A systematic review examining whether community-based self-management programs for older adults with chronic conditions actively engage participants and teach them patient-oriented self-management strategies

OBJECTIVE

To identify whether community-based Self-Management Programs (SMPs) actively engaged, or taught, individuals patient-oriented strategies; and whether having these attributes led to significant differences in outcomes.

METHODS

This systematic review included randomized controlled trials (RCTs)and cluster RCTs reporting on community-based SMPs with a group component for older adults with chronic conditions. The ways SMPS actively engaged participants and whether they taught patient-oriented strategies were analyzed. All study outcomes were reported.

RESULTS

The 31 included studies demonstrated community-based SMP programs actively engaged participants and provided strategies to improve health behaviour or care of their condition. Few included strategies to help manage the impact of conditions on their everyday lives. Seventy-nine percent of studies reported significant differences; variations in sample sizes and outcomes made it difficult to conclude whether having these attributes led to significant differences.

CONCLUSION

SMPs are not supporting older adults to use strategies to address the impact of conditions on their everyday lives, addressing the needs of older adults with multiple conditions, nor assessing outcomes that align with the strategies taught.

PRACTICE IMPLICATIONS

Health-care providers delivering SMPs to older adults need to tailor programs to the needs of older adults and assess whether participants are using strategies being proposed.

Delineating the concept of self-management in chronic conditions: a concept analysis

OBJECTIVES

Self-management is a concept frequently used within healthcare but lacks consensus. It is the aim of this study to clarify the concept.

DESIGN

Concept analysis according to Walker and Avant, comprises eight steps: select concept, determine purpose, identify uses, determine defining attributes, identify model case, identify additional cases, identify antecedents and consequences and define empirical referents.

SOURCES USED

PubMed, Scopus and Web of Science.

RESULTS

Ten attributes delineating the concept have been identified and organised into three groups. Group (a): person-oriented attributes: the person must (1) actively take part in the care process, (2) take responsibility for the care process and (3) have a positive way of coping with adversity. Group (b): person-environment-oriented attributes: (4) the person must be informed about the condition, disease and treatment and self-management, (5) should be individualised, which entails expressing needs, values and priorities, (6) requires openness to ensure a reciprocal partnership with healthcare providers and (7) demands openness to social support. Finally, Group (c): summarising attributes: self-management (8) is a lifetime task, (9) assumes personal skills and (10) encompasses the medical, role and emotional management.

CONCLUSIONS

The findings of this study recognise the complexity of the concept, but also show the need for further investigation to make the concept more measurable. Clarity about the concept will enhance understanding and facilitate implementation in self-management programmes for chronic conditions.

Patient education in the management of coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation.

OBJECTIVES

1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables.

MAIN RESULTS

This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains.

AUTHORS' CONCLUSIONS

We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.

Longitudinal Effects of Social Support on the Health and Functioning of Older Women with Heart Disease

This study examined the effects of: 1) four dimensions of social support, 2) the number of close social ties, and 3) marital status on the physical and psychological health and functioning of 471 women aged 60 years and over with heart disease. Linear mixed models were used to assess the impact of each baseline social relations predictor on health outcomes at four-, 12-, and 18-month follow-up intervals. A second set of models examined the association between change in support variables over time with concomitant change in health outcomes. Results indicated that baseline emotional/informational support, positive social interaction, affectionate support, tangible support, number of close friends and relatives, and marital status all significantly predicted ( p < .05) one or more health outcomes over time. Increases in positive social interaction and emotional support over time were significantly associated with concurrent improvement in all self-reported physical and psychological health outcomes. Interventions that enhance the availability of emotional/informational support and promote social interaction are needed for this population.

The Evolution of an Innovative Heart Disease Management Program for Older Women: Integrating Quantitative and Qualitative Methods in Practice

Few studies in the literature describe how to combine quantitative and qualitative methods to enhance the development of health education interventions. This article describes the evolution and refinement of an innovative disease management program “take PRIDE” for older adults with heart disease. Over 15 years, information obtained from data collection methods including telephone interviews, focus groups, face-to-face interviews, and program process data illuminated and guided subsequent refinement of the program and led to new iterations for different participants. Qualitative and quantitative data were incorporated into the two key areas of program development (theoretical framework, objectives, format, and content) and evaluation (evaluation design, sampling, and measurement). Combining both types of data enhanced the opportunity to detect needed program changes, to increase understanding of the mechanisms by which the program effects were produced, and to enhance the relevance of the program to different groups of program participants.

