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.

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.

Biopsychosocial contributions to the management of arthritis disability. Blueprints from an NIDRR-sponsored conference.

The contributions of MACs and RRTCs to the generation of arthritis-related biopsychosocial research over the last 15 years have been enormous. However, the assimilation of biopsychosocial concepts into mainstream clinical practice, professional education, and public awareness will require a sustained national effort.

Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs.

OBJECTIVE: To determine the effects of the Arthritis Self-Management Program 4 years after participation in it. METHODS: Valid self-administered instruments were used to measure health status, psychological states, and health service utilization. RESULTS: Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient. CONCLUSION: Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.

What's preventing more prevention? Barriers to development at academic medical centers.

OBJECTIVE: To determine the views of leaders in academic medicine concerning the need for programs in preventive medicine (PM) and the prevailing barriers to program development. DESIGN: Structured interviews. SETTING: Medical schools of the United States. PATIENTS/PARTICIPANTS: 90% of deans and chairpersons of departments of medicine and preventive medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 91% considered academic PM underdeveloped and 100% considered their own programs average or worse. Identified barriers to development included funding constraints, academic partiality to biomedicine, inadequate quality of preventive medicine research and faculty, public preferences for technologic care, and organization of academic medical centers (AMCs). While 80% perceived a shortage of able PM faculty and 60% considered PM research quality to be inadequate, only 12% of PM units gave research training high priority. While 95% of respondents held that AMCs should develop community programs and 75% identified social problems as a cause of chronic diseases, 65% agreed that community programs are not considered scholarly. Only 23% of PM units gave community service high priority. CONCLUSIONS: A policy contradiction exists: academic leadership agreed on the problems and needed changes in PM, yet the problems were often attributed to nonacademic sources, particularly finding and public preferences, and current academic practices commonly fail to address recognized developmental barriers within academic institutions. A chain of barriers is apparent. Breaking the chain may require a change in our understanding of the role of prevention.

Strategies for reducing excess morbidity and mortality in blacks with systemic lupus erythematosus.

The epidemiology of systemic lupus erythematosus suggests that the excess morbidity and mortality in blacks with the disease is related to lower socioeconomic status. Poverty and factors associated with poverty are powerful predictors of poor outcome in a variety of chronic diseases, and lupus appears to be no exception. A body of studies in other illnesses suggests ways to neutralize, at least partially, the disadvantages of lower socioeconomic status, even though the root causes of poverty may be insurmountable. These include improving access to quality health care; targeting educational programs to promote recognition and understanding of the disease and the comorbid conditions that affect outcome; implementing programs to improve self-monitoring and adherence to medical regimens; developing opportunities to facilitate homemaking, childrearing, and working outside the home; and applying psychosocial interventions to enhance self-confidence and social support. Improved access to quality health care may actually lead to a decrease in health care costs.

Long-term outcomes of an arthritis self-management study: effects of reinforcement efforts.

An underlying assumption of self-care interventions is that they are most effective when reinforced. To test this assumption, 8 months after baseline, 589 subjects who had taken a 6-week Arthritis Self-management Course (ASMC) were randomized to (1) receive a bi-monthly arthritis newsletter, (2) attend a new 6-week Arthritis Reinforcement Course (ARC) or (3) receive no reinforcement. Between 8 and 20 months there were no significant differences among the three randomized groups. The results were unaltered by inclusion of assumed data of no change for the 46 subjects who did not complete the full 20-month study. Between baseline and 20 months all participants reduced their pain by 20%, depression by 14%, and visits to physicians by 35% (P less than 0.01). There were no trends toward loss of these effects over time. These findings indicate that the effects of a self-care intervention were sustained over 20 months and that the tested forms of reinforcement did not alter those effects.

Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis.

There is evidence that the psychological attribute of perceived self-efficacy plays a role in mediating health outcomes for persons with chronic arthritis who take the Arthritis Self-Management Course. An instrument to measure perceived self-efficacy was developed through consultation with patients and physicians and through study of 4 groups of patients. Tests of construct and concurrent validity and of reliability showed that the instrument met appropriate standards. Health outcomes and self-efficacy scores improved during the Arthritis Self-Management Course, and the improvements were correlated.

The beneficial outcomes of the arthritis self-management course are not adequately explained by behavior change.

Evaluation of the Arthritis Self-Management Course revealed significant positive changes in the practice of behaviors that were taught and in health outcomes. However, utilizing a variety of statistical techniques, we were able to demonstrate only weak associations between changes in behavior and changes in health status. This suggests the need to examine the mechanisms by which health education affects health status.

A cognitive-behavioral treatment for rheumatoid arthritis.

This experiment tested a cognitive-behavioral rheumatoid arthritis treatment designed to confer skills in managing stress, pain, and other symptoms of the disease. We hypothesized that a mediator of the magnitude of treatment effects might be enhancement of perceived self-efficacy to manage the disease. It was predicted that the treatment would reduce arthritis symptoms and possibly would improve both immunologic competence and psychological functioning. The treatment provided instruction in self-relaxation, cognitive pain management, and goal setting. A control group received a widely available arthritis helpbook containing useful information about arthritis self-management. We obtained suggestive evidence of an enhancement of perceived self-efficacy, reduced pain and joint inflammation, and improved psychosocial functioning in the treated group. No change was demonstrated in numbers or function of T-cell subsets. The magnitude of the improvements was correlated with degree of self-efficacy enhancement.

A comparison of lay-taught and professional-taught arthritis self-management courses.

One hundred subjects with arthritis were randomized into lay-taught, or professional-taught 12-h arthritis self-management courses, or a control group. Outcomes, knowledge, exercise, relaxation, disability, pain, and number of physician visits were measured aat baseline and 4 months. Professional-taught groups demonstrated greater knowledge gain while lay-taught groups had greater changes in relaxation (p less than .01) and a tendency toward less disability. Although it is impossible to draw definitive conclusions, this study suggests that lay leaders can teach arthritis self-management courses with results similar to those achieved by professionals.

Outcomes of self-help education for patients with arthritis.

Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.

The relation of faculty academic activity to financing sources in a department of medicine.

Academic medical departments confront important changes in funding sources and consequent pressure to change faculty activities. Valid information has often been lacking concerning the existing relations of faculty activity to funding sources. We examined those relations in the Stanford Department of Medicine through a combination of randomized observations of faculty and faculty self-reports over a period of one year. For an average 62-hour workweek, there was approximate consonance between types of activities and sources of salary support. Sensitivity analyses indicated that even sizable errors in self-reports would not have changed the outcomes substantially. Over 60 per cent of the activity involved "joint products," representing two or more categories of activity. There was wide variation in activities and fund sources between divisions. Per full-time faculty equivalent, research generated far more income than the most lucrative specialty practice; thus, at least in this type of department, attempts to compensate for lost research revenue by intensifying clinical practice will probably fail and undermine present research activities. The method of analysis used here may be useful in improving prospective planning by departments and by larger medical-policy bodies, particularly in the public sector.