Effect of a self-management program on patients with chronic disease

CONTEXT

For patients with chronic disease, there is growing interest in "self-management" programs that emphasize the patients' central role in managing their illness. A recent randomized clinical trial demonstrated the potential of self-management to improve health status and reduce health care utilization in patients with chronic diseases.

OBJECTIVE

To evaluate outcomes of a chronic disease self-management program in a real-world" setting.

STUDY DESIGN

Before-after cohort study.

PATIENTS AND SETTING

Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data.

INTERVENTION

The Chronic Disease Self-Management Program is a 7-week, small-group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building.

MAIN OUTCOME MEASURES

Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires.

RESULTS

At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant.

CONCLUSIONS

We replicated the results of our previous clinical trial of a chronic disease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.

Chronic disease self-management program: 2-year health status and health care utilization outcomes

OBJECTIVES

To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization.

DESIGN

Longitudinal design as follow-up to a randomized trial.

SETTING

Community.

PARTICIPANTS

Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data.

MAIN OUTCOME MEASURES

Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured.

MAIN RESULTS

Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes.

CONCLUSIONS

A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.

Effect of a self-management program on patients with chronic disease

CONTEXT

For patients with chronic disease, there is growing interest in "self-management" programs that emphasize the patients' central role in managing their illness. A recent randomized clinical trial demonstrated the potential of self-management to improve health status and reduce health care utilization in patients with chronic diseases.

OBJECTIVE

To evaluate outcomes of a chronic disease self-management program in a real-world" setting.

STUDY DESIGN

Before-after cohort study.

PATIENTS AND SETTING

Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data.

INTERVENTION

The Chronic Disease Self-Management Program is a 7-week, small-group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building.

MAIN OUTCOME MEASURES

Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires.

RESULTS

At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant.

CONCLUSIONS

We replicated the results of our previous clinical trial of a chronic disease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.

Self-reports of health care utilization compared to provider records

This study compares self-reports of medical utilization with provider records. As part of a chronic disease self-management intervention study, patients completed self-reports of their last six months of health care utilization. A subgroup of patients was selected from the larger study and their self-reports of utilization were compared to computerized utilization records. Consistent with earlier studies, patients tended to report less physician utilization than was recorded in the computerized provider records. However, they also tended to report slightly more emergency room visits than were reported in the computerized utilization records. There was no association between demographic or health variables and the tendency toward discrepancy between self-report and computerized utilization record reports. However, there was a tendency for the discrepancy to increase as the amount of record utilization increased. Thus, the likelihood of bias caused by differing demographic factors is low, but researchers should take into account that underreporting occurs and is likely to increase as utilization increases.

Osteoarthritis: new insights. Part 2: treatment approaches

Osteoarthritis is the most common form of arthritis, affecting millions of people in the United States. It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of systemic factors, such as genetics, diet, estrogen use, and bone density, and local biomechanical factors, such as muscle weakness, obesity, and joint laxity. These risk factors are particularly important in the weight-bearing joints, and modifying them may help prevent osteoarthritis-related pain and disability. Major advances in management to reduce pain and disability are yielding a panoply of available treatments ranging from nutriceuticals to chondrocyte transplantation, new oral anti-inflammatory medications, and health education. This article is part 2 of a two-part summary of a National Institutes of Health conference that brought together experts in osteoarthritis from diverse backgrounds and provided a multidisciplinary and comprehensive summary of recent advances in the prevention of osteoarthritis onset, progression, and disability. Part 2 focuses on treatment approaches; evidence for the efficacy of commonly used oral therapies is reviewed and information on alternative therapies, including nutriceuticals and acupuncture, is presented. Biomechanical interventions, such as exercise and bracing, and behavioral interventions directed toward enhancing self-management are reviewed. Current surgical approaches are described and probable future biotechnology-oriented approaches to treatment are suggested.

Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial

OBJECTIVES

This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities.

METHODS

The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured.

RESULTS

Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being.

CONCLUSIONS

An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.

Pilot randomized trial of education to improve self-management skills of men with symptomatic HIV/AIDS

OBJECTIVE

To evaluate the acceptability, practicality, and short-term efficacy of a health education program to improve disease self-management in patients with symptomatic HIV/AIDS.

DESIGN

Randomized controlled trial, baseline and 3-month follow-up questionnaire assessments.

SETTING

San Francisco Bay communities.

PARTICIPANTS

Seventy-one men with symptomatic HIV or AIDS were randomly assigned to a seven-session group educational intervention (N=34) or a usual-care control group (N=37).