Heart disease management by women: does intervention format matter?

A randomized controlled trial of two formats of a program (Women Take PRIDE) to enhance management of heart disease by patients was conducted. Older women (N = 575) were randomly assigned to a group or self-directed format or to a control group. Data regarding symptoms, functional health status, and weight were collected at baseline and at 4, 12, and 18 months. The formats produced different outcomes. At 18 months, the self-directed format was better than the control in reducing the number (p ≤ .02), frequency (p ≤ .03), and bothersomeness (p ≤ .02) of cardiac symptoms. The self-directed format was also better than the group format in reducing symptom frequency of all types (p ≤ .04). The group format improved ambulation at 12 months (p ≤ .04) and weight loss at 18 months (p ≤ .03), and group participants were more likely to complete the program (p ≤ .05). The availability of different learning formats could enhance management of cardiovascular disease by patients.

Results of a community translation of the "Women Take PRIDE" heart disease self-management program

This article reports the results of a community demonstration of an evidence-based heart disease self-management program for older women. Women Take PRIDE (WTP) is a group-based education and behavior modification program, based on social cognitive theory, designed to enhance heart disease self-management among older women. We implemented the program in community settings with 129 participants. Evaluation data was collected at baseline and at 4- and 12-month follow-ups. Outcomes included general health status, functional health status, and knowledge. Results showed significant improvements in self-rated health, energy, social functioning, knowledge of community resources, and number, frequency, and bother of cardiac symptoms. These results demonstrate that an evidence-based heart disease self-management program can be effective at improving health and quality of life among older women with heart disease when implemented in community settings.

Cardiac self-efficacy and its predictors in patients with coronary artery diseases

AIMS AND OBJECTIVES

To investigate cardiac self-efficacy and its predictors among patients with coronary artery diseases.

BACKGROUND

Patients with coronary artery diseases must perform the health behaviour to prevent recurrent cardiac events. It has been already well known that self-efficacy is a vital factor in both initiating and maintaining health behaviours.

DESIGN

Descriptive correlational and cross-sectional survey design.

METHODS

Subjects were interviewed using structured study questionnaires. The data collected were statistically analysed by descriptive statistics and inferential statistics including the t-test, anova, Tukey's test, Pearson's correlation and hierarchical multiple regression analysis to determine the predictors of cardiac self-efficacy.

RESULTS

A convenience sample of 214 patients with coronary artery diseases was included. The mean age of subjects was 60·71 ± 10·07 years, and three-fourths were men. The overall model significantly explained 15·8% of variance in cardiac self-efficacy. Among predictors, occupation, diagnosis, body mass index, experience of receiving patient education and awareness of risk factors had statistically significant influences on cardiac self-efficacy.

CONCLUSIONS

Rather than disease knowledge, factors related to subject's perception were more likely to associate with cardiac self-efficacy. These findings might provide a theoretical basis to develop nursing interventions for enhancing cardiac self-efficacy of patients with coronary artery diseases.

RELEVANCE TO CLINICAL PRACTICE

Clinical nurses taking care of patients with coronary artery diseases should consider the patients' perception on their coronary artery diseases including experience of receiving patient education, and awareness of risk factors in encouraging the cardiac self-efficacy to promote the health behaviours for the secondary prevention of coronary artery diseases.

Effect of patient education in the management of coronary heart disease: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To assess the effects of patient education on mortality, morbidity, health-related quality of life (HRQoL), and healthcare costs in people with coronary heart disease (CHD).

DESIGN

Systematic review and meta-analysis.

METHODS

Data sources were Cochrane Library, Medline, Embase, PsycINFO, CINAHL, and ongoing trial registries until August 2010. We also checked study references. The study selection was based on design (randomized controlled trials with follow up of at least 6 months, published from 1990 onwards), population (adults with CHD), intervention (patient education stated to be the primary intervention), and comparators (usual care or no educational intervention).

RESULTS

Thirteen studies (68,556 people with CHD) were included. Educational interventions ranged from two visits to a 4-week residential stay with 11 months of reinforcement sessions. Compared to no educational intervention, there was weak evidence that education reduced all-cause mortality (pooled relative risk (RR) 0.79, 95% CI 0.55 to 1.13) and cardiac morbidity outcomes: myocardial infarction (pooled RR 0.63, 95% CI 0.26 to 1.48), revascularization (pooled RR 0.58, 95% CI 0.19 to 1.71), and hospitalization (pooled RR 0.83, 95% CI 0.65 to 1.07) at median 18-months follow up. There was evidence to suggest that education can improve HRQoL and decrease healthcare costs by reductions in downstream healthcare utilization.

