self-management & ehealth: the evidenceself-management as a skill- definition self-management...
TRANSCRIPT
Self-management & eHealth: the evidence
Dr. Jaap Trappenburg
Self-management is hot !
What’s in a name…
self-care shared-care paternalism
policy The chronic beast is approaching
We need more self-management to
strike increasing costs
What’s in a name…
Capacity
Autonomy I am self-managed
I want more autonomy
What’s in a name…
Exposure Interventions /
programs / support
We provide self-
management support
This will increase your
health-related quality of life !
Self-m
anagem
ent
skill
s
stimulus
Self-management as a skill- Definition
Self-management refers to the individual’s ability to manage the
symptoms, treatment, physical and psychosocial consequences and life
style changes inherent in living with a chronic condition……..
Barlow et al. 2002
Which abilities/skills ?
1. Problem solving: analyzing situations and finding solutions for present and future
2. Decision making: steps in choice of action
3. Resource utilization: contact resource persons, use of health services
4. Formation of patiënt-provider relationship: active role and collaboration in the plan of care
5. Action planning: day-to-day activities and prevention of symptoms
6. Self-tailoring: self-monitoring of condition such as symptom monitoring
Bourbeau et al. Patient Educ Couns 2004
Transfer of
information
Active stimulation of
symptom monitoring
+ ≥ 2
or
or
Enhancing
physical activity or Enhancing dietary
intake or Enhancing
smoking cessation or Enhancing medication
adherence
General approach for each
component should be enhancing
patients’ active role and
responsibility in plan of care Resource
utilization
Self-treatment
Stress / symptom
management
≥ 1
Enhancing problem solving
skills (= anticipation)
Definition: self-management intervention
“Self-management interventions aim to equip
patients with skills to actively participate in the management of their chronic condition through at
least knowledge acquisition and symptom monitoring, medication management, decision-
making or changing their health behavior in order to function optimally.”
RCT’s self-management (year)
Evidence for self-management
Etc.
Evidence for self-management
Chronic disease Meta-
analysis
# Included
RCT’s /
patients
Key significant findings
Disease specific outcomes Patient Reported Outcomes Healthcare utilization
parameter pooled result parameter pooled result parameter pooled result
Arthritis /
Chronic musculo-
skeletal pain
Du et al.
2011
19/ ? Arthritis-related pain
4 months
6 months
12 months
SMD: -0.23 [-0.36,-0.10]
SMD: -0.29 [-0.41,-0.17]
SMD: -0.14 [-0.23,-0.04]
Arthritis-related
disability
12 months
SMD: -0.17 [-0.27,-0.07]
Asthma Gibson et
al.
2003
36/4593 Nocturnal asthma
Peak Flow (l/min)
RR: 0.67 [0.56,0.79]
WMD: 0.18 [0.07,0.29]
HRQoL
miscellaneous
WMD: 0.29 [0.11,0.47]
Hospitalization
ER visits
Days off work
RR: 0.64 [0.50-0.82]
RR: 0.82 [0.73,0.94]
WMD: -0.18 [-0.28,-0.09]
CHF Jovicic et
al.
2006
6/857 1-year readmission
-all cause
-CHF-related
OR: 0.59 [0.44,0.88]
OR: 0.44 [0.27,0.71]
COPD Effing et al.
2007
15/2239 Dyspnea
Borg scale
WMD: -0.53 [-0.96,-0.10]
HRQoL
SGRQ total
SMD: -2.58 [-5.14,-0.02]
≥ 1 respiratory-related
hospital admission/year
OR: 0.64 [0.47,0.89]
DMII Deakin et
al.
2009
11/1532 HbA1c (%)
4-6 months
12-14 months
2 years
FB glucose (mmol/L)
12-14 months
Weight (kg)
12-14 months
SBP (mmHg)
4-6 months
WMD: -1.35 [-1.93,-0.78]
WMD: -0.82 [-0.99,-0.65]
WMD: -0.97 [-1.40,-0.54]
WMD: -1.17 [-1.63,-0.72]
WMD: -1.61 [-2.97,-0.25]
WMD: -5.37 [-9.53,-1.21]
Diabetes knowledge WMD: 1.0 [0.7, 1.2] Diabetes medication OR: 11.8 [5.2,26.9]
DMII – not using
insuline
Malanda et
al.
