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Improving Patient Care |

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

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

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


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

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

Potential Financial Conflicts of Interest: None disclosed.

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

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

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

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

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


Ann Intern Med. 2005;143(6):427-438. doi:10.7326/0003-4819-143-6-200509200-00007
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Chronic disease self-management programs probably have a beneficial effect on some (but not all) physiologic outcomes that have been assessed in controlled trials. In particular, we found evidence of statistically significant and clinically important benefits for measures of blood glucose control and blood pressure reduction for chronic disease self-management programs aimed at patients with diabetes and hypertension, respectively. Our conclusions are tempered by our finding of possible publication bias that favored beneficial studies in these 2 clinical areas. Regarding arthritis, the statistically significant effects on the physiologic outcomes of pain and function are clinically trivial, a result identical to a recent meta-analysis of the effect of chronic disease self-management programs on osteoarthritis and rheumatoid arthritis (87). There was no evidence of an effect on weight loss among diabetic patients.

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Figures

Grahic Jump Location
Figure 1.
Flow of evidence.

This diagram shows flow of evidence from the original sources to final acceptance for our review. CCT = controlled clinical trial; CDSM = chronic disease self-management; RCT = randomized, controlled trial.

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Grahic Jump Location
Figure 2.
Forest plot of diabetes studies.

Each effect size is shown with its CI as a solid block whose area is inversely proportional to the estimated trial variance. The pooled estimate and its CI are shown as a diamond with a dotted line indicating its location. A vertical solid line at 0 indicates no treatment effect.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Forest plot of osteoarthritis studies.

Each effect size is shown with its confidence interval (CI) as a solid block whose area is inversely proportional to the estimated trial variance. The pooled estimate and its CI are shown as a diamond with a dotted line indicating its location. A vertical solid line at 0 indicates no treatment effect.

Grahic Jump Location
Grahic Jump Location
Figure 4.
Forest plot of hypertension studies.

Each effect size is shown with its confidence interval (CI) as a solid block whose area is inversely proportional to the estimated trial variance. The pooled estimate and its CI are shown as a diamond with a dotted line indicating its location. A vertical solid line at 0 indicates no treatment effect.

Grahic Jump Location
Grahic Jump Location
Figure 5.
Meta-analysis results (n = 35) pooled across condition (pain, hemoglobin A1c level, systolic blood pressure).

As shown, effect sizes (represented by solid circles) generally support an association between increased effectiveness and the use of these intervention features; however, none of the differences are statistically significant (vertical lines represent 95% confidence interval).

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Tables

References

Letters

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Self-Management Education for Osteoarthritis
Posted on December 21, 2005
Halsted R. Holman
Stanford University
Conflict of Interest: None Declared

SELF-MANAGEMENT EDUCATION FOR OSTEOARTHRITIS

This letter examines the article by Chodosh J et al. Meta-Analysis: Chronic Disease Self-Management Programs for Older Adults. Ann.Intern Med. 2005;143:427-438.

We respond first about our articles that were included, and then about the quality of the study. We do not know how our concerns apply to other articles that were analyzed. Also, we discuss only the data on pain, not physical disability, because self-management education for osteoarthritis, unlike that for diabetes and hypertension, does not intend to change the biologic abnormality. The goal is greater comfort and activity for the patient despite physical limitation. Disability may improve minimally but usually worsens over time.

A valid meta-analysis must be accurate in its use of data. Beyond that, it should search the relevant databases thoroughly, assess the methodological quality of the studies being analyzed, and interpret numerical results with common sense and due regard for the broader aspects of the problem.1 The study fails these requirements:

1. The authors describe the unbiased effect size for pain change in our study reference 602 as having a positive value that favors no benefit. In reality, the effect size is in the opposite direction, favoring treatment -0.31 as calculated by the method the authors used. (A similar error of direction is made for disability change).

