title: Patient engagement as a risk factor in personalized health care: a systematic review of the literature on chronic disease.
abstract: BACKGROUND
  The role of patient engagement as an important risk factor for healthcare outcomes has not been well established. The objective of this article was to systematically review the relationship between patient engagement and health outcomes in chronic disease to determine whether patient engagement should be quantified as an important risk factor in health risk appraisals to enhance the practice of personalized medicine.
  
  
  METHODS
  A systematic review of prospective clinical trials conducted between January 1993 and December 2012 was performed. Articles were identified through a medical librarian-conducted multi-term search of Medline, Embase, and Cochrane databases. Additional studies were obtained from the references of meta-analyses and systematic reviews on hypertension, diabetes, and chronic care. Search terms included variations of the following: self-care, self-management, self-monitoring, (shared) decision-making, patient education, patient motivation, patient engagement, chronic disease, chronically ill, and randomized controlled trial. Studies were included only if they: (1) compared patient engagement interventions to an appropriate control among adults with chronic disease aged 18 years and older; (2) had minimum 3 months between pre- and post-intervention measurements; and (3) defined patient engagement as: (a) understanding the importance of taking an active role in one's health and health care; (b) having the knowledge, skills, and confidence to manage health; and (c) using knowledge, skills and confidence to perform health-promoting behaviors. Three authors and two research assistants independently extracted data using predefined fields including quality metrics.
  
  
  RESULTS
  We reviewed 543 abstracts to identify 10 trials that met full inclusion criteria, four of which had 'high' methodological quality (Jadad score ≥ 3). Diverse measurement of patient engagement prevented robust statistical analyses, so data were qualitatively described. Nine studies documented improvements in patient engagement. Five studies reported reduction in clinical markers of disease (for example HbA1C). All studies reported improvements in self-reported health status.
  
  
  CONCLUSIONS
  This review suggests patient engagement should be quantified as part of a comprehensive health risk appraisal given its apparent value in helping individuals to effectively self-manage chronic disease. Patient engagement measures should include assessment of the knowledge, confidence and skills to prevent and manage chronic disease, plus the behaviors to do so.
authors.affiliation: Current address: Duke University School of Nursing, DUMC Box 3322, Durham, NC 27710-3322, USA ; Center for Research on Prospective Health Care, Duke University Health System, Durham, NC 27710, USA.
authors.forename: Leigh Ann
authors.initials: LA
authors.lastname: Simmons
authors.affiliation: Current address: Duke Integrative Medicine, DUMC Box 102904, Durham, NC 27710-2904, USA ; Department of Psychiatry and Behavioral Sciences, Duke School of Medicine, Durham, NC 27710-2904, USA.
authors.forename: Ruth Q
authors.initials: RQ
authors.lastname: Wolever
authors.affiliation: Current address: Duke Integrative Medicine, DUMC Box 102904, Durham, NC 27710-2904, USA.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Bechard
authors.affiliation: Center for Research on Prospective Health Care, Duke University Health System, Durham, NC 27710, USA ; Current address: Department of Medicine, DUMC Box 3059, Durham, NC 27710-3059, USA.
authors.forename: Ralph
authors.initials: R
authors.lastname: Snyderman