CONCLUSIONS

Our review had insufficient power to exclude clinically important effects of education on mortality and morbidity. Nevertheless it supports the practice of CHD secondary prevention and rehabilitation programmes including education as an intervention. Further research is needed to determine the most effective and cost-effective format, duration, timing, and methods of education delivery.

Patient education in the management of coronary heart disease

BACKGROUND

Cardiac rehabilitation (CR) is a complex multifaceted intervention consisting of three core modalities: education, exercise training and psychological support. Whilst exercise and psychological interventions for patients with coronary heart disease (CHD) have been the subject of Cochrane systematic reviews, the specific impact of the educational component of CR has not previously been investigated.

OBJECTIVES

1. Assess effects of patient education on mortality, morbidity, health-related quality of life (HRQofL) and healthcare costs in patients with CHD.2. Explore study level predictors of the effects of patient education (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

The following databases were searched: The Cochrane Library, (CENTRAL, CDSR, DARE, HTA, NHSEED), MEDLINE (OVID), EMBASE (OVID), PsycINFO (EBSCOhost) and CINAHL (EBSCOhost). Previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies and extracted data. Attempts were made to contact all study authors to obtain relevant information not available in the published manuscript. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. For continuous variables, mean differences and 95% CI were calculated for each outcome.

MAIN RESULTS

Thirteen RCTs involving 68,556 subjects with CHD and follow-up from six to 60 months were found. Overall, methodological quality of included studies was moderate to good. Educational 'dose' ranged from a total of two clinic visits to a four-week residential stay with 11 months of follow-up sessions. Control groups typically received usual medical care. There was no strong evidence of an effect of education on all-cause mortality (Relative Risk (RR): 0.79, 95% CI 0.55 to 1.13), cardiac morbidity (subsequent myocardial infarction RR: 0.63, 95% CI 0.26 to 1.48, revascularisation RR: 0.58, 95% CI 0.19 to 1.71) or hospitalisation (RR: 0.83, 95% CI:0.65 to 1.07). Whilst some HRQofL domain scores were higher with education, there was no consistent evidence of superiority across all domains. Different currencies and years studies were performed making direct comparison of healthcare costs challenging, although there is evidence to suggest education may be cost-saving by reducing subsequent healthcare utilisation.This review had insufficient power to exclude clinically important effects of education on mortality and morbidity of patients with CHD.

AUTHORS' CONCLUSIONS

We did not find strong evidence that education reduced all cause mortality, cardiac morbidity, revascularisation or hospitalisation compared to control. There was some evidence to suggest that education may improve HRQofL and reduce overall healthcare costs. Whilst our findings are generally supportive of current guidelines that CR should include not only exercise and psychological interventions, further research into education is needed.

Psychosocial interventions for the prevention of depression in older adults: systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of psychosocial interventions for the prevention of depression in older people.

METHOD

Systematic review and meta-analysis of prospective controlled trials.

RESULTS

Thirty studies were included. Overall, psychosocial interventions had a small but statistically significant effect on depressive symptoms (17 trials, standardized mean difference = -0.17, 95% CI = -0.31 to -0.03). In comparison with no-intervention controls, social activities were effective in reducing depressive symptoms, but results should be interpreted with caution due to the small number of trials. No statistically significant effect on depressive symptoms was found for physical exercise, skill training, reminiscence, or for multicomponent interventions.

DISCUSSION

Psychosocial interventions have a small but statistically significant effect in reducing depressive symptoms among older adults. The current evidence base for psychosocial interventions for primary prevention of depression in older people is weak, and further trials warranted especially for the most promising type of interventions evaluated, that is, social activities.

Service organisation for the secondary prevention of ischaemic heart disease in primary care

BACKGROUND

Ischaemic heart disease (IHD) is a major cause of mortality and morbidity and its prevalence is set to increase. Secondary prevention aims to prevent subsequent acute events in people with established IHD. While the benefits of individual medical and lifestyle interventions is established, the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community settings is less so.

