Evaluation of the chronic disease self-management program (CDSMP) among chronically ill older people in the Netherlands

Adapting Stanford's Chronic Disease Self-Management Program to Hawaii's multicultural population

PURPOSE OF THE STUDY

Stanford's Chronic Disease Self-Management Program (CDSMP) has been proven to increase patients' ability to manage distress. We describe how we replicated CDSMP in Asian and Pacific Islander (API) communities.

DESIGN AND METHODS

We used the "track changes" tool to deconstruct CDSMP into its various components (e.g., recruitment and staffing) and the "adaptation traffic light" to identify allowable modifications to the original program. We monitored local leaders' fidelity of delivery of CDSMP and tracked participants' attendance, satisfaction, and 6-month outcomes.

RESULTS

Between July 2007 and February 2010, 584 completed a CDSMP workshop. Baseline and 6-month data were available for 422 (72%), including 53 Caucasians, 177 Asians, and 194 Pacific Islanders. All 3 groups realized significant decreases in social and role activity limitations and significant increases in communication with physicians. Asians and Pacific Islanders also realized significant increases in self-rated health and time spent engaging in stretching/strengthening exercise. Asians also reported significant reductions in health distress and self-reported physician visits and increases in time spent in aerobic exercise, ability to cope with symptoms, and self-efficacy.

IMPLICATIONS

Our experience suggests that CDSMP can be modified for increased cultural appropriateness for API communities while maintaining the key components responsible for behavior change.

Heart failure patients with a lower educational level and better cognitive status benefit most from a self-management group programme

OBJECTIVE

The Chronic Disease Self-Management Programme (CDSMP)was recently evaluated among patients with congestive heart failure (CHF) in a randomized controlled trial (n = 317) with twelve months of follow-up after the start of the programme. That trial demonstrated short-term improvements in cardiac-specific quality of life. The current study assessed which of the patients participating in this trial benefited most from the CDSMP with respect to cardiac-specific quality of life.

METHODS

Subgroup analyses were conducted using mixed-effects linear regression models to assess the relationship between patient characteristics and the effects of the CDSMP on cardiac-specific quality of life.

RESULTS

In the short term, patients with better cognitive status benefited more from the CDSMP than their poorer functioning counterparts. In addition, lower educated patients benefited more from the CDSMP than their higher educated counterparts during total follow-up.

CONCLUSION

Subgroup effects were found for cognitive status and educational level. Future research should be performed to validate current findings and further explore the conditions under which CHF patients may benefit more from the programme.

PRACTICE IMPLICATIONS

These results indicate that lower educated patients, in particular, should be encouraged to participate in the CDSMP. In addition, healthcare practitioners are recommended to take into account potential cognitive impairments of patients.

Evaluation of patient self-management outcomes in health care: a systematic review

BACKGROUND

The importance of self-management and its intervention for improving the ability and skill of self-management has been discussed in literatures. It is, however, unclear how to choose the fitted, objective and accurate evaluation system when assessing the outcome.

AIM

The aim of this article was to establish a general evaluation system for skill and ability of self-management in chronic diseases through systematic review on different evaluation indicators and scales.

METHOD

A systematic search of six electronic databases was conducted. Two authors independently reviewed each qualified study for relevance and significance. Subsequently, main evaluation indicators and scales were identified and categorized into themes and sub-themes.

RESULTS

Nineteen articles were identified in this review. Among them, six main evaluation indicators of self-management, including frequently used scales, were extracted and tabulated. Self-efficacy, health behaviour/attitude, health status, health service utilization, quality of life and psychological indicators were the main indicators in evaluating self-management outcome, and they could be used alone or in combination flexibly according to the different goals of programmes.

CONCLUSION

Accurate evaluation of skill and ability of self-management is crucial not only in baseline data collection but also in proving the effectiveness of intervention. The outcomes of this study provide future researchers or caregivers with a better understanding and a series of good choices in self-management outcome evaluation.

Effectiveness of web-based interventions on patient empowerment: a systematic review and meta-analysis

BACKGROUND

Patient empowerment is growing in popularity and application. Due to the increasing possibilities of the Internet and eHealth, many initiatives that are aimed at empowering patients are delivered online.

OBJECTIVE

Our objective was to evaluate whether Web-based interventions are effective in increasing patient empowerment compared with usual care or face-to-face interventions.

METHODS

We performed a systematic review by searching the MEDLINE, EMBASE, and PsycINFO databases from January 1985 to January 2009 for relevant citations. From the 7096 unique citations retrieved from the search strategy, we included 14 randomized controlled trials (RCTs) that met all inclusion criteria. Pairs of review authors assessed the methodological quality of the obtained studies using the Downs and Black checklist. A meta-analysis was performed on studies that measured comparable outcomes. The GRADE approach was used to determine the level of evidence for each outcome.

