Chronic Disease Self-Management Programs for Older Adults
Published in: Annals of Internal Medicine, v. 143, no. 6, Sep. 20, 2005, p. 427-438, W-99-W-106
Posted on RAND.org on December 31, 2004
BACKGROUND: Although enthusiasm is growing for self-management programs for chronic conditions, there are conflicting data regarding their effectiveness and no agreement on their essential components. PURPOSE: To assess the effectiveness and essential components of self-management programs for hypertension, osteoarthritis, and diabetes mellitus. DATA SOURCES: The authors searched multiple sources dated through September 2004, including the Cochrane Library, MEDLINE, PsycINFO, and Nursing and Allied Health databases, and bibliographies of 87 previous reviews. STUDY SELECTION: Randomized trials that compared outcomes of self-management interventions with a control or with usual care for diabetes mellitus, osteoarthritis, or hypertension; outcomes included hemoglobin A1c level, fasting blood glucose level, weight, blood pressure, pain, or function. DATA EXTRACTION: Two reviewers independently identified trials and extracted data regarding whether the intervention used tailored adjustments to meet individual patient needs, a group setting, feedback, and psychological services, and whether the intervention was provided by the patient's usual physician. DATA SYNTHESIS: Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis (26 diabetes studies, 14 osteoarthritis studies, and 13 hypertension studies). Self-management interventions led to a statistically and clinically significant pooled effect size of -0.36 (95% CI, -0.52 to -0.21) for hemoglobin A1c, equivalent to a reduction in hemoglobin A1c level of about 0.81%. Self-management interventions decreased systolic blood pressure by 5 mm Hg (effect size, -0.39 [CI, -0.51 to -0.28]) and decreased diastolic blood pressure by 4.3 mm Hg (effect size, -0.51 [CI, -0.73 to -0.30]). Pooled effects of self-management interventions were statistically significant but clinically trivial for pain and function outcomes for osteoarthritis. No consistent results supported any of the 5 characteristics examined as essential for program success. LIMITATIONS: Studies had variable quality, and possible publication bias was evident. CONCLUSIONS: Self-management programs for diabetes mellitus and hypertension probably produce clinically important benefits. The elements of the programs most responsible for benefits cannot be determined from existing data, and this inhibits specification of optimally effective or cost-effective programs. Osteoarthritis self-management programs do not appear to have clinically beneficial effects on pain or function.