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Am Fam Physician. 2006;73(7):1260-1263

Chronic disease management often falls short of recommended goals. Obstacles include problems with patient adherence, lack of physician awareness of guidelines, insufficient time, and imperfect office procedures. Chronic disease self-management programs are an attractive option for improving care because they allow patients to actively participate in the management of their disease. However, it remains unclear what the essential components of these programs should be and if they consistently improve disease-specific clinical outcomes. To answer these questions, Chodosh and colleagues conducted a systematic review and meta-analysis of self-management programs for hypertension, diabetes mellitus, and osteoarthritis.

The authors defined chronic disease self-management as a systematic disease intervention that involved self-monitoring, participation in decision making, or both. The meta-analysis included 53 randomized controlled trials from 1977 to 2004. It also included data on at least one of the following outcomes: clinical outcomes, measurable parameters with strong links to clinical outcomes (e.g., blood pressure, A1C levels), and intermediate outcomes related to clinical outcomes (e.g., disease knowledge, feeling of self-efficacy, health behaviors). Follow-up intervals in the trials ranged from three to 12 months for patients with diabetes and two to six months for patients with hypertension and osteoarthritis.

When compared with the control groups, diabetes self-management interventions produced a statistically significant pooled A1C reduction of 0.81 percent and fasting blood glucose decrease of 17 mg per dL (0.94 mmol per L). Interventions for osteoarthritis improved pain the equivalent of 2 mm on a 100-mm visual analogue scale. Interventions for hypertension produced a decrease of 5 mm Hg in average systolic blood pressure. Statistical analyses could not exclude publication bias as a possible explanation for the effects of the diabetes and hypertension self-management programs. Multiple strategies were unable to determine the relative contribution of different components of the programs.

The authors conclude that self-management programs appear to improve clinically significant parameters in patients with diabetes and hypertension. The positive effect of such programs for osteoarthritis was not statistically significant. These results led the authors to suggest that much of the observed benefit of chronic disease self-management programs may derive from improved patient adherence to medication regimens.

editor’s note: Although somewhat encouraging, the results of this rigorous study did not prove either the positive or negative effects of chronic disease self-management programs. Although “empowering the patient” is an appealing rhetorical concept that is hastening the spread of such programs, its evidence base remains thin. Even if the programs are sound, more studies are needed to identify which parts work and which do not. In an editorial1 in the same issue of the journal, Lawrence observes that the U.S. health care system may be poorly equipped to handle the present and future challenges posed by chronic diseases in an aging population. Observing that self-management programs are only one piece of the puzzle, he calls for a comprehensive approach to the big picture, including a reexamination of health care workforce needs and resource distribution.1—k.w.l.

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