RESULTS

In comparison with usual care or no care, Web-based interventions had a significant positive effect on empowerment measured with the Diabetes Empowerment Scale (2 studies, standardized mean difference [SMD] = 0.61, 95% confidence interval [CI] 0.29 - 0.94]), on self-efficacy measured with disease-specific self-efficacy scales (9 studies, SMD = 0.23, 95% CI 0.12 - 0.33), and on mastery measured with the Pearlin Mastery Scale (1 study, mean difference [MD] = 2.95, 95% CI 1.66 - 4.24). No effects were found for self-efficacy measured with general self-efficacy scales (3 studies, SMD = 0.05, 95% CI -0.25 to 0.35) or for self-esteem measured with the Rosenberg Self-Esteem Scale (1 study, MD = -0.38, 95% CI -2.45 to 1.69). Furthermore, when comparing Web-based interventions with face-to-face deliveries of the same interventions, no significant (beneficial or harmful) effects were found for mastery (1 study, MD = 1.20, 95% CI -1.73 to 4.13) and self-esteem (1 study, MD = -0.10, 95% CI -0.45 to 0.25).

CONCLUSIONS

Web-based interventions showed positive effects on empowerment measured with the Diabetes Empowerment Scale, disease-specific self-efficacy scales and the Pearlin Mastery Scale. Because of the low quality of evidence we found, the results should be interpreted with caution. The clinical relevance of the findings can be questioned because the significant effects we found were, in general, small.

[Happy and healthy aging: well-being, resources and self-management abilities]

This article gives an overview of the research program directed by the author. First, the integrated theoretical framework of the program is presented, including sub-theories. The following assumptions are central to the program: (a) there are physical and social basic needs that, if not fulfilled, lead to deficits in well-being; (b) for the fulfilment of these basic needs both external resources and self-management abilities (internal resources) are needed; (c) self-management abilities and external resources mutually influence each other, which makes it possible to intervene. This theoretical basis allows the formulation of clear criteria for happy and healthy aging, and the derivation of the most important (social) conditions that influence the fulfilment of the basic needs. The article also presents the main empirical tests and intervention studies that have been executed, along with the first steps that have been taken to implement the interventions in practice. Recently, the program is focussing more on a lifespan perspective because important influences on happy and healthy aging often originate at younger ages. More insight in the life-span development of external resources and of self-management ability promises a better understanding of what happy and healthy aging is about and of what can be done to positively influence it.

Promotion of self-management in vulnerable older people: a narrative literature review of outcomes of the Chronic Disease Self-Management Program (CDSMP)

With ageing, older people can become frail, and this has been shown to be associated with a decrease in well-being. Observational studies provide evidence of a positive effect of coping resources on well-being. The question is: can coping resources be improved in vulnerable older people? The Chronic Disease Self-Management Program (CDSMP) is a target group-specific intervention which aims to promote the self-management of older people who are confronted with deteriorating health. The aim of this study was to review intervention studies focusing on the CDSMP and to draw conclusions on the benefits of the program. A systematic search was conducted in PubMed and PsychINFO to identify randomized controlled trials (RCTs) focusing on the CDSMP. Nine RCTs focusing on relatively young older adults, 75% of whom with an average age between 49 and 65 years, were included. We found that the CDSMP was consistently beneficial for Health behaviour, especially with regard to the variables of exercise and self-care. For Health status, the majority of studies only showed improvement in the domain of health distress. Most of the studies that investigated Self-efficacy showed convincing improvement in self-efficacy, cognitive symptom management and mental stress management. In Health care utilization, there was no significant decrease. On the whole, the studies showed that CDSMP led to an increase in physical exercise, a decrease in health distress, an improvement in self-care, and it had a beneficial effect on self-efficacy.

Home-based, peer-led chronic illness self-management training: findings from a 1-year randomized controlled trial

PURPOSE

Studies suggest peer-led self-management training improves chronic illness outcomes by enhancing illness management self-efficacy. Limitations of most studies, however, include use of multiple outcome measures without predesignated primary outcomes and lack of randomized follow-up beyond 6 months. We conducted a 1-year randomized controlled trial of Homing in on Health (HIOH), a Chronic Disease Self-Management Program variant, addressing these limitations.

