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IMPROVING PATIENT CARE

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.

Meta-Analysis: Chronic Disease Self-Management Programs for Older Adults

Joshua Chodosh, MD, MSHS; Sally C. Morton, PhD; Walter Mojica, MD, MPH; Margaret Maglione, MPP; Marika J. Suttorp, MS; Lara Hilton, BA; Shannon Rhodes, MFA; and Paul Shekelle, MD, PhD

20 September 2005 | Volume 143 Issue 6 | Pages 427-438

Background: Although enthusiasm is growing for self-management programs for chronic conditions, there are conflicting data regarding their effectiveness and no agreement on their essential components.

Purpose: To assess the effectiveness and essential components of self-management programs for hypertension, osteoarthritis, and diabetes mellitus.

Data Sources: The authors searched multiple sources dated through September 2004, including the Cochrane Library, MEDLINE, PsycINFO, and Nursing and Allied Health databases, and bibliographies of 87 previous reviews.

Study Selection: Randomized trials that compared outcomes of self-management interventions with a control or with usual care for diabetes mellitus, osteoarthritis, or hypertension; outcomes included hemoglobin A_1c level, fasting blood glucose level, weight, blood pressure, pain, or function.

Data Extraction: Two reviewers independently identified trials and extracted data regarding whether the intervention used tailored adjustments to meet individual patient needs, a group setting, feedback, and psychological services, and whether the intervention was provided by the patient's usual physician.

Data Synthesis: Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis (26 diabetes studies, 14 osteoarthritis studies, and 13 hypertension studies). Self-management interventions led to a statistically and clinically significant pooled effect size of –0.36 (95% CI, –0.52 to –0.21) for hemoglobin A_1c, equivalent to a reduction in hemoglobin A_1c level of about 0.81%. Self-management interventions decreased systolic blood pressure by 5 mm Hg (effect size, –0.39 [CI, –0.51 to –0.28]) and decreased diastolic blood pressure by 4.3 mm Hg (effect size, –0.51 [CI, –0.73 to –0.30]). Pooled effects of self-management interventions were statistically significant but clinically trivial for pain and function outcomes for osteoarthritis. No consistent results supported any of the 5 characteristics examined as essential for program success.

Limitations: Studies had variable quality, and possible publication bias was evident.

Conclusions: Self-management programs for diabetes mellitus and hypertension probably produce clinically important benefits. The elements of the programs most responsible for benefits cannot be determined from existing data, and this inhibits specification of optimally effective or cost-effective programs. Osteoarthritis self-management programs do not appear to have clinically beneficial effects on pain or function.

Editors' Notes Context Do self-management programs improve outcomes of adults with chronic conditions? Contribution This meta-analysis summarizes data from 53 randomized, controlled trials of self-management interventions for adults with diabetes mellitus, hypertension, or osteoarthritis. Self-management helped reduce hemoglobin A1c and blood pressure levels in diabetes and hypertension, respectively, but had minimal effect on pain and function in patients with arthritis. The authors could not identify any self-management program characteristics that predicted successful outcomes. Cautions The authors found evidence of possible publication bias. Implications Self-management programs may improve some outcomes in patients with some chronic diseases, but how to design an optimal program is not yet clear. —The Editors

 

Author and Article Information

From Southern California Evidence-based Practice Center (RAND Health Division), Santa Monica, and University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.

Acknowledgments: The authors thank Daniel H. Solomon, MD, for providing his list of chronic disease self-management articles.

Grant Support: By a Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, grant to RAND Health, 500-98-0281. Dr. Chodosh is a Veterans Affairs Health Services Research and Development Career Development awardee. Dr. Shekelle was a senior research associate of the Veterans Affairs Health Services Research and Development Service during the time of this study.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joshua Chodosh, MD, MSHS, Greater Los Angeles Veterans Affairs Healthcare System, GRECC (11G), 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Current Author Addresses: Dr. Chodosh: Greater Los Angeles Veterans Affairs Healthcare System, GRECC (11G), 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Dr. Morton: RTI International, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194.

Dr. Mojica, Ms. Maglione, Ms. Suttorp, Ms. Hilton, and Ms. Rhodes: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401.

Dr. Shekelle: Greater Los Angeles Veterans Affairs Healthcare System, General Medicine (111G), 11301 Wilshire Boulevard, Los Angeles, CA 90401.

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