OBJECTIVES

To assess the effectiveness of service organisation interventions, identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity) and appropriate prophylactic medication.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 4), MEDLINE (1966 to Feb 2008), EMBASE (1980 to Feb 2008), and CINAHL (1981 to Feb 2008). Bibliographies were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of service organisation interventions in primary care or community settings in populations with established IHD.

DATA COLLECTION AND ANALYSIS

Analyses were conducted according to Cochrane recommendations and Odds Ratios (with 95% confidence intervals) reported for dichotomous outcomes, mean differences (with 95% CIs) for continuous outcomes.

MAIN RESULTS

Eleven studies involving 12,074 people with IHD were included. Increased proportions of patients with total cholesterol levels within recommended levels at 12 months, OR 1.90 (1.04 to 3.48), were associated with interventions that included regular planned appointments, patient education and structured monitoring of medication and risk factors, but significant heterogeneity was apparent. Results relating to blood pressure within target levels bordered on statistical significance. There were no significant effects of interventions on mean blood pressure or cholesterol levels, prescribing, smoking status or body mass index. Few data were available on the effect on diet. There was some suggestion of a "ceiling effect" whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached.

AUTHORS' CONCLUSIONS

There is weak evidence that regular planned recall of patients for appointments, structured monitoring of risk factors and prescribing, and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure. Further research in this area would benefit from greater standardisation of the outcomes measured.

Gender, Self-Care and Functional Status Among Older Persons with Coronary Heart Disease: A National Perspective

The risk and burdens of cardiovascular diseases rise in late life and shift from men to women at age 65. This study uses baseline data from the National Survey of Self-Care and Aging to assess the association of self-care and functional status of older men and women with coronary heart disease (CHD). We first compare men and women with and without CHD, then base subsequent analyses on 597 persons with CHD. Three types of self-care (behavior changes, environmental adaptations, medical equipment use) were examined, and functional status was measured as difficulty with basic, mobility, and instrumental ADLs. Regardless of gender, persons with CHD had more functional impairment and used more self-care than those without the disease. Women were more impaired and engaged in more self-care than men. Equipment use was associated with higher functioning for men and women. Behavioral changes were significant only for men, as were advanced age, non-white ethnicity, more depressive symptoms, and low physical activity for women. Education, intervention, and supportive care for older adults with CHD should consider the role of specific types of self-care in disease management and prevention of decline as well as gender differences in use of various self-care strategies.

The effect of patient choice of intervention on health outcomes

BACKGROUND

Patient preference may influence intervention effects, but has not been extensively studied. Randomized controlled design (N=1075) assessed outcomes when women (60 years+) were given a choice of two formats of a program to enhance heart disease management.

METHODS

Randomization to "no choice" or "choice" study arms. Further randomization of "no choice" to: 1) Group intervention program format, 2) Self-Directed program format, 3) Control Group. "Choice" arm selected their preferred program format. Baseline, four, twelve, and eighteen month follow-up data were collected. Two analyses: health outcomes for choice compared to being randomized; and preference effect on treatment efficacy.

RESULTS

Women who chose a format compared to being assigned a format had better psychosocial functioning at four months (p=0.02) and tended toward better physical functioning at twelve months (p=0.07). At eighteen months women who chose versus being assigned a format had more symptoms measured as: number (p=0.004), frequency (p=0.006) and bother (p=0.004). At four months women who preferred the Group format had better psychosocial functioning when assigned the Group format than when they were assigned the Self-Directed format (p=0.03). At eighteen months women preferring a Group format had more symptoms: number (p=0.001), frequency (p=0.001), bother (p=0.001) when assigned the Group format than when assigned the Self-Directed format.

CONCLUSIONS

Choice and preference for the Group format each enhanced psychosocial and physical functioning up to one year. Despite the preference for Group format, over the longer term (eighteen months) cardiac symptoms were fewer when assigned the Self-Directed format.

Heart disease management by women: does intervention format matter?

A randomized controlled trial of two formats of a program (Women Take PRIDE) to enhance management of heart disease by patients was conducted. Older women (N = 575) were randomly assigned to a group or self-directed format or to a control group. Data regarding symptoms, functional health status, and weight were collected at baseline and at 4, 12, and 18 months. The formats produced different outcomes. At 18 months, the self-directed format was better than the control in reducing the number (p < or = .02), frequency (p < or = .03), and bothersomeness (p < or = .02) of cardiac symptoms. The self-directed format was also better than the group format in reducing symptom frequency of all types (p < or = .04). The group format improved ambulation at 12 months (p < or = .04) and weight loss at 18 months (p < or = .03), and group participants were more likely to complete the program ( p < or = .05). The availability of different learning formats could enhance management of cardiovascular disease by patients.

