1. Research Proposal in Economic Outcomes
David Paschane, Ph.D.
Veteran Patient-Agency
The purpose of this research initiative is to prepare VA for effectively adopting transformations
in service delivery strategies, especially those that focus on post-military transitions. Although
the initiative emphasizes healthcare, the same model is appropriate in all VA-managed services.
Increasingly, healthcare providers are designing services that adapt to patients’ roles in managing
chronic and behavior-based conditions, adapting to home-based and spouse-based services, and
controlling processes through technological advancements. The underlining driver in these
transformations is patient-agency, which is the degree to which patients can and are willing to
manage their healthcare processes. VA is not well-prepared for this transformation because it
uses institution-based management structures. Although VA is serving veterans with unique
transitioning risks, the VA emphasis is not on the veteran as the manager of these experiences.
A lack of reinforcing patient-agency can lead to unsuccessful restoration efforts by VA,
including unwanted consequences, such as diminishing a veteran’s agency development.
Therefore, it is necessary for VA to develop an expertise in understanding, responding to, and
protecting patient-agency and its role in restoring physical, psychological, and economic
capacity in veterans.
Definition:
Patient-agency is the ability of a patient to evaluate, decide, and act according to personal
preferences. Its potential scope includes all the functions that are relevant to healthcare
management, and that can be transferred to the patient. These include control over (1) visible and
understandable information, (2) flexible and efficacious processes, and (3) effective and
authoritative decision-making. Successful treatment and prevention of the most prevalent health
problems, chronic diseases and behavior-driven conditions, is dependent on patient-agency.
Target:
Two groups of veterans are at high-risk because of diminished patient-agency. First, service
members returning from OIF/OEF face a combined set of stressors that include combat traumas
and transition anxieties, which can undermine patient-agency sustainment. Second, veterans with
diagnosed or latent service-connected mental health problems can have underdeveloped patient-
agency because of restoration difficulties.
Purpose:
The purpose of this initiative is to fund a targeted research agenda that includes three
interconnected foci. First, produce a standardized method for measuring patient-agency in
rehabilitation, medical, and processing settings, in terms of its development and sustainment.
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2. Second, explain the short-term and long-term impact of stressors on patient-agency change, in
terms of psycho-physiological differences between women and men, intensity and duration of
stressors, and the mediation of innovative communication and control devices. Third, construct a
streamline evaluation of VA programs that determines how each interacts with veterans and
affects the overall physical, psychological, and economic restoration goals, in terms of changing
patient-agency.
Benefits:
A patient-agency protection initiative can help guarantee that VA is appropriate, effective, and
efficient. First, a patient-agency expertise in VA can ensure that veterans are fully supported
throughout their life course, especially as they transition from military to civilian life. As VA
supports veterans overcoming physical, psychological, and economic hardships, it must
guarantee that its processes enable rather than diminish patient-agency. This is a crucial
objective, as patient-agency can affect veterans’ successful utilization of transition counseling,
retraining assistance, employment assistance, and physical and psychological treatments.
Second, patient-agency protection provides a unique research framework that is appropriate for
addressing the complex needs of veterans. Such a framework can help VA target a hierarchy of
research and reform goals, so as to ensure that VA resources are effectively responding to
changes in veterans. Third, VA will benefit from the efficiency and consistency it can build into
its programs, by tailoring best practices in terms of how VA affects patient-agency and at what
costs. These insights can become standards for consistent and adaptable operations.
Background:
A breadth of research illustrates that patient-agency is a primary driver of demand and outcomes
in healthcare. It is the patient who presents the illness, requests assistance, weighs the risks and
benefits, consents to care, and continues the process through changing health status, treatment,
and health-related behaviors. The following citations identify evidence that speaks to the critical
role of patient-agency in healthcare:
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).
Utilization Management
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3. • 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).
Medical Communication
• 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).
Twenty years ago, researchers experimented with how VA 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 mange unnecessary use of healthcare services and improve veterans’ ability to
prevent acute health problems.
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