Diana D. Laurent

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.

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.

Internet-Based Chronic Disease Self-Management A Randomized Trial

Background:The small-group Chronic Disease Self-Management Program (CDSMP) has proven effective in changing health-related behaviors and improving health statuses. An Internet-based CDSMP was developed to reach additional chronic-disease patients. Objectives:We sought to determine the efficacy of the Internet-based CDSMP. Design:We compared randomized intervention participants with usual-care controls at 1 year. We compared intervention participants with the small-group CDSMP at 1 year. Subjects:Nine-hundred fifty-eight patients with chronic diseases (heart, lung, or type 2 diabetes) and Internet and e-mail access were randomized to intervention (457) or usual care control (501). Measures:Measures included 7 health status variables (pain, shortness of breath, fatigue, illness intrusiveness, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 3 utilization variables (physician visits, emergency room visits, and nights in hospital), and self-efficacy. Results:At 1 year, the intervention group had significant improvements in health statuses compared with usual care control patients. The intervention group had similar results to the small-group CDSMP participants. Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year. Conclusions:The Internet-based CDSMP proved effective in improving health statutes by 1 year and is a viable alternative to the small-group Chronic Disease Self Management Program.

The internet-based arthritis self-management program: A one-year randomized trial for patients with arthritis or fibromyalgia†

OBJECTIVE To determine the efficacy of an Internet-based Arthritis Self-Management Program (ASMP) as a resource for arthritis patients unable or unwilling to attend small-group ASMPs, which have proven effective in changing health-related behaviors and improving health status measures. METHODS Randomized intervention participants were compared with usual care controls at 6 months and 1 year using repeated-measures analyses of variance. Patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia and Internet and e-mail access (n = 855) were randomized to an intervention (n = 433) or usual care control (n = 422) group. Measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy. RESULTS At 1 year, the intervention group significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found. CONCLUSION The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.

A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care.

Study Design. Randomized, controlled trial. Objective. To evaluate a four‐session self‐management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self‐care, and reduce activity limitations. Background Data. Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self‐management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self‐management was evaluated. Methods. Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self‐management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = −255) randomly were assigned to either a self‐management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four‐session group applying problem‐solving techniques to back pain self‐management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. Results. Participants randomly assigned to the self‐management groups reported significantly less worry about back pain and expressed more confidence in self‐care. Roland Disability Questionnaire Scores were significantly lower among participants in the self‐management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self‐management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. Conclusions. Self‐management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self‐care, and reducing activity limitations among patients with back pain in primary care.

Online Diabetes Self-Management Program: A randomized study

OBJECTIVE We hypothesized that people with type 2 diabetes in an online diabetes self-management program, compared with usual-care control subjects, would 1) demonstrate reduced A1C at 6 and 18 months, 2) have fewer symptoms, 3) demonstrate increased exercise, and 4) have improved self-efficacy and patient activation. In addition, participants randomized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement. RESEARCH DESIGN AND METHODS A total of 761 participants were randomized to 1) the program, 2) the program with e-mail reinforcement, or 3) were usual-care control subjects (no treatment). This sample included 110 American Indians/Alaska Natives (AI/ANs). Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups. RESULTS At 6 months, A1C, patient activation, and self-efficacy were improved for program participants compared with usual care control subjects (P < 0.05). There were no changes in other health or behavioral indicators. The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects. The subgroup with initial A1C >7% demonstrated stronger improvement in A1C (P = 0.01). At 18 months, self-efficacy and patient activation were improved for program participants. A1C was not measured. Reinforcement showed no improvement. CONCLUSIONS An online diabetes self-management program is acceptable for people with type 2 diabetes. Although the results were mixed they suggest 1) that the program may have beneficial effects in reducing A1C, 2) AI/AN populations can be engaged in and benefit from online interventions, and 3) our follow-up reinforcement appeared to have no value.

The expert patients programme online, a 1-year study of an Internet-based self-management programme for people with long-term conditions

Objectives: Evaluate the effectiveness of an online self-management programme (EPP Online) for England residents with long-term conditions. Methods: A prospective longitudinal study. Data were collected online at baseline, 6 and 12 months. The intervention was an asynchronous 6-week chronic-disease self-management programme offered online. We measured seven health status measures (health distress, self-rated health, illness intrusiveness, disability, fatigue, pain and shortness of breath), four behaviours (aerobic exercise, stretching exercise, stress management and communications with physician), and five utilization measures (GP visits, pharmacy visits, PT/OT visits, emergency visits and hospitalizations). We also measured self-efficacy and satisfaction with the health care system. Results: A total of 568 completed baseline data: 546 (81%) completed 6 months and 443 (78%) completed 1 year. Significant improvements (p<0.01) were found at 6 months for all variables except self-rated health, disability, stretching, hospitalizations and nights in hospital. At 12 months only decrease in disability, nights in hospital and hospitalizations were not significant with reduction in visits to emergency departments being marginally significant (p = 0.012). Both self-efficacy and satisfaction with the health care system improved significantly. Discussion: The peer-led online programme conditions appears to decrease symptoms, improve health behaviours, self-efficacy and satisfaction with the health care system and reducing health care utilization up to 1 year.

Arthritis patient education studies, 1987-1991: a review of the literature.

Arthritis is a chronic disease that is estimated to affect 14.5% of the American population and is the leading cause of functional dependency in the activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) in all persons over the age of 65 years. Clinical studies have shown that medical care, including the use of medications, can offer a 20-50% improvement in reported arthritis symptoms. Data from patient education studies suggest that a further improvement of 15-30% is attainable through patient education interventions. This literature review has been completed to update the reviews of patient education studies by Lorig and Riggs in 1983 and Lorig, Konkol, and Gonzalez in 1987. More specifically, the objectives of this review are: (1) to provide a summary of arthritis patient education studies published or presented since 1987; (2) to summarize the findings concerning the effectiveness of arthritis patient education studies which attempt to change knowledge, behavior, psychosocial status, and health status; (3) to discuss shifting trends in observed outcomes of arthritis patient education studies; and (4) to discuss implications for the future.

Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions.

Objective:The objective of this study was to test the effectiveness of a mail-delivered, tailored self-management intervention (SMART) and to compare it with the classic Arthritis Self-Management Program (ASMP). Methods:We performed 2 randomized controlled trials: 1) a study of 1090 participants randomized to SMART or USUAL CARE, and 2) a study of 341 participants randomized to SMART or ASMP. Dependent variables included disability, pain, depression, role function, global severity, doctor visits, and self-efficacy. SMART interventions were provided in months 0–18 and not reinforced. Results were assessed at 1, 2, and 3 years using analyses of covariance (ANCOVA). Results:Compared with USUAL CARE, SMART participants at 1 year had decreased disability, improved role function, and increased self-efficacy (all P <0.01). At 2 years, decreases in global severity, doctor visits, and increases in self-efficacy (all P <0.01) were noted. At 3 years without reinforcement, no statistically significant effects remained. Compared with ASMP, SMART at 1 year had greater decreases in disability (P = 0.02) and increases in self-efficacy (P = 0.01). There were no differences at 2 years. At 3 years, role function (P = 0.04) and doctor visit (P = 0.03) were improved in ASMP as compared with SMART. Improvements from baseline were seen for nearly all variables in both groups. Conclusions:A mail-delivered arthritis self-management program, SMART, was similarly effective to the classic ASMP, with slightly better results in the first year and a slightly more rapid attenuation over the next 2 years. Results suggest that both programs are effective, and that the addition of a mail-delivered program could improve accessibility to arthritis self-management treatment.

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.