Halsted R. Holman

Self-management education: History, definition, outcomes, and mechanisms

Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks—medical management, role management, and emotional management—and six self-management skills—problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

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.

Mixed connective tissue disease-an apparently distinct rheumatic disease syndrome associated with a specific antibody to an extractable nuclear antigen (ENA)

Abstract We describe the clinical and serologic findings in twenty-five patients with an apparently distinct rheumatic disease syndrome which we have termed mixed connective tissue disease. All these patients had hemagglutinating antibody to an extractable nuclear antigen (ENA) which consists mainly of protein and ribonucleic acid (RNA). A marked sensitivity of the hemagglutination antigen to ribonuclease indicated that the specificity of the antibody to ENA circulating in these patients was different from that of antibody to ENA which occurred in about 50 per cent of the patients with systemic lupus erythematosus. Serum from patients with mixed connective tissue disease also contained high titers of speckled pattern fluorescent antinuclear antibody which showed the same response of tissue antigens to enzyme digestion as found with hemagglutinating antibody. There was no detectable Sm antibody. Antibody to native deoxyribonucleic acid (DNA) was infrequent and of low titer, and serum complement levels were normal or elevated. The clinical characteristics of the patients with mixed connective tissue disease included a combination of features similar to those of systemic lupus erythematosus, scleroderma and polymyositis. Most of these abnormalities were responsive to corticosteroid therapy. Thus, the detection of antibody to ENA with a well defined specificity allows recognition of an apparently distinct mixed connective tissue disease syndrome which is characterized by an excellent response to corticosteroid therapy and a favorable prognosis.

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.

Patients as partners in managing chronic disease: Partnership is a prerequisite for effective and efficient health care

General practice p 550 Education and debate p 569 When acute disease was the primary cause of illness patients were generally inexperienced and passive recipients of medical care. Now that chronic disease has become the principal medical problem the patient must become a partner in the process, contributing at almost every decision or action level. This is not just because patients deserve to be partners in their own health care (which, of course, they do) but also because health care can be delivered more effectively and efficiently if patients are full partners in the process. Today in the United States chronic disease is the major cause of disability, is the main reason why people seek health care, and consumes 70% of healthcare spending. The differences between acute and chronic diseases are seen in the box on the BMJ s website. With acute disease, the treatment aims at return to normal. With chronic disease, the patients life is irreversibly changed. Neither the disease nor its consequences are static. They interact to create illness patterns requiring continuous and complex management. Furthermore, variations in patterns of illness and treatments …

Arthritis Self-Management Studies: A Twelve-Year Review

The Arthritis Self-Management Program (ASMP) is a program that has been developed and studied over 12 years. This paper is a summary of the results of these studies. Several conclusions have been reached. 1. The ASMP in randomized trails improves behaviors, self-efficacy, and aspects of health status. 2. Formal reinforcement does not appear to improve the long-term outcomes of the ASMP. 3. The effects of the ASMP last for as long as 4 years without formal reinforcement. 4. The improvement gains by the ASMP participants have importance both clinically and in terms of cost savings. 5. The mechanism by which the ASMP affects health status appears to be more closely linked to changes in self-efficacy than to changes in behaviors

Patient Self-Management: A Key to Effectiveness and Efficiency in Care of Chronic Disease

Halsted Holman, MDa The present health care system is neither effective nor efficient. The dominant Kate Lorig RN DrPH3 reason for this is a contradiction between the principle problem confronting the system?chronic disease?and the systems methods of operating, which were designed for acute disease. Resolution of the contradiction requires a different practice of health care, with new roles for the patients, for physicians and other health professionals, and for health services. Until the middle of the last century, acute disease was the major health problem in the United States. Then chronic disease began to emerge as the central health care issue. Now, chronic disease is the major cause of disability, the principle reason why patients visit physicians, and the reason for 70% of health care expenditures.1,2 The present health care system, designed early in the last century to cope with acute disease, did not change when chronic disease became the major issue. As a consequence, discontinuity and fragmen tation of care are widespread. Technology is often applied unnecessarily. Com munity and home-based care are poorly developed. Costs mount without obvi ous commensurate benefits for patients. And a large segment of the population is unable to obtain appropriate health care. Why is this so? The answer begins to emerge when we examine the differ ences between acute and chronic disease, as outlined in Tables 1 and 2. Among the many differences, the most crucial are: There is no cure for chronic disease; instead, management over time is essential.

