Do Program Implementation Factors or Fidelity Affect Chronic Disease Self-Management Education Programs' Outcomes?

PURPOSE: To evaluate whether implementation factors or fidelity moderate chronic disease self-management education program outcomes. DESIGN: Meta-analysis of 34 Arthritis Self-Management Program and Chronic Disease Self-Management Program studies. SETTING: Community. PARTICIPANTS: N = 10 792. MEASURES: Twelve implementation factors: program delivery fidelity and setting and leader and participant characteristics. Eighteen program outcomes: self-reported health behaviors, physical health status, psychological health status, and health-care utilization. ANALYSIS: Meta-analysis using pooled effect sizes. RESULTS: Modest to moderate statistically significant differences for 4 of 6 implementation factors; these findings were counterintuitive with better outcomes when leaders and participants were unpaid, leaders had less than minimum training, and implementation did not meet fidelity requirements. CONCLUSION: Exploratory study findings suggest that these interventions tolerate some variability in implementation factors. Further work is needed to identify key elements where fidelity is essential for intervention effectiveness.

A meta-analysis of health status, health behaviors, and health care utilization outcomes of the Chronic Disease Self-Management Program.

INTRODUCTION: The Chronic Disease Self-Management Program (CDSMP) is a community-based self-management education program designed to help participants gain confidence (self-efficacy) and skills to better manage their chronic conditions; it has been implemented worldwide. The objective of this meta-analysis was to quantitatively synthesize the results of CDSMP studies conducted in English-speaking countries to determine the program's effects on health behaviors, physical and psychological health status, and health care utilization at 4 to 6 months and 9 to 12 months after baseline. METHODS: We searched 8 electronic databases to identify CDSMP-relevant literature published from January 1, 1999, through September 30, 2009; experts identified additional unpublished studies. We combined the results of all eligible studies to calculate pooled effect sizes. We included 23 studies. Eighteen studies presented data on small English-speaking groups; we conducted 1 meta-analysis on these studies and a separate analysis on results by other delivery modes. RESULTS: Among health behaviors for small English-speaking groups, aerobic exercise, cognitive symptom management, and communication with physician improved significantly at 4- to 6-month follow-up; aerobic exercise and cognitive symptom management remained significantly improved at 9 to 12 months. Stretching/strengthening exercise improved significantly at 9 to 12 months. All measures of psychological health improved significantly at 4 to 6 months and 9 to 12 months. Energy, fatigue, and self-rated health showed small but significant improvements at 4 to 6 months but not at 9 to 12 months. The only significant change in health care utilization was a small improvement in the number of hospitalization days or nights at 4 to 6 months CONCLUSION: Small to moderate improvements in psychological health and selected health behaviors that remain after 12 months suggest that CDSMP delivered in small English-speaking groups produces health benefits for participants and would be a valuable part of comprehensive chronic disease management strategy.

The prevalence of refractive errors among adults in the United States, Western Europe, and Australia.

OBJECTIVE: To estimate the prevalence of refractive errors in persons 40 years and older. METHODS: Counts of persons with phakic eyes with and without spherical equivalent refractive error in the worse eye of +3 diopters (D) or greater, -1 D or less, and -5 D or less were obtained from population-based eye surveys in strata of gender, race/ethnicity, and 5-year age intervals. Pooled age-, gender-, and race/ethnicity-specific rates for each refractive error were applied to the corresponding stratum-specific US, Western European, and Australian populations (years 2000 and projected 2020). RESULTS: Six studies provided data from 29 281 persons. In the US, Western European, and Australian year 2000 populations 40 years or older, the estimated crude prevalence for hyperopia of +3 D or greater was 9.9%, 11.6%, and 5.8%, respectively (11.8 million, 21.6 million, and 0.47 million persons). For myopia of -1 D or less, the estimated crude prevalence was 25.4%, 26.6%, and 16.4% (30.4 million, 49.6 million, and 1.3 million persons), respectively, of whom 4.5%, 4.6%, and 2.8% (5.3 million, 8.5 million, and 0.23 million persons), respectively, had myopia of -5 D or less. Projected prevalence rates in 2020 were similar. CONCLUSIONS: Refractive errors affect approximately one third of persons 40 years or older in the United States and Western Europe, and one fifth of Australians in this age group.

Prevalence of open-angle glaucoma among adults in the United States.

OBJECTIVE: To estimate the prevalence and distribution of open-angle glaucoma (OAG) in the United States by age, race/ethnicity, and gender. METHODS: Summary prevalence estimates of OAG were prepared separately for black, Hispanic, and white subjects in 5-year age intervals starting at 40 years. The estimated rates were based on a meta-analysis of recent population-based studies in the United States, Australia, and Europe. These rates were applied to 2000 US census data and to projected US population figures for 2020 to estimate the number of the US population with OAG. RESULTS: The overall prevalence of OAG in the US population 40 years and older is estimated to be 1.86% (95% confidence interval, 1.75%-1.96%), with 1.57 million white and 398 000 black persons affected. After applying race-, age-, and gender-specific rates to the US population as determined in the 2000 US census, we estimated that OAG affects 2.22 million US citizens. Owing to the rapidly aging population, the number with OAG will increase by 50% to 3.36 million in 2020. Black subjects had almost 3 times the age-adjusted prevalence of glaucoma than white subjects. CONCLUSIONS: Open-angle glaucoma affects more than 2 million individuals in the United States. Owing to the rapid aging of the US population, this number will increase to more than 3 million by 2020.

