Philip L. Ritter

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.

CHAMPS Physical Activity Questionnaire for Older Adults: outcomes for interventions.

PURPOSE To evaluate effectively interventions to increase physical activity among older persons, reliable and valid measures of physical activity are required that can also detect the expected types of physical activity changes in this population. This paper describes a self-report physical activity questionnaire for older men and women, developed to evaluate the outcomes of the Community Healthy Activities Model Program for Seniors (CHAMPS), an intervention to increase physical activity. METHODS The questionnaire assesses weekly frequency and duration of various physical activities typically undertaken by older adults. We estimated caloric expenditure/wk expended in physical activity and created a summary frequency/wk measure. We calculated measures of each of these for: 1) activities of at least moderate intensity (MET value >/= 3.0); and 2) all specified physical activities, including those of light intensity. Six-month stability was estimated on participants not likely to change (assessment-only control group, physically active cohort). Several tests of construct validity were conducted, and sensitivity to change was analyzed based on response to the CHAMPS intervention. RESULTS The sample (N = 249) comprised underactive persons (N = 173 from the CHAMPS trial) and active persons (N = 76). The sample was aged 65-90 yr (mean = 74, SD = 6); 64% were women, and 9% were minorities. Six-month stability ranged from 0.58 to 0.67, using intraclass correlation coefficients. Nearly all construct validity hypotheses were confirmed, though correlations were modest. All measures were sensitive to change (P < or = 0.01), with small to moderate effect sizes (0.38-0.64). CONCLUSIONS The CHAMPS measure may be useful for evaluating the effectiveness of programs aimed at increasing levels of physical activity in older adults.

Single parents, extended households, and the control of adolescents.

This paper uses a representative national sample of adolescents to study the interrelationships among family structure, patterns of family decision making, and deviant behavior among adolescents. Mother-only households are shown to be associated with particular patterns of family decision making and adolescent deviance, even when family income and parental education are controlled. In contrast to adolescents in households with 2 natural parents, youth in mother-only households are perceived as more likely to make decisions without direct parental input and more likely to exhibit deviant behavior. The presence of an additional adult in a mother-only household, especially for males, is associated with increased parental control and a reduction in various forms of adolescent deviance. Finally, patterns of family decision making and family structure both make independent contributions to adolescent deviance, and the impact of family structure on deviance of adolescent males is hardly affected by controlling for patterns of family decision making.

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.

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.

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.

Community-Based Peer-Led Diabetes Self-management: A Randomized Trial

Purpose The purpose of this study is to determine the effectiveness of a community-based diabetes self-management program comparing treatment participants to a randomized usual-care control group at 6 months. Methods A total of 345 adults with type 2 diabetes but no criteria for high A1C were randomized to a usual-care control group or 6-week community-based, peer-led diabetes self-management program (DSMP). Randomized participants were compared at 6 months. The DSMP intervention participants were followed for an additional 6 months (12 months total). A1C and body mass index were measured at baseline, 6 months, and 12 months. All other data were collected by self-administered questionnaires. Results At 6 months, DSMP participants did not demonstrate improvements in A1C as compared with controls. Baseline A1C was much lower than in similar trials. Participants did have significant improvements in depression, symptoms of hypoglycemia, communication with physicians, healthy eating, and reading food labels (P < .01). They also had significant improvements in patient activation and self-efficacy. At 12 months, DSMP intervention participants continued to demonstrate improvements in depression, communication with physicians, healthy eating, patient activation, and self-efficacy (P < .01). There were no significant changes in utilization measures. Conclusions These findings suggest that people with diabetes without elevated A1C can benefit from a community-based, peer-led diabetes program. Given the large number of people with diabetes and lack of low-cost diabetes education, the DSMP deserves consideration for implementation.

Hispanic Chronic Disease Self-Management A Randomized Community-Based Outcome Trial

BackgroundIn light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory. ObjectiveThis study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes. MethodThe treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests. ResultsAt 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p < .05). At 1 year, the improvements were maintained and remained significantly different from baseline condition. ConclusionsThis community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.

Evaluation of champs, a physical activity promotion program for older adults

We evaluated physical activity changes resulting from a six-month public health model intervention that encouraged seniors (N=89) 62–91 years of age (mean=76) living in two low-income congregate housing facilities to increase their physical activity by participating in existing community-based physical activity classes and programs of their choice. The program was offered to everyone regardless of their health problems. Enrollees were encouraged to adopt activities tailored to their preferences, physical abilities, health status, income, and transportation resources. Using a comparison-group design, the intervention group was more active for all comparison months of the intervention period (p values<.05). The intervention also was associated with improvements in self-esteem (p<.05), though not with an array of other measures of health-related quality-of-life. Those who adopted and maintained a new physical activity over the six-month intervention period experienced improvements in anxiety, depression, and overall psychological well-being relative to those who did not. The intervention was subsequently replicated through a senior center (N=22). A much larger proportion of the senior center sample adopted and maintained a new activity for six months (68%) compared to the congregate facilities sample (35%), which may have been due to differences in recruitment methods and sample characteristics in the two settings. An intervention promoting increased physical activity through the use of existing community resources may help increase physical activity in older adults.