Self-management education for rehabilitation inpatients: A cluster-randomized controlled trial

Patient education interventions for the management of inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is a life-long condition for which currently there is no cure. Patient educational interventions deliver structured information to their recipients. Evidence suggests patient education can have positive effects in other chronic diseases.

OBJECTIVES

To identify the different types of educational interventions, how they are delivered, and to determine their effectiveness and safety in people with IBD.

SEARCH METHODS

On 27 November 2022, we searched CENTRAL, Embase, MEDLINE, ClinicalTrials.gov, and WHO ICTRP with no limitations to language, date, document type, or publication status. Any type of formal or informal educational intervention, lasting for any time, that had content focused directly on knowledge about IBD or skills needed for direct management of IBD or its symptoms was included. Delivery methods included face-to-face or remote educational sessions, workshops, guided study via the use of printed or online materials, the use of mobile applications, or any other method that delivers information to patients.

SELECTION CRITERIA

All published, unpublished and ongoing randomised control trials (RCTs) that compare educational interventions targeted at people with IBD to any other type of intervention or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment of the included studies. We analysed data using Review Manager Web. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

We included 14 studies with a total of 2708 randomised participants, aged 11 to 75 years. Two studies examined populations who all had ulcerative colitis (UC); the remaining studies examined a mix of IBD patients (UC and Crohn's disease). Studies considered a range of disease activity states. The length of the interventions ranged from 30 minutes to 12 months. Education was provided in the form of in-person workshops/lectures, and remotely via printed materials or multimedia, smartphones and internet learning. Thirteen studies compared patient education interventions plus standard care against standard care alone. The interventions included seminars, information booklets, text messages, e-learning, a multi professional group-based programme, guidebooks, a staff-delivered programme based on an illustrated book, a standardised programme followed by group session, lectures alternating with group therapy, educational sessions based on an IBD guidebook, internet blog access and text messages, a structured education programme, and interactive videos. Risk of bias findings were concerning in all judgement areas across all studies. No single study was free of unclear or high of bias judgements. Reporting of most outcomes in a homogeneous fashion was limited, with quality of life at study end reported most commonly in six of the 14 studies which allowed for meta-analysis, with all other outcomes reported in a more heterogeneous manner that limited wider analysis. Two studies provided data on disease activity. There was no clear difference in disease activity when patient education (n = 277) combined with standard care was compared to standard care (n = 202). Patient education combined with standard care is probably equivalent to standard care in reducing disease activity in patients with IBD (standardised mean difference (SMD) -0.03, 95% CI -0.25 to 0.20), moderate-certainty evidence. Two studies provided continuous data on flare-up/relapse. There was no clear difference for flare-ups or relapse when patient education (n = 515) combined with standard care was compared to standard care (n = 507), as a continuous outcome. Patient education combined with standard care is probably equivalent to standard care in reducing flare-ups or relapse in patients with IBD (MD -0.00, 95% CI -0.06 to 0.05; moderate-certainty evidence). Three studies provided dichotomous data on flare-up/relapse. The evidence is very uncertain on whether patient education combined with standard care (n = 157) is different to standard care (n = 150) in reducing flare-ups or relapse in patients with IBD (RR 0.94, 95% CI 0.41 to 2.18; very low-certainty evidence). Six studies provided data on quality of life. There was no clear difference in quality of life when patient education combined with standard care (n = 721) was compared to standard care (n = 643). Patient education combined with standard care is probably equivalent to standard care in improving quality of life in patients with IBD (SMD 0.08, 95% CI -0.03 to 0.18; moderate-certainty evidence). The included studies did not report major differences on healthcare access. Medication adherence, patient knowledge and change in quality of life showed conflicting results that varied between no major differences and differences in favour of the educational interventions. Only five studies reported on adverse events. Four reported zero total adverse events and one reported one case of breast cancer and two cases of surgery in their interventions groups, and zero adverse events in their control group. Two studies compared delivery methods of patient education, specifically: web-based patient education interventions versus colour-printed books or text messages; and one study compared frequency of patient education, specifically: weekly educational text messages versus once every other week educational text messages. These did not show major differences for disease activity and quality of life. Other outcomes were not reported.

AUTHORS' CONCLUSIONS

The ways in which patient educational support surrounding IBD may impact on disease outcomes is complex. There is evidence that education added to standard care is probably of no benefit to disease activity or quality of life when compared with standard care, and may be of no benefit for occurrence of relapse when compared with standard care. However, as there was a paucity of specific information regarding the components of education or standard care, the utility of these findings is questionable. Further research on the impact of education on our primary outcomes of disease activity, flare-ups/relapse and quality of life is probably not indicated. However, further research is necessary, which should focus on reporting details of the educational interventions and study outcomes that educational interventions could be directly targeted to address, such as healthcare access and medication adherence. These should be informed by direct engagement with stakeholders and people affected by Crohn's and colitis.

[The Autonomy of Patients in Inpatient Medical Rehabilitation - Aspects of Endangerment and Preservation]

PURPOSE

The aim of the study is to identify aspects within inpatient medical rehabilitation that may endanger or preserve the autonomy of patients.

METHODS

A scoping review was carried out on the basis of the current state of scientific knowledge. The methodological approach was based on the specifications of the Joanna Briggs Institute. The research and generation of findings were logged according to the PRISMA-ScR checklist.

RESULTS

The final study inclusion comprises 39 empirical and normative-theoretical contributions. Autonomy-threatening aspects were assigned to the following domains: Rehabilitation system, rehabilitation clinics, staff, patients and third parties. Aspects potentially preserving the autonomy of patients included the following domains: Rehabilitation clinics, staff, concepts and forms of expression as well as instruments.