2. The authors use 4 studies by us, one with two control-treatment comparisons with small sample sizes (27-29 persons per group). They omit 2 randomized studies by us with similar design done in the same time period with larger sample sizes (49-189 persons per group). These had effect sizes for pain clearly favoring treatment of about -0.36 and - 0.41 (depending on calculation method).3,4

On these grounds alone, a conclusion of no "clinically beneficial effect" from self-management programs for osteoarthritis is not legitimate. But there are more problems:

1. The included education programs differed widely: home-based reading with video demonstrations, computer programs, mailed information with audiotapes and telephone calls, and group meetings. Each intervention had different design, content and facilitators. Thus the programs are not comparable and the effectiveness of their teaching was not assessed as a condition for selection. . 2. The authors fail to mention that there are other valid methods to assess the benefits of a complex educational program. There are many examples including 2 longitudinal studies of ours with large sample sizes (113 and 263) that had benefits in pain and other outcomes persisting 3 to 4 years.5,6

3. While the goals of self-management have different definitions, none is restricted to pain and physical function.7,8 Just as osteoarthritis can have many consequences for a person, so self-management can have many benefits beyond pain reduction. Some that occur are mood improvement, enhanced perceived self-efficacy to cope with the consequences of chronic handicap, and reduced need for medical services. No mention is made of these benefits or the fact that benefits are additive to those of usual care.

Thus a conclusion from this study about the value of self-management in osteoarthritis would be invalid.

Why is all this important? Study integrity is only part of the answer. The impact of false conclusions can be substantial. Chronic disease is the dominant health care problem today and effective self- management is an essential part of the solution. We are just beginning to learn how best to instill and maintain patient's self-management skills. As we devise and test different methods, it is crucial that we assess without error each approach in order to select the best ways to improve health care. Failure to do so properly undermines the effort and harms the public good.

References:

1.Greenhalgh T. How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses). BMJ. 1997; 315:672-675

2.Lorig K,Lubeck D, Kraines R, Seleznick M, Holman H.Outcomes of self -help education for patients with arthritis. Arthritis Rheum. 1985; 28:680 -5.

3.Lorig K, Chastain R, Ung E, Shoor S, Holman H. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32:37-44.

4.Lorig K, Gonzalez V, Ritter,P. Community-based Spanish language Arthritis education program. A randomized trial. Med.Care. 1999;37:957 -963.

5. Lorig K, Mazonson P, Holman H. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis Rheum. 1993;36:439-446.

6. Lorig K, Ritter P, Laurent D, Fries J. Long-term randomized controlled trials of tailored-print and small- group arthritis self- management interventions. Med.Care. 2004;42:346-354.

7. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self- management approaches for people with chronic conditions: A review. Patient Educ. and Counselling. 2002;48:177-187.

8 Adams K, Greiner A, Corrigan J. Report of a summit. The 1st annual crossing the quality chasm summit - A focus on communities. 2004. Washington, DC: National Academies Press.

Conflict of Interest:

Federal, state and foundation grants, talk honoraria

Re: Self-Management Education for Osteoarthritis
Posted on February 13, 2006
Paul G. Shekelle
Veterans Affairs Health Services Research and Development Service, RAND Corporation
Conflict of Interest: None Declared

