Growing evidence supports the importance of engaging patients in research to share information about their disease and treatment experiences and health-related quality of life [1,2]. Where shared data flow into health care systems and clinical epidemiologic studies, better symptom management, improved treatments, and better outcomes result [3]. In support of engaging patients in sharing high-quality data, considerable investment has been made in developing standardized patient-reported outcomes measures (PROs) that characterize aspects of patients’ physical, mental, and social health [3-6]. PROs enable scientific rigor and help capture the patient voice, consistent with the paradigm shifting efforts to advance patient-centered outcomes research [7-10]. Yet, open questions remain about how to motivate ongoing patient engagement in research, and this question is central to ambitious efforts to activate vast cohorts in donating PROs and clinical data [11].

One possible approach is to operationalize a process whereby patients donate health data that are subsequently processed and returned in aggregate. Here, the return of aggregate research results (ARRs) about the cohort is hypothesized to motivate a virtuous cycle of data donation that can help grow the evidence base to advance more acceptable, effective therapies [12]. Viewing ARRs may be motivating for research participation if the returned information helps patients appraise personal experiences of disease and treatment [13] and informs conversations with health care providers and family members, factors that are relevant to health care decision making [14]. These actions, which reflect an engaged and activated patient and socially embedded nature of health care decision making, are central to models of chronic illness care [15-17]. These factors are also consistent with survey reports about what motivates sharing of personal health information [18-20] and are reflected in the appeal of Web-based patient-centered health information repositories [17]. Additional empirical testing of this “closed-loop” model is essential for ascertaining whether it fosters interest in research participation among clinical cohorts and to better understand its potential for being experienced as helpful or harmful—gap areas that are central to ensuring equipoise.

Returning ARRs may be informative and reassuring for some research participants, providing a normalizing context around experiences; ARRs may also be overwhelming and disquieting for others, including if ARRs show evidence of problems experienced by others with the same condition. Other factors, including the level of education and health literacy, might also affect acceptability. Concern about the balance of benefit or harm experienced when viewing ARRs may be especially acute for conditions that are rare, have treatments that rest on an immature evidence base or incompletely ameliorate symptoms or health-related quality of life, and pose risks for side effects [21]. Arguably, motivating ongoing research engagement for such conditions is especially important because gaps in knowledge might be filled, driving improvements in therapies at the system level and decision making at the patient or family level.

Pediatric-onset rheumatic disease (RD) is a trenchant case for examining these issues. Among youth, RD is rare but rising in incidence [22], with affected children facing significant hurdles regarding health-related quality of life due to the chronic relapsing nature of RD, unpredictable disease course, and difficult treatments [1-3]. Lack of a mature evidence base guiding RD care makes maintaining patient engagement in research especially important for gathering information about disease and treatment experiences to improve care and outcomes. For example, in a prior study focused on youth with RD, we found that treatment-related problems for standard RD therapies were common and contributed to poor health-related quality of life even after controlling for patient clinical characteristics and ameliorative effects of these treatments on symptoms, such as pain [23].

This study aims to investigate impacts of returning ARRs on interest in participating in future research within a larger project focused on investigating pediatric-onset RD. We engaged parents of children with RD in donating PROs about their child’s health and treatment experiences and then returned cohort-level summaries of clinical measures and PROs to parents, testing whether viewing these ARRs increased parents’ interest in future research participation and their intentions to discuss ARRs with others or seek further information. Such discussions might encourage shared decision making, consistent with theory [6,24]. We hypothesized that the receipt of ARRs would be highly motivating for future research engagement and that reactions to and planned actions arising from viewing ARRs would vary with participants’ experiences of benefit and burden.

This study provides evidence that returning ARRs to study participants who have donated data is highly motivating for ongoing research participation. By investigating effects of sharing ARRs on interest in research participation and planned actions stemming from this experience, findings extend the understanding of benefits of patient engagement in health care research [32]. More than half of the parents in the cohort exposed to ARRs reported increased interest in research participation as a function of receiving ARRs—good news for participatory research models, including those predicated on engaging cohorts in donating data. Moreover, parents endorsed plans for proactive engagement in their child’s treatment and outcomes after receiving ARRs, with specific plans varying as a function of validation/affirmation and information burden. Overall, reactions to ARRs aligned with hopes for fostering motivation for research participation and activation in the health care process [33,34].

As hypothesized, the experience of viewing ARRs was not “one size fits all”—participants’ responses to the model reflected both experiences of validation/affirmation, wherein parents gained value from contextualizing disease or treatment experiences through viewing cohort-level data, and information burden, wherein aggregate results may be cognitively overwhelming. Yet, as greater information burden was associated with plans to discuss results with a provider, even parent participants who may have felt overwhelmed by ARRs might benefit if they are stimulated to talk with health care providers to understand findings and discuss any implications for their child. Such activities could foster improved patient-provider partnership and shared decision making. Notably, experiencing greater information burden was evident among participants who reported lower levels of educational attainment. As such, achieving goals of optimizing and equalizing health benefits and reducing the potential for disparities stemming from this model may require additional support around interpreting and processing ARRs [34]. Nationally, low levels of health literacy and numeracy indicate that large segments of the US population may face barriers to understanding health data, underscoring the importance of attending to these issues [35,36].

This investigation was undertaken with a cohort situated in a well-defined national multisite disease registry, whose members’ diagnoses were clinically confirmed—significant strengths. Still, several limitations merit mention. First, findings reflect the experiences of engaged parents of registry participants who viewed a specific set of ARRs and may not generalize to other populations that may differ in conditions, concerns, and experiences (including the history of benefit or harm from research and care); the ARR contents are also specific to the population. Second, this study leveraged the visit structure of a registry-engaged clinical cohort, layering data collection and return onto the natural visit cycle of this cohort. Additional research using a randomized trial design would inform comparisons of engagement outcomes for participants who did and did not receive ARRs over time. Third, participants shared structured PROs, some validated, others novel; items describing motivation to participate in research and experiences of receiving ARRs are not validated but capture important patient-centered dimensions of research experience. Fourth, parent proxy reports of child clinical characteristics and PROs and parent reactions to the return of ARRs may differ from those of the child [9,37], and results from this study should not be construed as reflecting child (ie, patient) reactions to the return of ARRs or reactions of another parent or guardian. Relatedly, excepting the measure of the highest parent education attained, demographic characteristics describe the child not parents. Congruence between child and parent experiences of this model and further investigation of effects of parent demographics on outcomes may further inform this work and merit future study. Lastly, self-reported data are subject to recall and social desirability biases; however, the use of structured and validated measures and electronic data collection help protect against known validity threats.

In sum, viewing ARRs increased motivation for research participation among a majority of study participants and shows promise for driving greater patient activation and engagement. Results of this study are encouraging in light of national plans for engaging volunteers in donating personally generated data, including PROs, to drive precision medicine and comparative effectiveness research [7,11,38,39]. To the extent that these efforts utilize a closed loop approach in which ARRs are returned to a learning and sharing cohort, they may thrive. Protecting against the potential for unintentionally worsening health disparities is vital as results show that participants from households with less parent education were more likely to experience information burden from viewing ARRs. Should this lead to the differential engagement or attrition of less educated participants, biases in study findings could be introduced and the ultimate fairness and beneficence of the model undermined.