The Interaction Between Patient Activation And Patient-clinician Relationship Quality: Implications For Ambulatory Heart Failure Care

Abstract

Introduction Heart failure (HF) management is complex, requiring dedication from patient and clinician. Patient activation is associated with improved health outcomes, higher patient satisfaction, and decreased costs. Patient-clinician relationship quality may play a key role, with some studies finding that increased patient trust is associated with higher subjective health and patient activation; others suggest that patient activation is endogenous to the patient. Within this context, we aimed to understand how patient activation is produced and maintained among patients with HF. Methods The Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction Trial (EPIC-HF) randomized patients to usual care or a novel pre-clinic activation tool for prescribing. Of 290 study visits, 32 intervention clinic-appointments were audio recorded. 22 participated in an interview, during which the clinic recording was used as an elicitation tool to discuss patient recollections of the appointment and intervention. Interviews were transcribed and analyzed using content analysis. We developed codes iteratively and analyzed data within and across interviews to identify themes. We used method triangulation to confirm our findings with clinic recordings. Results Patient-clinician relationship quality and patient activation shaped patients’ perceptions of their role in medical care. We identified four situational typologies consisting of high/low patient activation and high/low relationship quality. Patients with a high-quality relationship either felt comfortable and engaged with their care, actively communicating with their clinician (Supported), or trusted their clinician to make decisions (Deferential). Those with a low-quality relationship were either spurred to action by negative interactions, (Skeptical), or felt unable to speak up (Unempowered). Typologies were sensitive to time and context—several patients described one typology in reference to a past clinician, but a different typology in reference to their current clinician. Finally, patient activation was not produced by the patient-clinician relationship, but rather moderated by it: patients who were naturally engaged might become more engaged as a result of a given patient-clinician dynamic, and vice-versa. Conclusion Patient-clinician relationship quality and patient activation do not operate separately or have a linear relationship. Rather, the interaction of relationship and activation informs patients’ perceptions of their role in managing their treatment; this interaction is fluid across contexts. These findings raise questions about how these typologies shape health over time, how experiences in multiple typologies shape patients’ overall activation in their care, and whether different typologies are more/less advantageous at different disease stages. Heart failure (HF) management is complex, requiring dedication from patient and clinician. Patient activation is associated with improved health outcomes, higher patient satisfaction, and decreased costs. Patient-clinician relationship quality may play a key role, with some studies finding that increased patient trust is associated with higher subjective health and patient activation; others suggest that patient activation is endogenous to the patient. Within this context, we aimed to understand how patient activation is produced and maintained among patients with HF. The Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction Trial (EPIC-HF) randomized patients to usual care or a novel pre-clinic activation tool for prescribing. Of 290 study visits, 32 intervention clinic-appointments were audio recorded. 22 participated in an interview, during which the clinic recording was used as an elicitation tool to discuss patient recollections of the appointment and intervention. Interviews were transcribed and analyzed using content analysis. We developed codes iteratively and analyzed data within and across interviews to identify themes. We used method triangulation to confirm our findings with clinic recordings. Patient-clinician relationship quality and patient activation shaped patients’ perceptions of their role in medical care. We identified four situational typologies consisting of high/low patient activation and high/low relationship quality. Patients with a high-quality relationship either felt comfortable and engaged with their care, actively communicating with their clinician (Supported), or trusted their clinician to make decisions (Deferential). Those with a low-quality relationship were either spurred to action by negative interactions, (Skeptical), or felt unable to speak up (Unempowered). Typologies were sensitive to time and context—several patients described one typology in reference to a past clinician, but a different typology in reference to their current clinician. Finally, patient activation was not produced by the patient-clinician relationship, but rather moderated by it: patients who were naturally engaged might become more engaged as a result of a given patient-clinician dynamic, and vice-versa. Patient-clinician relationship quality and patient activation do not operate separately or have a linear relationship. Rather, the interaction of relationship and activation informs patients’ perceptions of their role in managing their treatment; this interaction is fluid across contexts. These findings raise questions about how these typologies shape health over time, how experiences in multiple typologies shape patients’ overall activation in their care, and whether different typologies are more/less advantageous at different disease stages.