We thank Dr. Holman and Dr. Lorig for their interest in our paper. Regarding their concern about the effect size in one study, our calculated effect size is correct according to our methods, as it is based on the followup means for pain and function in the two groups. The effect size listed by Drs. Holman and Lorig in their letter is a "difference of difference" calculation that adjusts for baseline differences in pain and function between the two randomized groups in their study. While this is one valid method to analyze the results of an individual article, we do not prefer to combine "difference of difference" estimates with followup mean estimates in our meta-analyses because of reports that such an approach can increase susceptibility to bias.(1) On a practical level, combining just those studies which contain "difference of difference" estimates decreases the number of studies that can be included in a pooled analysis. In most circumstances, effect sizes calculated using the "difference of difference" method or using the followup means do not substantially differ. In this one particular study, they do. However, our pooled result is not very sensitive to which effect size is used from this study or similar studies; using the "difference of difference" effect size preferred by Drs. Holman and Lorig in their study only changes the pooled effect size for pain by 0.01. If we substitute a "difference of difference" effect size for all 6 studies where it is possible to do so in our pooled analysis of 14 studies, the effect for a decrease in pain diminishes to statistical insignificance (ES = -0.05, 95% CI -0.12, 0.03). Regarding the studies Drs. Holman and Lorig say we omitted, our study question of interest was the effect of chronic disease self-management programs on patients with osteoarthritis. All of the studies listed in their references were identified by us but rejected because they enrolled patients with mixed musculoskeletal conditions, and the proportion of patients with osteoarthritis was unacceptably low (about half of the patients in their references 3 and 4, as opposed to 77% of enrolled patients with osteoarthritis in their reference 2, which we did include in our analysis). Readers interested in a synthesis of evidence regarding self-management programs for patients with mixed diagnoses of arthritis are referred to the meta-analysis by Warsi and colleagues, which reported a pooled effect size very similar to our result (for pain = 0.12, for function = 0.07, (2)). In terms of the inclusion of different kinds of self-management programs, Dr. Holman and Dr. Lorig miss one the key points of our study - since there is no agreed upon definition of what constitutes a self-management program, we included a broad array of studies and used meta-regression in an attempt to identify components of particular significance. Unfortunately, our attempts were unrevealing, a result also echoed by Warsi and colleagues in another analysis, where meta -regression could not discern meaningful differences in the effectiveness of self-management programs as a function of a large number of different program components (3). There is simply an insufficient evidence base at present to conclude which components of a self-management program are most important in terms of effectiveness. We disagree with Dr. Holman and Dr. Lorig that longitudinal studies are "valid methods" to assess the effectiveness of interventions for a chronic disease with a variable clinical course, but do agree with Dr. Holman and Dr. Lorig that there are important outcomes other than pain and function, and we so stated this as a limitation of our analysis. Unfortunately, we could not include other outcomes because they were reported too infrequently and too variably to justify inclusion. Lastly, we did not conclude that self-management programs have "no clinically beneficial effect" for older adults with osteoarthritis, only that there are no data to suggest those benefits include clinically important improvements in pain and function. Future research is needed to determine which clinically and financially important outcomes are reproducibly improved by chronic disease self management programs for older adults with osteoarthritis, and which components are necessary in order to achieve these improvements.

1) Ray JA, Shadish WR. How interchangeable are different estimators of effect size? J Consulting and Clinical Psychology 1996;64:1316-25.

2) Warsi A, LaValley MP, Wang PS, Avorn J, Solomon DH. Arthritis self-management education programs: a meta-analysis of effects on pain and disability. Arthritis Rheum 2003;48:2207-13.

3) Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH. Self- management education programs in chronic disease. Arch Intern Med 2004;164:1641-49.

Conflict of Interest:

None declared

Reply to the author
Posted on February 24, 2006
Halsted Holman
Stanford University
Conflict of Interest: None Declared

To the Editor,

Because patients with chronic disease must be their own principal caretaker, education of patients for this task is essential for good health care. In evaluating education programs, there can be differences in selection of programs and in methods used for meta-analysis. However, as in this case, no contribution is made to improving health care by grouping and evaluating together widely different education programs delivered in widely different ways by people with widely different skills. What is needed is to identify successful programs and their components, and analyze the ways those components act and interact. In the process, rigorous longitudinal studies will be essential.

Halsted Holman, MD

Kate Lorig, DrPH

Conflict of Interest:

Federal, state and foundation grants, talk honoraria

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Summary for Patients

Chronic Disease Self-Management Programs for Older Adults

The summary below is from the full report titled “Meta-Analysis: Chronic Disease Self-Management Programs for Older Adults.” It is in the 20 September 2005 issue of Annals of Internal Medicine (volume 143, pages 427-438). The authors are J. Chodosh, S.C. Morton, W. Mojica, M. Maglione, M.J. Suttorp, L. Hilton, S. Rhodes, and P. Shekelle.

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