Manage Your Illness

Self-management is a topic repeatedly stressed in entries on this site. It is the theme because your performance of self-management skills will help you to control your illness, as well as alleviate the pain and distress you experience with an acute episode. With the latter, you want as much relief as possible; no one except you or, in some cases, your health care provider can offer such help. In addition, self-management processes are the only patient skills of proven value in controlling a chronic illness over time and across setting. In other words, they permit you to carry out the daily actions you need to manage your illness today, tomorrow, and for as long as necessary. As there are no known cures for most chronic conditions, this could mean you will be performing these skills for the remainder of your life. They are key to helping you live as good a life as you possible. If you are competent at performing self-management skills, you can use them at home, at work, or in any environment where you find yourself. They are processes that are with you no matter where you are and are able to perform.

The late Fred Kanfer, a pioneer in self-management, described 12 features of effective self-management programs. These characteristics can be rewritten to be applicable to anyone with a chronic illness, including you.

1. The skills continually focus on your concerns. Self-management skills are performed by you and you alone to maintain and better your health. You can receive advice on what you should do to manage a chronic illness, such as diabetes, but only you can perform the skills needed to control it. You are the one most concerned about your performance. If you have any questions about what to do or how to do it, be certain these have been answered before your leave your health care provider’s office.

2. Only you can monitor your own behavior. From time to time, all of us see a physician or health care provider. He or she may ask us questions, conduct tests, fill prescriptions, or offer advice. Whatever is done is but a brief moment in time, however, as all your provider obtains is a snapshot of you and whatever condition you have. He or she doesn’t obtain a continuous, ongoing record of what is occurring; for that reason, you want to make the health care provider’s knowledge of you more than a snapshot. What you do with respect to managing your illness, be it tracking blood pressure or blowing peak flow rates, is known only to you. You alone observe and monitor your illness and how you react to it. As will be repeatedly noted on this site, self-monitoring is the backbone of self-management for any condition or situation.

3. You must be a part of any plan developed to treat your condition. If you go to an emergency room with an acute condition, you generally are willing to go along with whatever treating health care personnel do. You need immediate help and you trust that they know what they are doing. The picture changes completely when you have a chronic illness, however. Here, you are responsible for the day-to-day management of your condition whether you want that responsibility or not. As you carry out the daily treatment routine yourself, you want some say in what you should and can do. If certain drugs are prescribed for you, when should you take them? Are there any skills required to use them properly? Can you take multiple medications together at a time convenient to your schedule? All the responsibilities of you and your health care provider should be considered in developing your treatment plan. When both parties decide on the best course of action, you should reach a consensus as to the responsibilities each party declares they will take in managing your condition. That will make you more committed to see the plan work that you have jointly developed and agreed upon with your health care provider.

4. Know the rationale and assumptions underlying each self-management skill you perform. No one wants to do something if they don’t know why they are doing it. This is not an issue with most actions you agree to perform; you know beforehand why your physician or health care provider has asked you to monitor your sugar level if you have diabetes or blood pressure if you have hypertension. Other issues, such as taking daily medications to maintain your condition without experiencing flare-ups, may be more difficult to accept. Many health care providers complain that patients fail to adhere to taking these preventive, maintenance, or controller medications; they say patients just don’t do what they are supposed to do. However, patients are often not provided with any explanation as to why they should take drugs day after day when they feel well. It is your responsibility to take any medications prescribed to maintain your condition, but it is the responsibility of your health care provider to offer a thorough explanation as to why you are taking a drug on a regular basis. Alas, such an explanation is often not provided. If you have any questions regarding your medication regime, or any other aspect of your treatment, ask for a more thorough explanation. Always ask questions if you don’t know what to do; even though you may think otherwise, there is no such thing as a dumb question in health care.

5. Have your physician or other provider demonstrate how you need to perform what is asked of you. Many patients with a chronic illness are often told to perform certain exercises or to take medications is a prescribed manner. If it is unclear as to how you should carry out these behaviors, ask for a demonstration. If your physician asks you to exercise as part of the treatment for arthritis, be certain you know what he or she wants you to do. You’ll likely receive written materials, including diagrams, of the exercises you are supposed to perform. If these instructions are unclear, have someone demonstrate them for you. Be certain you can do what is asked of you before attempting to do something. Taking medications can also be as trial. For example, inhaled drugs are often prescribed for the control of asthma or COPD. Use of the inhaler, however, can be tricky. If inhaled medication is prescribed for any condition, including asthma or COPD, be certain you can correctly use your inhaler before you leave your health care provider’s office. Drugs don’t do what they are supposed to do if they are not taken correctly. If your physician or health care providers have to demonstrate over and over again what to do, then have them do it. It is their responsibility to teach you what to do and your responsibility to act on these recommendations.

6. Others need to review and verify the information you collect. All of us can be pretty good at collecting and recording information on ourselves and our illness. It is with some satisfaction that we keep accurate records that we can take to our physician or health care provider. It is a real downer, however, when no one bothers to look over the data we provide. A cursory look followed by the comment, “Oh yeah,” just doesn’t cut it. Even though you may have missed some days of data collection, you still feel good that you have gathered enough information to give the provider an idea regarding the pattern of your illness. You may have to be very proactive to be certain others review the data you collect and provide them. Your responsibility is to gather such information, but it is their duty to review it with you.

In part 1, a half dozen features of effective self-management were outlined. The remaining characteristics are described in this entry.

7. Record and inspect qualitative and quantitative data you gather on yourself. This activity may sound like a no-brainer, but it isn’t. In self-monitoring, we may think that only our physician or health care provider is interested in the data we gather. They should be interested in the information you give them, particularly if they ask you to collect it. However, it has been our experience that patients often discover interesting patterns and valuable insights about their illness on their own. If your suffer migraine, for example, you may review what happened over several flare-ups. You may find that certain stimuli or warning signs occurred just before the headaches. If you can prevent them from occurring or if you can spot them early in a migraine, maybe you can prevent or halt an episode more quickly. You are the one experiencing the chronic condition; you may find that only you acquire the insights that help you manage it better than anyone.

8. Reinforce yourself. We are often reinforced for doing something via praise from others or financial remuneration. Yet the most effective and common reinforcement that changes and maintains our behavior is referred to as self-directed reinforcement or self-reinforcement. When you engage in activities, such as refraining from eating sweets during the holiday season, it may help keep your blood glucose levels on an even keel. Is anyone likely to reinforce you for doing so well in controlling your diabetes? Not likely. For that reason, you should take pride or satisfaction in a job well done. That is self-reinforcement. It may not always be enough to promote behavior change or to maintain the changes, but it is about all that we each can do to achieve the goals we have regarding control over our chronic condition.

9. Assess how well you do in controlling your condition at all times and in different settings. You may find that you are good at controlling a high level of cholesterol when you are at home. You or a member of your family may prompt you to do so by preparing meals that help you to do so. When out in a different environment, however, things may change. If you are in a restaurant, it is often hard to pass up foods with lower cholesterol in favor of food with the opposite characteristics. As there may be no one there to remind you to do otherwise, you may cave in to temptation and eat what you’ve been warned to avoid. Much of your behavior is, of course, a natural way that any of us would react. However, if you are serious about reducing your cholesterol level, you want to broaden the number of settings where you control your behavior. You can do so by reviewing the choices you have and the decision you wish to make. You’ll likely not be successful all the time, but you may discover that you are gradually remaining on a low-cholesterol diet across more and more settings. This outcome is reason enough for self-reinforcement.

10. Frequently revise your self-management skills, their effectiveness, and decide whether any can be changed or refined for better outcomes. It pays to review periodically what you did that worked and what you might do better to control your chronic illness in the future. Some patients, particularly those who have developed a keen sense of imagery, find that they can go back and review each step they performed both in the daily management of their condition or in controlling an exacerbation of the disease. They become very much aware of what actions worked and what actions were unnecessary; they can then make adjustments as to their future behavior. Revising self-management skills is strictly a personal decision: you may have been taught general strategies to perform to control your condition but find they are not that helpful to you. In this case, do what you found works better for you. The best lesson we’ve learned in teaching patients self-management skills over the past 40 years is that we learned more from them than we ever taught them.

11. Provide strong support to yourself for accepting responsibility for the management of your chronic illness. Let’s face it: if you don’t reinforce and support yourself for doing the day-to-day actions for managing your chronic illness, no one else will. You may receive some reinforcement and encouragement from health care providers or family members, but this is for your general behavior; these sources of support are not always there when you perform many of the tasks required to control a chronic illness. It was suggested that you use self-reinforcement contingent upon your successful performance. However, self-reinforcement is usually a murky concept and not always easy to apply on a consistent manner. The best thing is to use intrinsic reinforcement of some manner, a topic that will be explored in an upcoming entry.

12. Repeatedly summarize and reiterate key skills required to self-manage your condition. Basically, this requires that you summarize your performance over time and across settings. What worked for you? What didn’t work? Only you know the answer to these questions. Many of you will develop strategies that work for you, although you were not taught these techniques. That’s great as progress in self-management will mainly result from the observations and reports of you and others with a chronic illness.

Good luck in using these suggestions!

A recent article in the British Medical Journal added more evidence as to the importance of lifestyle changes in protecting against Type 2 diabetes. Changing to a healthier lifestyle appears to be at least as effective as taking prescription drugs to reduce the risk of developing Type 2 diabetes, according to the study.

Behavior changes can include:
Switching to a healthier diet
Increasing the amount of time you exercise

If you have already been diagnosed with the disease, these actions are also valuable in keeping your condition stable. On average, lifestyle changes helped to reduce by half the risk of developing Type 2 diabetes in the study. Lifestyle changes were also less likely to produce adverse side-effects.

As it is, throughout the world, diabetes is a growing problem in England, with approximately 1.3 million people afflicted with diabetes, and about 5% of the total health care resources in the country used for the care of people with diabetes.

Global rates of Type 2 diabetes are likely to double by 2030; thus, interventions to prevent the condition will have an important role to play in future health policies. However, these interventions rely heavily upon the individual’s ability to manage his or her own behavior. No one can perform self-management actions but you.

Pioneering work on the self-management of arthritis by Kate Lorig, Hal Holman, and their colleagues at Stanford University has led others to develop programs for patients with the condition.

A recent article from England showed that the self- management of arthritis program reduced anxiety and improved whether or not people thought they could manage their symptoms. The program had no significant effect on pain, physical functioning, or contact with primary care, however.

The authors of the study may have been disappointed with their study as there were no changes in pain, physical functioning, or contact with primary care. However, the duration of the study--12 months--is too short a period to expect major changes in these outcomes. The authors should follow their subjects longer, particularly as they obtained significant changes in the participant’s self-efficacy. The changes in the confidence patients have in managing a chronic illness are likely to produce positive changes in the long run.

Sometimes, readers may wonder if there is a difference between problem solving and self-management. There often isn’t.

Russ Glasgow and his co-workers have conducted a number of studies that looked at problem solving as a core aspect of effective diabetes and chronic illness self-management. In their most recent study, they examined a large sample of adults with type 2 diabetes by examining a number of factors, including patient characteristics, self-management behaviors, and biological and psychosocial measures. Diabetes problem solving proved to be an important patient skill related to several key diabetes management factors that appear useful across racial and ethnic groups.

In the studies my colleagues and I have conducted, we looked more on the processes of self-management, although almost a fourth of the course time was devoted to teaching patients to use these patient skills to solve problems. Thus, the difference between our work and the excellent research of Russ and his colleagues is one of emphasis, not major differences. Both approaches seek to teach you how to solve any problems you encounter and to manage your illness on a daily basis. In addition, the practice of self-management skills can help you solve all sorts of problems, most of which are not related to your illness.

R.E. Glasgow et al. Problem solving and diabetes self-management: investigation in a large, multiracial sample. Diabetes Care. 2007, 30:33-37.

In a recent study, Keith Petrie and his colleagues in New Zealand looked at whether providing normal findings obtained with a diagnostic test would reassure patients and reduce their anxiety about symptoms before they were tested. In the investigation, patients with chest pain referred for a diagnostic exercise stress test were randomly assigned to one of three conditions: (a) standard information; (b) a pamphlet explaining the test and the meaning of normal test results; or (c) the pamphlet and a brief discussion about the meaning of normal test results. The primary outcome was the patients' reported reassurance on a 5 item scale immediately after the test and at one month later. Secondary outcomes were the proportion of patients who still had chest pain and were still taking cardiac drugs at one month. Mean levels of reassurance after testing and feedback from the doctor were significantly higher in the discussion group than in the pamphlet and standard groups, a difference maintained at one month after participating in the study. The proportion of patients still reporting chest pain at one month decreased significantly in the discussion group (to 17%) and pamphlet group (to 28%) but not in the control group (to 36%). A trend was for fewer patients in the discussion group to be taking cardiac drugs at one month.
This is a nice study in that it demonstrated that if you have a chance to read information about a test and then discuss it a health care provider beforehand, you might experience fewer symptoms and require less medications after the test. As you are both a patient and health care consumer, you should be proactive in requesting this approach be taken with before you have a diagnostic test for which you have concerns.
British Medical Journal, 2007;334:352-355. Prof. Petrie’s e-mail address is: kj.petrie@auckland.ac.nz

A nice thing about self-management skills is that they can be used with a number of chronic disorders. This was recently shown in a study from England. The investigators looked at self-management as a first line treatment for men with lower urinary tract symptoms. In the study, half of the patients received self-management with standard care and half received standard care alone. Self-management patients took part in three small group sessions where they were provided with education about their condition, lifestyle advice, and training in problem solving. In the study, treatment failure was measured at 3, 6, and 12 months. The severity of symptoms was also examined. The results showed that treatment failure only occurred in 10% of the self-management group, but in 42% of patients given only standard care. These changes held up over time. Similar differences were also found in the symptom changes scores over the course of the study. The upshot is that the study showed that self-management significantly reduced the treatment failure and reduced urinary symptoms.

In thinking of self-management, you may not of thought of their use with urinary tract symptoms. We didn’t. Fortunately, someone did and the result may be a hopeful sign for others with the illness. What do you think?

van der Meulen J, Brown CT, Yap T, Cromwell DA, Rixon L, Steed L, Mulligan K, Mundy A, Newman SP, Emberton M. Self management for men with lower urinary tract symptoms: randomized controlled trial. British Medical Journal 2007, 334:25.

If you have had a chronic illness for a while, you have probably been in the hospital at least once. Usually, going to the hospital helps them make the right diagnosis or for you recover more quickly from a flare up with an illness such as diabetes or asthma. Have you ever wondered whether information on you was passed on to your primary care doctor after you got out of the hospital? You hope that everything learned about you was given to your doctor. Don’t hold your breath: there are often deficits in passing along information from hospital doctors to your primary care doctor. A recent study reviewed data on the exchange of information following discharge from a hospital. It found that communication between hospital physicians and primary care physicians did not occur all that much (between 3 and 20 percent of the time). Having a discharge summary at the first discharge visit was low and remained poor at 4 weeks. These failings affected the quality of care in approximately 25% of follow-up visits and led to primary care physician unhappiness.

Deficits in communication and information transfer at hospital discharge are common and may affect the care you receive. It was suggested that computer summaries and standardized formats may help make more timely transfer of patient information to primary care physicians, as well as make discharge summaries more available during later care. This is all well and good; like you, we all hope information transfer improves between physicians and, in turn, comes to help you. You may ask, however: “What can I do to make sure that what they learned about me in the hospital was passed along to my primary care doctor?” Being proactive about your illness is part of self-management. The next time you visit your doctor after being in the hospital, ask him or her whether a report was received from the hospital doctors. It is not only your right to know, but to make sure the hospital passed along information that may help your primary doctor treat you better. It is the best case for everyone looking out for your health, including yourself.

Any comments or suggestions?

Picture the following:

Doctor: “You aren’t doing as well as I thought you would. Are you taking those pills I asked you to take?”

Patient: “Yeah, I usually do.”

Doctor: “What do you mean, ‘I usually do?’ Do you take them or not?”

Patient: “I do when I remember, but it isn’t always easy for me to get to them.”

Doctor: “What do you mean, ‘It’s not always easy for me to take them?’

Patient: “Hey, I work as a roofer. I have problems getting to them when I’m on the top of a house.”

Doctor: “Well, how do you expect me to help you if you don’t do as I asked you to do?”

Patient: “I try, but I can’t always do so. Even when I take them, I’m not sure they do anything.”

Scenes like this take place each day all over the world. It may not be much of a problem if you have acute pain, but it can be if you have a chronic illness when you are asked to take pills every day whether or not you have any symptoms. A doctor would say that the patient was noncompliant or, a more soothing word (at least to him), nonadherent to what he asked the patient to do. The patient, on the other hand, might refer to the matter in a stronger term such as #@*#ƒΩ. The next step in this game played by both health care providers and their patients is that each party will heap blame and more blame upon the other party. Does it solve the matter? Not on your life: the gulf between parties just continues to widen.

Is there a better way to be certain patients take drugs as told? There certainly is with chronic illness. It requires that both you and your health care provider work together to solve whatever problems pop up in your taking medications. The right drug can usually help control your condition; you want to feel better by taking prescribed drugs. However, there are many problems that may be a barrier to you in wanting to improve you health. A series of entries on this site will describe barriers to taking drugs as prescribed. We hope you not only find them of interest, but also will offer your own comments on any of the topics discussed.

A growing number of studies have looked at how self-management can help patients with arthritis. A recent article told of 452 patients who were in a 6 week, 2 hour each session, arthritis educational and self-management program in Australia. Data were gathered at three different times: before intervention and at 6 months and 2 years following the program. At six months, there was reduction in pain, fatigue, and health distress, as well as in increase in self-efficacy. The latter was important as it predicted positive changes in patient’s health. These changes were maintained at 2-years. There was an increase in use of pain drugs at 6 months and an increase in anti-inflamatory drugs at 2 years. The authors concluded that although changes in health status were small, the low cost and widespread use of self-management shows the program may have a big public health effect.

Anyone with arthritis is encouraged by positive research findings on the value of self-management in helping them cope with their ailment. Their satisfaction in this case is that self-management proved to have a lasting value to arthritis patients.

Osborne RH, Wilson T, Lorig KR, McColl GJ. Does Self-Management Lead to Sustainable Health Benefits in People with Arthritis? A 2-year Transition Study of 452 Australians. Rheumatol. 2007, Mar 1.

Let's face it: many of us older adults are not as sharp as we used to be. We may recall something one moment, but fail to do so a short time later. This shows how age can influence whether we follow the advice we are given for managing a chronic illness, including the taking of prescribed drugs. There is often no problem with children as their parents usually want what is best for their child. They will check to be certain their youngster takes his or her medicine. Even so, children with some chronic conditions may fail to take drugs that control their illness. This may be a decision of either parents or children or, in some cases, both. There may be a number of issues here that need to be solved by doctors and their patients working together. Being a teenager can be a barrier, particularly if you have a chronic illness. In wanting to be like your friends you see as healthier then you or in showing your parents they don't know what they are talking about having you taking controller drugs every day, you may quit taking your medicine. If you stop taking your daily drugs, there is no often no short-term change in your condition. You may think, "Hey, I was right after all!"

Middle-aged and younger senior patients are usually the best at following instructions; they are becoming aware that they won’t be around forever and want to make the most out of the rest of their lives. Unfortunately, as noted, as we become older we may not be as sharp as we used to be. We may forget what drugs we need to take or whether we have already taken them for that day. The difficulties are increased by the fact that many seniors experience a situation where they are supposed to take drugs for several conditions. It is not unusual, for example, for a senior to take daily medications to control hypertension, high cholesterol, or any of the other maladies that occur as the result of the wear and tear of aging. On the positive side, if barriers to compliance can be detected for individual patients, behavioral strategies can be developed to help them change. Older patients can be great in making the effort to see these processes work.

Problem solving between patients and their health care partners is important at all ages. Have you any experiences you would like to share about the role of age in taking medicines? Are there any ways that work for you, no matter your age, in taking drugs?

A belief is something you think is true, although you often don’t have any proof that it is. It is an idea you have based on your views, thoughts, or been told. The beliefs each of us has determines how we perceive our lives and the actions we take. The taking of prescribed medications is no exception. We have long been told to take medications for some unpleasant symptoms we have whether it be to stop headaches or halt acid indigestion. We comply with the medical instructions because we want relief. These beliefs are present when we are told that instead of taking drugs only when we experience symptoms, we should take drugs for a chronic illness for as long as needed, likely the remainder of our lives. Switching our beliefs that we should take medicine only when sick to taking them to control a condition has often been a source of dismay to both patients and health care providers. We have been confused because were constantly reminded to take medications only when feeling ill; this is something we have heard all our lives. Our health care providers, on the other hand, become upset because patients don't do what they tell them to do to control a chronic ailment. If patients take drugs to relieve the symptoms of a cold, why won't they take drugs every day to control high blood pressure? This would, after all, lead to better overall health for us. Discussion of differences between relief and controller medications would stop this problem, but these discussions do not always occur. Furthermore, patients taught to rely upon what they see as a Catch 22 between what they have always been taught and what they are now being told are often uncertain about what to do. Beliefs are certainly a factor in how closely a patient follows his or her doctor’s instructions.

We have described but one set of beliefs that patients with a chronic illness cope with each day. There are many other kinds of beliefs that are important. Patients with a chronic condition, whether it is arthritis or asthma, are often thought to believe their condition is worst than it is. This type of belief, often thought to be an old wife’s tale, doesn’t help those of us with a chronic illness. A thing about self-management is that you can learn to ignore what others say and focus on what you have to do to manage your condition.

Other beliefs are important in our control of a chronic illness. The belief we have that we can do whatever we have to do to manage our condition, referred to as self-efficacy, is key to how successful we are in our role of caring for ourselves. In fact, the confidence we have that we can take care of ourselves each and every day will, in the long run, be what determines what we will do.

If a person is depressed, he or she may not follow medication instructions. After all, if nothing seems worthwhile, why take medications? This reaction is understandable. Alas, depression often occurs in patients with a chronic illness. There is nothing wrong about having these feelings; it seems natural to have them if you can’t see you are making progress in caring for your chronic condition. In many ways, it is a surprise that more patients with chronic illnesses don’t become depressed. When depression occurs, it is time for you to work closely with your physician and health care personnel to help you control your feelings. You must do so if you are to manage your chronic condition. This may include your seeing a mental health specialist or becoming involved in a group with patients like you. Learning and performing self-management skills can also help you as it helps you focus on controlling your illness.

Memory loss is common in all of us. Usually, however, it is one of those things where you say that it is “on the tip of my tongue” and can recall shortly after. If you have to remember to take drugs and perform other skills to control a chronic illness, you want to be certain that you can manage any memory loss. There are any number of things you can do from using daily pillboxes with the prescribed dose of drugs to writing up a daily schedule on your calendar. These approaches work, but they are only good if used correctly. If there is no one who periodically checks with the patient, then the problem of not taking drugs becomes an even greater barrier.
Emotional ups and downs accompany chronic illness and its treatment. These usually involve not just the patient, but other members of his or her family. For this reason, the patient and his or her family should make every effort to remain at an even keel and avoid the roller coaster of emotional ups and downs. If you need help to manage feelings that accompany an illness, don’t hesitate to contact your health care provider. No one wants you to suffer more than you have to with a chronic illness. That includes you. There are all kinds of safety nets, if you look for them, to help you.

Do any of you have any comments about tactics for these topics that have worked for you?

The barrier of not being able to read may reduce your ability to do well in the health care setting, influence how you communicate with your physician and, perhaps, lead to poor medical care. Low reading skills are associated with poor understanding of the medical advice, written or spoken, you are given. The results may be a poor health outcome for you. Reading problems may occur if you dropped out of school, if you are older or a member of certain racial or ethnic groups, or just not good with words. Poor reading or speaking in an unfamiliar language can be a big hurdle in everything you do from attempting to seek a correct diagnosis to learning how you should treat your condition.

Efforts have been taken to communicate with many new residents of our country. If you speak Spanish only, you may see a sign noting they speak Spanish in waiting rooms. This likely will help you. Other techniques used have included pictures labeled with captions in different languages. Some attention has also been directed towards making instructions more readable. This means telling you what to do in a way that you understand. The trick is to convey the message in a way that the reader understands without making patients think they can’t read as well as they actually can. Unfortunately, this doesn’t always happen and you may come away with only a foggy idea of what you have and how it should be treated.

Stronger effort on the part of health care providers could help. Many of them realize that their words aren’t getting through, they are changing the way to they talk to patients. However, it is up to you to learn what you should do before you leave your doctor’s office. If things aren’t clear, you must ask questions. If still uncertain, ask more questions. Remember there is no such thing as a dumb question. You can’t do what you are supposed to do if you don’t understand what you should do and why you should do it. If you feel you have problems with language, take someone with good language skills along when you see your health care provider. It is up to you to understand health care providers of what you have and how it should be treated.
Poor reading and language issues are a big problem in medicine.

Do any of you have any suggestions on how this barrier can be reduced? Do you know of ways of talking with health care providers that have worked for you?

In a recent entry, we pointed out that many patients who cannot read well often do not understand what they are supposed to do after they see their health care provider. This problem can be a barrier in your doing what you have been told to do to manage a chronic condition. The issue is very important when it comes to taking prescribed drugs as directed. A recent study looked at how poor reading can be a safety issue and may contribute to medication errors.

The research looked at the ability of patients to understand and follow instructions on the labels of common prescription drugs. It included 395 English-speaking adults who were waiting to see their providers in three primary clinics that mainly served poor populations. The investigation looked at understanding of instructions on five container labels and the demonstration of one label’s dosage instructions. Correct understanding of the five labels ranged from 67.1% to 91.1%. Patients reading at or below the sixth-grade level (low literacy) were less able to understand all five-label instructions. Although 70.7% of patients with low literacy understood the instructions, "Take two tablets by mouth twice daily," only 34.7% could demonstrate the number of pills to be taken daily. The authors concluded that lower literacy and a greater number of prescription drugs were associated with not understanding the instructions on prescription medication labels.

Poor reading skills can be a big problem in life. This is especially true if you have a chronic illness and take prescription drugs. If low reading skills are something you deal with, you must be certain you know what to do before you leave the office of your health provider. If you are not sure, have him or her go over instructions until you understand them. Even if you do understand what you have been told, if you have any questions about what to do, have someone show you how to do it. In turn, show the person that you can do what is being asked of you. It is better to do it in the doctor’s office before you are out on your own.

Do you have any comments on this entry?

Terry C. Davis and colleagues. Literacy and Misunderstanding Prescription Drug Labels Annals of Internal Medicine, 2006;145:887-894.

If you have a boy (or girl) with a chronic illness, you may wonder if he can learn to manage his condition by himself. The answer, in most cases, is yes. A recent study looked at how self-management plays a major role in early advances made by children. The authors concluded that although intelligence is generally thought to play a key part in children's early school progress, aspects of children's self-management abilities—including the ability to alternately shift and focus attention and to control acting out--are related to early success and account for greater variation in academic progress than do measures of intelligence.

These findings were not surprising to me. At a children’s treatment center for asthma, we taught children as young as five years of age to take control of their asthma drugs. We started by giving each child his or her week’s supply of drugs. We carefully monitored how well a youngster took the medicines on his or her own. Over time, we gradually checked on the children less and less until we saw that she was taking the drugs as told to by her doctor. We then only monitored occasionally to be certain that the child was doing what she had shown she could do.

Would this same approach work with your child? It probably would, although you need to be the judge of his or her being able to self-manage a chronic illness. The beauty of this approach is that it lets the child know that he or she plays a big role in managing the chronic illness. This results in fewer conflicts within a family but, more importantly, it helps a youngster acquire the self-confidence that he or she can really make a difference in caring for a chronic condition. Do you have any comments or questions about this entry?

Blair C, Razza RP. Relating effortful control, executive function, and false belief understanding to emerging math and literacy ability in kindergarten. Child Development 2007;78:647-63.

Weight loss programs, in general, rely on self-management. People must use these skills if any diet is to be successful. The problem often occurs not with dieting, however, but when it comes to keeping the pounds off. Maintaining weight loss is probably the major issue in dieting. In a recent article, Rena Wing and her colleagues looked at ways that weight loss might be maintained.