Association of Antibodies to Ribonucleoprotein and Sm Antigens with Mixed Connective-Tissue Disease, Systemic Lupus Erythematosus and Other Rheumatic Diseases

Extractable nuclear antigen contains ribo-nuclease-sensitive (ribonucleoprotein) and ribonuclease-resistant (Sm) components. To determine the diagnostic usefulness of antibodies to these antigens, a multicenter study was undertaken in which serums were analyzed for these antibodies and the findings compared with clinical and other laboratory characteristics of the patients. Of 100 patients with hemagglutinating antibodies to ribonuclease-sensitive extractable nuclear antigen, and only the same antibodies by immunodiffusion, 74 per cent had typical features of mixed connective-tissue disease; 12 features of systemic lupus erythematosus, eight those of scleroderma and six an undifferentiated mild connective-tissue disease. Of 27 patients with hemagglutinating antibodies to ribonuclease-resistant extractable nuclear antigen (and Sm antibodies by immunodiffusion), 85 per cent had typical systemic lupus. Thus, antibodies to nuclear ribonucleoprotein and Sm are of diagnostic use; if the serum contains only ribonucleoprotein antibody in high titer, it is likely that the patient has mixed connective-tissue disease.

A cognitive-behavioral treatment for rheumatoid arthritis.

This experiment tested a cognitive-behavioral rheumatoid arthritis treatment designed to confer skills in managing stress, pain, and other symptoms of the disease. We hypothesized that a mediator of the magnitude of treatment effects might be enhancement of perceived self-efficacy to manage the disease. It was predicted that the treatment would reduce arthritis symptoms and possibly would improve both immunologic competence and psychological functioning. The treatment provided instruction in self-relaxation, cognitive pain management, and goal setting. A control group received a widely available arthritis helpbook containing useful information about arthritis self-management. We obtained suggestive evidence of an enhancement of perceived self-efficacy, reduced pain and joint inflammation, and improved psychosocial functioning in the treated group. No change was demonstrated in numbers or function of T-cell subsets. The magnitude of the improvements was correlated with degree of self-efficacy enhancement.

Association of autoantibodies to different nuclear antigens with clinical patterns of rheumatic disease and responsiveness to therapy

Using a hemagglutination test which can detect antibodies to (a) native and denatured deoxyribonucleic acid (DNA) and (b) an extractable nuclear antigen (ENA), a comparative study of patterns of autoantibody formation has been done in systemic lupus erythematosus (SLE) and related rheumatic diseases. Antibody to native DNA was present in the serum in 96% of patients with active SLE and disappeared during remissions. Antibody to ENA was found in 86% of those patients with SLE nephritis who responded to treatment but in only 8% of those who did not. The highest titers of antibody to ENA were found in patients having a mixed connective tissue disease syndrome with features of SLE, scleroderma, and myositis. The latter syndrome was notable for the absence of renal disease and for a striking responsiveness to corticosteroid therapy. Hemagglutination testing of 277 sera from normal persons and patients with a wide variety of acute diseases other than SLE revealed the presence of antibody to native DNA in only 1.4% and antibody to ENA in only 0.4%. These results yield significant correlations among the pattern of autoimmune reactivity, the clinical form of the rheumatic disease, and responsiveness to treatment. They implicate the qualitative nature of the patients immune response as a conditioning factor in the type of disease. Together with other correlations they may allow classification of rheumatic diseases into more biologically meaningful groups and lead to more selective methods of therapy.