The contributions of psychological disposition and risk factor status to health following treatment for coronary artery disease

BACKGROUND

Successful adjustment following treatment for coronary artery disease is related to both psychological disposition and risk factor status. Consideration of the interplay between these variables is required to better acknowledge their relationship with health outcome.

AIMS

To determine the salience of self-efficacy and locus of control to both general self-rated health and current cardiac health, relative to risk factor status. To determine whether self-efficacy is a more salient predictor of health status than locus of control.

METHODS

Men (n=248) treated in the previous 3 years for either coronary artery disease alone or a myocardial infarction completed a questionnaire in which clinical, risk factor (knowledge of risk factors, current risk factors, change in risk factors), psychological (self-efficacy, locus of control) and health information were sought.

RESULTS

Self-efficacy and internal locus of control had both direct and indirect influences on health in the models in which knowledge of risk factors was treated as the potential mediator. This pattern of results was not evident when either current risk factors or change in risk factors were examined as potential mediators. In the models in which self-efficacy was considered as a potential mediator of locus of control in the prediction of health status, self-efficacy was determined to be the more relevant psychological construct.

CONCLUSION

The consistent positive associations obtained among self-efficacy, cognitive risk factor status and health suggest that health professionals involved in cardiac rehabilitation should be encouraged to tailor interventions that allow patients to both improve their understanding of CAD and also to develop greater self-confidence in their ability to implement the acquired knowledge.

FAMISHED for Support

BACKGROUND

Heart disease causes disproportionately heavy burdens on unpartnered elders (widowed, divorced, never married) who have limited social resources to contend with recovery demands and complications resulting from acute myocardial infarction (AMI) or coronary artery bypass graft (CABG) surgery. Research suggests that the availability of social support improves recovery after AMI and CABG, yet functional support expressly designed to modify health and stimulate recovery remains unspecified. Advanced practice nurses (APNs) in the clinical nurse specialist (CNS) role who provide social support to recovering elders may be able to improve health outcomes for this vulnerable group.

AIMS

The investigators' aims are to (1) quantify the duration and frequency of nurse contact with unpartnered elders recovering from cardiac events and (2) describe the functional support provided by the CNS to the unpartnered recovering elder.

METHODS

Forty narrative accounts comprising 670 entries by interventional CNS APNs were examined using thematic analytic techniques.

RESULTS

Over a 14-week period, CNS APNs contacted recovering elders 16 times, with a total of 4.5 hours spent per elder, or 13 minutes per phone call and 80 minutes per home visit. Analysis of 670 entries demonstrated functional and emotional support that was captured in the acronym, FAMISHED.

CONCLUSIONS

Functional and emotional support from the CNS may enhance self-efficacy for recovery from cardiac events for unpartnered elders.

Understanding and Reducing Stress and Psychological Distress in Older Women with Heart Disease

Stress and psychological distress were assessed in 457 older women who were subsequently randomized to a six-week heart disease management program ("Women take PRIDE") or to a "usual care" control group. Baseline distress was significantly associated with age, symptoms, physical functioning, social support, optimism, and self-esteem (p < .05). Only 20% of women reported their physician had recommended reducing stress. At four months follow-up, intervention women compared to controls were significantly more likely to report reductions in stress levels (p = 0.02) and also showed improvement in emotional behavior (p = 0.09).

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.

Management of chronic disease by patients

Chronic conditions dominate health care in most parts of the world, including the United States. Management of a disease by the patient is central to control of its effects. A wide range of influences in the person's social and physical environments enhance or impede management efforts. Interventions to improve management by patients can produce positive outcomes including better monitoring of a condition, fewer symptoms, enhanced physical and psychosocial functioning, and reduced health care use. Successful programs have been theory based. Self-regulation is a promising framework for the development of interventions. Nonetheless, serious gaps in understanding and improving disease management by patients remain because of an emphasis on clinical settings for program delivery, neglect of the factors beyond patient behavior that enable or deter effective management, limitations of study designs in much work to date, reliance on short-term rather than long-term assessments, and failure to evaluate the independent contribution of various program components.