They developed a program for keeping weight off that was based on self-regulation or self-management theory. The program was tested either face-to-face or over the Internet. The authors randomly assigned 314 participants who had lost weight in the previous 2 years to one of three groups: (a) a control group, which received quarterly newsletters; (b) a group that received face-to-face intervention; and (c) a group that received Internet-based intervention. The content of the programs in the two intervention groups was the same, emphasizing daily self-weighing and self-regulation. Wing and her coworkers found that compared with receiving quarterly newsletters, a self-management program based on daily weighing improved maintenance of weight loss, particularly when delivered face-to- face.

This was a nice study. You may say, however, “Do I need to see someone face-to-face to keep weight off?” This was a finding in the study. However, it likely is not too practical in most cases to see someone on a face-to-basis in order to keep pounds off. For this reason, you may just want to use daily self-weighing and using self-management skills. We hope it helps if you are one of a large number of people trying to keep off pounds that you found were so hard to lose. It could. Good luck!

Do any of you have any comments or suggestions?

Rena Wing and associates. A self-regulation program for maintenance of weight loss.
New England Journal of Medicine, 2006;355:1563-1571.

Up until about 50 years ago, patients trusted their doctors. They were trusted more than about any other group of professionals. You knew that if you needed urgent medical care, your doctor was there to help you night and day. There may not have been many treatments available, but at least you knew who was treating you and trusted his or her judgment. That trust has been declining in recent years. Furthermore, with the complexity in the number and potency of treatments in the past half-century or so, you often see more than one health care provider. This is really the case if you have a chronic illness and see a number of specialists. To be honest, you have no idea of whether they will all be helpful or not. All you know is that the first thing they want in any health provider’s office is that you have your health insurance and, if older, Medicare cards. If this is the main thing they seem to care about, is there any reason you should trust these guys? Generally, you may believe the answer is yes, but sometimes you may think no. Much of what you believe will depend upon the office staff. If you have to wait an hour or so to be seen by the doctor, he or she had better be good because no trust is being built between you and he. Sitting in the waiting room can further undermine the development of trust. You not only get to listen to the trials and sorrows of those around you, but you are bound to observe how the office staff reacts to patient’s questions. What you hear and see will influence how you later respond to the physician you see.

This is not good, is it? Yet, it describes health care today. Unless you and your health care provider each make an effort, trust is not going to occur on its own. Even the busiest doctor must make an effort to gain your trust. If she or he doesn’t, then you may be less willing to take whatever advice is given to you. On the other hand, the trust you have in your doctor is very valuable in helping you control your chronic condition. You must believe that what he is telling you will help.

The idea of building trust between patients and their health care providers has been the subject of much research and debate. It is a topic that everyone has an opinion about yet no one can define it. How do you build trust between you and your doctor? How can he or she building it in you? As everyone has an idea but no one an answer, what do you think?

A common barrier to taking medications is that patients fail to fill and refill their prescription for a drug. Bruce Bender and his colleagues recently showed the extent of the problem. In the study, they looked at the factors related to refilling prescriptions in a large group of patients. Filling prescriptions was examined for12 months from data of 5,504 asthma patients who filled their medication at a nationwide pharmacy chain. The results showed that, on average, patients filled enough medication to cover 22.2% of the days they were supposed to take the drug. More than half the patients filled a 30-day prescription only once over the 1-year interval. Higher adherence levels were related to being male, being older than 35 years, having more than one chronic disorder, having a lower amount to copay for a drug, previous use of a medication, and a prescription for higher-dose drugs. The conclusion of Bruce and his co-workers was that medication adherence levels were much lower than those reported in most clinical trials, and suggestive of the point that most adults taking controller drug only obtain a single fill of the medication before abandoning the drug.

This was a nice study conducted over one year with a large number of patients. Filling and refilling prescriptions seems to be a huge problem when patients are asked to take a drug to control their chronic illness. We all know what to do if we have an acute illness: we’ll take whatever action we must to get back on track as soon as we can. With a chronic condition, on the other hand, things are not always this clear. The basic question is, “Why should we have to take a drug each day when we don’t see big changes in our health?” This is an excellent question, particularly if the role of the controller drug has never been explained to you as a patient.
The problem of filling and refilling prescriptions is the perfect example of a problem that should be jointly solved by patients and their health care providers. For your part, you must know why each drug you take is required. Always ask questions, particularly if the drug is intended to maintain your health, not to control an acute crisis. Don’t, as has been said before, be afraid to ask questions. Remember there is no such thing as a dumb question.

Do any of you have any comments or suggestions?

Bender BG, Pedan A, & Varasteh LT. Adherence and persistence with fluticasone propionate/salmeterol combination therapy. Joural of Allergy & Clinical Immunology, 2006 118:899-904.

If you have a serious chronic condition, can you extend your life by managing your medications as directed? The answer may be yes, at least in some cases. A recent study in Canada looked at how drug adherence related to mortality in survivors of an acute myocardial infarction. It examined 31,455 elderly survivors of this serious heart condition between 1999 and 2003. All patients filled a prescription for statins, ß-blockers, or calcium channel blockers, with the latter drug considered a control in the absence of proven survival benefits. Patient compliance was subdivided into three categories--high, intermediate, and low--and compared with long-term mortality. The results showed that long-term survival after a severe heart attack appeared to be related both to the drug prescribed and patient adherence to a treatment schedule. It was not, however, a result of adherence alone.

The relationship between the progression of a chronic illness and taking your medications is far more complicated than was shown by this study. However, the findings do suggest that in combination with proper medical care, your performance of self-management skills, such as taking any prescribed drugs as directed, may improve your health and prolong your life. Your health care provider needs to do his or her part in prescribing the best treatment regimen for you. However, it is solely up to you to do your part by adhering to in the instructions provided to here. This is where your performance of self-management skills can really make a difference.

Do you have any suggestions or comments?

Jeppe N and colleagues. Relationship Between Adherence to Evidence-Based Pharmacotherapy and Long-term Mortality After Acute Myocardial Infarction..Journal of the American Medical Association, 2007; 297: 177-186.

Studies of self-efficacy, or the beliefs one have that they can perform the skills required to manage a situation, are increasingly being presented. One recent study examined self-efficacy as shown by diabetic patients involved with the Department of Veteran Affairs. Surveys were mailed to patients with type 2 diabetes who attended a VA Medical Center. The surveys looked at the patient’s willingness to changes, their self-efficacy, the provider advice they received, and diabetes self-care practices. Responses were obtained by 717 (56%) of those sent the surveys.

Most respondents reported receiving advice from physicians regarding physical activity, nutrition, and glucose monitoring, but many were not ready to change self-management behaviors. Individuals with higher self-efficacy scores were more likely to adhere to medications, follow a diabetic meal plan, eat a lower fat diet, have higher levels of physical activity, and monitor their blood sugars.

Comment: The conclusions reached by the authors was that although veterans with poor diabetes control receive appropriate medical advice, many were not sufficiently confident or motivated to make and maintain self-management changes. We concur with the authors that patients should receive more training to emphasize increasing readiness to change and increasing self-efficacy.

Do you have any comments or suggestions?

K.M.Nelson and colleagues. Factors influencing disease self-management among veterans with diabetes and poor glycemic control. Journal of General Internal Medicine, 2007;22:442-447.

To many of us, it seems the older we get, the more pain we experience. It may be due to a chronic illness or it may be a sign of the wear and tear of aging. Many older patients with common chronic conditions experience chronic pain. A recent study examined how chronic pain affected the ability of older adults to perform self-management activities, in addition to looking at how it was influenced by self-efficacy or the level of confidence in one's own ability to perform a specific task. The investigators looked at a sample of data from a nationwide survey of 543 older patients, primarily older men, with chronic health conditions. Chronic pain was defined as pain present most of the time for 6 months or more during the past year. The ability to follow self-management recommendations was found by asking respondents to rate their level of difficulty in performing three commonly recommended activities as suggested by their doctor.

More than 60% of respondents in the survey reported chronic pain. Chronic pain was significantly associated with difficulty exercising regularly and taking prescribed medications, but not with following a recommended eating plan. However, when self-efficacy was taken into account, chronic pain was no longer significantly associated with either exercise or taking medications.

Comments: As the authors reported, chronic pain is a common condition among older patients and is associated with greater reported difficulty performing certain essential self-management activities. Self-efficacy, however, plays an important role in the success of self-management. Specifically, higher self-efficacy weakened the link between chronic pain and reported difficulty exercising and taking medications. We agree with the authors that promoting self-efficacy among older adults with multiple chronic health problems is a promising strategy to improve their ability to perform self-management skills.

S.L. Krein et al. Overcoming the influence of chronic pain on older patients' difficulty with recommended self-management activities. Gerontologist, 2007;47:61-68.

Growth of the Internet has sparked more and more health care programs for chronic diseases. One study described a pilot phase of an Internet program to help adolescents moving to adult-centered medical care. The online program consisted of information on diabetes, goal-setting exercises with personal feedback, role-playing, group discussions, taking control activities, and communication skills training to improve interactions with health care professionals. Low-income young adults with diabetes were recruited from two inner-city clinics, and given recycled desktop computers and dial-up Internet service. They also received encouragement and computer use reminders from a diabetes educator. During a 6-month intervention period, the investigators checked on participant utilization of the Internet program.
The results indicated that participants logged onto the program 4,445 times, with the discussion board receiving the greatest activity (2,256 total posted and read messages). Participants used the program most frequently at night, with an overall gradual decline in computer use over the 6-month period. To help maintain utilization, the diabetes educator placed a total of 439 telephone calls over 6 months (15-38 calls per participant).

Comments: The study showed the Internet was able to meet the informational and social needs of adolescents and young adults with diabetes. You would expect the hits on the Internet to decrease over time as the participants required less and less information. That is what occurred. The approach has considerable promise for the future. However, a weakness suggested by the authors was that involvement by patients relied heavily upon reminders and encouragement from a diabetes educator and immediate family members. This raises the question as to whether self-management skills were emphasized in the program. For this reason, it is suggested that future programs include a major stress on self-management in order to insure that patients learn to take more care for their diabetes.

B.S. Gerber et al. Evaluation of an Internet diabetes self-management training program for adolescents and young adults. Diabetes Technology Therapy, 2007;9:60-67.

Reports on self-management often focus on use of the skills with three diseases: arthritis, asthma, and diabetes. This is not only because of the prevalence of the conditions, but because they are likely the disorders where patients can make the biggest impact on the control of their illness. By only looking at these three chronic illnesses, however, we often overlook other uses of self-management. An article by Morris in the U.K. examined how patients can use self-management skills to help control their back pain. He combined interviews, observations, and other methods to determine the views of patients on self-management following a program designed to change behavior, increase activity levels, and the encouragement of these skills. There was a small sample of patients, only six participants, but all said they were using self-management by continuing to exercise and using the advice they received in the program. Two patients felt they should continue attending the therapy department to exercise in order to gain benefit; these views suggested a reliance on continued health care support and, in turn, less reliance upon their own self-management skills. Participants listed barriers to continuing to exercise as pain, time, and family constraints.

Comments: The study showed the importance of patient beliefs and outlooks prior to and after a self-management program for back pain. As only a small number participated in the study, there is need to expand self-management to more patients with back problems. Of additional interest would be a greater focus on what parts of the program were particularly valuable in both teaching self-management skills and in maintaining performance once participation in the program ended. It would also be important to be sure that patients were actually gaining self-management skills and not relying on support from the staff of the program. Still, however, the approach showed a promising beginning.

Do you have any comments or suggestions?

A.L. Morris. Patients' perspectives on self-management following a back rehabilitation program. Musculoskeletal Care, 2004;2:165-179.

In past entries, we have described different issues that hinder the compliance of patients to taking prescribed medications. A common barrier centers on the costs of drugs. There is no doubt that this can be a problem, particularly if a patient lacks health insurance or has a plan that fails to cover the costs of medications. Increasing, patients face greater cost sharing through higher deductibles and other out of pocket expenses. Under this situation, the costs have uncertain effects on decision making by patients and health care professionals alike.

In a recent study, Hoangmai and colleagues looked at data on 6,628 patients who responded to a survey to see how often physicians considered their patients out of pocket expenses when prescribing drugs, ordering diagnostic tests, and choosing inpatient vs outpatient care settings. Responses were divided into two categories: always/usually vs sometimes/rarely/never. The results of the survey found that 78% of physicians reported they considered out of pocket expenses when prescribing drugs, while 51.2% reported doing so when selecting care settings, and 40.2% when selecting diagnostic tests. Primary care physicians were more likely than medical specialists to consider patients' costs in choosing prescription drugs, care settings, and diagnostic tests. Physicians working in large groups or health maintenance organizations were more likely to consider out of pocket costs in prescribing generic drugs, but those in solo or 2-person practices were more likely to do so in choosing tests and care settings. Physicians providing at least 10 hours of charity care a month were more likely than those not providing any to consider out of pocket costs in both diagnostic testing and care setting decisions.

Comments: Despite the practices of some health care providers, the authors of the study concluded that cost-sharing arrangements are likely to have limited effects in reducing health care spending because physicians do not routinely consider their patients’ out of pocket costs when deciding upon more expensive medical services. These are the major conclusions that emerged from the study. However, as we all know, the practices of individual physicians vary widely. Some do consider their patients’ costs, often giving out samples of drugs to reduce patients’ costs. The majority, however, are like those in this survey and do not consider these costs. It would be impractical for all physicians to give free drugs all the time with all of their patients; this would be impossible both for them and for pharmaceutical companies. Maybe what we need as patients is some sort of guide as to the amount of charity work physicians performs before when selecting a health care provider! We have no idea, however, how we could find out this information.

Do you have any comments or suggestions on this growing problem and barrier to medication adherence? As out of pocket expenses are increasing, it would be great to hear some useful suggestions.

H. Hoangmai et al. Physician Consideration of Patients' Out-of-Pocket Costs in Making Common Clinical Decisions. Archives of Internal Medicine, 2007;167:663-668.

We are always interested in reading about alternative therapies and chronic illness. Most of these approaches seem to be of dubious value. Some, in fact, likely cause more harm than good. However, there are times when a therapy could be useful, particularly when it is similar to approaches of proven scientific value. An example is a recent study that examined qigong, a popular form of alternative medicine practiced in the Orient. Qigong--an approach that combines gentle exercise with breathing techniques, meditation and visualization – reportedly benefited those who used the techniques during the severe acute respiratory syndrome (SARS) outbreak in Hong Kong. The study by Siu and colleagues looked at 98 people – mostly in their 40s to 50s -- who had enrolled before the SARS outbreak and 70 who enrolled after the disease hit Hong Kong. Three classes were observed for four months before the SARS crisis and for another four months during the outbreak. The participants, who were suffering from chronic health problems such as high blood pressure, diabetes, and heart disease, continued practicing qigong during the outbreak. The researchers gathered patient-observation from the classes and in-depth interviews with 30 participants. It was reported that none of the participants became infected with SARS.

Comments. The results are vague and unclear, particularly in showing a link between qigong and prevention of SARS. However, there are three findings that suggest performing qigong had its value: First, the skills of breathing techniques, exercise, and visualization, are also used in self-management. Thus, they are the skills that might have been done had participants performed self-management, a method of proven value. Second, qigong gave patients something to do in the face of the uncertainly that accompanied SARS. No one knew whether or not they would be infected with the disease, but they could do what they thought might be useful in preventing SARS. Performing these exercises, in turn, likely led them to think clearly of other steps they could perform to prevent the disease. Finally, the sense of success they found helped them continue their practice of qigong. Qigong may have produced a type of placebo effect but, at the same time, it probably led to some degree of self-confidence that they could prevent SARS through their performance of the qigong exercises.

Do any of you wish to comment about the use of qigong in chronic illness?

J. Y. Siu et al. Qigong practice among chronically ill patients during the SARS outbreak. Journal of Clinical Nursing, 2007;16:769-776.

It should becoming clear to readers that we describe how self-management can be used by patients with a wide variety of chronic conditions. So it is that we discuss how patients with bronchiectasis are using self-management skills to improve their health. Bronchiectasis is a lung disease that results from an infection or other factors that injure the walls of the airways, the tubes that carry air in and out of your lungs. The injury starts a cycle in which the airways slowly lose their ability to clear out mucus. The mucus, in turn, builds up and creates an environment in which bacteria can grow. This leads to repeated serious lung infections with each infection causing more damage to the airways. Over time, the airways become stretched out, flabby, and scarred; they can no longer move air in and out of the lungs. As with most chronic conditions, bronchiectasis cannot be cured, although it can generally be controlled.

The characteristics of bronchiectasis appear to make it ideal for self-management.
A recent study in the U.K. looked at the physical and psychosocial impact of the condition to see, to whether patients with bronchiectasis were receptive to self-management. A second aim was to identify any obstacles or sources of support for a disease-specific self-management program. A total of 32 patients with a diagnosis of bronchiectasis attended four focus groups. Each group was videotaped and analyzed. As expected, bronchiectasis had an impact on the patients' physical and psychosocial well-being. Patients demonstrated they could self-manage their condition with strategies that included self-control of medication and airway clearance. Perceived obstacles to self-management included lack of information and confidence.

Comments. The authors concluded that while patients with bronchiectasis have their lives disrupted, but are willing to learn and perform self-management. This is really only a pilot program, but it does suggest yet another target population for self-management. There is no cure for bronchiectasis, but successful performance of self-management skills could result in a far better quality of life for patients with the condition. This alone is a goal worth pursuing. The broad array of programs developed for asthma and COPD offer a foundation upon which to build an effective program for the self-management of bronchiectasis. This should hasten progress for widespread development and application of self-management programs for the condition.

K. Lavery et al. Self-management in bronchiectasis: the patients' perspective. European Respiratory Journal, 2007;29:541-547.

Heart disease can be a costly burden to many patients with the disorder. Ways to reduce expenses related to the condition are welcome. How can self-management reduce costs from heart disease? Jovicic and colleagues examined the impact of self-management interventions on hospital readmission rates, mortality, and quality of life in patients diagnosed with heart failure. The investigation reviewed and analyzed controlled trials conducted on the topic. These studies were located by looking at a number of databases, reference lists, and by talking with experts in the fields. Included in the search were randomized controlled trials of self-management interventions with patients 18 years of age or older who were diagnosed with heart failure. The primary outcomes of interest were all-cause hospital readmissions, hospital readmissions due to heart failure, and mortality. Secondary outcomes were compliance with treatment and quality of life scores.

The authors found that of 671 identified citations, 6 randomized trials with 857 patients met their standards for the review. Self-management was found to decrease all-cause hospital readmissions and heart failure readmissions. The effect on mortality was not significant. Adherence to prescribed medical advice improved, but there was no significant difference in functional capabilities, symptom status, and quality of life. The reported savings, however, ranged from $1,300 to $7,515 per patient per year.

Comments: The authors concluded that self-management programs targeted for patients with heart failure decrease overall hospital readmissions and readmissions for heart failure. This was a major conclusion of the study. However, the results showed a dramatic reduction in the burden of health care costs to patients and health care programs. While this change seemingly did not increase the quality of life of patients, it undoubtedly brought some peace of mind to them and their families. The finding alone is cause enough for developing and promoting more self-management programs for patients with heart disease. As with all self-management programs applied to a chronic illness, there is also a need for long-term follow-up data.

A. Jovicic et al. Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BMC Cardiovascular Disorders, 2006 6:43.

While not called self-management, daily home hemodialysis (DHD), 5 to 7 short-duration hemodialysis treatments per week, promotes a patient’s ability to manage his or her condition. As a result, there are beneficial effects with a number of clinical outcomes including blood pressure and volume control, electrolyte balance, uremic symptoms and consequences, and quality of life. Kumar and colleagues reported on their attempt to demonstrate that DHD is feasible and results in clinical benefits that permit savings in overall healthcare costs despite expenditures on program infrastructure and supplies. The researchers examined the following outcomes each month for all patients: laboratory values, dialysis adequacy, hospital admission records, surgical and interventional radiology records, and prescription medication usage.

Twelve patients completed training in the home hemodialysis unit between April 2003 and April 2006. The mean age at the time of training was 58 years and mean vintage was 62 months. The mean treatment time was 147 min, and the mean number of treatments performed was 5.3 per week. When one patient with morbid obesity was excluded due to intentional weight loss, the mean dry weight at initiation of training increased by the end of the study. The mean albumin and phosphate binder usage also increased. During the 234 months the patents were studied, there were 11 hospital admissions, with a mean length of stay of 3.7 days.

Comments: The authors concluded that DHD improved nutritional status and decreases hospital admissions for dialysis-dependent patients. This, in turn, resulted in cost savings for the patients. The program used for home hemodialysis is straight forward in the actions required of patients. This would provide little wiggle room in the patient’s performance. Nevertheless and despite the present results, training in self-management could be expected to refine patient skills not only for more effective performance, but to help patients acquire the self-efficacy that they were making a contribution to their own health.

Do you have any comments?

V.A. Kumar et al. Daily home hemodialysis at a health maintenance organization: Three-year experience. Hemodialysis International, 2007;11:225-230.

It was not too many years ago when almost all self-management programs for respiratory diseases were developed for asthma. This has changed in the past couple of decades with programs being designed and tested for respiratory disorders ranging from bronchiecstasis to chronic obstructive pulmonary disorder (COPD). COPD, in particular, has been the focus of attention in the use self-management. There is evidence, for example, to suggest that disease management with self-management education provided by a case manager might benefit COPD patients. A study by Bourbeau and colleagues sought to determine whether this approach was more cost-effective than usual care by comparing patients provided self-management with those receiving usual care over a 1-year follow-up period. One hundred ninety-one Canadian COPD patients who required hospitalization in the year preceding enrollment were recruited from seven respiratory outpatient clinics. In addition to usual care, patients in the intervention group received standardized education on a COPD self-management program called "Living Well with COPD" with ongoing supervision by a case manager. Costs between the two groups were compared with estimates of the cost per hospitalization prevented.
The additional cost of the self-management program as compared to usual care, $3,778 (2004 Canadian dollars) per patient, exceeded the savings of $3,338 per patient based on the study design with a caseload of 14 patients per case manager. However, through a sensitivity analysis, it was shown that if case managers followed up 50 patients per year, the self-management intervention would be cost saving relative to usual care (cost saving of $2,149 per patient). With more realistic potential caseloads of 50 to 70 patients per case manager, estimated program costs would be $1,326 and $1,016 per prevented hospitalization, respectively.

Comments: The authors concluded that self-management of COPD would produce positive economic benefits with increased patient caseload and rising costs of hospitalization. More patients with COPD are living longer lives. Cost of these extra years for COPD patients should also be factored into any future analysis of economic expenses. In addition, the quality of life of COPD patients can be assessed through a number of reliable and valid paper-and-pencil instruments. Determining that patients who perform self-management skills also maintain a higher quality of life with COPD is also worthy of analysis in the future. Economic values of quality of life can also be calculated.

J. Bourbeau et al. Economic benefits of self-management education in COPD. Chest, 2006; 130:1704-1711.

In an earlier entry, the costs savings of the self-management for chronic obstructive pulmonary disease (COPD) were described. Different researchers have looked at other aspects of the self-management of the disorder. As is frequently noted, self-efficacy--the confidence patients have that they can perform the skills needed to manage a condition--has been highlighted. Self-efficacy is certainly central to the self-management of COPD. A study by Davis and co-workers recently examined the effect of self-management on COPD, as well as the relationship between domain-specific self-efficacy, walking performance, and symptom severity in patients with the disorder. One hundred and two COPD patients received one of three self-management interventions. Self-efficacy for walking and managing shortness of breath, walking performance, and shortness of breath severity were measured at baseline and after intervention. The results showed that self-efficacy increased after the intervention was presented. Self-efficacy for walking was positively related to walking performance; there was also a positive relation between self-efficacy and reduced symptom severity.

Comments: The study by Davis and colleagues demonstrated that self-efficacy is an important component of self-management interventions. As such, the findings are similar to other self-management programs where self-efficacy is assessed. Many of these studies are the benchmarks against which an effective self-management program should be judged. One might think that the assessment of self-efficacy is included in all self-management programs for chronic illness, but this is not the case. However, if self-management skills are to be maintained, self-efficacy must be emphasized. It is the fuel that drives performance for, at least in the case of chronic illness, may be the remainder of a patient’s life.

A.H. Davis et al. Effects of treatment on two types of self-efficacy in people with chronic obstructive pulmonary disease. Journal Pain Symptom Management, 2006;32:60-70.

Sickle cell disease is caused by a mutation in the hemoglobin-ß gene found on chromosome 11. Hemoglobin transports oxygen from the lungs to other parts of the body. Red blood cells with normal hemoglobin (hemoglobin-A) are smooth and round and glide through blood vessels.

In people with sickle cell disease, however, abnormal hemoglobin molecules - hemoglobin S - stick to one another and form long, rod-like structures. These structures cause red blood cells to become stiff, assuming a sickle shape. Their shape causes these red blood cells to pile up, causing blockages and damaging vital organs and tissue. Sickle cells are destroyed rapidly in the bodies of people with the disease, leading to anemia. This anemia is what gives the disease its commonly known name - sickle cell anemia. The sickle cells also block the flow of blood through vessels, resulting in lung tissue damage, and injury to the spleen, kidneys and liver. Sickle cell disease is the most common inherited blood disorder in the United States, with approximately 80,000 Americans having the disease. In the United States, sickle cell disease is most prevalent among African Americans. About one in 12 African Americans and about one in 100 Hispanic Americans carry the sickle cell trait, which means they are carriers of the disease.

Given the severity of sickle cell disorder, is it any wonder that self-management is being introduced as a strategy to help prevent the pain and harm of disease? The movement is only in its nascent stage but the approach has promise. In a nice study, Yoon and Goodwin set out to see whether playing a simple CD-ROM educational game, specifically developed for children with sickle cell disease, would improve children's knowledge and confidence in selected symptom management and practice. In the investigation, twenty-two eligible children completed a pretest to determine knowledge and confidence levels, played the Sickle Cell Slime-O-Rama Game, then completed an identical posttest. Yoon and Goodwin found significant increases in knowledge and confidence in the ability to apply the knowledge between pre- and posttests.

COMMENTS: The authors concluded that a simple, interactive CD-ROM game allowed children with sickle cell disease to quickly acquire knowledge about the disease and symptom management, and increased their confidence to apply this knowledge. As the technology is relatively simple, the approach has great potential for application to other populations of patients with sickle cell disorder. There is a great need for such application as we could find only three references on MEDLINE on the use of self-management with the sickle cell disorder. There may not be an overwhelming number of patients with the chronic illness, but this should never dismiss the critical need for more studies on self-management and sickle cell disorder. Just ask those with the disease.

S.L. Yoon and A. Goodwin. Enhancing self-management in children with sickle cell disease through playing a CD-ROM educational game: a pilot study. Pediatric Nursing, 2007;33:60-63,72.

Hardly a month goes by when there isn’t some report describing obesity in children. It is considered to be an epidemic in the United States. The number of children who are overweight has doubled in the last two or three decades, with one child in five considered overweight. The increase has been found in both children and adolescents, and across all age, race and gender groups. Obesity has led to other health problems. For example, obese children now have diseases like type 2 diabetes that used to only occur in adults. As overweight kids tend to become overweight adults, they are at greater risk for heart disease, high blood pressure, and stroke. Just as important, is the social discrimination that occurs with overweight and obese children. There are many factors that lead to childhood obesity. Genetics undoubtedly plays a role, but they alone can’t account for the skyrocketing increase in rates of obesity over the past few decades. The major factors are the same as those for adult obesity: eating too much and moving around too little. It is estimated that almost half of children aged 8-16 years watch three to five hours of television a day. Youngsters who watch the most hours of TV have the highest rates of obesity.

Solving the problem of childhood obesity will require much more attention than is currently directed at the problem. A big change has been to improve the foods that children consume at school. Modifications have been made in what kids and adolescents eat in the lunchroom, as well as removing pop and junk food machines from schools. But, how do we get children to exercise more? The time youngsters have to exercise at school has been reduced in recent years. There are even calls that these opportunities be totally eliminated through the removal of recess from schools.

In his pioneering work, Len Epstein and his colleagues have looked at many variables affecting exercise by children. Recently, they reported on a study designed to understand factors associated with a child's choice to be physically active or sedentary. In particular, they looked at how neighborhood and home environments may be related to this choice by attempting to determine whether the neighborhood environment or number of television sets in the home environment were independently associated with child physical activity and television time.