METHODS

We randomized outpatients (N = 415) aged 40 years and older and who had 1 or more of 6 common chronic illnesses, plus functional impairment, to HIOH delivered in homes or by telephone for 6 weeks or to usual care. Primary outcomes were the Medical Outcomes Study 36-ltem short-form health survey's physical component (PCS-36) and mental component (MCS-36) summary scores. Secondary outcomes included the EuroQol EQ-5D and visual analog scale (EQ VAS), hospitalizations, and health care expenditures.

RESULTS

Compared with usual care, HIOH delivered in the home led to significantly higher illness management self-efficacy at 6 weeks (effect size = 0.27; 95% CI, 0.10-0.43) and at 6 months (0.17; 95% CI, 0.01-0.33), but not at 1 year. In-home HIOH had no significant effects on PCS-36 or MCS-36 scores and led to improvement in only 1 secondary outcome, the EQ VAS (1-year effect size = 0.40; CI, 0.14-0.66). HIOH delivered by telephone had no significant effects on any outcomes.

CONCLUSIONS

Despite leading to improvements in self-efficacy comparable to those in other CDSMP studies, in-home HIOH had a limited sustained effect on only 1 secondary health status measure and no effect on utilization. These findings question the cost-effectiveness of peer-led illness self-management training from the health system perspective.

Understanding the self-care strategies of patients with asthma

OBJECTIVE

The objective was to understand how adults living with asthma deal with their chronic illness, perceive self-management and develop self-care strategies.

METHODS

24 in-depth, semi-structured interviews were conducted in Montreal, Canada with low- and middle-income adults living with asthma. The interviews were tape-recorded and transcribed for purposes of analysis. The analysis consisted of debriefing sessions, coding and interpretive analysis.

RESULTS

We identified 3 types of self-care strategies adopted by the participants in order to deal with asthma: (1) strategy of controlling symptoms leads to patients following the recommendations of their physician; (2) strategy of preventing symptoms involves a holistic approach to treating illness, and leads patients to prefer lay methods and alternative treatments for preventing symptoms instead of relying on medications; (3) strategy of tolerating symptoms leads people to experience aggravated symptoms and to seek emergency care.

CONCLUSION

This study reveals that important subjective as well social factors influence the way people deal with a chronic illness like asthma. Future research should: (1) identify the difficulties encountered by vulnerable patients in regard to treatment and care interactions; (2) provide health professionals with the right tools so that they can take into consideration the treatment perceptions and the effects of life conditions on self-management.

PRACTICE IMPLICATIONS

Patients with asthma need comprehensive care that addresses social conditions, reluctance to take medication, exploration of lay and alternative treatment and difficulties in accessing preventive care.

The impact of a self-management group programme on health behaviour and healthcare utilization among congestive heart failure patients

AIMS

The 'Chronic Disease Self-Management Programme' (CDSMP) emphasizes patients' responsibility for the day-to-day management of their condition(s) and has shown favourable effects on health behaviour and healthcare utilization among various groups of patients with chronic conditions. However, the effects of the CDSMP among congestive heart failure (CHF) patients are unknown. We therefore aimed to assess the effects of the CDSMP on health behaviour and healthcare utilization in patients with CHF.

METHODS AND RESULTS

This randomized, controlled trial with 12 months of follow-up included 317 CHF patients with a slight to marked limitation of physical activity. Control patients (n = 131) received usual care, consisting of regular checkups at an outpatient clinic. Intervention group patients (n = 186) received usual care and participated in a 6-week self-management group programme. Favourable effects on walking for exercise and other physical activities such as aerobic, stretching, and strength exercises, sports, and gardening were reported in the intervention group immediately after completion of the programme. The effect of the programme on other physical activities extended to 6 months of follow-up. No favourable effects were found for the other outcomes.

CONCLUSION

The CDSMP significantly improved physical activity among CHF patients for up to 6 months after the end of the programme; however, it did not affect other health behaviour outcomes or healthcare utilization.

Feasibility of a group-based self-management program among congestive heart failure patients

OBJECTIVE

This study assessed the feasibility of the Chronic Disease Self-Management Program (CDSMP) among patients with congestive heart failure (CHF). The program emphasizes patients' central role and responsibility in managing their illness.

METHODS

Patients were randomly assigned to the program, which was led by a cardiac nurse specialist and a CHF patient. Data on performance according to protocol, adherence, and opinion about the program were collected among 186 patients and 18 leaders.

RESULTS

Eighty percent of the group sessions were carried out largely according to protocol. Three fourths of the patients attended at least 4 of the 6 sessions. Female sex and lower New York Heart Association classification predicted good attendance.

CONCLUSION

Directly after the program and at 12-month follow-up, approximately three fourths of the patients stated that they had benefited from the program. Recommendations mainly concerned spending more time on several program topics and specifying patient-selection criteria in more detail. The program was considered feasible.