Can a disease self-management program reduce health care costs? The case of older women with heart disease

BACKGROUND

There is increasing interest in the potential for chronic disease self-management interventions to provide health benefits while reducing health care costs.

OBJECTIVES

To assess the impact of a heart disease management program on use of hospital services; to estimate associated hospital cost savings; and to compare potential cost savings with the cost of delivering the program.

RESEARCH DESIGN

Randomized, controlled study design. Data were collected from hospital billing records during a 36 month period. Multivariate models were used to compare health care use with cost between treatment and control groups. Estimated differences were then compared with the program costs to determine cost-effectiveness.

SUBJECTS

Participants were recruited from 6 hospital sites. Screening criteria included: female, 60 years or older, diagnosed cardiac disease, and seen by a physician approximately every 6 months. The study included 233 women in the intervention group and 219 in the control group. The "Women Take PRIDE" program utilizes a self-regulation process for addressing a problematic area of the heart regimen recommended by each woman's physician. It is tailored to the unique needs of older women.

MEASURES

Hospital admissions, in-patient days, emergency department visits.

RESULTS

Program participants experienced 46% fewer in-patient days (P <0.05) and 49% lower in-patient costs (P <0.10) than women in the control group. No significant differences in emergency department utilization were found. Hospital cost savings exceeded program costs by a ratio of nearly 5-to-1.

CONCLUSIONS

A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan.

The influence of social support on chronic illness self-management: a review and directions for research

A review of the empirical literature examining the relationship between social support and chronic illness self-management identified 29 articles, of which 22 were quantitative and 7 were qualitative. The majority of research in this area concerns diabetes self-management, with a few studies examining asthma, heart disease, and epilepsy management. Taken together, these studies provide evidence for a modest positive relationship between social support and chronic illness self-management, especially for diabetes. Dietary behavior appears to be particularly susceptible to social influences. In addition, social network members have potentially important negative influences on self-management There is a need to elucidate the underlying mechanisms by which support influences self-management and to examine whether this relationship varies by illness, type of support, and behavior. There is also a need to understand how the social environment may influence self-management in ways other than the provision of social support

The role of choice in health education intervention trials: a review and case study

Although the randomized, controlled trial (RCT) is considered the gold standard in research for determining the efficacy of health education interventions, such trials may be vulnerable to "preference effects"; that is, differential outcomes depending on whether an individual is randomized to his or her preferred treatment. In this study, we review theoretical and empirical literature regarding designs that account for such effects in medical research, and consider the appropriateness of these designs to health education research. To illustrate the application of a preference design to health education research, we present analyses using process data from a mixed RCT/preference trial comparing two formats (Group or Self-Directed) of the "Women take PRIDE" heart disease management program. Results indicate that being able to choose one's program format did not significantly affect the decision to participate in the study. However, women who chose the Group format were over 4 times as likely to attend at least one class and were twice as likely to attend a greater number of classes than those who were randomized to the Group format. Several predictors of format preference were also identified, with important implications for targeting disease-management education to this population.

Quality of life in newly diagnosed glaucoma patients : The Collaborative Initial Glaucoma Treatment Study

OBJECTIVE

The Collaborative Initial Glaucoma Treatment Study (CIGTS) was designed to determine whether patients with newly diagnosed open-angle glaucoma are better treated initially by medicine or immediate filtering surgery. This paper describes the quality-of-life (QOL) measurement approach, instruments included, and the CIGTS participants' QOL findings at the time of diagnosis.

DESIGN

Baseline results from a randomized, controlled clinical trial.

PARTICIPANTS

Six hundred seven patients from 14 clinical centers were enrolled.

INTERVENTION

Patients randomized to initial medication received a stepped medical regimen (n = 307). Those randomized to initial surgery underwent a trabeculectomy (n = 300). The baseline interview was conducted before treatment initiation. All baseline and posttreatment QOL assessments were conducted by telephone from a centralized interviewing center.