In the investigation, the associations of the neighborhood and home environments on active and sedentary behaviors were studied in 44 boys and 44 girls who wore accelerometers and recorded their television watching behaviors. Neighborhood environment variables were measured using extensive geographic information systems analysis. The complex analysis found that increased access to parks was related to increased physical activity in boys but not in girls. The number of televisions in the home accounted for 6% of the variability in television watching behavior. Neighborhood environment variables did not predict television watching that occurs in the home.
COMMENT: The research by Epstein and his colleagues has added significantly to our knowledge of childhood obesity and how it might be reversed. In the present study, the neighborhood environment was more strongly associated with physical activity of boys than girls. Sedentary behaviors, as in past studies, were associated with access to television in the home environment. The authors concluded that to promote physical activity in children, planners need to design environments that support active living and parents must limit access to television viewing in the home. The latter issue is something that can only occur by parents working with their children to teach them to manage their television behavior. A goodly amount of self-management skills may be required for this to occur. The former issue is more problematic: in planning new areas for homes, most developers do add in parks and open space. As they are starting at the beginning, this presents no difficulties. In older, more established neighborhoods, however, it is often difficult to free up space for parks. Even when smaller areas become available, too many governing boards would rather go for more building, as well as the tax base that comes with it, than create a place for kids to play in. This is short sighted, particularly considering the future bill of childhood obesity. The thoughts of that bill are almost incomprehensible.

J.N. Roemmich, L.H. Epstein, S. Raja, & L. Yin. The neighborhood and home environments: disparate relationships with physical activity and sedentary behaviors in youth. Annals of Behavioral Medicine, 2007;33:29-38.

It doesn’t seem that long ago when AIDS was considered an almost certain death sentence. This was usually the case in the first two decades of the HIV/AIDS epidemic. The development and use of newer drugs, however, moved the disease from one that usually led to death to a chronic condition that requires the consistent performance of self-management behaviors on the part of patients with HIV/AIDS. Despite these advances, however, there are many patients with the disease who do not perform the basic practices of safe sex. This was noted in a presentation at the Society of Behavioral Medicine in March by Travis Lovejoy and Tim Heckman. In their study, they found that one out of three sexually active older adults infected with HIV has unprotected sex. They surveyed 260 HIV-positive older adults and found that of those having sex, most were male, took Viagra and were in a relationship. AIDs cases among the over-50 crowd reached 90,000 in 2003. The findings that one-third of respondents practiced unsafe sex is disturbing because, according to the Centers for Disease Control and Prevention, they will account for half of all HIV/AIDS cases in the United States by 2015. This will occur because medical progress has extended the lifespan of those infected with HIV. In addition, drugs such as Viagra have made it possible for older adults to remain sexually active longer. The study also found that sexual activity was more prevalent among HIV-positive older adults who were not cognitively impaired, were younger and who considered their overall health to be good.

COMMENTS: Lovejoy and Heckman concluded that while many older adults with HIV are not sexually active, those who do have unprotected sex account for just 13 percent of the overall number of infected people who are aged 50 or older. However, one-third of those who are sexually active have unprotected sex, which suggests that prevention efforts may need to be more highly targeted toward these individuals. These findings suggest that the teaching, performance, and maintenance of self-management skills is not just for the young, but also for older adults with HIV/AIDS. This is particularly required considered the large number of patients expected to have the condition in only 8 short years. As suggested by the study of Lovejoy and Heckman, now is the time to act.

Do you have any comments or suggestions?

Travis Lovejoy may be contacted at (503) 314-1182 or tl399805@ohio.edu. Tim Heckman can be contacted at (740) 597-1744 or heckmant@ohio.edu;

When we talk about the use of self-management skills, we usually refer to how they can be used to help control the outcomes that occur in having a chronic condition. They are just as helpful, however, in coping with different thoughts and behaviors that accompany a given illness. This was shown in a large study conducted by Kemppainen and colleagues with HIV patients. The research looked at the frequency and effectiveness of commonly used strategies for self- management of anxiety in an international sample of 502 participants from Norway (n=42), Taiwan (n=35), and the U.S. (n=426). An activities checklist filled out by the patients summarized five categories of self-care behaviors including activities/thoughts, exercise, medications, complementary therapies, and substance use determined self-care behaviors. Ratings of frequency and effectiveness for each self-care activity were also included.

The findings showed that praying received the highest overall rating of effectiveness of any self-management strategies included in the study, followed by meditation, exercising, using relaxation techniques, cooking, and walking. An analysis of effectiveness scores for each self-care strategy by country reflected a wide variation. The three most effective anxiety self-care strategies reported by participants from Norway included exercise, walking, and reading. The highest ratings of effectiveness by participants from Taiwan included talking with others with HIV, attending support groups, and exercising. U.S. participants reported highest ratings of effectiveness to complementary/alternative therapies, including praying, meditating, and using relaxation techniques. Regardless of the country, watching television and talking with family and friends were the two most frequently reported strategies.

COMMENT: This is an interesting study because it looked at how patients in three countries--Norway, Taiwan, and the United States--coped with the anxiety related to HIV. The most frequently used strategies--viewing TV and talking with others--were not the most effective strategies used by patients. This reflects the uniqueness of individual patients in deciding how best to cope with anxiety surrounding their condition and independent of what might work for others. A patient's decision, however, appears to be partially dependent upon where he or she lives. This is especially true for the patients from Taiwan. The authors concluded that strategies for self-management of HIV-related anxiety are important for clinicians to be aware of in the care of persons with HIV/AIDS. We echo this conclusion.

Do you have any comments or questions?

J.K. Kemppainen et al. Strategies for self-management of HIV-related anxiety. AIDS Care, 2006;18:597-607.

If you have ever been in the hospital for a heart condition, it is likely that before discharge, someone will come around, give you a book on heart disease and tell you to modify your life in order to live longer. In most cases, there is never any attempt to follow up with you after discharge. The hospital staff likely refers to this process as patient education, but unless they actually spend time to teach you the skills you need to perform, as well as observe your performance, education reverts back to your either reading the book or, as is often the case, discarding it where it will never be read. Fortunately, there are facilities where they add elements of self-management to help you deal more effectively with heart failure.

A study by Wright and colleagues in New Zealand looked at whether patient education and self-management strategies, such as daily recording of body weight and use of a patient diary, decrease hospital readmissions and improve quality of life. They were particularly interested in the role of individual components of these programs and their contribution to patient benefit. Patients with heart failure were randomized into a management or usual care groups. Those in the management group were given a heart failure diary for the recording of daily weights, attended a heart failure clinic, and were encouraged to attend three education sessions. Patients in the usual care group received routine clinical care, mainly from general practitioners. All participants were followed to 12 months. The study investigated self-management components by looking at diary use and self-weighing behavior in the group receiving the heart failure intervention, and compared the level of knowledge of heart failure self-management of the management group to the control group after 12 months.

Of the 197 patients in the study, 100 patients were included in the management group and received a diary and education about heart failure self-management including monitoring weight daily. Of these patients, 76 patients used the diary. These patients were on more medication; and were more likely to attend the education sessions, the heart failure clinic, used primary care, and had a lower mortality rate over the course of the study. Variables independently associated with use of the diary included less severe symptoms, frequent attendance at the heart failure clinic, and attendance at an education session. Of the 76 patients who used the diary, 51 weighed themselves regularly. More of these patients owned scales at home; they were also more likely to attend the education sessions, and experienced fewer hospital admissions than those patients who did not weigh themselves regularly. Variables independently associated with regular self-weighing included the presence of scales at home and attendance at the education session(s). Patients in the management group exhibited higher levels of knowledge at 12 months of follow-up, and were more likely to monitor their condition using daily weighing compared to the control group.

COMMENTS: The authors concluded that at 12 months of follow-up, use of self-management skills including daily weight monitoring and level of education on self-management was significantly higher in the management group than the control group. This outcome would be expected as self-monitoring is the backbone of self-management. In fact, self-monitoring by itself can lead to behavior change. For example, many of us lose weight by regularly monitoring our weight. This approach does not work for everyone; regular weighing may, in fact, produce negative behaviors when there is failure to see weight loss. Nevertheless, as demonstrated here, the combination of education and self-monitoring was effective when used in a heart failure management program. The moral here is not to give up on your bathroom scales when dieting!

Do you have any comments?

S.P. Wright et al. Uptake of self-management strategies in a heart failure management programme. European Journal of Heart Failure, 2003;5:371-380.

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

Acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to treat it. Chronic pain, however, persists. Pain signals keep firing in the nervous system for weeks, months, or even years. According to the National Institutes of Health, there may have been an initial mishap -- sprained back, serious infection, or an ongoing cause of pain -- arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults. Common complaints of chronic pain include headache, low back pain, cancer pain, arthritis pain, neurogenic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself), and psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside or outside the nervous system).

People do a number of things in attempting to control pain. Pain coping skills training been shown to produce immediate improvements in pain and disability in rheumatoid arthritis. However, some patients have difficulty maintaining these gains. A study by Carson, Frank Keefe, and their colleagues compared a convention coping skills training approach with a similar approach that also included maintenance training. Patients with arthritis (n = 167) were randomly assigned to either conventional pain coping skills training, pain coping skills training plus maintenance, arthritis education control, or usual care control. Data were collected daily on joint pain, coping, coping efficacy, and mood. Analyses following treatment showed pain coping skills training was superior to all other conditions in joint pain, coping efficacy, and negative mood, whereas similar training plus maintenance was superior to all other conditions in emotion-focused coping and positive mood. At the 18 months follow-up, both pain coping skills training conditions were superior to standard care in joint pain and coping efficacy.

COMMENTS: There was a high dropout rate in both of the coping skills groups, thus suggesting that the maintenance component did not appear to produce significant improvements over conventional coping skills training. We have no idea the extent to which self-efficacy was emphasized in the program. Had that been a major component of the coping skills program, different results might have been obtained in the maintenance of these skills. This suggestion is based upon the findings of Kate Lorig and her colleagues in maintaining self-management skills in patients with arthritis. However, despite this possible shortcoming, this was still an excellent study.

Do you have any questions or comments?

J.W. Carson, F.J. Keefe et al. A comparison of conventional pain coping skills training and pain coping skills training with a maintenance training component: a daily diary analysis of short- and long-term treatment effects. Journal of Pain, 2006;7:615-625.

Effective treatment of chronic illness requires patients to manage their own condition. Fortunately, one of the beauties of self-management is that it can be used by anyone with a chronic illness regardless of their ethnicity and socioeconomic levels. This point has been amply demonstrated in a number of self-management programs, such as that shown in the inner-city projects established for childhood asthma in the United States. Whether all patients with a chronic illness have equal opportunities to learn and perform self-management is another matter. A study by Greene and Yedidia looked at the influence of provider support for self-management on patients' performance of these activities, a widely presumed but understudied relationship, particularly among underserved populations. The authors surveyed an ethnically diverse, primarily low-income sample of 956 patients (or parents of pediatric patients) with diabetes or asthma in 17 outpatient-teaching settings across the country. Analysis of the data found that patients with strongly positive assessments of their providers were much more confident in self-care. Furthermore, among patients with diabetes, high assessments of provider support, in comparison with low, were significantly associated with performance of self-management tasks, amounting to approximately one more day per week. These relationships were significant for patients with either illness and from varied socioeconomic backgrounds.

COMMENTS: The conclusion by Greene and Yedidia was that their findings validate their measure of provider support, its relevance to underserved populations, and its usefulness for evaluating quality of care. It likely did. At the moment, poor patients receive less than optimal medical treatment in the U.S. Despite Medicaid, there are few safety nets that they can count on to provide health care assistance when needed. Reducing their burden through teaching them to perform self-management skills would be of great help. Thus, any method we can use to better identify these patients, as well as to tailor programs more closely to their needs, is welcomed.

Do you have any questions or comments?

J. Greene & M.J. Yedidia. Provider behaviors contributing to patient self-management of chronic illness among underserved populations. Journal of Health Care in the Poor and Underserved, 2005 ;16:808-824.

Ankylosing spondylitis is a type of arthritis of the spine. It causes swelling between the vertebrae, the disks that make up the spine, and in the joints between the spine and pelvis. Ankylosing spondylitis is an autoimmune disease where the immune system, normally protective of the body from infection, attacks a body's own tissues. The disease is more common and more severe in men, and often runs in families. Early symptoms include back pain and stiffness, which often start in late adolescence or early adulthood. Over time, ankylosing spondylitis can fuse vertebrae together, thus limiting movement. Symptoms can worsen, improve or stop altogether. The disease has no cure, but medicines can relieve the pain, swelling and other symptoms. Exercise can also help.

A study by Luszcynska and colleagues described an intervention designed to enhance preaction self-efficacy beliefs--the beliefs you have about your ability to initiate behaviors to manage a given situation--and tested it in patients with spondylosis in relation to initiation of exercises recommended by a consultant in orthopedic rehabilitation. Sixty patients (age 28-83 years) with spondylosis who had not previously performed exercises for degenerative spine diseases were randomly assigned to a control or intervention group. Three weeks later, intervention patients performed recommended exercises more frequently than control patients. Analysis for all patients showed that preintervention, preaction self-efficacy predicted exercise. Age and preintervention self-efficacy moderated the intervention effects. Among older patients, only those with weak preintervention, preaction self-efficacy beliefs benefited from the intervention, whereas among younger patients, only those with strong preintervention, preaction self-efficacy beliefs benefited from the intervention.

COMMENT: Normally, self-efficacy beliefs is measured at the beginning and end of a study and treated as an outcome. In self-management, the aim is to see if self-efficay is involved in a person’s ability to perform these skills changes from before to after training. In this study, however, the examiners looked at how beliefs held before intervention were later influenced by the intervention. The results are somewhat conflicting between older and younger patients, but nevertheless interesting. They suggest a way to predict which patients may do well or less well when later taught self-management.

Do you have any questions or comments?

A. Luszczynska et al. Effects of a self-efficacy intervention on initiation of recommended exercises in patients with spondylosis. Journal of Aging and Physical

If you have a chronic illness and are linked to the Internet, you likely use it on a regular basis. The Internet presents a number of options to you from keeping abreast of new findings with your conditions to reading about the side effects of any newly prescribed drugs. But, there are many other possible uses for the Internet, including its use in teaching you self-management skills. The small-group Chronic Disease Self-Management Program (CDSMP), developed by Kate Lorig and her colleagues at Stanford University, has proven effective in changing health-related behaviors and improving health statuses. It has been effective not only throughout the U.S., but in China and the Netherlands.

Recently, Internet-based self-management programs have been developed to reach a greater numbr of chronic-disease patients. The efficacy of the Internet-based CDSMP was tested in a study conducted by Kate and her colleagues by comparing randomized intervention participants using the Internet with usual-care controls at 1 year. Nine hundred and fifty-eight patients with chronic diseases (heart, lung, or type 2 diabetes) were randomly assigned to the CDSMP, plus Internet and e-mail access, intervention (457) or usual care control (501). Outcome measures included seven health status variables (pain, shortness of breath, fatigue, illness intrusiveness, health distress, disability, and self-reported global health), four health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), and three utilization variables (physician visits, emergency room visits, and nights in hospital), and self-efficacy.

The investigators found that at one year, the intervention group had significant improvements in health statuses compared with usual care control patients. The intervention group also had similar results to the small-group CDSMP participants. Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year.

COMMENTS: Lorig and her coworkers concluded that the Internet-based CDSMP proved effective in improving health statutes by one year, and was a viable alternative to the small-group Chronic Disease Self Management Program. This could prove to be an invaluable study. The CDSMP has, as noted, has amassed solid data as to the effectiveness of the program. Teaching self-management via the Internet, however, greatly expands the possibility that others throughout the world can be taught these skills to help manage their chronic condition.

K.R. Lorig et al. Internet-based chronic disease self-management: a randomized trial. Medical Care, 2006;44:964-971.

Cystic fibrosis (CF) is an inherited disease of the mucus glands that affects many body systems. In particular, the disorder causes progressive damage to the respiratory system and results in chronic digestive problems. Many of the issues occur because of mucus, the slippery substance that lubricates and protects the linings of the airways, digestive system, reproductive system, and other organs and tissues. In people with cystic fibrosis, the body produces mucus that is abnormally thick and sticky. This abnormal mucus can obstruct the airways, leading to severe problems with breathing and bacterial infections in the lungs. The infections cause chronic coughing, wheezing, and inflammation. Over time, mucus buildup and infections result in permanent lung damage, including the formation of scar tissue (fibrosis) and cysts in the lungs.

Despite the many problems presented by CF, progress is being made in helping patients live and cope with the disease. An illustration of a new approach was reported by Christian and D’Auria in a recent study. The aim of their study was to test the effectiveness of an intervention to improve psychosocial adjustment, functional health, and physiological health in children (8-12 years of age) with CF by teaching them life skills for managing their chronic illness in their everyday lives. An two-group, repeated-measures design was used to compare 116 children with CF randomly assigned to intervention and usual care groups. Assessment occurred at baseline and at 3, 6, and 9 months post-intervention. Children received an individual, tailored intervention during a home visit and a structured group intervention. Four instruments were used to measure psychosocial health status, and functional health status was measured with the Functional Disability Inventory for Children. Physiological status was determined by pulmonary function testing and physical growth. The results indicated that compared with children in the usual care group, the participants in the intervention groups demonstrated decreased perceived impact of illness and decreased loneliness. Improvements were maintained at 9 months for impact of illness and loneliness.

COMMENTS: Christian and D’Auria concluded that the developmentally appropriate, problem-solving, and social skills intervention has promise for decreasing the social consequences of chronic illness (CF) in children's lives. We concur. Although it was not designed as a self-management intervention per se, there are elements from these programs, such as problem solving, that are used in both approaches to CF. A number of promising changes have occurred in the management of CF in the past decade or so. The biggest advance has undoubtedly been the steadily increasing average length of life experienced by patients with the disease. It has been creeping up because of both medical and behavioral changes. Many patients with CF are followed at regional centers established for the disease. The variability of success in increasing life at these centers was the subject of a fascinating article by Atul Gawande, now reprinted in his book, BETTER. Gawande reported how treatment success for CF fell along a bell-shaped curve with outstanding facilities at one end of the spectrum and less successful programs falling at the other end of the spectrum. This was, by itself, a major finding. However, the real hope may be that Gawande later found that facilities later improved their performance with excellent facilities leading the way. As a center’s ranking can be found online, it has prompted all centers to improve their performance. This is great news for those who have CF as they now have the promise of longer and better lives.

B.J. Christian & J.P. D'Auria. Building life skills for children with cystic fibrosis: effectiveness of an intervention. Nursing Research, 2006; 55: 300-307.

A. Gawande. Better: a surgeon’s notes on performance. New York: Metropolitan Books, 2007.

The soaring rate of chronic illness has led behavioral and health care scientists to think of ways to reach and educate these patients. The result has been self-management, an approach born less of initial curiosity than of immediate necessity. Traditional approaches, such as residential treatment centers for asthma, were forced to give way for strategies that would reach a much greater population of patients. The movement, now fueled more by curiosity and creativity, is continuing. Russ Glasgow and his colleagues, for example, noted there remained a need for practical, efficient, and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviors such as healthy eating and weight loss. The objective of their study was to evaluate whether the need they saw could be solved by a computer-assisted intervention. In the study, 335 Type 2 diabetes primary care patients from fee-for-service and health maintenance organization settings were randomized to social cognitive theory-based tailored self-management (TSM) or to computer-aided enhanced usual care (UC). The intervention they introduced consisted of computer-assisted self-management assessment and feedback, tailored goal-setting, barrier identification, and problem-solving, followed by health counselor interaction and follow-up calls. The outcomes were changes in dietary behaviors (fat and fruit/vegetable intake), hemoglobin Alc, lipids, weight, quality of life, and depression. Glasgow and his coworkers found that TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up. Among patients having elevated levels of HbA1c, lipids or depression at baseline, there were consistent directional trends favoring intervention, but these differences did not reach significance.

COMMENTS: The intervention proved feasible and was implemented successfully by a variety of staff. Russ and his colleagues found that their relatively low-intensity intervention, (a) appealed to a large, generally representative sample of patients; (b) was well implemented; and (c) produced improvement in targeted behaviors. This was an exciting study as it suggested ways that the ever growing population of type 2 diabetes patients might acquire and perform self-management skills. As many think that the size of this population has now reached epidemic proportions, use of the computer-assisted self-management program is apt to be the key to helping these patients care for themselves.

R.E. Glasgow et al. Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes. Chronic Illness, 2006;2:27-38. 

A common complaint of health care personnel is that patients do not always complete the course of treatment that is prescribed for them. This sometimes centers on the taking of antibiotics to control infections. Taking these drugs may seem to be a no-brainer: who wants to be sick? However, there are doubtlessly many medicine cabinets throughout the world that have bottles with some remaining antibiotic pills. The problem is that the desire to take the drug fades once patients begin to feel better. When this happens, they fail to complete the course of treatment, a source of frustration to those who prescribed the drugs.

Aronson conducted a descriptive study to look at the medication-taking experiences of undergraduate college students who were prescribed short-term antibiotic therapies and to describe factors influencing their adherence. Thirty-four undergraduate students who had been prescribed antibiotics for treatment of an acute infection at a large university health center were recruited to participate in this study. Semi-structured telephone interviews were conducted after students finished their course of treatment. Content analysis was used to analyze the transcripts typed from the audio taped phone interviews. The main theme that emerged from the study was the appropriate antibiotic-taking self-management by the students. Most participants were able to adapt the taking of the antibiotic drugs into their daily routines, and used events in their day and specific reminder strategies to help them to remember to take their medications. This occurred despite an ever-changing class and work schedule, and sometimes being prescribed complex, lengthy antibiotic regimens. Most dosing errors occurred during times when schedules changed or students were off campus during weekends or college breaks. A small number of students discontinued therapy early because of side effects or forgetfulness.

COMMENTS: Aronson concluded that understanding factors that influence antibiotic adherence from a college student perspective suggests strategies to promote adherence tailored to the specific needs of this unique population. This was certainly the case in this study. We have found that college students are greatly interested in self-management. Some, such as those in this study, already use self-management skills to perform well in these schools. There is usually no formal training to acquire these skills; it naturally occurred as the students did well in high school and developed self-efficacy through their successful performance. Other students, however, require more formal training. We taught a college course on self-management for several years and found an enthusiastic audience. Once acquired, students used self-management skills to control other aspects of their lives. Maintenance of the skills was also found to be strong. Our only regret was that the students did not take the course as freshman as it might have helped them achieve greater success in their college work and lives.

B.S. Aronson. Antibiotic-taking experiences of undergraduate college students. Journal of American Academic Nurse Practice, 2006;18:591-598.

Self-management has no borders. It is as effective when applied in the U.S. with arthritis as it is in controlling HIV/AIDS in Africa. In an illustration of the worldwide appeal of self-management, Wattana and colleagues described its use in Thailand where uncontrolled diabetes is a major health problem. The objective of the study was to determine the effects of a diabetes self-management program on glycemic control, coronary heart disease risk, and quality of life in 147 diabetic patients with an average age of 56.8 years. Type 2 diabetic patients who met the research criteria were randomized into two groups for a period of 6 months: the experimental group received the diabetes self-management program and the control group received the usual nursing care. Findings indicated that the experimental group demonstrated a significant decrease in the hemoglobin level and coronary heart disease risk, with an increase in quality of life compared to the control group. The diabetes self-management program was effective for improving metabolic control and the quality of life for individuals with diabetes.

COMMENT: Further studies with the approach should be replicated using larger groups over a longer time frame. However, it appears as if the approach taken by Wattana and colleagues proved effective in diabetic patients in Thailand. Thus far, most of the reported studies on self-management have came from developed countries. This is, perhaps, a reflection of the greater impact of chronic illness in these countries. However, the World Health Organization has described that the gulf between developed and developing countries with respect to the rate of chronic illness is narrowing. Now would be the best time to establish uses of self-management in all countries, but particularly in those where chronic disease is beginning to emerge as a serious problem.

C. Wattana et al. Effects of a diabetes self-management program on glycemic control, coronary heart disease risk, and quality of life among Thai patients with type 2 diabetes. Nursing Health Science, 2007;9:135-141.

World Health Organization. The World Health Report, 1997: Conquering suffering, enriching humanity. Geneva: World Health Organization, 1997.

A major concern of health care personnel who treat diabetes concerns complications that could result from the disease. One issue relates to problems that can occur in patient’s feet. High blood glucose from diabetes can result in two problems that can damage patients’ feet. The first problem concerns nerve damage in the legs and feet. With damaged nerves, diabetic patients may not feel pain, heat, or cold in their legs and feet. A sore or cut on their foot may get worse because they do not know it is there. This lack of feeling is caused by nerve damage, also called diabetic neuropathy. Nerve damage, in turn, can lead to a sore or an infection. The second problem is poor blood flow. This occurs when not enough blood flows to a patient’s legs and feet. Poor blood flow makes it hard for a sore or infection to heal. The problem is called peripheral vascular disease.

Self-management has found a permanent home in the treatment of diabetes. It is not only an accepted procedure for overall control of the disorder, but for controlling complications of diabetes. Lavery and colleagues demonstrated this point in a study designed to evaluate the effectiveness of a temperature-monitoring instrument to reduce the incidence of foot ulcers in individuals with diabetes with a high risk for lower extremity complications. In this physician-blinded, randomized, 15-month, multicenter trial, 173 subjects with a previous history of diabetic foot ulceration were assigned to: (a) standard therapy, (b) structured foot examination, or (c) enhanced therapy groups. Each group received therapeutic footwear, diabetic foot education, and regular foot care. Subjects in the structured foot examination group performed a structured foot inspection daily and recorded their findings in a logbook. If standard therapy or structured foot examinations identified any foot abnormalities, subjects were instructed to contact the study nurse immediately. Subjects in the enhanced therapy group used an infrared skin thermometer to measure temperatures on six-foot sites each day. Temperature differences more than 4 degrees between left and right corresponding sites were supposed to prompt patients to contact the study nurse and reduce activity until temperatures normalized. The enhanced therapy group had fewer foot ulcers than the standard therapy and structured foot examination groups. Patients in the standard therapy and structured foot examination groups were 4.37 and 4.71 times more likely, respectively, to develop ulcers than patients in the enhanced therapy group.

COMMENTS: Lavery and coworkers concluded that infrared temperature home monitoring, in serving as an "early warning sign," was a simple and useful adjunct in the prevention of diabetic foot ulcerations. It showed the value of the simple daily self-monitoring of one’s feet could reduce the possibility of developing foot ulcers. We don’t know how expensive the infrared skin thermometer was, but it would add but a small cost in adding benefits for diabetic patients prone to foot ulcers. The study is a nice addition to the literature.

L.A. Lavery et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care, 2007;30:14-20.

When we were adolescents, we had the opportunity to test ourselves with respect to our abilities and identity. Most of what we did was helpful in that the period permitted us to bridge being a dependent child to being an independent adult. How we achieved this change varied from person to person, but most of us made the transition in one piece. If we happened to have a chronic illness, however, the shift from childhood to being an adult presented other difficulties. In a review from Australia, Sawyer and colleagues focused attention on the interaction between adolescents with chronic conditions and the health systems that support them. At least 12% of adolescents live with a chronic condition. Some conditions are characterized by increasing incidence, such as diabetes, or improving survival rates, such as cystic fibrosis, while others, such as cancer, are concerning because of there are differentially poorer outcomes in adolescents in comparison to both children and adults. Sawyer and coworkers pointed out that growing evidence suggests that young people with chronic conditions are doubly disadvantaged--they engage in risky behaviors to at least similar if not higher rates as healthy peers, while having the potential for greater adverse health outcomes from these behaviors.

COMMENTS. The conclusion of this review was that in addition to increase their life chances, we need to better understand how the social and emotional outcomes of young people with a chronic disease can be improved, while better supporting their emerging capacity for self-management. What was not mentioned in the review was how we can achieve these aims. Fortunately, the literature on several chronic illness, including asthma, diabetes, and cystic fibrosis, suggests that we have made progress by developing self-management programs specifically for children and adolescents. The approach has proven efficacy and efficiency. However, we need not applaud just yet: there are no doubt that by considering problems faced in adolescence, we can develop and test even more effective self-management programs in the future. This will mean that we help adolescents develop self-efficacy, a lesson that will likely help them throughout their lives. This remains the challenge for scientists and patients alike.

