A major concern of health care policy makers in the United States is how to deal with the expected surge in the population who have more than one chronic condition. While the problem is already huge, it is anticipated that current situation will be dwarfed by the problem in the future. Anderson noted the extent of the issue in 2005 when he reported that anyone hoping to change Medicare must consider that 23 percent of beneficiaries with five or more chronic conditions account for 68 percent of the program's spending. In addition, he continued, the treatment of these beneficiaries is likely to remain a high-cost item until they die, since every year they see an average of 13 physicians and fill an average of 50 prescriptions. How we reduce these health care costs is likely to be the most perplexing issue in health care the coming few decades.

The U.S. is not alone in facing the problem of comorbid conditions, particularly in the elderly. A recent article reported that many chronically ill older patients in the Netherlands have a combination of more than one chronic disease. The authors noted there is a need for self-management programs that address general management problems, rather than the problems related to a specific disease. They chose to use the Chronic Disease Self-Management Program (CDSMP) developed by Kate Lorig and her colleagues at Stanford University. In evaluations of the CDSMP program that have been carried out in the United States and China, positive effects were found in self-management behavior and health status. The specific aim the study by Elzen and coworkers was to evaluate the short-term and longer-term effects of the CDSMP program among chronically ill older people in the Netherlands.

One hundred and thirty-nine people aged 59 or older, with a lung disease, a heart disease, diabetes, or arthritis, were randomly assigned to an intervention group (CDSMP) or a control group (usual care). Demographic data and data on self-efficacy, self-management behavior, and health status were collected at three measurement moments (baseline, after 6 weeks, and after 6 months). The patients who participated rated the program with a mean of 8.5 points (range 0-10), and only one dropped out. However, the study did not yield any evidence for the effectiveness of the CDSMP on self-efficacy, self-management behavior, or health status of older patients in the Netherlands. Because the patients who participated were very enthusiastic, which was also indicated by high mean attendance (5.6 out of 6 sessions) and only one dropout, the authors suspected it was too early to conclude that the program was not beneficial for these patients.

COMMENTS: We concur with the conclusion of this investigation. If there is a flaw, it was that the time line of the study (6 months) was too short to determine if the CDSMP program was effective. In research we’ve conducted on self-management, we have conducted follow-ups for 5 to 7 years after self-management training to determine the effectiveness of our programs. Our assumption was that teaching patients what to do, such as occurred here, was only one part of what is required in a successful self-management program; education can only teach patients what to do. To be effective at self-management, however, a patient must have the opportunity to perform self-management skills required to manage a chronic illness or comorbid conditions. Only by performing self-management skills effectively can self-efficacy develop. Hence, we suggest that patients in the study should have been followed for a year or more.

G.F. Anderson. Medicare and chronic conditions. New England Journal of Medicine, 2005;353: 305-309.

H. Elzen et al. Evaluation of the chronic disease self-management program (CDSMP) among chronically ill older people in the Netherlands. Social Science and Medicine, 2007;64:1832-1