MAIN OUTCOME MEASURES

The primary outcome measure described in this paper was QOL. The QOL instrument is multidimensional and incorporates both disease-specific and generic measures, including the Visual Activities Questionnaire, Sickness Impact Profile, and a Symptom and Health Problem CHECKLIST:

RESULTS

The correlations between QOL measures and clinical outcomes were in the expected direction, but relatively weak. At initial diagnosis, difficulty with bright lights and with light and dark adaptation were the most frequently reported symptoms related to visual function, whereas visual distortion was the most bothersome. Approximately half of the patients reported at least some worry or concern about the possibility of blindness. Within the Visual Activities Questionnaire, higher scores on the Peripheral Vision subscale were associated with more field loss (P < 0.01). In regression analyses controlling for sociodemographics and nonocular comorbidities, increased visual field loss was significantly associated with higher dysfunction among five disease-specific QOL measures (P < 0.05).

CONCLUSIONS

Newly diagnosed glaucoma patients reported experiencing some visual function symptoms at the time of diagnosis that would not be intuitively expected based on clinical testing. Some discussion about the association between clinical presentation and worry about blindness may reduce unnecessary concern. These results provide the basis for long-term comparisons of the QOL effects of initial medical and surgical treatment for open-angle glaucoma.

Gender differences in the associations of self esteem, stress and social support with functional health status among older adults with heart disease

This study explored and compared the role of self esteem, stress and social support in maintenance or improvement in physical and psychosocial functioning over 12 months in older men and women with cardiovascular disease. Data from 502 adults over 60 years of age showed that self esteem and stress were both significantly associated with functioning when demographic and clinical factors were controlled. Men were significantly more likely than women to maintain or improve in functioning. Self esteem, stress, compliance with medication regimens, and marital status were significantly associated with maintenance or improvement of functioning among women. Only age and stress were significantly associated with maintenance or improvement in functioning among men. Findings indicated that: (1) stress and self esteem were stronger predictors of functioning, especially among women, than demographic and clinical factors; and (2) women in the highest quartile of the self esteem distribution were approximately five times as likely to maintain or improve their functioning as women in the lowest quartile.

The impact of a disease-management program on the symptom experience of older women with heart disease

This study describes the symptom experience of 570 older women with heart disease and evaluates a disease-management program's impact on symptoms over time. Women were randomly assigned to either usual care or a 4-week program ("Women take PRIDE") designed to improve self-regulation skills by focusing on increasing physical activity. At 4 months follow-up, program women, compared to controls, reported fewer total symptoms (p = 0.01) and decreased symptom frequency (p = 0.02) and bothersomeness (p = 0.02). By 12 months, positive intervention effects emerged within the common cardiac and sleep and rest symptom categories. Program group women reported more improvements in symptoms likely to be affected by increasing physical activity at both follow-ups (p < 0.05).

Changes in functional health status of older women with heart disease: evaluation of a program based on self-regulation

OBJECTIVES

This study involving 570 women aged 60 years or older with heart disease, assessed the effects of a disease management program on physical functioning, symptom experience, and psychosocial status.

METHODS

Women were randomly assigned to control or program groups. Six to eight women met weekly with a health educator and peer leader over 4 weeks to learn self-regulation skills with physical activity as the focus. Evaluative data were collected through telephone interviews, physical assessments, and medical records at baseline and 4 and 12 months post baseline.

RESULTS

At 12 months, compared with controls, program women were less symptomatic (p < .01), scored better on the physical dimension of the Sickness Impact Profile (SIP; p < 0.05), had improved ambulation as measured by the 6-minute walk (p < 0.01), and lost more body weight (p < .001). No differences related to psychosocial factors as measured by the SIP were noted.

CONCLUSION

A self-regulation-based program that was provided to older women with heart disease and that focused on physical activity and disease management problems salient to them, improved their physical functioning and symptom experience. Psychosocial benefit was not evident and may be a result of measurement error or due to insufficient program time spent on psychosocial aspects of functioning.

Exploring self-efficacy as a predictor of disease management

Self-efficacy is posited in social cognitive theory as fundamental to behavior change. Few health behavior studies have examined self-efficacy prospectively, viewed it as part of a reciprocal behavioral process, or compared self-efficacy beliefs in the same population across different behaviors. This article first discusses self-efficacy in its theoretical context and reviews the available prospective studies. Second, it explores self-efficacy as a predictor of disease management behaviors in 570 older women with heart disease. Although the R2 statistics in each case were modest, the construct is shown to be a statistically significant (p<.05) predictor at both 4 and 12 months postbaseline of several disease management behaviors: using medicine as prescribed, getting adequate exercise, managing stress, and following a recommended diet. Building self-efficacy is likely a reasonable starting point for interventions aiming to enhance heart disease management behaviors of mature female patients.