S.M. Sawyer et al. Adolescents with a chronic condition: challenges living, challenges treating. Lancet, 2007;369:1481-1489.

A goal in self-management or self-care is to determine the costs of an intervention. In the self-management of chronic illness, for example, the costs of many programs have been evaluated. The aim was to see if any intervention would not only pay for the cost of itself, but if application of a treatment approach would reduce health care costs over time. Strong and colleagues, for example, reported on two randomized and controlled trials that looked at the cost-effectiveness of psychologist-led and lay-led interventions in reducing disability in two groups of primary care patients with back pain. Although self-care interventions have been advanced as effective tools to reduce back pain-related activity limitations, few studies have evaluated the added costs of these programs relative to their added benefits. The purpose of the studies by Strong and coworkers was to estimate the benefits and costs associated with the two self-care interventions. Effectiveness was measured as the number of low-impact back pain days (i.e., days when patients were satisfied with their level of back pain) over a one-year follow-up. Costs of back-pain related services were estimated from health plan cost data. Results indicated that patients assigned to the lay and psychologist interventions had a mean of 14.3 and 26.2 additional low-impact back pain days, respectively, compared with patients receiving usual care. The incremental per-person costs of the lay-led and psychologist-led interventions were $139 and $161, respectively. The mean cost of an additional low-impact back pain day was dollar $9.70 for the lay-led intervention and $6.13 for the psychologist-led intervention.

COMMENTS: The authors concluded that both the lay and psychologist interventions were associated with modest improvements in outcomes but with somewhat higher costs compared to usual care. This conclusion is what might be expected within the time frame of the two studies. However, a year’s follow-up is not a good gauge of how self-care or self-management can reduce the costs of health care of a chronic disease over time. In self-management, all costs for the intervention occur in year one. However, as the patient is expected to have the illness for a far longer period, cost savings should really be seen in year two and in later years with application of a program. This is another argument for gathering long-term data on the maintenance of self-management. Long-term follow-up information is not only needed, but should be a requirement of cost-benefit analyses of self-management.

L.L. Strong et al. Cost-effectiveness of two self-care interventions to reduce disability associated with back pain. Spine, 2006, 31:1639-1645.

It is likely that articles on medication adherence are published several times each week somewhere in the world. They each add something to our knowledge of the issues involving the topic. A recent article by Gordon and colleagues from England is an example of research on adherence. They examined medication-related problems from the point of view of patients with a chronic condition, as well as identifying how patients may be supported in managing their medications. Patients prescribed medication for heart disease were recruited through five general medical surgeries and four community pharmacies in south London. Data were collected in 98 face-to-face interviews in the participants' own homes. Interviews were designed to give a detailed and holistic picture of medication-related problems from the point of view of patients. Data were recorded and transcribed to allow analysis. The authors found five broad categories of medication-related problems that were examined in the context of patients' views on, and experiences of, the use of medicines and health services. These problems showed: (1) concerns about and management of side effects; (2) differing views on the use of medicines; (3) cognitive, practical and sensory problems; (4) lack of information or understanding; and (5) problems with access to and organization of services.

COMMENTS: Gordon and coworkers concluded that all five categories of problems had potential implications for the success of therapy in that they could create barriers to adherence, access to medication, or informed decision-making. An equally important aspect of the study was that it reflected how patients actively engage in decision-making about their medicines in the home and consultation. Decision-making by patients in complying with medication instructions is an area that has largely been ignored in the past. However, it is a topic that will require much more research if the rate of medication adherence is ever to be improved from the approximately 50% rate found in chronic illness. The traditional view of health care personnel was that all they had to do was prescribe drugs. If they didn’t work, it was usually regarded as a failure of the patient to take the medicines as directed. It is now known that the problem is far more complex, particularly in chronically ill patients who often taken take several drugs a day to control their condition. To move the area of patient decision-making forward, however, will require greater interaction and communication among patients and their health care providers. This may prove an even greater barrier to adherence than those identified in the article.

K. Gordon et al. Effective chronic disease management: patients' perspectives on medication-related problems. Patient Education and Counseling, 2007; 65:407-415.

A recent entry on this site described cystic fibrosis (CF) and the attempt to improve the lives of patients with the disorders through skills training. Advances in self-management would, in turn, increase the life expectancy of those with the disease. A study by Downs and colleagues reported that adherence to recommended aerosol medicines and airway clearance techniques (ACT) for children with CF require self-management skills. They conducted a randomized and controlled trial to investigate the effectiveness of a self-management education program called 'Airways' for six- to 11-year old children with CF and their caregivers. Assessments were conducted immediately before and after the intervention period, and six and 12 months after the post-intervention assessment. The child and caregiver completed the pen and paper education program together at home. Participants in the intervention and control groups had similar baseline characteristics. A pre-protocol analysis was conducted for variables that changed significantly. An additional intention-to-treat analysis was performed that included data from participants in the intervention group who withdrew from the study during the intervention period. The intervention group increased the percentage of prescribed aerosols taken, which was maintained at 12-month follow-up. There was no change in the percentage of prescribed ACT performed, although when the child was unwell, caregivers in the intervention group increased the frequency and/or duration of ACT in the pre-protocol analysis but not in the intention-to-treat analysis. Children in the intervention group increased their knowledge of ACT, which was maintained at 12-month follow-up. They felt more positively about their chest treatment regimens immediately following the intervention but not at the 12-month follow-up. There were no significant changes in the control group in these variables over time, nor did significant changes occur in the caregivers' reports of self-management behaviors and self-efficacy in either group.

COMMENTS: Downs and coworkers concluded that 'Airways' intervention is a valuable educational tool for primary school-aged children with CF and their caregiver. The study adds to our increasing knowledge of how self-management skills may make a major difference in the health of CF patients both now and in the future. As the average life span of patients with the disease is increasing, this will make performance of the skills even more important as patients grow older.

J.A.G. Downs et al. Benefits of an education program on the self-management of aerosol and airway clearance treatments for children with cystic fibrosis. Chronic Respiratory Disease, 2006;3:19-27.

A significant change has occurred in health care with increasing reliance on evidence-based guidelines in the performance of medical and behavioral treatments. The standards used to evaluate medical treatments are usually straightforward: randomized, controlled trials (RCTs) can be conducted to determine if changes occurred before or after treatment. Changes before and after taking a pill, for example, can usually be easily accessed. Consistent results in conducting similar results is what is used to set up evidence-based guidleines. When it comes to assessing educational and behavioral interventions, however, you not only need to access acquisition of skills, but also if and how they are performed. You thus have the complexity of measuring two changes: learning and behavioral. As self-management skills need to be used across time in the management of chronic illness, the matter becomes even more complex. Lenz and colleagues pointed out that common methodologies used in systematic reviews do not allow for adequate appraisal of complex interventions. They described and critically look at current methods of systematic reviews on complex interventions, using diabetes and hypertension patient education as examples. They searched several sets of reviews, including those found in the Cochrane Library. Systematic reviews focusing on diabetes or hypertension patient education were included. Two investigators independently evaluated the reviews, with evidence of three patient education programs of diabetes and hypertension self-management implemented in Germany used as a reference. The authors included 14 reviews in their summary.

COMMENTS: Lenz and coworkers concluded that methods of current systematic reviews are not fully equipped to appraise patient education and self-management programs. Since these are complex and heterogeneous interventions, consideration of aggregated evidence is necessary. We concur completely with the authors in believing that systematic reviews are of little value in evaluating complex interventions, including self-management. Treating behavioral change that occurs over time is not identical to taking a pill. Systematic reviews of most medical treatments are highly useful, but these topics are not as complex as assessing learning and behavioral changes. As a result, reviews such as the Cochrane Library offer only sterile conclusions that have little value in helping those wishing to create and evaluate self-management programs for chronic illnesses, including diabetes and hypertension.

M. Lenz et al. Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review. Diabetologia, May 23, 2007.

A repeated theme of entries on this site reflects the application of self-management to an increasingly wide array of chronic illnesses. Bleeding disorders, particularly hemophilia, illustrates this point. Julie Barlow and colleagues in the UK highlighted the point by describing a survey of information and self-management needs of patients with hemophilia. They contacted 1,082 members of the UK Haemophilia Society. Of this number, 307 took part in the survey. The mean age of the respondents was 52.4 years, with 85% male, 96% white, and 66% with hemophilia A. Of this group, 90% felt that there was a lack of understanding among the public regarding bleeding disorders, 76% felt that health professionals understood their health and information needs, and 32% had experienced problems managing anxiety and/or depression. The respondents believed there was a 'stigma' attached to having a bleeding disorder, and almost half are very careful about informing others that they had a bleeding disorder. Self-efficacy was relatively high within the sample, however. Many respondents wanted to be kept informed about current research and the opportunity to participate in research. Women experienced a greater need for more information than men, particularly in the area of the 'medical management' and 'emotional' topics. Men appeared to need more information and/or training on 'physical' aspects such as physiotherapy and joint replacement.

COMMENTS: Barlow and her coworkers concluded that their study provided an insight into the educational and self-management needs of those affected by bleeding disorders, while highlighting the importance of providing accessible information. They are correct in this observation. Having hemophilia is bad enough, but having to cope with both the disorder and the stigma attached to it has been a difficult challenge in the past 25 years. All one has to do is recall the shadow cast over these patients in the early days of HIV/AIDS. Many were shunned because they developed the virus through no fault of their own: they were infected through the blood transfusions they had required. These patients showed uncommon courage in face of such a double whammy of both the disorder and its treatment. One only has to recall the courage displayed by Ryan White, the American youngster with hemophilia, who appealed to the nation for understanding in the face of his impending death. The intolerance he faced was a sad moment in the life of the country.

J.H. Barlow et al. Information and self-management needs of people living with bleeding disorders: a survey. Haemophilia, 2007;13:264-270.

The major concern in the self-management of chronic illness is not in teaching skills to patients, but in being certain that they perform what they have been taught to control their disorder. The issue becomes more acute in considering how to be sure these patients continue to maintain the performance of these skills for as long as they need. Most of the current research centers on the construct of self-efficacy, the belief a patient has that he or she can perform self-management skills over time and across different situations. Other investigators, however, have looked at other constructs with respect to applying self-management or self-care. Yi and colleagues in an investigation of the role of resilience reported an example of such research in worsening HbA(1c) and self-care behaviors in the face of rising diabetes-related distress. A total of 111 patients with diabetes completed surveys and had their hemoglobin (HbA(1c)) assessed at baseline and at 1-year follow-up. Resilience, in turn, was defined by a factor score of self-esteem, self-efficacy, self-mastery, and optimism. Diabetes-related distress and self-care behaviors were also assessed. Results showed that baseline resilience, diabetes-related distress, and their interaction predicted physical health at 1 year. Patients with low, moderate, and high resilience were identified. Those with low or moderate resilience levels showed a strong association between rising distress and worsening HbA(1c) across time. However, those with high resilience scores did not show the same associations. Low resilience was also associated with fewer self-care behaviors when faced with increasing distress. These correlation coefficients remained significant after controlling for starting-points.

COMMENTS: The authors concluded that in patients with diabetes, resilience predicted future HbA(1c) and buffered worsening HbA(1c) and self-care behaviors in the face of rising distress levels. It likely did. Combining the factors of self-esteem, self-efficacy, self-mastery, and optimism into one measure, however, may have been unwieldy: measuring self-efficacy only would have likely produced similar findings. Resilience, in other words, may be too general a construct to use in practical clinical settings where health care personnel want to determine the factors leading to consistent and sustained performance of self-management. Still, this is an interesting study.

J.P. Yi et al. The role of resilience on psychological adjustment and physical health in patients with diabetes. British Journal of Health Psychology, Mar 1, 2007 (online).

The development and testing of a self-management program for any chronic illness can be difficult and time consuming. There is not only the task of creating the educational part, but of deciding what measures are going to be used to test the program. The latter may be complicated, particularly if there are no valid paper-and-pencil instruments that can be used. For these reasons, it is nice when a proven program can be used. It is especially fine when a program can be transported from one country to another. An example of use of a tested program is the application of the Arthritis Self-Management Program, a course developed and tested by Kate Lorig and her colleagues at Stanford University, to another country. Kip and colleagues illustrate this strategy by applying the Arthritis Self-Management program, along with an added exercise part, to patients who suffered osteoarthritic knee problems in Hong Kong. In the study, 88 participants were assigned to an intervention group and 94 participants to a control group. One hundred and forty-nine participants completed the first week and 120 participants (65.6%) the 16-week post-intervention assessments. Participants in the intervention group received a 6-week program with an added exercise component. Measures included arthritic pain and fatigue rating, practice of light exercise routines, functional status, and number of unplanned arthritis-related medical consultations. The results showed that at 16 weeks, there were significant changes between groups in four outcome measures: reduction in arthritis pain and fatigue, and increased duration of weekly light exercise practice and knee flexion. The ability to perform daily activities and the number of unplanned arthritis-related medical consultations show statistically significant improvements among three time-points within the intervention group only, but not between-groups. Both groups showed no changes in muscle strength.

COMMENTS: Kip and coworkers reported their findings showed that the intervention had a positive effect in reducing pain, fatigue, range of knee motion, in the practice of exercise routines, in the number of medical consultations, and in improving functional status over a 16-week period. The results showed that by taking into account the local context and ethnicity of the group, the Arthritis Self-Management Program transferred nicely from the US to Hong Kong. The importance of the program is not only that it provided assistance to patients with arthritis, but also that it offered more proof the soundness of the program that was applied.

Y.B. Kip et al. Impact of an Arthritis Self-Management Programme with an added exercise component for osteoarthritic knee sufferers on improving pain, functional outcomes, and use of health care services: An experimental study. Patient Education & Counseling, 2007;65:113-121.

Shared decision-making occurs when both health care providers and patients agree, in a give-and-take setting, on what should be the best treatment strategy for a patient. The approach is rapidly being recognized as the ideal model of patient-physician communication, especially in chronic diseases. Here, there must be agreement as to what a patient will do in the day-to-day management of his or her disorder. In a study conducted in Germany, Heesen and colleagues studied prerequisites for patient participation in decision making, as well as the effects of evidence-based patient information on decision making processes in patients with multiple sclerosis (MS). In their initial work, they found that 80% of MS patients demand autonomous roles in treatment decisions, although they often had poor knowledge of risks. On the other hand, these same patients understood evidence-based information and could transfer this information to their actions in new settings. The patient’s major information interests were related to symptom alleviation, diagnostic procedures, and prognosis. The investigators reported they were looking at the effects of a 4-hour education program on relapse management versus an information leaflet as controls in 150 multiple sclerosis patients in a controlled trial. In a second trial including 280 MS patients, the investigators plan on seeing what the effects will be of an evidence-based decision aid on immunotherapy, on decisional role preference, and performance in the patient-physician encounter. As the article described ongoing research, no data were presented.

COMMENTS: Heesen and coworkers assume that patient education programs will improve self-management abilities and the sense of control over the disease. If this occurs, they added, further modules covering all aspects of multiple sclerosis can be developed and tested. In a way, this report places the cart before the horse, as there is no solid evidence that their program will generate the data they predict. On the other hand, however, there is no reason to question that these results will not occur. Patients and their families assume considerable responsibility for the daily care of M.S. Most are highly motivated to learn and perform skills that might improve the management of their condition. In turn, the performance of these skills will not only control, but perhaps retard the progressive nature of the disorder. We, along with M.S. patients and their families, eagerly await the findings from this study and others like it.

C. Heesen et al. Shared decision making and self-management in multiple sclerosis - a consequence of evidence. Journal of Neurology, 2007;254, Suppl 2:II116-II121. 

One of the reasons to use self-management skills to control a chronic illness is that it can be tailored to fit a population of patients or, for that matter, an individual patient. The skills are similar across conditions, but how they are applied differs according to the nature of the illness and the ability of individual patients to manage their disorder. Heisler and colleagues pointed out that patient self-management is a critical determinant of heart failure outcomes, yet patients with the illness are often frail and isolated, factors that may limit their ability to manage self-care and access clinic-based services. Mobilizing peer support among heart failure patients is a promising strategy to improve self-management. In the pilot work they conducted, the authors evaluated the feasibility and acceptability of an interactive voice response system to facilitate telephone peer support among older adults with heart failure. Participants completed a baseline survey, and were then offered a 3-hour training session in peer communication skills. The patients were all paired with another person who had heart failure. Participants were asked to contact their partner weekly using a toll-free interactive phone system that protected their anonymity and provided automated reminders if contacts were not made. Times and duration of participants' telephone contacts were monitored and recorded. After the 7-week intervention, participants completed surveys and brief face-to-face interviews. The authors found high levels of use and satisfaction and improvements in depressive symptoms among the 20 pilot study participants.

COMMENTS: The authors concluded that the interactive voice response system proved feasible, was acceptable to patients, and may have positive effects on heart failure patients’ social support and health outcomes. They suggested that it be tested in a randomized, control trial. It should be. This is just one of many studies that suggest the use of interactive communication devices, whether the telephone, television, or the internet, offer better ways for patients to communicate among themselves or with their health care providers. All of these approaches promise better methods for patients, particularly those with a chronic illness, to learn and perform self-management skills.

M. Heisler et al. "I am not alone": the feasibility and acceptability of interactive voice response-facilitated telephone peer support among older adults with heart failure. Congestive Heart Failure, 2007;13:149-157.

One of the key parts of self-management is to have patients make the correct decision regarding the actions they take. From the medical side, decision-making means transferring information about the benefits and risks of certain procedures or drugs to the patient. By explaining to patients what they should do, it is hoped that the patients will make informed decisions. From the cognitive-behavioral side, decision-making means that the patient can see whatever options he or she has and then perform whatever actions are needed. A study by Weymiller and colleagues was concerned that information about the benefits and risks of statin drug use could cause patients not to make informed decisions. They tested a decision aid about statin drugs on treatment decision-making in 98 patients with diabetes in a randomized trial of decision aid versus control pamphlet. Patients in the intervention group received Statin Choice, a tailored decision aid that presents the estimated 10-year cardiovascular risk, the absolute risk reduction with use of statin drugs, and the disadvantages of using statin drugs. Patients in the control group received a pamphlet about cholesterol management. The investigators measured acceptability, knowledge about options and cardiovascular risk, and decisional conflict immediately after the visit, and adherence to pill taking three months later. The results indicated that patients favored using the decision aid. Patients who received the decision aid (n = 52) knew more, had better estimated cardiovascular risk and potential absolute risk reduction with statin drugs, and had less decisional conflict than did patients in the control group (n = 46). Of 33 patients in the intervention group taking statin drugs at three months, two reported missing one dose or more in the last week compared with six of 29 patients in the control group who supposedly took statin drugs.

COMMENTS: The authors concluded that the aid they used to improve decision-making about statin drugs might have favorably affected drug adherence. Perhaps this was the case. However, there are two fundamental flaws to the study. First, the wrong control was used. Since the study was about decision-making, the authors should have used a control that featured some kind of decision-making and not one that discussed the content topic. Second, a three-month follow-up is too brief a period to determine whether any changes occurred in the behavior of drug taking (what data were presented are weak as well). As diabetes is a chronic illness, a far longer period of follow-up should have been conducted for the study to have any value. What may have been seen was more likely something akin to the remaining level of reinforcement that remained following participation in the study.

A.J. Weymiller et al. Helping Patients With Type 2 Diabetes Mellitus Make Treatment Decisions Statin Choice Randomized Trial. Archives of Internal Medicine, 2007;167:1076-1082.

A major aim of self-management programs in the past three decades has been to target children living in urban areas. In particular, the aim has been to develop and test programs for African-American youth in the inner cities of the US. Reports from these efforts are scattered throughout the literature. A study by Joseph and colleagues looked used a multimedia and web-based asthma management program to specifically target urban African-American high school students. The program used tailoring of information in an attempt to change behaviors through individualized health messages based on the user's beliefs, attitudes, and barriers to change. Students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access general asthma web sites (control). The program was made available on school computers. Functional status and medical care use were measured at study initiation and 12 months post-baseline, as were selected self-management behaviors. The intervention period was 180 days; a total of 314 students were involved. At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per treatment group student.

COMMENTS: The authors concluded that a web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in their patient population. It likely is. However, there are a number of flaws in the study that are similar to those found three decades ago in studies of the self-management of asthma. The biggest error was not to confirm the diagnosis of asthma in the patients before the study. Relying solely on supposed symptoms of asthma as an outcome measure considerably weakens the data. A second error was to rely on self-reported data gathered from the patients. Comparing these data to objective measures would have strengthened the study. However, these flaws do not comprise the fact that the study is a beginning.

C.L.M. Joseph et al. A Web-based, Tailored Asthma Management Program for Urban African-American High School Students. American Journal of Respiratory and Critical Care, 2007;175: 888-895.

Heart diseases can be expected to increase in the coming years. The epidemic of overweight and obese individuals alone promises that outcome. As a result, more and more people with chronic heart problems will be taking more medicine in an attempt to control their condition. A study by Fritschi and colleagues noted that the need for oral anticoagulation has grown in recent years. The treatment requires frequent monitoring of the prothrombin time to keep the intensity within the therapeutic range and to minimize the risk for complications. Patient self-management has been found to improve the taking of the drug and, in turn, the quality of the medication. The study investigated the first 330 patients performing self-management for the anticoagulant in Switzerland. A questionnaire was sent to all patients who followed a teaching program for self-management for heart disease between 1998 and 2003. Physicians were contacted and/or discharge letters were obtained from the hospitals or the treating physicians. Out of the 300 patients providing information 254 still perform self-management skills. At least one prothrombin determination per two weeks was done by 74% of the patients and 25% performed at least one measurement every 15-30 days. No thromboembolic complications occurred among the 13 patients who died during the study. When counting these events as arterial thromboembolic complications the frequency was 0.6 per 100 patient-years. The frequency of major bleeding was 0.6 per 100 patient-years.

COMMENTS: The authors concluded that self-management was suitable and safe for participants trained to perform the skills required taking heart disease medications. The findings are similar to other studies that reported the success of self-monitoring in controlling other chronic illnesses, such as diabetes, asthma, and high blood pressure. As self-management works, it is time for all patients with a chronic illness that requires close monitoring to learn how to take responsibility for these actions.

J. Fritschi et al. Patient self-management of long-term oral anticoagulation in Switzerland. Swiss Medical Weekly, 2007;137:252-258.

One of the things we’ve discovered in writing entries is that there is more going on with self-management that we realized. This has been shown in the wide array of notes put on the site. Heart failure is a major public health problem and a major cause of death in the US. Having nurses use telephone follow-up has been suggested as a convenient and effective mechanism to promote the self-management of heart failure. A patient empowerment approach to the management of chronic disease has also been suggested as one that may improve self-management in individuals with chronic illness. The purpose of a study by Cisar and colleagues was to examine the effects of a telephone-delivered intervention on clinically and theoretically relevant outcomes in patients with heart failure. A convenience sample of men and women aged 21 years and older with a clinical diagnosis of heart failure. Patients obtained from a metropolitan hospital located were randomly assigned to the control group (n = 45) or intervention group (n = 45). All participants received standardized heart failure patient education; the intervention group also received self-management delivered through telephone follow-up calls from a registered nurse. The telephone-delivered intervention facilitated self-management of heart failure through self-care activities in intervention group members.

COMMENTS: The authors concluded that knowledge gained from the study provides preliminary information on an understanding of strategies to enhance health care providers' ability to facilitate self-management of among patients with heart failure. This was basically a pilot study, but it suggests that the self-management approach taken has value with heart failure patients. More research is needed with the program.

N. Cisar et al. A telephone-delivered empowerment intervention with patients diagnosed with heart failure. Heart and Lung, 2007;36:159-169.

As noted in previous entries on this site, adherence to medication regimens usually hovers around the 50 percent mark. This suggests that, on average, patients take their drugs half of the time, but fail to do so the remaining half. In reality, it is more complicated than this, but you get the idea. Failure to take medications as directed has long been a festering thorn in the side of health care personnel. They complain that the treatments they prescribe don’t work because patients, particularly those with chronic illness, do not take them as told. Many personnel, in fact, blame any failure of treatment on nonadherence. Patients, on the other hand, often fail to understand the need to take drugs on a daily basis, particularly when they do not have any symptoms. As many have been conditioned to only take drugs to manage acute episodes, taking medications on a regular basis flies against everything they have been taught. Needless to say, the issue of medication compliance is a long way from being resolved, a matter unlikely to occur under the best of circumstance. Charles and colleagues set about to see whether an audiovisual reminder would improve adherence with patients prescribed inhaled corticosteroids to control their asthma. They studied 110 adult or adolescent subjects with asthma who were randomized to receive 24 weeks of inhaled corticosteroids, one actuation twice daily via a metered dose inhaler with or without an audiovisual reminder function. All the inhalers had electronic adherence monitors that could record adherence, defined as the proportion of medication taken as prescribed over the final 12 weeks of the study. Adherence was also assessed as the proportion of subjects who took more than 50%, 80%, or 90% , respectively, of prescribed medication. The results indicated that the proportion of medication taken in the last 12 weeks was greater in the group given the audiovisual reminder compared with the control group. The proportion of patients taking more than 50%, 80%, or 90%, respectively, was also greater when patients had the audiovisual reminder.

COMMENTS: The audiovisual reminder function improved adherence to inhaled corticosteroid therapy in adult asthma. This appears to be an approach that may work with larger groups of patients given inhaled corticosteroids to control their asthma. However, a couple of questions are raised by the study. First, how expensive is the inhaler device used in the study? Unless it was inexpensive, which it likely isn’t, then the reality of introducing it with a large population of asthma patients is slim. Second, is there any evidence that the inhaler would be used for a prolonged period of time? That issue was not addressed in this study, as the aim was mainly to test the inhaler device. However, as inhaled steroids are prescribed for as long as needed for asthma patients, there is no evidence that patients would continue to use the inhaler over time. The likelihood of this occurring, however, can only be found in future research with the inhaler used in this study.

T. Charles et al. An audiovisual reminder function improves adherence with inhaled corticosteroid therapy in asthma. Journal of Allergy & Clinical Immunology, 2007; 119: 811-816.

As noted in previous entries on this site, adherence to medication regimens usually hovers around the 50 percent mark. This suggests that, on average, patients take their drugs half of the time, but fail to do so the remaining half. In reality, it is more complicated than this, but you get the idea. Failure to take medications as directed has long been a festering thorn in the side of health care personnel. They complain that the treatments they prescribe don’t work because patients, particularly those with chronic illness, do not take them as told. Many personnel, in fact, blame any failure of treatment on nonadherence. Patients, on the other hand, often fail to understand the need to take drugs on a daily basis, particularly when they do not have any symptoms. As many have been conditioned to only take drugs to manage acute episodes, taking medications on a regular basis flies against everything they have been taught. Needless to say, the issue of medication compliance is a long way from being resolved, a matter unlikely to occur under the best of circumstance. Charles and colleagues set about to see whether an audiovisual reminder would improve adherence with patients prescribed inhaled corticosteroids to control their asthma. They studied 110 adult or adolescent subjects with asthma who were randomized to receive 24 weeks of inhaled corticosteroids, one actuation twice daily via a metered dose inhaler with or without an audiovisual reminder function. All the inhalers had electronic adherence monitors that could record adherence, defined as the proportion of medication taken as prescribed over the final 12 weeks of the study. Adherence was also assessed as the proportion of subjects who took more than 50%, 80%, or 90% , respectively, of prescribed medication. The results indicated that the proportion of medication taken in the last 12 weeks was greater in the group given the audiovisual reminder compared with the control group. The proportion of patients taking more than 50%, 80%, or 90%, respectively, was also greater when patients had the audiovisual reminder.

COMMENTS: The audiovisual reminder function improved adherence to inhaled corticosteroid therapy in adult asthma. This appears to be an approach that may work with larger groups of patients given inhaled corticosteroids to control their asthma. However, a couple of questions are raised by the study. First, how expensive is the inhaler device used in the study? Unless it was inexpensive, which it likely isn’t, then the reality of introducing it with a large population of asthma patients is slim. Second, is there any evidence that the inhaler would be used for a prolonged period of time? That issue was not addressed in this study, as the aim was mainly to test the inhaler device. However, as inhaled steroids are prescribed for as long as needed for asthma patients, there is no evidence that patients would continue to use the inhaler over time. The likelihood of this occurring, however, can only be found in future research with the inhaler used in this study.