The prevalence of diabetic retinopathy among adult type 1 diabetic persons in the United States.

OBJECTIVE: To estimate the US prevalence of diabetic retinopathy (DR) among persons with type 1 diabetes mellitus (DM). METHODS: Prevalence data from the New Jersey 725 and Wisconsin Epidemiologic Study of Diabetic Retinopathy were used to estimate the prevalence of DR by age, gender, and race among persons 18 years and older having type 1 DM diagnosed before age 30 years. Severity of DR was determined via masked grading of 7-field stereoscopic fundus photographs. Any DR was defined as retinopathy severity level of 14 or more; and vision-threatening retinopathy, as retinopathy severity level of 50 or more, the presence of clinically significant macular edema, or both. The estimates of the prevalence of DR among persons with type 1 DM were applied to the estimated number of persons with type 1 DM diagnosed before age 30 years in the 2000 US population to obtain prevalence estimates of DR due to type 1 DM in the general population. RESULTS: Among 209 million Americans 18 years and older, an estimated 889 000 have type 1 DM diagnosed before age 30 years. Among persons with type 1 DM, the crude prevalences of DR of any level (74.9% vs 82.3% in black and white persons, respectively) and of vision-threatening retinopathy (30.0% vs 32.2%, respectively) are high. The prevalence of DR due to type 1 DM diagnosed before age 30 years in the general population 18 years and older is estimated at 767 000 persons having DR of any level (0.37%), and 376 000 persons having vision-threatening retinopathy (0.18%). CONCLUSION: Retinopathy due to type 1 DM is an important public health problem in the United States, affecting 1 per 300 persons 18 years and older, and 1 per 600 persons with advanced, vision-threatening retinopathy.

The prevalence of diabetic retinopathy among adults in the United States.

OBJECTIVE: To determine the prevalence of diabetic retinopathy among adults 40 years and older in the United States. METHODS: Pooled analysis of data from 8 population-based eye surveys was used to estimate the prevalence, among persons with diabetes mellitus (DM), of retinopathy and of vision-threatening retinopathy-defined as proliferative or severe nonproliferative retinopathy and/or macular edema. Within strata of age, race/ethnicity, and gender, US prevalence rates were estimated by multiplying these values by the prevalence of DM reported in the 1999 National Health Interview Survey and the 2000 US Census population. RESULTS: Among an estimated 10.2 million US adults 40 years and older known to have DM, the estimated crude prevalence rates for retinopathy and vision-threatening retinopathy were 40.3% and 8.2%, respectively. The estimated US general population prevalence rates for retinopathy and vision-threatening retinopathy were 3.4% (4.1 million persons) and 0.75% (899 000 persons). Future projections suggest that diabetic retinopathy will increase as a public health problem, both with aging of the US population and increasing age-specific prevalence of DM over time. CONCLUSION: Approximately 4.1 million US adults 40 years and older have diabetic retinopathy; 1 of every 12 persons with DM in this age group has advanced, vision-threatening retinopathy.

Prevalence of age-related macular degeneration in the United States.

OBJECTIVE: To estimate the prevalence and distribution of age-related macular degeneration (AMD) in the United States by age, race/ethnicity, and gender. METHODS: Summary prevalence estimates of drusen 125 microm or larger, neovascular AMD, and geographic atrophy were prepared separately for black and white persons in 5-year age intervals starting at 40 years. The estimated rates were based on a meta-analysis of recent population-based studies in the United States, Australia, and Europe. These rates were applied to 2000 US Census data and to projected US population figures for 2020 to estimate the number of the US population with drusen and AMD. RESULTS: The overall prevalence of neovascular AMD and/or geographic atrophy in the US population 40 years and older is estimated to be 1.47% (95% confidence interval, 1.38%-1.55%), with 1.75 million citizens having AMD. The prevalence of AMD increased dramatically with age, with more than 15% of the white women older than 80 years having neovascular AMD and/or geographic atrophy. More than 7 million individuals had drusen measuring 125 microm or larger and were, therefore, at substantial risk of developing AMD. Owing to the rapidly aging population, the number of persons having AMD will increase by 50% to 2.95 million in 2020. Age-related macular degeneration was far more prevalent among white than among black persons. CONCLUSION: Age-related macular degeneration affects more than 1.75 million individuals in the United States. Owing to the rapid aging of the US population, this number will increase to almost 3 million by 2020.