Patient Engagement

Patient Engagement Survey: What Creates Behavior Change May Not Sustain It

Insights Report · May 17, 2018

Analysis of the NEJM Catalyst Insights Council Survey on Patient Engagement: Driving and Sustaining Behavior Change. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Kevin G. Volpp and Namita Seth Mohta

Health care leaders are largely committed to the idea that they must play a role in helping patients adopt and maintain behaviors to prevent disease and promote wellness. However, results of a new NEJM Catalyst Insights Council survey reveal a healthy dose of skepticism about the effectiveness of existing tools, including employee wellness programs. The results also point to shortcomings of current benefit design rules and a need for more rigorous research and evaluation of new patient behavior change strategies.

Respondents appropriately find a distinction between effective means of initiating behavior change and sustaining that change. For example, more than half (56%) of respondents say more education about preventable conditions is effective in initiating behavior change, but just a quarter consider that to be effective in sustaining behavior change. So, even though providers can focus on educating the patient in a clinical setting, they know that providing information is unlikely to sustain the patient’s behavior change.

Unfortunately, clinicians often do not have the right tools at hand to effect long-term change.

Different Means of Initiating and Sustaining Behavior Change

From the Patient Engagement Insights Report: What Creates Behavior Change May Not Sustain It. Click To Enlarge.

Insights Council members report that the most effective methods of initiating patient behavior change include improved access to care (chosen by 65% of respondents), in-person social support (63%), and more education (56%). While these approaches are commonly used, most are, at best, only modestly effective in initiating change, and are necessary but not sufficient for sustaining behavior change. For example, patients may be willing to try to quit smoking based on the recommendation of their physician and access to a smoking cessation program, but for most smokers that combination alone is unlikely to produce sustained results.

It is noteworthy that in-person social support is the only method cited by a majority of respondents as effective in both initiating (63%) and sustaining (64%) behavior change. While technological advances continue to enable innovations in health care, human interaction and social support will remain pivotal for many people to maintain and improve their future health. Even though activity trackers and an assortment of health-related apps have become popular, only 36% of our survey respondents consider those to be effective in sustaining patient behavior change.

When considering the effectiveness of employee wellness programs in getting patients to improve their health, 4 in 10 respondents say the programs are not very effective or not at all effective. Only 1 in 5 respondents consider the programs very or extremely effective. These views may in part reflect a natural skepticism among providers about the role of employers when it comes to a patient’s health, or providers’ sense that the data demonstrating effectiveness of employee wellness programs is limited.

Survey respondents were asked to cite the most effective means of sustaining better health outcomes through employee wellness programs. A range of choices rose to the top, but none stood out or was supported by a majority. Peer participation and support was the top response (34%), followed by financial gains (29%), financial savings (27%), and health coaching (25%). From the provider perspective, there is no single core ingredient that is highly correlated to the effectiveness of employee wellness programs. Financial incentives may have promise, but the lack of consensus around an effective approach highlights that rigorous evidence on effective approaches is only starting to emerge and, as such, clinicians are unlikely to have a clear sense of the evidence.

On the whole, these findings indicate the importance of peer participation and support and validate earlier NEJM Catalyst surveys that point to the power of peer support for patients. In our January 2018 Insights Report, Social Networks to Improve Patient Health, 69% of respondents cited face-to-face group sessions as a useful mode of communication for social networks, and half of the respondents cited faceto-face, one-on-one sessions with social network members and patients as useful. And, while 9 in 10 respondents acknowledged that social networks are not mature or only slightly mature, a similar share estimated that, when mature, social networks would have a major or moderate impact on patient engagement.

So, what are the biggest barriers in bringing about patient behavior change to improve prevention and wellness? Lack of patient buy-in/ engagement is an obvious culprit, and NEJM Catalyst Insights Council respondents cite that as the biggest obstacle (68%). Personal patient cost (46%) and insurance coverage (34%) are cited next by respondents, which suggests the importance of reducing financial barriers and of benefit redesign.

Interestingly, more than one-quarter (28%) of respondents say that providers themselves have not bought in to patient behavior change. This may reflect the recognition of many clinicians that they are not particularly good at initiating and sustaining patient behavior change. Providers typically are trained to focus on treating disease and addressing acute issues, and many approaches that are believed to be effective for chronic conditions — like peer or family social support or financial incentives — are not often within the direct control of the provider. Physicians cannot write a prescription for friends and companions, nor for financial rewards.

This Insights Council survey reveals that many providers see the need for — and are committed to — increasing the rate of healthy patient behavior. The results also demonstrate the need to conduct and publish more research on effective tools, and for health systems and health plans to increasingly provide those tools in support of clinicians’ efforts to help patients initiate and sustain healthy behaviors.


What should your organization do to more effectively support patients in meeting prevention and wellness goals?

“Attend to person’s individual story, needs, resource availability, goals. Negotiate a deal consistent with organization goals and individual goals. Provide maximum resources and minimize barriers to facilitate health behavior changes.”
— Clinician at a small nonprofit ancillary provider in the Northeast

“Actually provide some real options rather than lip service.”
— Executive for a small allied provider in the South

“[First, use] motivational interviewing and experiential learning to engage patients/ members in self-care. [Second, use] educational programs given outside the 9 a.m.–5 p.m. time period.”
— Clinical leader for a large nonprofit health plan in the West

“Don’t think it’s up to the doctor; it’s really up to the patient/employee. The workplace is not daycare.”
— Clinician at a small for-profit clinic in the South

“Consistent messaging to employees. Consistent incentives. Role modeling, where possible. Sharing patient testimonials.”
— Executive at a large nonprofit teaching hospital in the Midwest

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

In January 2018, we surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about driving and sustaining behavior change for prevention and wellness. The survey explores effective means of initiating and sustaining behavior change, levels of organizational commitment, the impact of employee wellness programs on health quality and cost of care, and barriers to behavior change related to prevention and wellness among patients. Completed surveys from 775 respondents are included in the analysis.

Patient Engagement Is the Biggest Barrier to Behavior Change

From the Patient Engagement Insights Report: What Creates Behavior Change May Not Sustain It. Click To Enlarge.

When it comes to initiating behavior change, Insights Council members identify a trio of approaches as most effective: improved access to care, in-person social support, and more education about preventable conditions. Improved access to care and in-person social support are also among the top means of sustaining behavior change. Beyond that, there are substantial differences in how respondents rate various means of initiating versus sustaining behavior change. For example, virtual social support is the second-highest rated means of sustaining change, but far down on the list of approaches for initiating change. Education about preventable conditions is among the top-rated means of initiating change, but second to last for sustaining change — a difference of 31 percentage points.

While there is overall agreement with these rankings across audience segments, there is some variation: greater shares of clinicians (60%) and executives (58%) than clinical leaders (48%) cite more education about preventable conditions as an effective means of initiating behavior change. There is also a wide discrepancy in optimism between executives and clinicians when it comes to virtual social support (56% versus 43%, respectively), electronic reminders (52% versus 43%), personal technology devices (42% versus 32%), and financial penalties (17% versus 11%).

Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.

Download Full Report

NEJM Catalyst wishes to thank Mark Berman, MD, an internist at One Medical in San Francisco, for assistance in constructing this survey. Check NEJM Catalyst for monthly Insights Reports not only on Patient Engagement, but also on Leadership, the New Marketplace, and Care Redesign.

Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.

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