T. Charles et al. An audiovisual reminder function improves adherence with inhaled corticosteroid therapy in asthma. Journal of Allergy & Clinical Immunology, 2007; 119: 811-816.

As noted in previous entries on this site, adherence to medication regimens usually hovers around the 50 percent mark. This suggests that, on average, patients take their drugs half of the time, but fail to do so the remaining half. In reality, it is more complicated than this, but you get the idea. Failure to take medications as directed has long been a festering thorn in the side of health care personnel. They complain that the treatments they prescribe don’t work because patients, particularly those with chronic illness, do not take them as told. Many personnel, in fact, blame any failure of treatment on nonadherence. Patients, on the other hand, often fail to understand the need to take drugs on a daily basis, particularly when they do not have any symptoms. As many have been conditioned to only take drugs to manage acute episodes, taking medications on a regular basis flies against everything they have been taught. Needless to say, the issue of medication compliance is a long way from being resolved, a matter unlikely to occur under the best of circumstance. Charles and colleagues set about to see whether an audiovisual reminder would improve adherence with patients prescribed inhaled corticosteroids to control their asthma. They studied 110 adult or adolescent subjects with asthma who were randomized to receive 24 weeks of inhaled corticosteroids, one actuation twice daily via a metered dose inhaler with or without an audiovisual reminder function. All the inhalers had electronic adherence monitors that could record adherence, defined as the proportion of medication taken as prescribed over the final 12 weeks of the study. Adherence was also assessed as the proportion of subjects who took more than 50%, 80%, or 90% , respectively, of prescribed medication. The results indicated that the proportion of medication taken in the last 12 weeks was greater in the group given the audiovisual reminder compared with the control group. The proportion of patients taking more than 50%, 80%, or 90%, respectively, was also greater when patients had the audiovisual reminder.

COMMENTS: The audiovisual reminder function improved adherence to inhaled corticosteroid therapy in adult asthma. This appears to be an approach that may work with larger groups of patients given inhaled corticosteroids to control their asthma. However, a couple of questions are raised by the study. First, how expensive is the inhaler device used in the study? Unless it was inexpensive, which it likely isn’t, then the reality of introducing it with a large population of asthma patients is slim. Second, is there any evidence that the inhaler would be used for a prolonged period of time? That issue was not addressed in this study, as the aim was mainly to test the inhaler device. However, as inhaled steroids are prescribed for as long as needed for asthma patients, there is no evidence that patients would continue to use the inhaler over time. The likelihood of this occurring, however, can only be found in future research with the inhaler used in this study.

T. Charles et al. An audiovisual reminder function improves adherence with inhaled corticosteroid therapy in asthma. Journal of Allergy & Clinical Immunology, 2007; 119: 811-816.

Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. Ulcers form where inflammation has killed the cells that usually line the colon, then bleed and produce pus. Inflammation in the colon also causes the colon to empty frequently, causing diarrhea. According to the National Institutes of Health, the disease can occur in people of any age, although it usually starts between the ages of 15 and 30 years. It affects men and women equally, and appears to run in families, with reports of up to 20 percent of people with ulcerative colitis having a family member or relative with ulcerative colitis or Crohn’s disease. One method to manage the condition is to change lifestyle patterns through teaching self-care strategies to patients. A study by Lanhorst and colleagues in Germany sought to analyze the effects of a comprehensive lifestyle modification program on health-related quality-of-life, psychological distress, and clinical measures in patients with ulcerative colitis. Sixty patients with the disease in clinical remission or with low disease activity were randomly assigned to an intervention group or a usual-care control group. The lifestyle intervention consisted of a structured 60-hour training program conducted over a period of 10 weeks. The program included stress management training, psychoeducational elements, and self-care strategies. Quality-of-life, psychological distress, and clinical disease activity were assessed with standardized questionnaires at baseline, and at three months and 12 months after lifestyle modification training. The results showed that at three months after comprehensive lifestyle modification, patients in the intervention group showed significantly greater improvement in physical function, and a greater reduction in anxiety scores. Use of relaxation techniques was a significant predictor of improvement in the psychological score after three months of training. No other changes were noted in the other measures used in the investigation.

COMMENTS: The conclusions was that the results were consistent with possible short-term benefits of a comprehensive lifestyle modification program on some aspects of quality-of-life and emotional well-being, but no effects were found twelve months after completion of therapy. Thus, comprehensive lifestyle modification had no effect on clinical disease variables. The study offers some interesting outcomes, particularly with respect to what was not done. The program would have benefited if it had been put under the umbrella of teaching specific self-management skills to participants. As it is, the program focused on teaching patients what they should do, and did not check to see what they actually did. In other words, there does not seem to have been any attempt to see if what was taught to patients actually was translated to improved actions for dealing with their disease by the patients. As limited, short-term benefits occurred, the study should serve as a starting point for future research on ulcerative colitis, however.

J. Lanhorst et al. Effects of a comprehensive lifestyle modification program on quality-of-life in patients with ulcerative colitis: A twelve-month follow-up. Scandinavian Journal of Gastroenterology, 2007;42:734-745.

As reported in other entries, generic approaches have been taken to teach patients to manage an array of chronic conditions. The work of Kate Lorig and her colleagues at Stanford has been used to show this point. Other approaches have been taken in other countries. In the U.K., self-care or self-management support has been developed through the "Expert Patients Program", which provides lay-led generic courses to improve patients' self-care skills. The clinical and cost effectiveness of such courses, however, has remained unclear. In a study by Kennedy and coworkers, a randomized controlled trial design with waiting list control was conducted in community settings in England. The subjects were 629 patients with a range of self-defined long-term conditions. The lay-led self care support group involved 6-weekly sessions to teach self-care skills. Primary outcomes were self-efficacy, reported energy, and routine health services utilization at six months. A cost-effectiveness analysis was also conducted. Patients receiving immediate course access reported considerably greater self-efficacy and energy at six-month follow-up, but reported no reductions in routine health services utilization over the same time period. The cost-effectiveness analysis showed that patients receiving immediate course access reported considerably greater health related quality of life, but a small reduction in costs. If a quality adjusted life year was valued at $39,191, this suggests there was a 70% probability that the intervention was cost effective.

COMMENTS: Lay-led self care support groups proved effective in increasing self-efficacy and energy levels among patients with long-term conditions, and are likely to be cost effective over 6 months at conventional values of a decision-maker's willingness to pay. They may be a useful addition to current services in the management of long-term conditions. Many developed self-management programs can be used with patients who have different chronic conditions. This was illustrated not only by the work of Lorig and colleagues, but by taking a program such as we developed for childhood asthma and adapting it for successful use in teaching self-management skills to adults with asthma, patients with cystic fibrosis, and adolescents who had undergone renal transplantation. Self-management programs exist; what is required is for others to show ingenuity and adapt them for other chronic conditions. The task then will be to demonstrate that these programs can yield long-term benefits to patients.

A. Kennedy et al. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomized controlled trial. Journal of Epidemiology & Community Health, 2007;61:254-261.

In most cases, self-management programs are developed for specific chronic illnesses. As a result, programs have been developed and tested for a number of conditions, including diabetes, asthma, and arthritis. The results have, in general, been positive. What if you wanted a generic program, however, that could be used with patients who have a variety of chronic illnesses, such as might be seen in a primary care office? There are programs available, such as the generic Chronic Disease Self-Management Program, that have proven records of success. Your next question may concern how a generic program compares against one designed to be used with a specific population of patients. Kate Lorig and her colleagues carried out a study to answer your question. In their study, they compared the relative effectiveness of two programs for individuals with arthritis, the Chronic Disease Self-Management Program and a program designed specifically for arthritis. Patients were randomly assigned to one of the two conditions, and outcome measures for the two programs were compared at four months and one year. Measures included quality of life outcomes (self reported, health distress, disability, activity limitation, global health, pain, and fatigue), health behaviors (practice of mental stress management, stretching and strength exercise, aerobic exercise), self-efficacy, and health care utilization (physician visits and hospitalizations). The results showed that both programs had positive results. The disease-specific program appeared to have advantages over the more generic CDSMP for patients with arthritis at four months, but these advantages had lessened slightly by one year.

COMMENTS: The authors concluded that the disease-specific program should be considered first where there are sufficient resources and participants. However, both programs had positive effects, and the generic program could be considered a viable alternative. This is a positive result for those in primary care who wish to introduce self-management to the gamut of patients they see. The generic model should be useful in treating patients with a variety of chronic conditions. Perhaps even better, however, would be to apply the generic model to all patients, and then add a part to deal with the specific diseases. With this approach, there could be some tailoring of materials for patients whether they have arthritis or diabetes.

K. Lorig et al. A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients. Arthritis & Rheumatology, 2005;53:950-957.

A question that nags at all investigators or self-manage of chronic conditions is: Can we do a better job? Of course we can. Although we have made impressive gains, there is a long way to go in developing the most effective self-management approach for any given patient with a chronic illness. One way we might go about creating new programs is to have a better understanding of what the patients tell us they need. Acquiring this information requires that we conduct studies to see what they wish in a program. Schneider and coworkers sought to identify and evaluate an empirically derived classification system of distinct self-management styles in youths with type 1 diabetes. The youngsters, ages 10 to 16 years, and their parents were given a modified version of the Diabetes Self-Management Profile. Analyses were performed independently on parent and youth report forms to categorize patients based on their patterns of scores in five diabetes self-management areas. The analyses found three self-management styles that emerged from both youth and parent report: a "methodical style" (33%) with an emphasis on careful meal planning and correct insulin administration; an "adaptive style" (46%), characterized by high rates of blood glucose testing, exercise, and self-care adjustments; and an "inadequate style" (21%) with moderate rates of self-care adjustments and otherwise low self-management scores. The agreement between parent and youth report classifications was moderate.

COMMENTS: The authors suggested their findings offer support for recognizing subgroups of patients with unique patterns of self-care behaviors. The assessment of self-management styles may prove useful for customized treatments that are targeted directly to a patient's needs. The results of the study indicate that if planning to teach self-management behaviors to patients with type 1 diabetes, a general program can be used. However, to make a self-management program more effective, there should be parts developed to assist patients to use their unique styles to better perform these skills.

S. Schneider et al. Identification of distinct self-management styles of adolescents with type 1 diabetes. Diabetes Care, 2007;30:1107-1112.

Self-management training is often included as part of an overall package to control a chronic illness. When this occurs, the program may be called a multidisciplinary, interdisciplinary, or integrated care intervention. A study in Spain examined an integrated treatment that included education, coordination among levels of care, and improved accessibility and reduced hospital readmissions in chronic obstructive pulmonary disease (COPD) after one year. Garcia-Aymerich and coworkers analyzed the effectiveness of this intervention in terms of clinical and functional status, quality of life, lifestyle, and self-management. Their hypothesis was that changes in these factors could explain the observed reduction in readmissions. The 113 COPD patients were recruited after hospital discharge in Barcelona, Spain, and randomly assigned to integrated care or usual care. The intervention consisted of an individually tailored care plan at discharge shared with the primary care team and access to a specialized case manager nurse through a web-based call center. One year after intervention, subjects in the intervention group improved body mass and scored better in self-management items, including COPD knowledge, exacerbation identification, early treatment of exacerbations, inhaler adherence, and correct use of the inhaler. No differences in breathlessness, lung function, quality of life scores, lifestyle factors, or medical treatment occurred.

COMMENTS: The authors concluded that the study showed improved disease knowledge, and treatment adherence after one year of intervention, suggesting that these factors may play a role in the prevention of severe COPD exacerbations that triggered hospital admissions. This may be the case. One might hope that changes in breathlessness and lung function to also occur, but this rarely happens in studies of COPD. Nevertheless, at this stage, any programs for teaching self-management skills to COPD patients is welcomed.

J. Garcia-Aymerich et al. Effects of an integrated care intervention on risk factors of COPD readmission. Respiratory Medicine, 2007;101:1462-1469.

A number of risk factors are found with any chronic illness. Controlling these factors would help patients do a better job of managing their condition. Hyman and coworkers noted that many patients who receive treatment for cardiovascular disease in primary care present multiple behavioral risk factors. They suggested there was little information on the most effective ways to approach multiple behavior change counseling in clinical settings. To determine how this issue could be approached, they conducted a trial to test whether the one-by-one use of counseling to halt smoking, reduce salt intake, and increase activity would be more effective than counseling to change these behaviors all at once. African Americans with hypertension, aged 45 to 64 years, initially ineffective at changing their behavior, were randomized to the following conditions: (1) one in-clinic counseling session on all three behaviors every six months, supplemented by motivational interviewing by telephone for 18 months; (2) a similar protocol that addressed a new behavior every six months; or (3) one-time referral to existing group classes ("usual care"). The primary end point was the number in each arm that met at least two behavioral criteria after 18 months. A total of 289 individuals were randomized into the trial; 230 (79.6%) completed the study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point. However, results for single behavioral goals consistently favored the simultaneous group. At six months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care arms had reached the urine sodium goal. At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care arms showed they had quit smoking.

COMMENTS: This study provides evidence that changing multiple behaviors one-by-one is not superior to, and may be inferior to, a simultaneous approach. These data are not all that surprising: in self-management studies, an aim is made to teach patients to alter several behaviors at once. These behaviors range from careful self-monitoring to taking action to relieve an acute episode of a condition. The current study reinforces the findings found in self-management studies.

D. J. Hyman et al. Simultaneous vs. Sequential Counseling for Multiple Behavior Change Archives of Internal Medicine, 2007;167:1152-1158.

It is no secret that many older patients with common chronic conditions also report chronic pain. This may be the result of a number of factors ranging from arthritis to the normal wear and tear of aging. Krein and coworkers looked at how chronic pain affected the difficulty patients had with recommended self-management activities, and the intervening role of self-efficacy (the confidence one has in his or her ability to perform a specific task) in doing these tasks. Data were obtained from a nationwide survey of older patients, primarily older men, with chronic health conditions. Chronic pain was defined as pain that was present most of the time for 6 months or more during the past year. The researchers assessed ability to follow self-management recommendations by asking respondents to rate their level of difficulty in performing three commonly recommended activities as suggested by their doctor. Results showed that more than 60% of respondents reported chronic pain. Chronic pain was significantly associated with difficulty exercising regularly and taking prescribed medications, but not with following a recommended eating plan. However, when self-efficacy was taken into account, chronic pain was no longer significantly associated with either exercise or taking medications.

COMMENTS: Chronic pain is prevalent among older patients and is associated with greater reported difficulty doing certain self-management activities. Self-efficacy, however, plays an important role. According to Krein and coworkers, higher self-efficacy reduced the association between chronic pain and reported difficulty exercising and taking medications. These findings are similar to those found throughout the self-management literature. Self-efficacy insures that patients, including older adults with multiple chronic health problems, perform self-management recommendations.

S.L. Krein et al. Overcoming the influence of chronic pain on older patients' difficulty with recommended self-management activities. Gerontologist, 2007;47:61-68.

Self-management has found a home in the treatment of long-term oral anticoagulation (OAC). A study by Siebenhofer and coworkers assessed the safety and efficacy of OAC self-management in elderly patients with major thrombombolic and hemorrhagic complications as primary outcomes. In this multicenter trial, patients aged 60 years or more were randomized into a self-management group or routine care group. Data on the rationale, design, baseline characteristics and interim analyses of oral anticoagulation control quality within the first year of follow-up were described. The medians of the squared normalized ratio value deviations after six and 12 months were significantly lower in self-management compared to routine care. The percentage of time within target range and the percentage of normal ratio value measurements within target range were significantly higher in the self-management group versus usual care within the first 6 months, and during the second 6 months of the study. The numbers of all thrombombolic events requiring hospitalization, major bleeding events, and deaths were similar in both groups.

COMMENTS: These preliminary results suggest that self-management of oral anticoagulation is safe and feasible for elderly patients willing to participate in a structured training program. This is good news for older patients who need oral anticoagulation therapy. It suggests they can make a major contribution in the day-to-day care of their chronic condition.

S. Siebenhofer et al. Self-management of oral anticoagulation in the elderly: rationale, design, baselines and oral anticoagulation control after one year of follow-up. A randomized controlled trial. Thrombolysis Haemostasia, 2007;97:408-416.

As has been noted in previous entries, self-efficacy is the fuel that propels the use of self-management skills across all chronic disorders. A study by Fraser and coworkers examined if there was a difference in the level of self-efficacy between men and women with relapsing-remitting multiple sclerosis and progressive forms of multiple sclerosis (MS). A quantitative, descriptive, comparative design was used. The convenience sample included 556 individuals with MS, of which 124 were men and 432 women. Participants completed the Multiple Sclerosis Self-Efficacy Scale. Results showed gender differences in self-efficacy among those living with MS. Women also had a greater belief in their ability to control their MS than the men, although the difference was not significant. This study found significant differences in self-efficacy between those with rapid-remitting MS and those with progressive forms of MS. When men were compared by type of MS, those with the rapid-remitting form had significantly greater belief in their ability to control their disease and function with it than those with progressive forms of MS. Women with rapid-remitting MS had significantly greater belief in their ability to control their MS and function with it than women with progressive forms of MS.

COMMENTS: The study affirms the importance of self-efficacy in controlling MS. The authors concluded that individuals with MS could benefit from strategies that enhance self-efficacy. This is a reasonable conclusion.

C. Fraser et al. A comparative study of self-efficacy in men and women with multiple sclerosis. Neuroscience Nursing, 2007;39:102-106.

If you have a chronic illness, chances are that you see more than one physician. Some of them may use a computer when seeing you while others may not. What do you think of doctors who use computers versus those who do not? This may not seem a big issue, but it apparently can be. In a nice study, Hal Arkes and colleagues looked at whether a physician who used a computer-assisted diagnostic system would be rated less capable than a physician who did not. They conducted four experiments. Students played the role of a patient with a possible ankle fracture (experiment 1) or a possible deep vein thrombosis (experiment 2). They read a scenario that described an interaction with a physician who used no computer, one who used an unspecified computer system, or one who used a system developed at a prestigious medical center. Participants were then asked to rate the interaction on five criteria, the most important of which was the diagnostic ability of the physician. In experiment 3, patients in the waiting room of a clinic were randomly assigned to the same three types of groups as used in experiment 1. In experiment 4, 3rd- and 4th-year medical students read a scenario of a physician-patient interaction and were randomly assigned to 1 of 4 groups: the physician used no computer, heeded the recommendation of a computer system, defied a recommendation of a system by treating in a less aggressive manner, or defied a recommendation of a diagnostic by treating in a more aggressive manner. Results showed that participants always deemed that the physician who used no decision aid had the highest diagnostic ability.

COMMENTS: Patients may believe that a physician who uses a diagnostic system is not as capable as a physician who makes the diagnosis with no assistance from such a program. Like most of you, we have seen doctors who either do or do not use computer systems when treating us. We do feel somewhat uncomfortable to those who spend more time in looking at a computer screen than interviewing us. It may seem impersonal. On the other hand, we like to see our doctors spend some time at the computer when we see them. This way, we know they are checking on information they have about us. It is particularly nice when physicians check the computer when they are prescribing a new drug. This way, they not only see if we need another drug, but if it would interact in a bad way with the other medicines we take. You feel more comfortable when the new drug is prescribed. What do you think?

H.R. Arkes et al. Patients derogate physicians who use a computer-assisted diagnostic aid.Medical Decision Making, 2007;27:189-202.

Anyone with a chronic illness is often reminded to take his or her medications as directed. Adherence to this advice can help control the condition. How good are you at taking all your drugs as told? Most research looks at how different people adhere to instructions, but an occasional study looks at how well each patient does at this task. A study by Russell and coworkers looked at how individual patients adhered to two drugs taken twice a day. A cap was used to record the exact time the medications were taken over six months in adults who had received renal transplantation. The findings showed that two twice-daily medications were taken within 5 minutes of each other 77% of the time and within 10 minutes of each other 92% of the time. When only the first scheduled dose of the day was examined, the results were 79% and 95%, respectively.

COMMENTS: These findings suggest that adults who undergo renal transplantation are better at adhering to medication instructions than might be expected. In fact, it can be said that the patients appear to make an optimal effort to do what they need to do to keep their new organ. Bravo for them!

C.L. Russell et al. Intrasubject medication adherence patterns. Clinical Nursing Research, 2007; 16:153-63.

Use of Continuous Subcutaneous Insulin Infusion (CSII) requires specific skills and level of autonomy for these tasks among youth with type 1 diabetes. Weissberg-Benchell and coworkers looked at how these skills were performed as reported by their parents and clinicians who treated the condition. Parents reported their child's mastery and autonomy of CSII-specific skills, and clinicians indicated the age at which 50% of their patients mastered these skills. The results from parents suggest CSII skill mastery occurred between 10.9 and 12.8 years, although very few achieved skill mastery on all CSII-related tasks. Parent- and clinician-findings for age of skill acquisition were consistent with one another. Parents shared CSII task responsibility with their children, even after their children had attained skill mastery.

COMMENTS: The authors concluded that an emphasis on maintaining parental involvement in diabetes care seems to have been translated into clinical practice. Parents are included in their child's CSII care even after they believe their child has mastered these skills. There comes a point, however, when older children will want to assume total responsibility for use of CSII. It is here where additional self-management training will be important in helping them make the transition to adulthood. The self-efficacy developed by children in performing CSII tasks by themselves will be particularly important. Do you agree?

J. Weissberg-Benchell et al. The Use of Continuous Subcutaneous Insulin Infusion (CSII): Parental and Professional Perceptions of Self-care Mastery and Autonomy in Children and Adolescents. Journal of Pediatric Psychology, 2007.

For a number of years, patients requiring regular dialysis have had the choice of going to centers for the treatment or to undergo home dialysis. Recently, there has been resurgence in home dialysis treatment. According to Moran, this has occurred because of five factors: (1) improved outcomes with home dialysis; (2) patient preferences for the treatment; (3) lower costs; (4) reduced staffing requirements; and (5) the use of equipment specifically suited for self-care/home treatment. The recognition that outcomes are similar between in-center and home treatment has also influenced patient choice. Regional home dialysis programs offering patient and education and support have also helped increase the use of home dialysis.

COMMENTS: Moran concluded that a shift away from in-center treatment toward home treatment will continue to improve outcomes, while effectively treating the growing population who dialysis therapy. We agree with Moran. Including patient self-management in any treatment for chronic conditions is bound, in the long run, to improve outcomes.

J. Moran. The Resurgence of Home Dialysis Therapies. Advances Chronic Kidney Disease, 2007 14:284-289.

Why do some older adults continue to exercise while others do not? We don’t know the answer, although we all agree that exercise is related to physical and psychological health benefits in older adults. Umstattd and Hallam looked at the role that three social cognitive variables--self-efficacy, self-regulation, and outcome-expectancy value--had in predicting the exercise behavior of older adults. The analyses revealed that regular exercise was associated with being male, White, and married; having higher income, education, and self-efficacy; using self-regulation skills; and expecting their performance to pay off. In a different model, however, self-regulation was the only variable independently associated with regular exercise.

COMMENTS: The authors concluded that exercise interventions for older adults should include ways to increase the use of self-management strategies. This is a reasonable suggestion. Through self-regulation or self-management, patients should not only increase their ability to exercise, but develop self-efficacy regarding their capacity to do so.

M.R. Umstattd & J. Hallam. Older adults' exercise behavior: roles of selected constructs of social-cognitive theory. Journal of Aging and Physical Activity, 2007;15:206-18.

A strength of self-management is that is has no borders: it can be used in the United States as well as any developing nation or with immigrant groups from those nations. Griffiths and coworkers sought to reduce the impact of chronic disease by introducing a lay-led self-management program for Bangladeshi adults with chronic disease who lived in England. Adults with diabetes, cardiovascular disease, respiratory disease, or arthritis from general practices were randomized to a self-management group or a waiting-list control. Self-efficacy, self-management behavior, communication with clinicians, depression scores, and healthcare use were assessed by questionnaires before the study and four months later. The self-management program improved self-efficacy and self-management. In the 51% of intervention participants who attended three or more of the 6-weekly education sessions, the program led to greater improvements in self-efficacy and self-management behavior, as well as to reduced depression scores. Communication and healthcare use were not significantly different between groups.

COMMENTS: The culturally adapted self-management program improved self-efficacy and self-care behavior in Bangladeshi patients with chronic disease, although the effects on health status were marginal. Benefits in the study were limited by attendance by participants. However, the program was valuable to those who attended more than half of sessions. The lack of any long-term follow-up data is a weakness of the study, but this could be corrected in further research. You can’t expect changes to occur in health care in a four-month period.

C. Griffiths et al. Randomized controlled trial of a lay-led self-management program for Bangladeshi patients with chronic disease. British Journal of General Practice, 2005; 55:831-837.

A wide array of skills can be taught in a self-management program. A common practice is to teach relaxation skills to participants. Occasionally, a study may use a novel technique to teaching patients with a chronic condition to control their illness. Kohen and Zajac, for example, described the use of self-hypnosis by youth with recurrent headaches. The study was based on a review of outpatient clinical records of 178 consecutive youths referred for recurrent headaches. All patients had been taught self-hypnosis for self-management. Intensity, frequency, and duration of headaches before, during, and after treatment were measured; outcomes included number and frequency of visits, types of medication, and nature of self-hypnosis practice. Compared with self-reports before learning self-hypnosis, children and youth taught to use the skills for recurrent headaches reported reductions in frequency of headache from an average of 4.5 per week to 1.4 per week, in intensity, and in the average duration of episodes from 23.6 hours to 3.0 hours. There were no adverse side effects of self-hypnosis.

COMMENTS: The authors concluded that training in self-hypnosis produced significant improvement of chronic recurrent headaches in children and adolescents. Equally important, however, the study showed that self-hypnosis might play a role in future self-management studies according to the aims of the researchers and the patients they are treating.

D.P. Kohen, R. Zajac. Self-hypnosis training for headaches in children and adolescents. Journal of Pediatrics, 2007;150:635-639.

One of the issues with self-management is how to insure that patients will still perform the skills taught to them once a self-management program has ended. If patients learn self-management skills but don’t perform them after training has taken place, what is the value of the skills? Some may say that the training still has value while others could argue just as strongly that the training was a waste of time. Nour and coworkers noted continued use of health behaviors is a determinant of successful symptom reduction for older adults with arthritis. They looked at whether or not short-term improvements in exercise involvement were maintained 8 months after a home-based arthritis self-management intervention, as well as the role of individual characteristics may play in keeping up behavior change. Results indicated that some improvements in exercise involvement were maintained at eight months. More specifically, weekly exercise frequency, particularly regarding walking frequency, and variety of exercise activities were still greater in the experimental group than in the control group eight months following the completion of the intervention. No influences were observed for any of the individual characteristics.

COMMENTS: The authors concluded that gains in exercise achieved through a self-management intervention was maintained 8 months following the intervention. This is good news. However, adults need to maintain gains in exercising for as long as they can. For this reason, it is hoped that future research will look at performance far beyond 8 months.

K. Nour et al. Long-term maintenance of increased exercise involvement following a self-management intervention for housebound older adults with arthritis. International Journal of Behavior, Nutrition, and Physical Activity, 2007;4:22.

Many older patients experience compression of their spine with age. The compression results in pain that is treated by exercise, medications, or, in some cases, surgery. Decompression of the spine is increasingly the most common type of spinal surgery carried out in older patients. The surgery is then often followed by rehabilitation. The aim of a study by Mannion and coworkers was to examine the effects for up to 2 years after spinal decompression surgery of two types of rehabilitation compared with self-management. One hundred and fifty-nine patients undergoing decompression surgery for spinal stenosis/herniated disc were randomized to one of the following groups beginning two months post-op: (1) recommendation to "keep active" (self-management); (2) physiotherapy (PT), spine stabilization exercises; and (3) PT, mixed techniques. Both PT programs involved two 30 minute sessions per week for up to 12 weeks, with home exercises. Pain intensity and self-rated disability were assessed before surgery, before and after the rehabilitation phase (2 and 5 months post-op), and at 12 and 24 months after the operation. At 24 months, 151 patients returned questionnaires. Significant reductions in leg and back pain and self-rated disability were recorded after surgery, although pain showed no further changes in any group up to 24 months later. Disability declined further during the "rehabilitation" phase, then stabilized, but with no significant group differences. Twelve weeks of postoperative physiotherapy did not influence the course of change in pain or disability up to 24 months after decompression surgery.