INTERVENTION

Interactive health education groups were used to teach wide-ranging disease self-management skills and information: symptom assessment and management, medication use, physical exercise, relaxation, doctor-patient communication, and nutrition. Each group was led by two trained peer-leaders (one of whom was HIV-positive) recruited from the community.

MAIN OUTCOME MEASURES

The primary outcome of interest was symptom status. Secondary outcomes were self-efficacy and health behaviors. Analysis of covariance was used to compare experimental and control group mean outcomes, adjusting for baseline value differences.

RESULTS

The symptom severity index (number of symptoms moderate or greater severity) decreased in the experimental, and increased in the control group (-0.9 versus +0.5; p < .03). Pain, fatigue, and psychological symptoms were not significantly different between groups. Self-efficacy for controlling symptoms improved in the experimental, and decreased in the control group (+4 versus -7; p < .02). Changes in stress/relaxation exercises and HIV/AIDS knowledge were not different between groups. A trend was shown toward more frequent physical exercise in the experimental group compared with less in the control group (+1.3 versus -0.5 times/week; p=.06).

CONCLUSIONS

Health education emphasizing self-management skills for HIV/AIDS patients can be implemented and evaluated and was accepted by patients, peer-leaders, and health care providers. Whether this educational program can lead to prolonged improvement in HIV symptoms and behaviors can be adequately addressed only by a larger trial of longer duration.

Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment

OBJECTIVE

To compare the effects of education interventions and nonsteroidal antiinflammatory drug (NSAID) treatment on pain and functional disability in patients with osteoarthritis (OA), and on pain, functional disability, and tender joint counts in patients with rheumatoid arthritis (RA).

METHODS

Two meta-analyses were performed: one of controlled trials of patient education interventions and one of placebo-controlled trials of NSAID treatments.

RESULTS

Nineteen patient education trials comprised of 32 treatment arms and 28 NSAID trials comprised of 46 treatment arms were included. The weighted average effect size for pain was 0.17 in the education trials and 0.66 in the NSAID trials. The average effect size for functional disability was 0.03 in the education trials and 0.34 in the NSAID trials; effects of education were much larger in RA studies than in OA studies. In RA studies, the average effect size for the tender joint count was 0.34 in the education trials and 0.43 in the NSAID trials. Because most patients in the education trials were being treated with medications, the effect sizes of these trials represent the additional, or marginal, effects of patient education interventions beyond those achieved by medication.

CONCLUSIONS

Based on this meta-analysis, patient education interventions provide additional benefits that are 20-30% as great as the effects of NSAID treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60-80% as great as NSAID treatment in reduction in tender joint counts in RA.

Balanced incomplete block design: description, case study, and implications for practice

This article discusses the use of balanced incomplete block design for process evaluation and presents a case study of its use. This technique produces a weighted ranking of program elements, showing the relative importance of each element and allowing comparison of process and content elements. The article presents a case study in which the technique was used to evaluate the Chronic Disease Self-Management Program. Participants and lay course leaders were asked to rank 13 course elements for their helpfulness. The most valued element, sharing or unstructured interactions among participants, was not an explicitly planned part of the intervention. Some of the elements least valued (nutrition, use of community resources, and medication use) are elements most emphasized by the health care system and by patient education. We found that balanced incomplete block design was easy to administer and tally. The results could be readily applied to program redesign and to needs assessment.

Biopsychosocial contributions to the management of arthritis disability. Blueprints from an NIDRR-sponsored conference

The contributions of MACs and RRTCs to the generation of arthritis-related biopsychosocial research over the last 15 years have been enormous. However, the assimilation of biopsychosocial concepts into mainstream clinical practice, professional education, and public awareness will require a sustained national effort.

Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs

OBJECTIVE

To determine the effects of the Arthritis Self-Management Program 4 years after participation in it.

METHODS

Valid self-administered instruments were used to measure health status, psychological states, and health service utilization.

RESULTS

Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient.

CONCLUSION

Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.

Converging and diverging beliefs about arthritis: Caucasian patients, Spanish speaking patients, and physicians

Ninety-eight Caucasian patients, 46 Spanish speaking patients, and 50 physicians (mainly rheumatologists) took part in surveys of salient beliefs about arthritis and its treatment. The beliefs of Caucasian patients and those of physicians were similar. However, beliefs of physicians about patients' beliefs and actual patient beliefs diverged as did the beliefs of Caucasian and Spanish speaking patients. These results suggest that arthritis education and treatment should be based on patients' perceptions rather than on physicians' beliefs about patients' perceptions.