2012
12/3259 HbA1c (%)
6 months
WMD: -0.26 [-0.39,-0.13]
Hypertension Chodosh et
al 2005
13/ ? SBP (mmHg)
DBP (mmHg)
PES: -0.39 [-0.51,-0.28]
PES: -0.51 [-0.73,-0.30]
Patients on long-
term oral
anticoagulation
Garcia-
Alamino et
al. 2012
18/4723 Thromboembolic
events
All-cause mortality
RR: 0.50 [0.36,0.69]
RR: 0.64 [0.46,0.89]
Trappenburg et al. Patient
Education Counseling 2013
UK: Whole System Demonstrator
• Multi-center cluster randomized trial in patients with COPD,
diabetes and irritable bowel syndrom; n = 5599
Regular care (normal access)
Kennedy et al. BMJ 2013
12 months
Practice level training in a whole systems
approach to self-management support
Self-management in COPD
Substantial number of
non-responders
Example: 3x Living well with COPD
Canada 2007 The Netherlands 2012
N = 191
Recruitment: Secondary care
> 1 hospital admision / last year Age: 69 ± 7 years
FEV1lit: 0.99 ± 0.32 liters
Low education: 77%
N = 110
Recruitment: Primary care
Age: 64 ± 9 years
FEV1pred: 66 ± 17%
Low education: 55%
Bourbeau et al. Arch Int med 2003 Bischoff et al. BMJ 2012
Admissions: -39%
SGRQ: -3.5 (-6.5 to -0.5)
Cost-savings: $2,149
Unscheduled contacts: 1.09 (0.42 to 2.81)
CRQ: −0.22 (−0.49 to 0.042)
Self-management is harmless ?
Self-management 4 individual 90-minute weekly sessions
Monthly telephonic reinforcement for 3 months
Multiple topics + action plan (self-treatment)
Regular care
N= 426
Age 66 years
FEV1: 38% pred
Heterogeneity in content
So what do we know…
Heterogeneous
programs Heterogeneous
patients
Large variance
in effect size
‘One size does
not fit all’
Tailored self-management
Tailored self-management
Etc
Disease management
Care intensity / costs
Monitoring
Case-
management
Self-
management
education
Self
Provider
Case-management
Self-monitoring
Decision making
Decision support
Surveillance
Patient
E-learning
E-consultation
E-therapy
EPD
Telemedicine
Evidence for telehealth (meta-analysis)
COPD Polisena et al. 2010 Telemonitoring or Telephone support McLean et al. 2011 Healthcare at a distance Low number of trials Low quality of trials Effects: None
CHF Anker et al. 2011 Telemonitoring (invasive + non-invasive) Moderate number of trials Moderate to good quality of trials Effects: mortality, hospitalizations
Diabetes Polisena et al. 2011 Telemonitoring or Telephone support Moderate to high number of trials Low to moderate quality of trials Effects: Glycaemic control, unscheduled healthcare contacts
Whole System Demonstrator Trial
• Pragmatic multi-center (n=238 GP’s) cluster randomized trial,
DM II, CHF, COPD; n = 3230
Regular UK primary care
Minimisation: practice size, disease prevalence, and other characteristics.
Tunstall RTX 3370 Viterion V100 Philips Motiva Personal
Healthcare System
Steventon et al. BMJ 2012
12 months
Results
Steventon et al. BMJ 2012 (incremental costs £92.000 per QALY)
Mayo Clinics
• Multi-center randomized trial, patients at risk for hospitalization
(frail elderly: incl. COPD, CHF) ; n = 205
Regular care (normal access)
Intel-GE
Takahashi et al. Arch Int Med 2012
12 months
Negative / adverse effects
Conclusion & recommendations
• Grote heterogeniteit in interventies, uitkomsten, populaties en resultaten. • ‘Samengeteld’ is hierdoor de bewijskracht voor (kosten-reductie van) zelfmanagement
programma’s en telehealth te diffuus om nu over te kunnen gaan tot grootschalige implementatie.
• Zelfmanagement/zelfzorg & telehealth (telemonitoring) zijn niet per definitie risicioloos.
• Er is te weinig kennis beschikbaar over welke programma karakteristieken de grootste effecten sorteren (Wat werkt?).
• Te weinig kennis over patiënt-gerelateerde factoren om onderscheid te kunnen maken in (Bij wie werkt wat ?):
• non-responders van responders • Compliantie van non-compliantie
• TAILORING !! Echter, bovenstaande kennis is nodig om inhoud, modus en dosis op maat te kunnen aanpassen aan de individuele patiënt en zodoende grotere effecten te sorteren.
• ‘Complexe interventies’ dienen ontwikkeld en geëvalueerd te worden volgens pre-gespecificeerde kwaliteitsstandaarden: Non-inferioriteit (en kosten-neutraliteit) is de minimale ondergrens voor grootschalige implementatie.
TASTE: Research agenda
Thank you for your attention !
IPD meta-analysis “Would you be willing to share your data?”
COPD n = 22
CHF n = 33
Study 1: exposure X
Study 2: exposure X
Study 3: exposure Y
Etc.
Success = f(exposure | patient characteristics (effect modifiers))