VALUE OF STUDY: The authors concluded that advising patients to keep active by carrying out the type of physical activities that they most enjoy appears to be just as good as administering a supervised rehabilitation program with added costs to a patient’s medical bill. These findings could have great value if you plan or have had decompression surgery on your back. Regularly doing the activities you enjoy seems to be as valuable as entering a rehabilitation program. In this study, the investigators used self-management as a no treatment control group. This was not a good control group as self-management is as much a treatment as physical therapy, a finding that is likely shown in the findings of the study.

A.F. Mannion et al. A randomized controlled trial of postoperative rehabilitation after surgical decompression of the lumbar spine. European Spine Journal, 2007, June 26.

HIV/AIDS has traveled a twisting road in the past 25 or so years. It arrived on the scene with limited fanfare, particularly as no one knew what it was or what caused it. Soaring rates of death among those infected with HIV/AIDS, however, brought the disease to the forefront as a major cause of death among some segments of the population. The death rate from HIV/AIDS has declined in most developed countries, although it is a major health threat in Africa, India, and other less-developed parts of the world. The reduction in mortality rates in developed countries turned the disease from an almost certain death sentence to a chronic disease in many patients. As a chronic condition, it must be managed in the same manner as other chronic illnesses. Various approaches have been taken in this task, including use of self-management skills. Lightfoot and his coworkers examined the impact of repeated risk assessments for self-monitoring as an intervention strategy for reducing sexual and substance use risk behaviors in persons living with HIV. Participants recruited from community clinics, health management organizations, and health departments, completed self-assessments over time. It was found that increased self-monitoring resulted in increases in protected sex with sexual partners of HIV-negative or unknown serostatus, and changes in attitudes conducive to reducing risk.

VALUE OF STUDY. The authors concluded that self-monitoring was a relatively low cost and easily implementable strategy for reducing the HIV-related transmission risk of persons living with HIV. We concur with these thoughts. What is interesting in this study is that self-monitoring by itself apparently resulted in change. Why this occurred with HIV patients and not with other groups of patients, such as that reported a few entries ago concerning self-monitoring by diabetic patients, is unknown. People do change their behavior as a result of self-monitoring. This effect is referred to as reactivity. However, reactivity in self-monitoring only is relatively rare. Use of the skill may have worked here because the persons with HIV were monitoring less frequent and more salient behaviors than the daily monitoring of blood sugar levels. What do you think?

M. Lightfoot et al. Self-monitoring of behavior as a risk reduction strategy for persons living with HIV. AIDS Care, 2007;19:757-763.

Variations of issues related to the self-management of diabetes are a staple of the literature. A study by Nansel and coworkers looked at the social-cognitive, behavioral, and physiological outcomes of a self-management intervention for youth with type 1 diabetes. Participants with type 1 diabetes between the ages of 11 to 16 were randomized to usual care versus a "diabetes personal trainer" intervention. The latter consisted of six self-monitoring, goal setting, and problem solving sessions with trained nonprofessionals. Assessments were completed at baseline and multiple follow-up intervals. Hemoglobin A1c data were obtained from medical records. Results showed that at both short-term and one-year follow-up, there was a nonsignificant trend for an overall intervention effect on A1c, and a significant intervention-by-age interaction, indicating a great effect among older than younger youths. Subgroup analyses found no treatment-group difference among younger youth, but a significant difference among the older youth. No treatment-group differences in parent or youth report of adherence were observed.

VALUE OF STUDY: The authors concluded that the diabetes personal trainer intervention demonstrated significant effects on hemoglobins A1c among middle adolescents. This is not what was found, however, as some findings were not statistically significant. Furthermore, there are two other weaknesses to the study: First, the term “diabetes personal trainer” is little more then fluff: what really took place was that the patients in the intervention group received limited self-management training. Second, a follow-up of one year is not appropriate for a diabetes intervention (nor for any intervention for a chronic illness). Long-term follow-up data is required to assess self-management interventions in these populations. Using more established self-management programs for diabetes would likely have produced more robust results.

T.R. Nansel et al. Diabetes Personal Trainer Outcomes: Short-term and One-year Outcomes of a "Diabetes Personal Trainer" Intervention among Youth with Type I Diabetes. Diabetes Care, 2007, July 9.

As with any other chronic condition, it is important that patients with heart failure perform self-care skills. Mastering these skills can be challenging as few patients with the illness develop the needed expertise to avoid repeated hospitalizations. A study by Riegel and coworkers sought to describe how expertise in heart failure self-care or self-management develops. Case sampling was used to identify predominately poor or particularly good self-management practices in chronic heart failure patients. Participants were interviewed about self-care, surveyed to measure factors anticipated to influence self-care, and tested for cognitive functioning. Audiotape interviews were analyzed using content analysis. Data were combined to produce a listing of patients considered as poor, good, or expert in heart failure self-care. The results indicated that only 10.3% of the sample was expert in heart failure self-care. Patients poor in self-care had worse cognition, more sleepiness, higher depression, and poorer family functioning. The primary factors distinguishing those good versus expert in self-care were sleepiness and family engagement. Experts had less daytime sleepiness and more support from engaged loved ones who fostered self-care skill development.

VALUE OF STUDY TO READER: The authors concluded that supporters could help persons with chronic heart failure to overcome barriers to self-care. They added that research is needed to understand the effects of excessive daytime sleepiness on heart failure self-care. There is nothing wrong with these conclusions. However, a better solution would be to develop and apply self-management programs tailored to the needs of heart failure patients. By doing systematic training, both during and following hospitalizations, patients could be taught specific skills to perform to avoid exacerbations of their conditions. The result should be fewer hospital admissions and, perhaps, a reduction in medication use.

B. Riegel et al. Factors associated with the development of expertise in heart failure self-care. Nursing Research, 2007;56:235-243.

Treatment guidelines for chronic illnesses often suggest that patients should be partners in the management of their conditions. Often, however, these guidelines are set without knowing patients’ attitudes or opinions about their illness and how it should be controlled. May studied back pain by using semi-structured interviews with patients who had recently received physiotherapy for back pain. A topic guide was used to steer the interview, and themes were extracted and analyzed from the data. Thirteen key themes were revealed; seven of these related to issues of satisfaction with physiotherapy and six themes dealt with the participants' experience of and attitudes to back pain and its management. The latter six themes were: (a) the impact of back pain on their life; (b) perspectives about back pain; (c) its management; (d) their involvement in its management; (e) self-management strategies they knew; and (f) their expectations about physiotherapy. Results suggested that a common finding was a degree of acceptance of the back pain problem and the belief that patient involvement in management was essential.

VALUE OF STUDY TO READER: May concluded that many patients with back pain might respond positively to the message of self-management. Acceptance of this message was not automatic, but generally occurred over time in line with patients' experience of back pain and treatment. We concur with these comments: patients with back pain would likely use self-management if they were taught the skills required to help control their condition. The next step is to develop and apply a formal self-management program for these patients.

S. May. Patients' attitudes and beliefs about back pain and its management after physiotherapy for low back pain. Physiotherapy Research International, June 8, 2007.

How does one teach patients chronic illness to take responsibility for their condition and become valuable partners with health care providers? This is a question that is always in the thoughts of those who design and implement self-management programs. In a review on patient education in heart failure, Edwardson noted that the preparation of chronically ill patients for self-care has traditionally rested on the assumption that patients require certain knowledge and skills. However, the author continued by pointing out that a review of the subject of patient education in heart failure suggests that although teaching patients about the care of a chronic condition is necessary, it may be more effective if supplemented by continuing reinforcement, symptom monitoring, and behavioral reinforcement by an interdisciplinary team. Edwardson concluded by noting that nurses have an opportunity and a responsibility to dissect and test the teaching-learning process in heart failure.

VALUE OF STUDY TO READER: What Edwardson found does help improve the role of patient’s in caring for their condition. What was not explained, however, was that those teaching patients must accomplish two aims: teaching patient self-management skills and insuring that they perform the skills. Self-management education alone rarely works, but when accompanied by monitoring patient performance, it plays an invaluable role in caring for a chronic illness. The skills found in the review can strengthen patient performance and help maintain it over time. Nurses can be invaluable role in monitoring these skills in their patients.

S.R. Edwardson. Patient education in heart failure. Heart and Lung, 2007;36:244-252.

A major barrier to teaching patients with chronic illnesses to manage their condition centers around low levels of literacy. Previous reports have shown that individuals with poor literacy have less health knowledge, worse self-management skills, lower use of preventive services, and poorer health. Baker and coworkers sought to determine whether low health literacy levels independently predict mortality. To do so, they studied 3260 Medicare managed-care enrollees in four U.S. metropolitan areas. They were interviewed to determine their demographic characteristics, chronic conditions, self-reported physical and mental health, and health behaviors. Participants also completed the shortened version of the Test of Functional Health Literacy in Adults. Main outcome measures included all-cause and cause-specific (cardiovascular, cancer, and other) mortality using data from the National Death Index through 2003. Results showed that mortality rates for participants with adequate, marginal, and inadequate health literacy were 18.9%, 28.7%, and 39.4%, respectively. After adjusting for demographics, socioeconomic status, and baseline health, the hazard ratios for all-cause mortality were 1.52 and 1.13 for participants with inadequate and marginal health literacy, respectively, compared with participants with adequate health literacy. Years of schooling were only weakly associated with mortality. Participants with inadequate health literacy had higher risk-adjusted rates of cardiovascular death but not of death due to cancer.

VALUE OF STUDY TO READER: The authors found that inadequate health literacy, as measured by reading fluency, independently predicted all-cause mortality and cardiovascular death among elderly persons. Reading fluency is a more powerful variable than education for examining the association between socioeconomic status and health. Studies such as this are important to those who design and conduct self-management programs. If patients cannot read the educational materials are prepared, why should we think they could translate what they learn to manage their condition? The answer is that we cannot expect them to do so. This is why it is important that all written materials, including those used to assess a program, be readable. A rule of thumb is that, on average, patients on Medicare read at about the 5th grade level, and that the overall reading level is at the 8th grade level in the U.S. This finding should be always considered in designing and applying a self-management program for any chronic illness.

D.W. Baker et al. Health Literacy and Mortality Among Elderly Persons. Archives of Internal Medicine, 2007;167:1503-1509.

A misunderstanding in self-management centers on the role of self-monitoring. Many view it as an intervention, although the data does not support this premise. Rather, it is simply a way of measuring some event. Still, as noted in other entries, research on self-monitoring as an intervention continues to occur. The most recent example was a study by Farmer and coworkers. They wished to determine whether self monitoring, alone or with instruction in incorporating the results into self care, is more effective than usual care in improving blood glucose control in non-insulin treated patients with type 2 diabetes. The participants all had non-insulin treated type 2 diabetes for a median duration of three years. They were assigned to three groups: (a) usual care with blood glucose measurements every three months; (b) blood glucose self monitoring with advice for patients to contact their doctor for interpretation of results, in addition to usual care; and (c) and blood glucose self monitoring with additional training of patients in interpretation and application of the results to enhance motivation and maintain adherence to a healthy lifestyle. Results showed that at 12 months the differences in blood glucose level between the three groups were not statistically significant.

VALUE OF STUDY TO READER: Farmer and his coworkers concluded that there is no convincing evidence that self-monitoring, alone or together with instruction, improved blood glucose control in patients. Sadly enough, these results could have been predicted before the study was designed and carried out. It has been widely accepted that self-monitoring, in and of itself, rarely changes behavior. When it does, it is referred to as reactivity. Self-monitoring is nothing more than measuring a particular event. That’s all it is. Suggesting that the process changes behavior is incorrect.

A. Farmer et al. Impact of self-monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomized trial. British Medical Journal, 2007; 335:132.

Increasing information highlight the fact that internet-based disease management programs have great potential to improve patient care. The aim of a study by O’shea and coworkers was to determine whether an interactive, internet-based system, which allowed supervised, patient self-management of oral anticoagulant therapy, would offer treatment comparable to that provided by an established anticoagulation clinic. Sixty patients receiving chronic oral anticoagulant with access to the internet and a printer were enrolled into the study. They learned how to use a home prothrombin time monitor and how to access the system through the internet. Patients used the system for six months, with daily review by the supervising physician. The primary outcome variable was the difference in time in therapeutic range prior to and following introduction of internet-supervised patient self-management. Results showed that the mean time in therapeutic range increased from 63% in the anticoagulation clinic (control period) to 74.4% during internet-supervised patient self-management (study period). The mean difference score between control and study periods was 11.4%. There were no hemorrhagic or thromboembolic complications.

VALUE OF STUDY TO READER: O’shea and colleagues concluded that internet-supervised patient self-management improved time in therapeutic range compared to that provided by a anticoagulation clinic. The findings of the study are highly relevant across a wide band of chronic illnesses. It suggests that an internet-based expert system offers remote and effective management of a chronic illness no matter where patients may live.

S.I. O’shea et al. Direct-to-patient expert system and home INR monitoring improves control of oral anticoagulation. Journal of Thrombosis and Thrombolysis, 2007.

One not only has to look at childhood chronic conditions in terms of the perspectives of children, but also of their parents. The children have disorders that produce pain and discomfort, but parents have stress and worry about their children’s condition. Salisbury and coworkers pointed out that spinal fusion surgery for scoliosis during adolescence is a tremendous stressor for parents. They examined parents' pre- and postoperative stressors and how they coped with them. Ninety-two parents identified their predominant stressor and completed a coping questionnaire during their adolescent's preoperative clinic visit and 77 completed this procedure 4 days postoperatively. Results showed that primary stressors were parental role loss (28.26%), possibility of poor surgical outcomes (28.26%), and uncertainty about successful recovery (27.17%) before the operation, and concerns about pain (32.47%) and parental role loss (32.47%) after the operation. The greatest increase between the two periods centered on concerns about pain. Parents used both emotion-focused and problem-focused coping strategies with significant increases post operatively in coping, problem solving, and positive reappraisal. They also showed significant decreases in self-control and seeking social support.

VALUE OF STUDY TO READER: In working with childhood surgical patients, the authors conclude that providers should target interventions to alleviate stress and bolster coping skills for parents. This is a reasonable conclusion. However, teaching self-management skills to patients and their parents before surgery could not only alleviate unnecessary worry, but provide skills that could be used on a systematic basis to help patients cope better and recover faster from their back surgery. This outcome should wipe away the stress experienced by their parents.

M.H. Salisbury et al. Parents' self-identified stressors and coping strategies during adolescents' spinal surgery experiences. Clinical Nursing Research, 2007;16:212-230.

In social cognitive theory, self-efficacy is the construct that refers to a person’s confidence that he or she can perform a particular skill in a given situation. Other investigators have introduced other constructs. A study by Hibbard and coworkers sought to determine whether patient activation is a changing or changeable characteristic, and to assess whether changes in activation are accompanied by changes in health behavior. To assess activation and self-management behavior, a controlled trial with chronic disease patients assigned into either intervention or control conditions was employed. Changes in activation that occurred in the total sample were also examined. Activation growth classes were identified and used in the analysis to predict changes in health behaviors and health outcomes. Survey data from the 479 participants were collected at baseline, 6 weeks, and 6 months. Results indicated that positive change in activation was related to positive change in a variety of self-management behaviors. This was true even when the behavior in question was not being performed at baseline. When the behavior was already being performed at baseline, an increase in activation was related to maintaining a relatively high level of the behavior over time. The impact of the intervention, however, was less clear, as the increase in activation in the intervention group was matched by nearly equal increases in the control group.

VALUE OF STUDY TO READER: The authors concluded that if activation were increased, a variety of improved behaviors would follow. The question remains, however, as to what interventions will improve activation. This is an interesting study. Whether activation is a new construct or one that overlaps with others is unknown. It currently does not have the empirical background to place it along side self-efficacy. However, further research on the construct should clarify this matter.

J.H. Hibbard et al. Do increases in patient activation result in improved self-management behaviors? Health Services Research, 2007;42:1443-1463.

Patients with comorbid illnesses present the major cause of expenses in Medicine. The majority of older adults have two or more chronic conditions; among patients with diabetes, 40% have at least three. Kerr and coworkers wished to understand how the number, type, and severity of comorbid conditions influence the self-management and treatment priorities of patients with diabetes. Data gathered from a total of 1,901 diabetes patients who responded to the 2003 Health and Retirement diabetes survey were analyzed. Analyses assessed the association between presence of comorbidities and each of two self-reported outcomes, diabetes prioritization and self-management ability. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (macrovascular and microvascular), and finally by severity of one serious comorbidity: heart failure. The study found that 40% of respondents had at least one microvascular comorbidity, 79% had at least one macrovascular comorbidity, and 61% had at least one non-diabetes-related comorbidity. Patients with a greater overall number of illnesses placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, heart failure was associated with lower diabetes prioritization and self-management scores.

VALUE OF STUDY TO READERS: Kerr and coauthors concluded that the type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities. The study points out one of the main challenges facing those who conduct self-management research in patients with diabetes and other chronic conditions: how to teach the skills so they are used not only to manage diabetes, but to control other comorbid conditions experienced by patients. As comorbid conditions are expected to rise with the increase in age, this is not a problem to be taken lightly. It is one that is going to require a considerable amount of research in the coming decades. Studies such as this merely point out the extent and complexity of the problem. Another issue here is to find out how the interactions among the many medications taken for comorbid conditions influence the progress of diseases, as well as self-management. We also have limited information on this topic.

E.A. Kerr et al. Beyond Comorbidity Counts: How Do Comorbidity Type and Severity Influence Diabetes Patients' Treatment Priorities and Self-Management? Journal of General Internal Medicine, 2007.

The need for self-management programs for patients with more than one chronic illness has been described in previous entries. It was suggested that much more research is needed on this topic. Eakin and coworkers evaluated a trial of a lifestyle (activity and diet) intervention that targeted low-income, largely Spanish-speaking patients with multiple chronic conditions. The controlled trial was conducted with 200 patients recruited from an urban community health center and assigned to intervention and usual care conditions. The intervention involved two face-to-face self-management support and community linkage sessions with a health educator, three follow-up phone calls, and three tailored newsletters. Outcomes measured at 6-months were changes in dietary behavior and physical activity. Changes in support for healthy living were evaluated as a secondary outcome. Results indicated that significant intervention effects were found for dietary behavior and for support for healthy lifestyles but not for physical activity.

VALUE OF STUDY TO READER: The authors concluded that their intervention provided an effective and practical model for improving health behavior among low-income, Spanish-speaking patients with multiple chronic conditions. This study, however, should be considered as preliminary and as an attempt to show the value of the intervention. In this result, it has value. However, more research with this particular model and the assessment of enduring changes now needs to be conducted.

E.G. Eakin et al. Resources for health: A primary-care-based diet and physical activity intervention targeting urban Latinos with multiple chronic conditions. Health Psychology, 2007;26:392-400.

Problems linked to chronic illnesses are often said to be the result of the sedentary lifestyle of patients. To reverse this trend, a number of approaches have been taken to prompt people to engage more in physical activities. Efforts include whether patients would be more active if they exercise by themselves or with others. Ways to present exercise materials have also been explored. Marcus and coworkers sought to determine whether activity interventions delivered via the Internet would be more effective and less expensive than print-based interventions. A number of adults were assigned to one of three physical activity groups: (a) motivationally tailored Internet; (2) motivationally tailored print; and (3) six researcher-selected Web sites available to the public. Participants in the tailored Internet and tailored print arms received the same tailored content. Participants were assessed at baseline and at six and 12 months. The results showed that at six months, participants in the tailored print arm reported they spent more time in exercising that did those in the tailored Internet and standard Internet arms. At one year, the physical activity minutes per week were the same for both the tailored Internet and printed arms. There were no significant differences between the tailored arms.

VALUE OF STUDY TO READER: It was concluded that the use of tailored Internet, tailored print, and standard Internet as part of a behavior change program increased physical activity behavior similarly. This was the major finding of the study. However, the authors went on to say that because the use of the Internet was no different from the print-based intervention, this may be an opportunity to reach more sedentary adults in a more cost-effective way. There is no compelling evidence to support this claim, however. It costs to print up materials, but it also costs to use the Internet. Maybe costs are similar, but not to the extent that either the tailored print or tailored Internet is likely superior to the other.

B.H. Marcus et al. A comparison of internet and print-based physical activity interventions. Archives of Internal Medicine, 2007;167:944-949.

A value of self-management is that it not only helps patients to control their chronic disorder, but it can improve other aspects of their health well being. This is often shown in enhanced quality of life, but the performance of self-management can also improve other physical functions. Kroll and coworkers conducted a self-report mail survey, with two points of measurement one year apart, to determine the predictors of pressure ulcers and urinary tract infections in adults with spinal cord injury. Data gathered during the two points were analyzed; independent variables included demographic, health care-related, functional, access to care, and health behavior measures. Dependent variables were the occurrence of ulcers and urinary infections at the second measurement. The results showed significant associations between various independent variables and the occurrence of pressure ulcers and urinary tract infections. Separate analyses indicated that being single, not having access to primary care services when needed, and reporting a greater number of activities of daily living requiring assistance were significant predictors of ulcers. A greater number of activities requiring assistance and failing to engage in weekly exercise were significant predictors of subsequent occurrence of urinary infections.

VALUE OF STUDY TO READERS: The authors concluded that their findings emphasize the need to provide self-management education to at-risk subpopulations of spinal cord injury patients, including individuals with greater personal assistance needs and functional limitations. This seems a reasonable conclusion. It was a noteworthy study in that it suggested that self-management would not only improve the lives of these patients, but also reduce the pressure ulcers and urinary infections that sometimes accompany spinal injury.

T. Kroll et al. Secondary conditions in spinal cord injury: Results from a prospective survey. Disability Rehabilitation, 2007;29:1229-1237.

An occasional article in the press will detail how a person stung by a bee or who has consumed peanuts in one form or another experienced anaphylaxis. This is a potentially life-threatening disorder that can affect people of all ages, although young people are at an increased risk of anaphylaxis deaths. Reasons cited for these fatalities often include a failure to perform long-term management skills. A better understanding of the factors that contribute to the lack of this performance, in turn, could reduce the impact of anaphylaxis. Akeson and coworkers conducted a study to explore: (a) the psychosocial impact of living with anaphylaxis on adolescents and their parents; (b) management of the condition; and (c) perceptions of health care for the condition. In-depth interviews were conducted with 15 participants, including seven adolescents aged 13 and 16 years with a history of clinician-diagnosed anaphylaxis and eight of their parents. Responses suggested that the adolescents perceived anaphylaxis as 'no big deal' and described a low impact on their day-to-day life when compared with their parents. Perhaps this was explained by the fact that most adolescents could not remember an anaphylactic reaction. Obstacles to effective long-term self-management included inadequate knowledge to support risk assessment enhanced by a lack of confidence to make further enquiries about the ingredients of meals when with peers. Parents reported anxiety about 'handing over' the main responsibility for avoidance and emergency management to their children. Medical support for these families was limited, with primary care teams in some cases actively hindering effective self-management.

VALUE OF STUDY TO READER: The authors concluded that having a child with anaphylaxis might have a long-term effect on parents; their anxiety, in turn, may be transferred from parents to their children. It was suggested more long-term self-management training for adolescents, along with better access to appropriate medical care, might reduce the impact of anaphylaxis. These seem reasonable suggestions. Fortunately, it appears as if a greater effort to identify patients, particularly children, who could experience anaphylaxis has occurred in the United States in the past two decades. These efforts have also included more education on how to treat anaphylaxis by self-administered shots when needed. A considerable amount of information on anaphylaxis and its prevention can be found at the Food Allergy and Anaphylaxis Network.

N. Akeson et al. The psychosocial impact of anaphylaxis on young people and their parent. Clinical and Experimental Allergy, 2007;37:1213-1220.

Past entries have described outcomes obtained in applying disease-specific or general self-management programs to patients with chronic diseases. Usually, disease-specific programs have a better record, although this outcome depends upon the circumstances in which the programs are used. Goeppinger and coworkers compared short-term and long-term effectiveness of an arthritis self-help approach against a chronic disease self-management program. Forty-eight workshops, involving 416 patients, were randomly assigned to a disease-specific or a general self-management program. At four months, the disease-specific participants showed significant improvements in self-efficacy, stretching and strengthening exercises, aerobic exercises, and general health. Participants assigned to the general program showed significant improvements in self-efficacy, disability, pain, and general health. Significant differences between the two programs at four months were seen in pain and disability with the general program producing stronger results. Significant results at one year within and between programs were minimal for both groups.

VALUE OF STUDY TO READER: The authors are likely correct in suggesting that in populations with arthritis and multiple comorbid conditions, the general self-management program may be most cost effective. However, if the outcomes could not be maintained for one year or more, than neither program was cost-effective. As repeatedly noted, change in outcomes in a chronic disease are valuable only if they show long-term maintenance of behavioral change. That was not demonstrated in the study.

J. Goeppinger et al. Self-management education for persons with arthritis: Managing comorbidity and eliminating health disparities. Arthritis and Rheumatology, 2007;57:1081-1088.

An increasing number of studies have reported on the evaluation of self-efficacy in patients with chronic illnesses. Kara and coworkers conducted a study to assess the construct in patients with chronic obstructive pulmonary disease (COPD). In particular, they wished to determine family support, self-efficacy perception, and self-care behaviors, as well as to ascertain the relationship among these variables, among patients with COPD. In a descriptive and correlational study, 200 patients were recruited. They were evaluated using a number of standardized paper-and-pencil instruments. Results showed that although most participants (91.5%) perceived that they had family support and more than three quarters (73.0%) engaged in an adequate amount of self-care behaviors, only twenty five participants' (12.5%) perceived their self-efficacy as high. There were statistically significant positive relationships between family support and self-care behavior and between self-efficacy and self-care behavior. There was also a statistically significant positive relationship between family support and self-efficacy.

VALUE OF STUDY TO READER: Weak to moderate, but statistically significant, relationships were found between family support and self-care behaviors, self-efficacy, and self-care behavior and family support and self-efficacy in the COPD patients. The authors concluded that the assessment of the family support, self-efficacy and self-care behaviors of COPD patients with should be an essential part of nursing practice. We concur. Knowledge of factors examined in the study might increase the likelihood that patients will acquire self-efficacy and be more apt to use self-management skills they are taught to control their COPD.

K. Kara et al. Family support, perceived self-efficacy and self-care behavior of Turkish patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing, 2007;16:1468-1478.

The chronic illnesses of many patients are not under optimal medical control. When this occurs, one question pops up: Is the result due to the health care provided to patients or to their lack of taking proper steps to control the illness? The answer is somewhere in the middle in that is likely both patients and health care professionals share the blame for less than maximal control being established over a chronic illness. The issue of what is best available control often arises with respect to the management of asthma. Peters and coworkers sought to assess the prevalence, morbidity, and factors associated with uncontrolled asthma in a national sample of patients who used recommended medications to manage moderate-to-severe asthma. A Web-based survey was administered to patients with diagnoses of asthma who had received multiple controller medications for at least one year. The Asthma Control Test score was used to stratify respondents into controlled and uncontrolled cohorts. A total of 1812 patients were assessed; 809 (45%) had controlled asthma, and 1003 (55%) had uncontrolled asthma. Most patients had health care coverage and received care from a general practitioner; a large proportion of patients with controlled asthma (74%) and patients with uncontrolled asthma (65%) reported never receiving an asthma action plan. Inhaled corticosteroid plus long-acting beta-agonist was the most common medication regimen in patients with controlled asthma (60%) than with patients who had uncontrolled asthma (48%). Patients with uncontrolled asthma reported significantly higher rates of health care use. Several comorbidities were predictive of uncontrolled asthma.

VALUE OF STUDY TO READER: Uncontrolled asthma was prevalent (55%) in patients using standard asthma medications. There is need for improved asthma care in patients with moderate-to-severe asthma, including a evaluation of asthma control, implementation of treatment plans and asthma control tests, and addressing comorbid conditions. This study does a nice job of presenting data with respect to the percentage of patients with controlled or uncontrolled asthma. It does not offer any specific ways to remedy the situation, however. Providing an asthma action plan does not, by itself, change behavior: this change only occurs through the patient performing whatever steps are required to control their condition. Optimal control over any chronic illness cannot be expected to occur unless health care providers and their patients with asthma become equal partners in the management of asthma. The change is occurring, but in an often imperceptible manner.