CONCLUSION

A large number of heterogeneous aspects can endanger, but can also preserve or promote the autonomy of patients during their stay in inpatient medical rehabilitation. These are located throughout in the entire rehabilitation process and concern the structural, organizational and personal level. The autonomy of patients should not only be treated as an outcome of rehabilitation, but also as a requirement for structures and actors during the rehabilitation stay.

[Work Participation after Multimodal Rehabilitation due to Respiratory Diseases - Representative Analyses using Routine Data of the German Pension Insurance]

PURPOSE

For the German rehabilitation system there are only few representative findings on occupational reintegration after medical rehabilitation. For persons who have undergone rehabilitation on behalf of the German Pension Insurance (GPI) due to a respiratory disease, it is therefore needed to determine (a) what socio-medical risks exist prior to rehabilitation, (b) how well persons were able to participate in working life after rehabilitation, and (c) what conditions determine the work participation.

METHODS

The study is conducted on the basis of the GPI's database of rehabilitation statistics. Included were all persons, who completed medical rehabilitation in 2016 with a main discharged diagnosis from chapter J of the ICD-10. The analyses were carried out for the entire group and also in a differentiated manner for the the 2 main diseases bronchial asthma and COPD. Work participation was operationalized both via a monthly status variable until 24 months after rehabilitation and as a rate of all persons who were employed at the 12 and 24 months follow up and in the 3 months before, respectively. To analyze the factors influencing stable work participation, multiple logistic regression models with stepwise inclusion were calculated separately for the rates after 12 and 24 months.

RESULTS

A total of 19,287 data sets were included in the analysis (bronchial asthma: n=9,108, 47%; COPD: n=6,215, 32%). Patients with respiratory diseases were 53 years old on average, both genders were equally distributed. 14% had no absenteeism, 11 % stated an absence leave 6 months or more in the year prior to rehabilitation. Mental and cardiovascular comorbidity was documented in 39 and 38% of the cases, respectively. Overall, patients with COPD had higher socio-medical risks before rehabilitation than asthma patients. Accordingly, only about half of the COPD patients remained in active employment, while about 80% of the asthma patients succeeded in this. The strongest influencing factors on stable work participation were the time of sick leave as well as income prior to rehabilitation.

CONCLUSION

About two thirds of all persons with respiratory diseases are in stable employment after medical rehabilitation in Germany, with large differences between asthma bronchiale and COPD. In particular, the absenteeism as well as the wage before rehabilitation determine this. The analysis provides representative data on occupational reintegration after medical rehabilitation due to a respiratory disease for the first time.

Effects of a HAPA-based multicomponent intervention to improve self-management precursors of older adults with tuberculosis: A community-based randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a multicomponent intervention based on the Health Action Process Approach (HAPA) model to improve the self-management precursors of older adults with tuberculosis (TB).

METHODS

A cluster-randomised controlled trial was conducted. Older adults with TB in the intervention communities received HAPA-based multicomponent interventions at the beginning of treatment and in the first and sixth months after treatment initiation, and those in the control communities received health education alone. Self-management precursors were measured at baseline and 1 week after each intervention.

RESULTS

Among 262 randomized patients, 244 (93%) completed the trial. Compared with the control group, self-management precursor scores for the intervention group increased significantly over time (β_group*time = 2.92, p < 0.001) in the following 3 precursors: behaviour belief (β_group*time = 0.35, p < 0.001), behaviour plan (β_group*time = 0.72, p < 0.001), and self-efficacy (β_group*time = 1.85, p < 0.001). Education was significantly associated with behaviour belief (β = 0.18, p < 0.05). Chronic comorbidity was significantly associated with behaviour plan (β=-0.26, p < 0.05).

CONCLUSION

Compared with single health education, the HAPA-based multicomponent interventions significantly improved the self-management precursor of older adults with TB.

PRACTICE IMPLICATIONS

This HAPA-based multicomponent intervention strategy may be a promising self-management mode for the routine health care of TB patients.

[Evidence-Based Approaches in Rehabilitation - Research Designs and Conceptual Foundations for Analyzing the Efficacy and Effectiveness of Rehabilitation Treatments]

Rehabilitation is evidenced based if treatments are applied that proved to enhance rehabilitation outcomes - generally patients' health or participation- effectively in a causal manner. Randomized control trials (RCTs) allow determining the efficacy of treatments unambiguously. If alternative research designs (e. g. case-control studies, cohort studies, observational studies) are adopted, the association of the treatment and the improvement of the health status or participation may be biased by confounding variables (limitations of internal validity). Several variants of the basic RCT designs have been developed (e. g. cluster-randomized trials, factorial designs, pragmatic trials) to adapt RCTs to the demands of practical applications. Additionally, deciding and acting evidence-based requires rehabilitation treatments and recommendations which have been developed on a solid theoretical basis and which are applied in practical rehabilitation care appropriately. Especially, because treatments have to be chosen and provided according to rehabilitation patients' individual needs. Furthermore, in every day care the application of treatments has to be matched to the specific conditions of the respective rehabilitation institution. Thus, a comprehensive understanding of evidence requires not only efficacy studies adopting RCTs. Additionally, knowledge about treatment efficacy has to be complemented by studies investigating conceptual and theoretical foundations of effective treatments (intervention design) as well as studies to apply treatments in practical rehabilitation care (implementation research) appropriately.