Professional Documents
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KATE R. LORIG, RN, DRPH
Effect of a Self-
Stanford University School of
Medicine Management Program
Stanford, Calif
ecause of the large impact of chronic disease on health status and health care
Edited by John D. Birkmeyer,
MD
B expenditures, there is growing interest in self-management programs.1, 2 Such
programs emphasize the patient’s central role in managing their illness. Self-man-
Mean attendance per person 5.3 sessions Measures of health behavior and self-efficacy included
frequency of exercise, cognitive symptom management,
TOPICS and communication with physician health care
providers. These were developed and tested for the orig-
Overview of self-management and
chronic health conditions inal CDSM study and have been described elsewhere.16
Relaxation/cognitive symptom
Four types of health care utilization were assessed: visits
management to physicians, visits to hospital emergency departments
(EDs), number of hospitalizations, and number of nights
Feedback/problem solving spent in a hospital. In a previous study, self-reported uti-
Anger/fear/frustration lization for all Northern California Kaiser Permanente
members (n = 216) who participated in the CDSMP
Fitness/exercise during the last 6 months of 1995 were validated against
Fatigue management computerized medical records and medical charts.3 Self-
reported outpatient physician visits, including emer-
Healthy eating gency room visits, were well correlated with visits
Advance directives
recorded in the computerized medical record (r = 0.70).
Patients tended to underreport recorded visits by 17%
Communication when compared with the computerized medical records.
Conversely, the computer records sometimes had visits
Medications
recorded that were incorrectly classified. For days in the
Making treatment decisions hospital, medical records data correlated even more
highly with patient self-report (r = 0.83). Reporting dis-
Depression
crepancies were similar over time, which lessened the
Informing the health care team concern that reporting errors biased study results.17 It
should be noted that for the present study, self-reported
Working with health care
professionals
data may well be more valid than computerized records,
as 33% of the participants reported receiving some of
their care outside of Kaiser Permanente.
Analysis
modified version of the Medical Outcome Study health
distress scale).12 The health distress scale assesses the Paired t-tests were used to assess changes in outcome
amount of time the patient has been distressed about measures (health status, utilization, health behaviors,
health (e.g., discouraged, worried, fearful, frustrated by and self-efficacy) between baseline and 1 year. We used
health problems). Illness intrusiveness was measured by analysis of covariance to determine if health status and
using a previously developed index that assesses the health care utilization outcomes differed among the
impact of disease on multiple aspects of one’s daily life: programs taught by two peer leaders; two professional
physical well-being and diet, work and finances, marital leaders; or a mixed pair of leaders, one of whom was a
stability, sexual and family relations, recreation and social peer and the other a professional. These analyses were
relations, and other aspects of life.13 Shortness of breath, done by controlling for demographic variables and base-
line status of each outcome variable. Bonferroni correc- fewer visits to physicians (0.4 fewer; P = 0.19) and fewer
tions were also conducted for this last analysis to account days in the hospital (0.5 fewer; P = 0.12).
for multiple comparisons.
Results
TA B L E 3
Changes at 1 Year in Health Status, Health Behaviors, Self-Efficacy, and Health Care Utilization
Health status*
Disability (0–3) 0.4 ± 0.4 0.0 ± 0.3 0.77
Health distress (0–5) 2.3 ± 1.3 –0.3 ± 1.2 ≤ 0.001
Social/role activity limitation (0–4) 2.0 ± 1.1 –0.2 ± 1.0 ≤ 0.001
Illness intrusiveness (1–7) 3.3 ± 1.4 –0.2 ± 1.2 ≤ 0.001
Fatigue (1–10) 5.8 ± 2.5 –0.3 ± 2.4 0.002
Shortness of breath (1–10) 3.3 ± 3.0 –0.3 ± 2.5 0.003
Pain (1–10) 5.2 ± 3.0 –0.3 ± 2.5 0.03
Self-rated health (1–5) 3.3 ± 0.9 0.04 ± 0.8 0.20
Depression (0–3) 1.3 ± 0.6 –0.1 ± 0.5 ≤ 0.001
Health behaviors
Aerobic exercise (min/wk) 87 ± 94.7 13 ± 97.3 0.01
Range-of-motion exercise (min/wk) 35 ± 49.2 9 ± 55.8 ≤ 0.001
Cognitive symptom management (0–3) †
1.3 ± 0.9 0.4 ± 0.9 ≤ 0.001
Communication with physician (0–5)† 2.9 ± 1.2 0.2 ± 1.0 ≤ 0.001