S.P. Peters et al. Real-world Evaluation of Asthma Control and Treatment (REACT): Findings from a national Web-based survey. Journal of Allergy and Clinical Immunology, 2007;119:1454-1461.

With the onslaught of TV commercials, we have all learned a lot about osteoporosis. We know it affects older women, and can be controlled by weekly or monthly pills. Beyond these advertisements, we don’t hear too much about how self-management skills can improve bone health, life quality, pain perception, physical function, and balance in osteoporotic subjects. Alp and coworkers conducted a randomized controlled study that included a total of 50 sedentary women with postmenopausal and idiopathic osteoporosis were selected according to their physical activity level and T scores of dual-energy x-ray absorptiometry as the inclusion criteria. They were randomly assigned to a self-management or a control group in a six-month study. Participants in the self-management received five weeks of instruction. A number of assessment instruments, including a pain-sensitivity evaluation and the SF-36 for measuring quality of life, were used. Results showed that in comparing the groups, improvements were observed in pain intensity, and significant SF-36 changes for physical function, physical role limitations, social function, mental health, vitality, pain, general health perceptions, and emotional role limitations were found in the self-management group. Balance and time taken to stand also improved in this group. Seventy-four percent of patients in the self-management group were found in regular physical activities, and 92% of them declared that they understood the purpose and benefits of medications and dietary calcium intake. Fifty-seven percent formed personal plans for preventing traumas, whereas 8% of the subjects in the control group experienced new falls but no fractures.

VALUE OF STUDY READER: The authors concluded that their self-management program led to significant improvements in the participants’ functional, balance, and life-quality outcomes and to reductions in pain perception. The short period of time in which follow-up data was gathered (6 months) leaves unanswered whether the effects of the intervention could be maintained. However, there seems little doubt that self-management, including the taking of appropriate medications as prescribed, could play a major role in reducing osteoporosis experienced by older women.

A. Alp et al. Efficacy of a self-management program for osteoporotic subjects. American Journal of Physical and Medical Rehabilitation, 2007;86:633-640.

In an article from Australia, Sawyer and coworkers pointed out that approximately one in 10 adolescents have limitations of activity from chronic disease or disability. They suggested that while the self-management of chronic disease is increasingly recommended in adults, but there has been remarkably little discussion of its application in adolescents. This weakness, they continued, has occurred despite evidence showing better outcomes for patients who are able to self-manage their disease. The authors then set about outlining article challenges associated with working with adolescents with chronic disease. Self-management was discussed, focusing on how it can inform clinical strategies with both the adolescent and their parents.

VALUE OF ARTICLE TO READER: It was noted that developmental challenges faced by adolescents with chronic conditions, and their parents, are common across disease categories. This is no doubt true. Clinicians are required both to support the adolescent's emerging capacity for self-management while simultaneously supporting parents to take on a different role in relationship to their child's health care. Playing a different role can often be hard for parents to grasp, particularly when their child has had a chronic illness for a long period of time. The context has been created to permit only parents to control their youngster’s condition. Passing control of illness management to children requires a totally different context, a problem that may be difficult for parents who cling to their key role and children who may feel they cannot accept control of managing their condition. It is a problem faced by anyone who attempts to teach self-management skills for controlling chronic illness to children and adolescents. Any comments?

S. Sawyer et al. Adolescents with chronic disease - The double whammy. Australian Family Physician, 2007;36:622-626.

Heart disease is a major chronic illness throughout the world. A study by McGillion and coworkers sought to determine the meaning of cardiac pain for chronic stable angina patients who participated in a standardized angina education program. The patients documented what angina meant to them at sessions one and six of a 6-week standardized program aimed at enhancing angina self-management. At session one, angina was described as a major negative life change characterized by fear, frustration, limitations, and anger. At session six, angina had involved into a broad and ongoing pain problem requiring continual self-management in order to maximize quality of life.

VALUE OF STUDY TO READER: The findings suggest that the meaning of angina shifted from being a burdensome and debilitating life change before education to one of angina as a broad pain problem requiring ongoing self-management. Self-management does shift the perceptions people with a chronic illness have towards their condition. If you can evolve from one who feels hopeless towards believing you can live a worthwhile life, it is a major achievement. You can expect similar work as this to be conducted with angina patients in the future.

M. McGillion et al. Positive shifts in the perceived meaning of cardiac pain following a psychoeducation program for chronic stable angina. Canadian Journal of Nursing Research, 2007 ;39:48-65.

Lay people are sometimes asked to teach self-management skills to patients. The idea is that they may more readily relate to patients, particular if they have had experiences with the same chronic condition. The use of lay instructors has been particularly popular in England. A study by Brown and coworkers attempted to capture the experiences and feelings of lay educators in an asthma self-management program to gain greater understanding of optimal methods of recruitment, training and retention, and enhancing their value within the program. Educators and primary care practice-based nurses served as subjects in the randomized controlled trial. An analysis of diaries kept by eight educators provided data. They reflected personal comments about the programs, constructive thoughts on training, and needs for preparing for the realities of clinical practice, and significant ongoing support and training.

VALUE OF STUDY TO READER: Lay educators are a potential resource for providing self-management education to patients with long-term conditions such as asthma. However, there are some considerations that need to be taken into account regarding contracts, retention, and continual support according to the authors. The latter considerations are likely not the answer to improving the long-term maintenance of self-management skills taught by lay people, however. The answer would reside more in how the patients perform the skills they are taught and, in particular, the self-efficacy they develop with respect to their performance. This, in turn, is dependent upon the context created by the program. It is for the latter reason that considerable thought must occur in designing a self-management program for any chronic illness.

C. Brown et al. Lay educators in asthma self-management: Reflections on their training and experiences. Patient Education and Counseling, 2007.

A number of self-management programs for type 2 diabetes have been developed and tested. Most have had great success in teaching patients to care for their condition. How can the results of these programs be transferred to different groups, including those with both diabetes and limited reading skills? An answer is found in a study by Carbone and coworkers who tested an interactive measure to assess learning preferences of Latinos with diabetes and limited literacy. The measure utilized interactive learning activities to represent four learning styles--visual (seeing), kinesthetic (doing), affective (feeling/sensing), and cognitive (thinking)--in targeting four diabetes self-management behaviors: (a) choosing healthy foods; (b) understanding portion sizes; (c) distinguishing foods to eat often/sometimes/rarely; and (d) limiting fat. The ability to read was determined by the Spanish Short Test of Functional Health Literacy in Adults. Individual interviews asked participants to identify learning activities that most reflected their own experience with diabetes. Participant observations provided additional data. Ten Spanish-speaking adults with type 2 diabetes and limited literacy participated in two randomly selected target behaviors and identified easiest and most difficult to understand learning activities. The scores on the literacy test ranged from 0 to 21 points, and identified eight participants with inadequate and two with marginal health literacy. It was determined that the easiest to understand tasks were doing and the most difficult to understand tasks were thinking.

VALUE OF STUDY TO READER: Overall, the results of the study are not that impressive. However, the results do offer ideas for future programs. For example, the findings are similar to those found in early investigations of the self-management of childhood asthma. Hands-on tasks, such as having the children wrap a string around a tube and tighten it, showed what happens in asthma when smooth muscle tightens around the airway. Other methods that involve patients doing activities have been proven useful across the spectrum of chronic diseases.

E.T. Carbone et al. Testing the feasibility of an interactive learning styles measure for U.S. Latino adults with type 2 diabetes and low literacy. International Quarterly of Community Health Education, 2005-2006;25:315-335.

We’ve repeatedly made the case that self-efficacy is key to the performance and maintenance of self-management skills. Still there is need for data on how self-efficacy occurs across populations, including those with limited health literacy. Sarker and coworkers conducted such study by administering a questionnaire in Spanish and English to patients with type 2 diabetes at two primary care clinics. They measured self-efficacy, health literacy, and self-management behaviors using established instruments, and tested for interactions between self-efficacy, race/ethnicity, and health literacy on self-management. The study participants were ethnically diverse (18% Asian/Pacific Islander, 25% African American, 42% Latino/a, and 15% white), and 52% had limited health literacy. Diabetes self-efficacy was associated with four of the five self-management domains in that patients were more likely to report optimal diet, exercise, self-monitoring of blood glucose, and foot care, but not medication adherence. Associations between self-efficacy and self-management were consistent across race/ethnicity and health literacy levels.

VALUE OF STUDY TO READER: The authors suggested that self-efficacy was associated with self-management behaviors in this population, across both race/ethnicity and health literacy levels. However, the magnitude of the associations suggests that among diverse populations, further study of the determinants of and barriers to self-management is warranted. These are encouraging findings with respect to the positive relationship between self-efficacy and self-management. The need to delineate potential barriers to the successful performance of these skills, particularly over time, exists with regards to any self-management program used with chronically ill patients.

U. Sarker et al. Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy? Diabetes Care, 2006;29:823-829.

As noted in a number of entries, self-management is rapidly being used across the globe. Nowhere is this more noteworthy than in a study by Kart and coworkers, who examined the lay explanations and self-management of diabetes among residents in greater Kathmandu, Nepal. Interviews were conducted with 300 respondents drawn from diabetes patient listings and members of a national diabetes club. Sociodemographic and health-related data were collected with two standardized instruments, including one that examined illness perceptions and one that tapped diabetes self-care activities. Analyses examined predictors of self-management of diabetes. Results showed that with the exception of one domain of self-management (blood sugar testing), one or more lay explanatory factors entered each equation. Respondents appeared to hold lay explanations of diabetes that are similar to those of their peers in developed nations.

VALUE OF STUDY TO READER: This interesting study showed that those with diabetes have more in common than the disease: lay explanatory factors of their condition. In other words, those in Nepal perceive their diabetes in much the same way as those in the United States.

C.S. Kart et al. Lay explanations and self-management of diabetes in Kathmandu, Nepal. Journal of Aging & Health, 2007;19:683-704.

Before designing and applying a self-management program, we need to know whether our program will fit all patients or whether different components must be added for different segments of our targeted population. This information is important when we tailor programs to meet the needs of specific groups within the population we are teaching self-management skills. McKinley and coworkers did such an analysis by examining and comparing demographic and functional outcomes for individuals with spinal cord injury clinical syndromes, including central cord, Brown-Sequard, anterior cord, posterior cord, cauda equina, and conus medullaris. The prospective study was a retrospective review of eight hundred thirty-nine consecutive admissions with acute spinal cord injury treated at a tertiary care unit. The outcome measures were functional independence, functional independence subgroups (motor, self-care, sphincter control), length of stay, and discharge disposition. One hundred seventy-five patients were diagnosed with spinal cord clinical syndromes, with central cord injury the most common followed by cauda equina and Brown-Sequard. Significant differences were found between groups with regard to age, race, etiology, total admission functional independence, motor admission functional independence, self-care admission and discharge functional independence, and length of stay.

VALUE OF STUDY TO READER: Spinal cord clinical syndromes represent a significant proportion of admissions to acute rehabilitation, with central cord injuries presenting most commonly and representing the oldest age group with the lowest admission functional level of all spinal cord clinical syndromes. Patients with cervical Brown-Sequard achieved higher functional improvement by discharge compared with patients with central cord injury. The authors outlined these and other differences among subgroups. These differences are undoubtedly important for those who rehabilitate these patients. However, the knowledge is also significant when it comes to designing a self-management program for spinal cord injury patients. A general program would be effective, particularly if augmented with training targeted at specific subgroups of spinal cord injury patients.

McKinley W, Santos K, Meade M, Brooke K. Incidence and outcomes of spinal cord injury clinical syndromes. Journal Spinal Cord Medicine, 2007;30:215-24.

Self-management techniques are increasingly finding homes with many chronic conditions. Rees and coworkers examined the needs of individuals with low vision in order to form the contents of a low vision self-management program. In addition, they wished to determine potential barriers to participation. Semi-structured interviews were conducted with 48 people with low vision. An analysis was conducted in order to identify major themes. All participants described a range of consequences as a result of vision loss including difficulties with functional activities, social interactions, and emotional distress. Less than half of those surveyed, however, were interested in attending a self-management program. Barriers included practical reasons as well as a perceived lack of need and unclear or negative perceptions of such a program.

VALUE OF ARTICLE TO READER: The authors concluded that self-management programs for low vision are a promising way to help address the range of difficulties experienced by this population, but only if barriers to participation can be overcome. Such programs could include vision-specific strategies, training in generic problem solving and goal setting skills, and coping with emotional reactions to vision impairment. Self-management programs for individuals with low vision sound exciting. It is hoped that researchers can figure ways around the barriers they found in their study.

G. Rees et al. Self-management programs for adults with low vision: Needs and challenges. Patient Education & Counseling, 2007.

The barrier created by low literacy has been described in a number of entries on this site. It is a major problem in that 23 million Americans have limited proficiency in English. The barrier can have major adverse consequences in health care, in part because little is known about whether pharmacies provide adequate services to patients with limited English proficiency. A study by Bradshaw and coworkers sought to evaluate the ability of pharmacies to provide non–English language prescription labels, information packets, and verbal communication; and to assess pharmacies' satisfaction with communication with patients who have limited English proficiency. A cross-sectional survey was conducted with questions on social and language-service characteristics of pharmacies. A pharmacist or technician at each pharmacy was asked 45 questions by telephone, fax, or mail. Of 175 pharmacies contacted, 73% responded. Forty-seven percent of the pharmacies never/only sometimes could print non–English language prescription labels, 54% never/only sometimes could prepare non–English language information packets, and 64% never/only sometimes could verbally communicate in non-English languages. Eleven percent of the pharmacies used patients' family members/friends to interpret. Only 55% were satisfied with their communication with patients who have limited English proficiency. The analyses indicated that community pharmacies had significantly lower odds of being able to verbally communicate in non-English languages, whereas pharmacies using telephone-interpreting services had significantly higher odds.

VALUE OF STUDY TO READER: Deficits in a pharmacies ability to communicate with non-English customers were outlined. Improvements in pharmacies' communication with patients who have limited English proficiency may increase the quality and number of non-English languages by using existing computer programs, hiring bilingual staff, and using telephone-interpreting services when in-person interpreters are unavailable. The study has implications for the management of chronic illness. If a patient doesn’t understand medication instructions, it is unlikely that he or she will comply with these directions. As medication adherence is an integral part of self-management, these skills will not work if patients don’t understand their drug regimen.

M. Bradshaw et al. Language barriers to prescriptions for patients with limited English proficiency: A survey of pharmacies. Pediatrics, 2007;120:e225-e235.

Different groups often have differing perceptions of what self-management is intended to do. Physicians who see it as an extension of their advice with patients being guided by what they, the physicians, tell them anchor one end of the spectrum. At the other end, there are those patients who believe they can totally control their asthma without any medical advice. Both approaches are inappropriate: the right mixture involves a shared relationship where patients assume the daily management of their condition. A study by Garbutt and coworkers described how pediatricians provide maintenance care for children with persistent asthma, as well as identified opportunities for improvement. Community pediatricians in St. Louis, Missouri completed a 34-item survey. They reported the percentage of patients for whom they would prescribe inhaled corticosteroids, and selected from checklists the activities and questions they would use during maintenance care visit. A total of 135 (60%) of 225 eligible pediatricians responded and reported they prescribed inhaled corticosteroids for most patients. Although most respondents used specific questions to assess the burden of asthma, including inquiring about the frequency of daytime (86%) and nighttime (83%) symptoms, fewer asked about activity limitations such as school absences (58%). Some reported using specific questions to assess medication adherence such as how often doses were missed (49%), or included collaborative activities to support daily self-management such as setting asthma care goals (60%), but fewer asked how symptoms were monitored (44%) or assessed the effect of the child's asthma on the parent and family (24%).

VALUE OF STUDY TO READER: The authors concluded that asthma management practices fall short of optimal standards. Opportunities for improvement include more comprehensive and detailed assessment of asthma control and medication adherence, collaborative goal setting, and better cooperation with parents to support effective self-management. We concur. It certainly appears as if these suggestions would increase the value of self-management by patients with pediatric asthma.

J. Garbutt et al. What constitutes maintenance asthma care? The pediatrician's perspective. Ambulatory Pediatrics, 2007;7:308-312.

With chronic illness, it is important to reduce comorbid conditions that accompany a major illness. Thoolen and coworkers examined the effectiveness self-management course in reducing cardiovascular risk in patients with type-2 diabetes, taking ongoing medical treatment into account. One hundred and sixty screen-patients, receiving either intensive pharmacological or usual-care treatment since diagnosis, were subsequently randomized to a control or self-management condition. The investigators evaluated the behavioral intervention (self-management course versus control) nested within the medical treatment (intensive versus usual-care), to analyze changes in patients' weight, blood sugar, blood pressure, and lipid profiles over 12 months, from the start of the 3-month course to 9-month follow-up. The self-management course significantly reduced weight and systolic blood pressure at the 9-month follow-up, regardless of medical treatment. However, intensive medical treatment was also independently associated with lower blood pressure, blood sugar, total cholesterol and low-density lipids before the course and further improvements in systolic blood pressure. Therefore, patients receiving both intensive medical treatment and the self-management course had the best outcomes

VALUE OF STUDY TO READER: The authors showed that the self-management course was effective in achieving sustained reductions in weight and blood pressure, independent of medical treatment. A combination of behavioral and medical interventions appeared particularly effective in reducing cardiovascular risk in newly diagnosed patients. This was a nicely designed and conducted study suggesting that combining the self-management and intensive medical care resulted in what appeared to be the optimal treatment for patients in the study.

B. Thoolen et al. The effectiveness of a self-management intervention in patients with screen-detected type-2 diabetes. Diabetes Care, 2007.

As self-management has proven successful in the United States, the techniques are being adapted in other countries. A recent study described use of diabetes self-management training as a component of effective blood sugar control and as an important part of clinical diabetes management in China. He and Wharrad explored the relationship between patients' diabetes knowledge and their blood sugar control by conducting a cross-sectional study in a large Shanghai hospital. Forty inpatients and 60 outpatients with type 2 diabetes were recruited. A Chinese version of the Diabetes Knowledge Scale was used to assess subjects' diabetes knowledge and to collect demographic data and blood sugar levels. The mean diabetes knowledge scores among Chinese with type 2 diabetes were 22.1 out of a possible 30 marks. There was no difference in overall diabetes knowledge in people with good sugar control versus those with poor blood sugar control. However, there were differences in scores between the two groups for some specific questions on sick day management and food substitution. Moreover, sociodemographic characteristics such as age and occupation were significantly correlated with diabetes knowledge. Age was negatively correlated with diabetes knowledge, and white-collar workers had the highest mean knowledge scores and housewives the lowest.

THE IMPORTANCE OF STUDY TO THE READER: He and Wharrad pointed out that sociodemographic characteristics need to be considered when developing diabetes self-management programs for Chinese people with type 2 diabetes. These findings are similar to those found in other countries in the development of self-management programs for diabetes.

X. He, H.J. Wharrad. Diabetes knowledge and glycemic control among Chinese people with type 2 diabetes. International Nursing Review, 2007;54:280-287.

Perhaps the major barrier to self-management for chronic illness is ensuring that once patients learn self-management skills, they continue to perform them. Data on the long-term maintenance of self-management is sadly lacking, a huge flaw in that chronic illness requires chronic self-management. Different approaches have been taken, but Bradshaw and coworkers tested the efficacy of resiliency training for people who have previously received diabetes self-education. A randomized design was employed with repeated measures (baseline, 3 months, 6 months) with 67 participants assigned to either treatment as usual or the resiliency classes. Outcome variables included physiological measures (blood sugar, waist measurement, eating and exercise habits) and psychosocial measures (self-efficacy, locus of control, social support, and purpose in life). Analyses of the data indicated that the intervention group had higher levels of resiliency as reported by knowing positive ways of coping with diabetes-related stress, knowing enough about themselves to make right diabetes choices, having fun in life, eating healthier, and increasing physical activity compared with the control group at 3 months. Blood sugar and waist measurement improved but not significantly.

VALUE OF STUDY TO READER: The authors concluded that the resiliency approach in tandem with standard diabetes education programs could assist their patients to become more self-directed in their diabetes care. This may be true. The approach is one tactic that may be taken to improve the performance and maintenance of self-management skills in patients with a chronic illness. However, this was not shown in the current study and awaits future research. As noted at the outset, the issue of chronic self-management is the major barrier in the control of chronic illness.

B.G. Bradshaw et al. Determining the efficacy of a resiliency training approach in adults with type 2 diabetes. Diabetes Education, 2007;33:650-659.

In designing self-management programs for children and adolescents with a chronic illness, it is important to consider parenting styles. These styles should be considered in deciding what kind of training will be offered to parents. A study by Butler and coworkers investigated the relationship between maternal parenting style and well being among adolescents with diabetes. Seventy-eight adolescents with type 1 diabetes and their mothers separately reported perceptions of maternal parenting style. Adolescents reported their own depressed mood, self-efficacy for managing diabetes, and diabetes regimen adherence. The findings showed that adolescents' perceptions of maternal psychological control were associated with greater depressed mood regardless of age and gender. Firm control was strongly associated with greater depressed mood and poorer self-efficacy among older adolescents, but less strongly among younger adolescents. Adolescents' perceptions of maternal acceptance were linked to less depressed mood, particularly for girls, and with better self-efficacy for diabetes management, particularly for older adolescents and girls. Maternal reports of acceptance were associated only with adherence.

VALUE OF STUDY TO READER: The authors concluded that maternal parenting style was associated with well being in adolescents with diabetes, but the association was complex and moderated by age and gender. Data such as these are important to considered in designing and implementing a self-management program for children and adolescents. Making the transition from having parents make the decisions regarding their health to accepting responsibility for their own condition is difficult for many children and adolescents. Successfully making this shift can make or break a self-management program for any chronic illness of children or adolescents.

J.M. Butler et al. Maternal Parenting Style and Adjustment in Adolescents with Type Diabetes. Journal of Pediatric Psychology, 2007.

Gregg and coworkers recently reported on whether all-cause and cardiovascular disease mortality rates have declined among the U.S. population with and without diabetes. Data were obtained from three consecutive and national surveys with mortality follow-up assessment. The participants were aged 35 to 74 years with and without diabetes. Diabetes was determined by self-report for each survey, and mortality rates were determined through 1986, 1992, and 2000 for the three surveys, respectively. Among diabetic men, the all-cause mortality rate decreased by 18.2 annual deaths per 1000 persons, following the decreases found in the no diabetes population. Trends for cardiovascular disease mortality paralleled those of all-cause mortality, with 26.4 annual deaths per 1000 persons in 1971 to 1986 and 12.8 annual deaths per 1000 persons in 1988 to 2000. Among women with diabetes, however, neither all-cause nor cardiovascular disease mortality declined between 1971 to 1986 and 1988 to 2000, and the all-cause mortality rate difference between diabetic and no diabetic women more than doubled. The difference in all-cause mortality rates by sex among people with diabetes in 1971 to 1986 was essentially eliminated in 1988 to 2000.

VALUE OF STUDY TO READER: The authors concluded that progress in reducing mortality rates among persons with diabetes has been limited to men. Diabetes continues to greatly increase the risk for death, particularly among women. These findings suggest that parts of self-management programs for diabetes should be tailored more closely to fits the needs of women. It may help increase their lives.

E.W. Gregg et al. Mortality trends in men and women with diabetes, 1971 to 2000. Annals of Internal Medicine, 2007;147:149-155.

Chronic pain is one of the most difficult problems that patients have to manage. Pain not only causes physical and psychological distress, but it can be difficult to treat. Woods and Asmundson pointed out that psychological treatments for chronic pain based on cognitive behavioral principles have been shown to be valuable in treating pain. They noted the use of a treatment using a fear-avoidance model of chronic musculoskeletal pain suggests chronic pain can be relieved by exposing individuals to movements and tasks that have been avoided due to fear of reinjury. As this graded exposure treatment was found to be beneficial in case studies, the authors conducted a trial to assess the effectiveness of graded exposure relative to other conditions. Forty-four chronic low back pain patients were randomly assigned to graded exposure, graded activity, or a wait-list condition. While only trend differences were observed for pain-related disability, patients in the graded exposure condition demonstrated: (a) significantly greater improvements on measures of fear of pain/movement, fear avoidance beliefs, pain-related anxiety, and pain self-efficacy when compared to those in the graded activity condition, and (b) significantly greater improvements on measures of fear-avoidance beliefs, fear of pain/movement, pain-related anxiety, pain catastrophizing, pain experience, and anxiety and depression when compared to those in the wait-list control condition. In addition, patients in the graded exposure condition maintained improvements in these areas at one-month follow-up.

VALUE OF STUDY TO READER: The study may have value for those who treat patients with chronic pain. However, while the results are impressive, a one-month follow-up is not. Patients with chronic pain need to learn techniques they can perform for as long as they experience pain. This may be, in some instances, for the remainder of their lives.

M.P. Woods, G.J. Asmundson. Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: A randomized controlled clinical trial. Pain, 2007.

As repeatedly stated, self-management skills help control a variety of chronic conditions. Most efforts have been directed towards more common chronic illnesses, such as arthritis, diabetes, and asthma. Self-management skills, however, have found a use with rare conditions, such as cauterization of the urethra. Bray and Sanders pointed out that the need to catheterize through the urethra can begin at any age and stage of development in a child's life and may involve different strategies for teaching. Intermittent self-catheterization, as a self-management technique, can be of benefit both physically and psychologically to children and young people. Educational strategies are available to aid health care providers in teaching children and young people self-intermittent catheterization. Use of innovative techniques and resources may assist the practitioner in teaching self-catheterization successfully to this challenging population.

VALUE OF STUDY TO READER: The discussion by Bray and Sanders offers yet more evidence for the increasing value of self-management across chronic conditions.

L. Bray, G. Sanders. Teaching children and young people intermittent self-catheterization. Urological Nursing, 2007;27:203-209, 24.2

Wilson and coworkers noted that self-care is a key to managing resources in chronic disease and as a right to patients. The Chronic Disease Self-Management Program developed in the United States has been adopted in a number of countries. In England, it has been as adapted as the Expert Patients Program. However, despite its potential as a lay-led initiative, the program has been criticized as pushing the medical model and failing to reach patients in most need. The authors critiqued the Expert Patients Program, and drew upon a qualitative study to explore whether the program enables patients to be more involved in the patient-professional relationship. An approach utilized focus groups, in-depth interviews, and participant observation. Data were gathered from 66 individuals with a chronic illness who were knowledgeable, active, and informed. A number of characteristics common to expert patients were linked to a systematic, proactive, and organized approach to self-management; a clear communication style; and the ability to handle emotion. The study included participant observation of an Expert Patients Program and a professional-led self-management course. A paradoxical nature of the Expert Patients Program was revealed in that while there was evidence that it reinforced the medical paradigm, there was a concurrent support for the subjective experience of living with a long-term condition. Furthermore, while the policy emphasis has been on individual action within the Expert Patients Program, there is some evidence that it may be triggering a health consumer movement.

VALUE OF STUDY TO READER: The study showed that as patients are taught self-management skills, they become more active and proactive in taking care of their own health. They become, in short, effective consumers of health care services.

P.M. Wilson et al. The Expert Patients Programme: a paradox of patient empowerment and medical dominance. Health Social Care & Community, 2007;15:426-438.

As some types of cancer are no longer a death sentence, greater attention has been directed towards helping patients control a chronic illness. Sheppard recently reviewed the evidence for long-term breast cancer follow-up to see if routine post-treatment for breast cancer has benefits for patients. There is little evidence with regards to long-term survival rates. There is also a lack of information relating as to the value of long-term follow-up in terms of psychological outcomes, quality of life, patient satisfaction, access to specialist advice, and reassurance from others. Nevertheless, most breast units in England continue to undertake routine six-month clinical reviews of patients up to a minimum of five years. A thorough literature search was undertaken and, as expected, there was a lack of evidence in relation to the long-term needs of breast cancer survivors. Alternatives to hospital-based follow-up were reported such as general practitioner or nurse-led follow-up, but the question of the importance of follow-up in relation to psychological morbidity and quality of life remained unanswered. Further research is needed to investigate the importance of follow-up to patient survivorship.

VALUE OF STUDY TO READER: Sheppard stressed the need for research to explore the concept of point of need access, as well as the qualitative experiences of patients post-discharge, informational needs at discharge, and ongoing psychosocial support. Greater choice and involvement of patients in determining their future follow-up needs is required. The author said this would include providing the patient with a personalized package of care based on risk assessment and subsequent education programs to teach patients self-management skills following discharge. This suggestion must be acted on quickly as survival rates from breast cancer continue to increase throughout the world.

