outcomes – and quality healthcare overall, given its direct influence on successful treatment and prevention of the most prevalent health problems, namely chronic diseases and behavior-driven conditions.
And healthcare executives can directly affect patient agency. In fact, that might be where our public policy and plans should begin—where health is foundational to an individual experience—patient agency and the healthcare executive.
What is the scientific research supporting this conversation?
There are numerous examples, some noted below, that demonstrate how the patient is the legitimate leader of her or his health and medical interactions. There is substantial evidence demonstrating the value of patient agency both in the demand for healthcare and the outcomes of treatment.
Patient agency drives healthcare outcomes:
- Greater sense of control enhances patient’s resiliency (Diesnstbier, 1989; Herbert and Cohen, 1993; Sieber et al., 1992; Wiedenfeld et al., 1990).
- Disengaged cancer patients tend to have unfavorable outcomes (DiClemente and Temoshok, 1985; Greer, Morris, and Pettingale, 1979; Pettingale et al., 1985).
- Pain control training produces better dosage schedules and less pain at follow-up (Rimer, Levy, and Keintz, 1987).
- Cardiac patients who can control visits and their timing demonstrated lower mean heart rate and diastolic blood pressure (Lazure and Baun, 1995).
Patient agency is useful in managing service utilization:
- Preparatory information is associated with shorter hospital stays, reduced morbidity, and reduced need for analgesics (Eisendrath, 1987).
- Video presentations on back surgery improved patients’ knowledge about options and reduced the demand for surgery (Deyo et al., 2000; Phelan, 2001).
- Under severe conditions (ovarian cancer), greater understanding of information is a strong determinant of treatment choices (Elit, Levine, and Gafni, 1996).
- Patient-controlled analgesia devices maintain effective concentrations (Hull and Sibbald, 1981) while keeping constant rates (Austin, Stapleton, and Mather, 1980).
Patient agency is reinforced by thoughtful clinical communications:
- Patients’ medical comprehension is dependent on clarity and specificity of the content (Hall, Roter, and Katz, 1988), and manner of delivery (Larsen and Smith, 1981).
- Patient’s medical objectivity is appropriate, given age (Stiggelbout et al., 1996; Yellen, Cella, and Leslie, 1994) and responsibilities (Yellen and Cella, 1995).
- Patients are consistent in medical decisions (Cassileth, Seidman, and Soloway, 1989; Danis et al., 1994; Everhart and Pearlman, 1990; Slevin, Stubbs, and Plat, 1990).
- Patient’s can communicate preferences when multiple trade-offs characterize complicated treatment decisions (Brundage et al., 1998).
A classic study on patient agency was completed at the U.S. Department of Veterans Affairs. VA researchers experimented with how they could affect patient agency through innovative techniques (Greenfield et al., 1985). They found that both veterans and programs could benefit significantly from designs that reinforce patient agency development. The examination was of a 20-minute pre-visit coaching program. The study demonstrated sustained and significant benefits in patient agency and physical health, without additional clinical time. In their conclusions, they contended that without well-developed patient agency, veterans “may not acquire the knowledge, skill, and more importantly the confidence and sense of control they need in the management of chronic disease” (p. 456). The study also illustrated that reinforced patient agency could help manage unnecessary use of healthcare services and improve veterans’ ability to prevent acute health problems.
Patient agency is developed in a person, and reinforced by local experiences. It is the foundational aspect of health outcomes, and largely shaped by the experiences designed by local healthcare executives.
We need to shift our attention away from the grand plans for healthcare and look to the value of the local leadership – leadership in personal health and healthcare services. Our common national objectives, lower cost, quality care, better outcomes begin with patients, not bureaucrats. We need to align our reform processes accordingly.