C. Sheppard. Breast cancer follow-up: Literature review and discussion. European Journal of Oncology Nursing, 2007.

Responses of patients to the onset of stroke symptoms can determine whether the individuals live or die. Management of acute ischemic stroke is dependent on early referral for thrombolysis. Shah and coworkers explored motivational factors affecting stroke sufferers and bystanders and their cognitive and behavioral responses, especially those that would affect prompt management of stroke. They conducted a survey of patients admitted to a stroke unit in an area where thrombolysis for acute stroke had not yet been introduced. Outcome measures, such as knowledge of stroke, health beliefs, self-efficacy, and self-care responses, were recorded. Only 41% of the patients correctly assessed their symptoms to be stroke; 44% perceived their symptoms to be mild; and 59% would wait to see whether their symptoms would improve spontaneously. About 61% of the patients and 80% of the bystanders worried about troubling other people with their problem. The bystander was a relative in 68% of cases. Of the bystanders, 65% correctly assessed the symptoms as stroke; only 42% perceived the patient's symptoms as severe. About 25% of the bystanders took a passive approach and would wait and see whether symptoms improved spontaneously; 93% did not find it difficult to ask for assistance.

VALUE OF STUDY TO READER. The authors concluded that in order to promote early referral to a hospital, educational strategies must address the public's knowledge and information base, and seek to address the cognitive and behavioral processes involved so as to overcome barriers to action. These processes are the basic parts of the self-management of a stroke. As such, everyone need have some knowledge about the signs of a stroke and what actions to take. It is also important that patients not wait, but to be proactive in seeking treatment. The data also suggest that maybe the patient needs to be more proactive than those around him or her in seeking help.

M. Shah, K.A. Makinde, P. Thomas. Cognitive and behavioral aspects affecting early referral of acute stroke patients to hospital. Journal of Stroke & Cerebrovascular Diseases, 2007;16:71-76.

Before patients can be taught self-management to manage chronic illness, they need to show interest in learning the skills. This is often a flaw that weakens later actions taken by patients: they may simply not want to learn and perform what they need to do to take control. Adolescents with chronic illnesses often wish to avoid these responsibilities. To overcome the problem, researchers have developed a number of ways to motivate patients. These often include new wrinkles in the use of computers and other electronic devices. Beale and coworkers described the use of a video game, Re-Mission, to involve young people with cancer in their own treatment. The efficacy of Re-Mission was investigated in a randomized, controlled study with 375 adolescent and young adult cancer patients. Participants either received a regular commercial game (control) or both the regular game plus Re-Mission (Re-Mission group). Participants were given a mini-PC course with the games installed and requested to play for an hour each week for three months. A test on cancer-related knowledge was given prior to game play (baseline) and again after one and three months. At three months, the Re-Mission group also rated the acceptability and credibility of the program. Analyses of the knowledge test scores showed that whereas scores of both groups improved significantly over the follow-up periods, the scores of the Re-Mission group improved significantly more. The size of this effect was related to usage of Re-Mission.

VALUE OF STUDY TO READER: The results showed strong effects of Re-Mission play on cancer knowledge that was not attributable to patients' expectations. The authors concluded that video games could be an effective vehicle for health education in adolescents and young adults with chronic illnesses. This was a nice study showing how tools of interest to patients, such as computers, can be used to teach knowledge about a condition and, hopefully, self-management skills.

I.L. Beale et al. Improvement in cancer-related knowledge following use of a psychoeducational video game for adolescents and young adults with cancer. Journal of Adolescent Health, 2007; 41:263-270.

How patients perceive their illness is key to how they cope with the condition. Reynolds and coworkers looked at how perceptions of HIV were related to self-care behavior and health outcomes. Survey data were collected at 16 sites in the United States, Taiwan, Norway, Puerto Rico and Colombia. A large number of HIV positive participants (n = 1,217) completed surveys based on an accepted five-part structure: identity, time-line, consequences, cause, and cure/controllability. Analyses were conducted to determine relationships among illness perceptions, self-care behaviors, and quality-of-life outcomes. Perceptions of illness were associated with self-care and health outcomes, indicating that perceptions of HIV had consequences for effective illness management. For example, the perception that little that can be done to control HIV was significantly associated with fewer and less effective self-care activities, and poorer health function in quality-of-life.

VALUE OF STUDY TO READER: The investigation showed that health perceptions offer a useful framework for understanding HIV symptom management, and may be useful in directing development of effective patient-centered interventions. Positive perceptions about their ability to help control their conditions form the foundation that patients will learn and perform self-management skills for HIV and all other chronic conditions.

N.R. Reynolds et al. HIV Illness Representation as a Predictor of Self-care Management and Health Outcomes: A Multi-site, Cross-cultural Study. AIDS Behavior, August 18, 2007.

A growing amount of evidence suggests poor oral health is a risk factor for a number of health conditions, including cardiovascular diseases, diabetes, adverse pregnancy outcomes, and pneumonia. High costs for clinical assessment of periodontal disease limit information needed to assess the prevalence and trends of periodontal diseases in the United States population. However, self-reports can be used to assess the population-based prevalence of various medical conditions and health-related behaviors and characteristics. The goal of an analysis by Taylor and Borgnakke was to identify self-report items correlated with clinical periodontal disease. Data were collected for a project that focused on oral health and included face-to-face interview items regarding oral health-related self-care, professional care, and barriers; knowledge, beliefs, and attitudes; risk behaviors; impact on quality of life; and demographic characteristics. To validate the data, participants had complete oral examinations. Analyses identified self-reported items contributing to two models that predicted moderate or severe periodontal disease. Age, gender, race/ethnicity, smoking, and periodontal health-related self-report items produced predictive models with maximum sensitivity and specificity.

VALUE OF STUDY TO READER: The analyses suggest that self-report may be valid for surveillance of periodontal disease burden and trends in the American population, in place of more costly clinical periodontal examinations. Most readers likely do not recognize the importance of oral health as a risk factor for a number of chronic illnesses. It is hoped that more research on the topic will be conducted in the future.

GW Taylor, WS Borgnakke. Self-reported periodontal disease: validation in an epidemiological survey. Journal of Periodontics, 2007;78:1407-1420.

A finding in many behavioral management programs is an improvement in the quality of life experienced by patients. Those with heart failure are no exception. In a study from India, patients attending a heart failure clinic were randomized into two groups: a control group received usual care and an intervention group received the same care plus two other interventions: (I) provider sessions with the patient and spouse to instruct them about the disease, drugs, and self-management of fluid intake and diuretic dose; and (II) a telephone helpline where regular telephone calls were made to reinforce instruction and to modify drug dosages. Quality of life was assessed using a proven heart questionnaire, and functional capacity was measured by a 6-minute walk test. Results showed a significant improvement in the quality of life and functional capacity of patients in the intervention group compared with control patients. Patients in intervention were placed on higher doses of the same drugs taken by control patients. There was no significant difference in the number of emergency room visits or admissions between group.

VALUE OF STUDY TO READER: In the a developing country, improvement in quality of life by intensive management patients through heart failure instruction with a telephone reinforcement and a helpline was greater than usually achieved in a heart failure clinic. Apparently, change occurred through more regular assessment and adjustments in drug dosage. The study was by no means a self-management study, but it did show what could happen when both when patients receive education about their condition and are in greater contact with health care providers.

K Ramachandran et al. Impact of a comprehensive telephone-based disease management programme on quality-of-life in patients with heart failure. National Medical Journal of India, 2007 ;20:67-73.

A major concern in the prevention of chronic illness is that children and adolescents do not exercise as much as they should. A study by Lubans and Morgan examined possible correlates of physical activity among a sample of Australian adolescents. The participants were 14-15 year old students from three secondary schools. Students wore pedometers for four consecutive school days and completed questionnaires assessing demographic, social, psychological and behavioral correlates of physical activity. Mean steps/day were 11,865 for boys and 9466 for girls. Approximately one-third of boys and girls satisfied existing step recommendations (girls 11,000 steps/day and boys 13,000 steps/day). The relationship between factors and physical activity was assessed using correlation methods. Enjoyment of physical activity, use of self-management strategies, and perceived barriers were significantly related to mean steps/day among boys. Peer support and the use of self-management strategies were significantly associated with mean steps/day for girls. An analysis revealed that gender, peer support, self-management strategies, and perceived barriers accounted for 16% of the variance in mean steps/day.

VALUE OF STUDY TO READER. The study identified a number of correlates of physical activity in a sample of Australian adolescents. It is possible that with instruction in self-management, physical education activities could be changed in many children and adolescents. It offers one proven way for preventing some types of chronic illness.

DR Lubans, PJ Morgan. Social, psychological and behavioural correlates of pedometer step counts in a sample of Australian adolescents. Journal of Science and Medicine in Sports, September 18, 2007.

Excess weight can contribute to osteoarthritis of the knee. Preventing weight gain is a method of prevention of this chronic condition. If a patient does have the condition, however, the aim becomes to teach patients to control it. Pells and coworkers looked at arthritis self-efficacy and self-efficacy for resisting eating as predictors of pain, disability, and eating behaviors in overweight or obese patients with osteoarthritis of the knee. Patients with a body mass index between 25 and 42 completed measures of arthritis-related self-efficacy, weight-related self-efficacy, pain, physical disability, psychological disability, overeating, and demographic and medical information. Several analyses were conducted to examine whether arthritis self-efficacy (efficacy for pain control, physical function, and other symptoms) and self-efficacy for resisting eating accounted for significant variance in pain, disability, and eating behaviors after controlling for demographic and medical characteristics. Results showed that self-efficacy for pain accounted for 14% of the variance in pain, compared to only 3% accounted for by self-efficacy for physical function and other symptoms. Self-efficacy for physical function accounted for 10% of the variance in physical disability, while self-efficacy for pain and other symptoms accounted for 3%. Self-efficacy for other (emotional) symptoms and resisting eating accounted for 21% of the variance in psychological disability, while self-efficacy for pain control and physical function were not significant predictors. Self-efficacy for resisting eating accounted for 28% of the variance in eating behaviors.

VALUE OF STUDY TO READER: The findings show that self-efficacy is important in understanding pain and behavioral adjustment in overweight or obese arthritis patients. Moreover, as the contributions of self-efficacy were domain specific, interventions targeting both arthritis self-efficacy and self-efficacy for resisting eating could be helpful in this population. Excess weight is a major problem in our population. Patients at risk for developing osteoarthritis should include, as part of any self-management program, self-efficacy training that could increase both arthritis self-efficacy and resistance to eating. If we aren’t confident we can do something in a given situation, we are unlikely to do it.

JJ Pells et al. Arthritis self-efficacy and self-efficacy for resisting eating: Relationships to pain, disability, and eating behavior in overweight and obese individuals with osteoarthritic knee pain. Pain, August 29, 2007.

The prevalence of cardiovascular disease is increasing in both developed and developing. Improved treatments increase survival after an acute myocardial infarction or sudden cardiac arrest, although patients often have difficulty adjusting and regaining control of their daily lives. Smeulders and coworkers noted that, in particular, patients who received an implantable defibrillator experience physical and psychological problems. Interventions to enhance perceived control and acceptance of the device are therefore necessary. The paper describes a small-scale study to explore the feasibility and the possible benefits of a structured nurse- and peer-led self-management program (Chronic Disease Self-Management Program) among patients receiving a defibrillator. Ten male patients who received such a device participated in a group program, consisting of six sessions led by a team consisting of a nurse specialist and a patient with cardiovascular disease. Program feasibility was evaluated among patients and leaders by measuring performance of the intervention according to protocol, attendance, and adherence of the participating patients, and patients and leaders opinions about the program. In addition, before and directly after attending intervention, program benefits (e.g. perceived control, symptoms of anxiety and depression, and quality of life) were assessed. Results indicated that eight patients attended at least four sessions, and adherence ranged from good to very good. On average, the patients reported they benefited very much from the program; those conducting the program considered it feasible as well. Furthermore, improvements were identified for general self-efficacy expectancies, symptoms of anxiety, physical functioning, social functioning, role limitations due to physical problems, and pain.

VALUE OF STUDY TO READER. It is feasible to use a self-management program led by a team consisting of a nurse specialist and a patient with cardiovascular disease. The program may improve general self-efficacy expectancies, symptoms of anxiety, and quality of life (physical functioning, social functioning, role limitations due to physical problems, and pain) as well. The study was based upon a small sample of patients. For this reason, further investigation of the program's effectiveness among a larger sample of patients with cardiovascular disease is recommended. Such a study must incorporate a long-term measure of gains, as patients with defibrillators are apt to use the devices for the remainder of their lives.

ES Smeulders et al. Nurse- and peer-led self-management programme for patients with an implantable cardioverter defibrillator; a feasibility study. BMC Nursing, 2007;6:6.

We have repeatedly noted that accurate self-monitoring is the foundation of any self-management attempt. A study by Eastwood and coworkers compared the clinical and hospital outcomes of heart failure patients who are using or not using a diary to record weight, vital signs and, symptoms and adoption of the diary format. All patients enrolled in an outpatient heart failure clinic were given a Heart Health Diary. Seventy patients used the diary and 54 did not. A review of these 124 patients (82 men and 42 women) was completed 6 months after enrollment. Results showed that those who did not use the diary were likely to be younger women with a lower ejection fraction and worse functional status. Those using a diary had 35% and 47% more contacts via telephone and clinic, respectively. Both groups had significant functional and B-type peptide improvement. If hospitalized after enrollment in the heart failure clinic, the average length of stay for all hospital admissions for diary users decreased by 58% and average cost per case decreased by 56%. Length of stay and cost per case did not significantly change for those not using diaries.

VALUE OF STUDY TO READER: Diary users showed evidence of improved clinical and hospital outcomes. The study suggests that the authors should conduct a thorough study with an added emphasis upon the maintenance of diary use.

CA Eastwood et al. Weight and symptom diary for self-monitoring in heart failure clinic patients. Journal of Cardiovascular Nursing, 2007;22:382-389.

Many in the behavioral and health care field stress that we must do more to emphasize primary prevention. By doing so, we could avoid many costly chronic illnesses and their consequences. A study by Reynolds and coworkers sought to determine the effects of a preventive intervention on the health and well being of an urban cohort in young adulthood. The study featured a 19-year follow-up of 1539 low-income patients who had been enrolled in a nonrandomized alternative-intervention when they were 24 years. The program they attended provided school-based educational enrichment and comprehensive family services from preschool to third grade. The investigators looked at educational attainment, adult arrest and incarceration, health status and behavior, and economic well-being. Relative to the comparison group and adjusted for many factors, the participants had higher rates of school completion and attendance in 4-year colleges as well as more years of education. They were more likely to have health insurance coverage. Preschool graduates, relative to the comparison group, also had lower rates of felony arrests, convictions, incarceration; depressive symptoms; and out-of-home placement. Participation in both preschool and school-age intervention relative to the comparison group was associated with higher rates of full-time employment, higher levels of educational attainment, lower rates of arrests for violent offenses, and lower rates of disability.

VALUE OF STUDY TO READER: The study showed that participation in a school-based intervention beginning in preschool was associated with a wide range of positive outcomes. Findings provide evidence that established early education programs could have enduring effects on general well-being into adulthood. This fine investigation is an all-to-rare indication of what could occur if more programs of this nature were developed and implemented. We don’t target primary prevention in the United States, however, but wait until a health condition develops. Our only tactic then centers on secondary prevention or management of the chronic illness. It would be great if we could put more of our time and effort into primary prevention because it would likely save us considerable costs in the future. Don’t look for this change to happen anytime soon, however.

A J Reynolds et al. Effects of a School-Based, Early Childhood Intervention on Adult Health and Well-being. A 19-Year Follow-up of Low-Income Families. Archives of Pediatric and Adolescent Medicine, 2007;161:730-739.

A study recently noted on the blog concerned the objective measurement of exercise using pedometers. Ratings of perceived exertion, on the other hand, have been consistently used as a subjective index of exercise intensity for both exercise testing and prescriptions for exercise. Few empirical efforts have been made to determine how psychological factors influence changes in perceived exercise. A study by Hu and coworkers examined the influence of self-efficacy expectations on changes in ratings of perceived exercise as a function of exercise intensity. The participants were 193 sedentary older adults who completed an assessment of exercise self-efficacy and aerobic capacity. Analyses indicated that ratings of perceived exercise changed as intensity increased and that self-efficacy was a predictor of change. Participants high in self-efficacy maintained a constant rate of change in ratings of perceived exercise as exercise intensity increased, whereas less efficacious participants exhibited a slower rate of change in perceived exercise as a function of exercise intensity, with an initial gradual curve at lower intensity and a more dramatic trajectory at higher intensity.

VALUE OF STUDY TO READER: The results support the importance of ratings for perceived exercise in prescribing exercise for older adults. They also indicate that self-efficacy is implicated in patterns of ratings of perceived exercise change. It would be interesting to repeat this study by using some device, such as pedometers, to provide an objective measure of exercise. The results would be highly valuable.

L Hu et al. Influence of self-efficacy on the functional relationship between ratings of perceived exertion and exercise intensity. Journal of Cardiopulmonary Rehabilitation and Prevention, 2007;27:303-308.

Questions are often raised as to whether self-monitoring is as effective as close monitoring by a clinic. Connock and coworkers reviewed the evidence to determine the clinical effectiveness and cost-effectiveness of self-testing and self-management of oral anticoagulation treatment compared with clinic-based monitoring. A review of relevant data from selected studies was done. Results about complications and deaths were pooled in meta-analyses using risk difference as the outcome statistic. In the 16 randomized and eight nonrandomized trials selected, patient self-monitoring of oral anticoagulation therapy was found to be more effective than poor-quality usual care provided by family doctors, and as effective as good-quality specialized anticoagulation clinics in maintaining the quality of anticoagulation therapy. There was no significant risk difference of major bleeding events between patient self-monitoring and usual care controls and pooled analyses found that compared with primary care or anticoagulation control clinics, self-monitoring was statistically significantly associated with fewer thromboembolic events. However, the reduction in complication events and deaths was not consistently associated with improvement of clinics; in some trials this may be due to alternative explanations, including patient education and patient empowerment. Also, improved clinics and the reduction of major complications and deaths by patient self-monitoring were mainly observed in trials conducted outside the United Kingdom. Seven cost-effectiveness studies were identified; the study that provided the most relevant UK data found that patient self-management was more expensive than current routine care and concluded that using a cost-effectiveness threshold of 30,000 pounds per quality-adjusted life-year gained, patient self-management does not appear to be cost-effective. Projecting these costs over time, however, suggested that self-monitoring would be cost effective over a ten-year period.

VALUE OF STUDY TO READER: The authors concluded that for selected and successfully trained patients, self-monitoring is effective and safe for long-term oral anticoagulation therapy. In general, patient self-management was unlikely to be more cost-effective than the current specialized anticoagulation clinics in the UK; self-monitoring may enhance the quality of life for some patients who are frequently away from home, who are in employment or education, or those who find it difficult to travel to clinics. Further research is needed on the issue of self-monitoring versus clinic monitoring, particularly over a period of time. If these studies are conducted, self-management based on self-monitoring will likely emerge as the most effective procedure with lower costs that can be conducted with patients receiving anticoagulation therapy.

M Connock et al. Clinical effectiveness and cost-effectiveness of different models of managing long-term oral anticoagulation therapy: a systematic review and economic modelling. Health Technology Assessment, 2007;11:1-86.

The last entry on this site compared self-monitoring to close clinical monitoring. It was found that self-monitoring would be cheaper and more cost effective over time. Trinacty and coworkers sought to evaluate whether there were racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring. The authors looked at 10 years of electronic medical record data collected on 1,732 adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large group practice. Outcomes included incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards. No evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients was found, but lower rates of initiation among black patients living in low-income areas were. The intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up for insulin and oral hypoglycemic, with both groups monitoring well below recommended standards. Among insulin-treated patients, less than 1% of blacks and 10% of whites self-monitored their condition three times per day; 36% of whites and 10% of blacks self-monitored themselves at least once per day.

VALUE OF STUDY TO READER: Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a system providing equal access to services for diabetes patients. Trinacty and coworkers concluded that early and continued emphasis on adherence among black diabetics could be necessary to reduce racial differences in long-term glucose self-monitoring. This could be right, but it seems as if more effective training in self-monitoring, particularly when included as part of an overall self-management package, would solve the problems found in the study. It would also provide better care for the patients over time.

CM Trinacty et al. Racial Differences in Long-Term Self-Monitoring Practice Among Newly Drug-Treated Diabetes Patients in an HMO. Journal of General Internal Medicine, September 1, 2007.

The efficacy of self-management programs is typically shown in clinical trials. Whether the procedures are cost-effective, however, is another matter. Hurley and coworkers did a cost evaluation of a program, ESCAPE-knee pain. They estimated the costs of usual primary care and participation in ESCAPE-knee pain program delivered to individuals or groups of participants. Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years. Rehabilitation, either individual or in groups, cost 224 pounds more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Individual cost were more than double that of courses taught in groups. However, the probability of individual programs is more cost-effective than group programs as increased willingness to pay increased. The lack of differences in quality-adjusted life years across the arms led to lower probabilities of cost-effectiveness based on this outcome.

VALUE OF STUDY TO READER: The authors concluded that the ESCAPE-knee pain programs had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduced costs without reducing clinical effectiveness, thus increasing the probability of cost-effectiveness with the programs. As in similar instances, we’ve argued that the real cost-savings of self-management programs, such as that described, can only be seen if patients are followed over a period of time. This could have been demonstrated in the study had they conducted long-term follow-up with the patients.

MV Hurley et al. Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain. Arthritis and Rheumatology, 2007; 57:1220-1229.

Chronic arthritis has been the subject of a number of self-management studies. Hurley and coworkers compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain. The criteria for participation was that the patients were 50 years or older and had reported knee pain for over 6 months. Fifty-four inner-city practices were randomized to continue usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of participants. The primary outcome was self-reported functioning six months after completing rehabilitation. A total of 418 participants were recruited; 76 dropped out due to adverse events. Rehabilitated participants had better functioning than participants who received usual primary care. Improvements were similar whether participants received individual rehabilitation or group rehabilitation.

VALUE OF STUDY TO READER: The ESCAPE-knee pain program provided a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants. As noted in an earlier entry, the approach was also cost-effective. A strength of the study is that a large number of patient participated in the trial; the weakness of the study is the short-term follow-up (6 months).

MV Hurley et al. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: A cluster randomized trial. Arthritis and Rheumatology, 2007;57:1211-1219.

Self-management skills may be assessed by paper-and-pencil or web-based approaches. Cruz-Correia and coworkers in Portugal compared a web-based asthma self-management tool to paper-and-pencil methods in assessing the opinion of patients and their adherence to monitoring asthma. Twenty-one adults with asthma were included in a crossover study using the web-based program or a paper asthma diary and action-plan each for 4 weeks in a random sequence. More negative comments were generated in using paper-and-pencil tools versus the web-based approach; more positive comments were obtained with the web-based method. More patients using the latter were interested in continue monitoring their asthma. Paper diary records were thorough, although more patients reported filling it out several days at once. This was not allowed with the web-based method.

VALUE OR STUDY TO READER: Participants liked the web-based approach better than completing paper-and-pencil assessment tools. In addition, the web-based method resulted in more reliable data. With the increased use of the Internet and personal computers, additional studies can be expected using web-based tools to monitor chronic illnesses.

R Cruz-Correia et al. Web-based or paper-based self-management tools for asthma--patients' opinions and quality of data in a randomized crossover study. Student Health Technology Information, 2007;127:178-189.

A major concern to those who treat older patients is to develop self-management programs that can be used for those with several chronic illnesses. The goal of a study by Bayliss and coworkers was to identify barriers to self-management associated with lower perceived health status and, secondarily, with lower reported physical functioning for a population of seniors with multiple chronic conditions. They surveyed 352 health maintenance organization members aged 65 years or older with, at a minimum, coexisting diagnoses of diabetes, depression, and osteoarthritis. Validated questions were based on previous interviews that had elicited potential barriers to the self-management process for persons with multimorbidities. Associations between morbidity burden and potential barriers to self-management were analyzed. The response rate was 47%. Sixty-six percent of respondents were female; 55% were aged 65 to 74 years, and 45% were aged 75 years or older. Fifty percent reported fair or poor health. On average they each had 8.7 chronic diseases. In the analysis, higher level of morbidity, lower level of physical functioning, less knowledge about medical conditions, less social activity, persistent depressive symptoms, greater financial constraints, and male sex were associated with lower perceived health status. Potential barriers to self-management significantly associated with lower levels of physical functioning were higher level of morbidity, greater financial constraints, greater number of compound effects of conditions, persistent depressive symptoms, higher level of patient-clinician communication, and lower income.

VALUE OF STUDY TO READER: The study showed that in addition to morbidity burden, specific psychosocial factors were independently associated with lower reported health status and lower reported physical functioning in seniors with multiple physical disorders. These factors, suggested the authors, would be amenable to intervention to improve health outcomes. Changing these factors might be needed before self-management programs can be developed and tested for patients with multiple chronic conditions. In other cases, interventions for these issues might be included as components in an overall self-management program for use across chronic illnesses.

EA Bayliss et al. Barriers to Self-Management and Quality-of-Life Outcomes in Seniors With Multimorbidities. Annals of Family Medicine, 2007;5:395-402.

Self-management as the standard of care for vitamin K-antagonist therapy management requires a detailed, point-of-care device-specific training program to ensure quality patient care. In a multi-center trial using the ProTime System (training program plus point of care device), 105 patients were enrolled to evaluate efficacy of training, knowledge retention, patient satisfaction, and quality of life. In the trial described by Voller and coworkers, patients returned to the centers 1, 3, and 6 months after training to complete questionnaires and demonstrate test proficiency. Training assessment employed self-evaluation and comparison of point of care results between self-management and professional operators. Patient satisfaction and quality of life were assessed using a questionnaire and the SF-12 Survey, respectively. Patients demonstrated statistically significant improvements in knowledge after training and retained the acquired information at six months. Trained patients yielded equivalent results to professional operators across all clinic visits. Compliance with weekly testing improved from one to three months, remaining at the required weekly frequency through 6 months. Average patient satisfaction improved significantly during the first month and remained constant thereafter. There was a statistically significant improvement in the Physical Component Summary of SF-12 between baseline and 3/6 month assessments in all centers.

VALUE OF STUDY TO READER. The authors said that self-management requires a comprehensive system including appropriate disease and point-of-care device training. Such a system, they concluded, fostered compliance, improved knowledge, patient satisfaction, and quality of life. The weakness of the study is the usual one found in self-management programs of chronic conditions: the follow-up of 6 months was simply too brief to yield information as to the long-term benefits of the program. This should be determined by conducting additional trials with longer follow-up of the procedure used in the study. It would also be nice if actual patient performance were assessed in addition to knowledge.

H Völler et al. ProTime self-management yielding improvement of fluency and quality of life. Thrombosis & Haemostasis, 2007;98:889-895.

An aim in recent years has been to develop self-management programs for patients with epilepsy. Pramuka and coworkers, for example, described a trial of self-management intervention for adults with the disorder. The study looked at a 6-week psychosocial intervention designed to improve self-efficacy and quality of life for 61 adults with diagnosed epilepsy. Measures used included the Quality of Life in Epilepsy-89 Inventory, the Washington Psychosocial Seizure Inventory, a locus of control scale, and the Epilepsy Self-Efficacy Scale-2000. Group differences were analyzed with statistical procedures. There was a significant improvement in the Quality of Life in Epilepsy-89 Role Limitations-Emotional score in the treatment group at follow-up, but no significant differences in overall quality of life. Strong and significant correlations were observed between outcome measures.

VALUE OF STUDY TO READER: The authors said that although the intervention had little effect on improving overall quality of life, promising trends were observed in comparisons linking self-efficacy and other psychosocial factors with quality of life. The findings suggest that the intervention should be redone with a larger population of patients. We concur with this thought. Any future study should also include more measures on epilepsy and consequences.

M Pramuka et al. A psychosocial self-management program for epilepsy: A randomized pilot study in adults. Epilepsy & Behavior, September 27, 2007.

A new specialty in medicine is that of the hospitalists. These are phys