Self-management plans handy for seniors with comorbidities

A CLINICIAN-led chronic disease self-management support (CDSMS) program may be beneficial for older patients with multiple chronic conditions, Australian researchers have reported.

In a randomised controlled trial, published in the MJA, researchers found that, in an intention-to-treat analysis, patients who participated in a CDSMS program were more likely than control participants to report improved self-rated health after 6 months (odds ratio, 2.50; 95% confidence interval, 1.13–5.50). The CDSMS program, based on components of the Flinders Chronic Condition Management Program, incorporated patient-centred goal setting and individualised care plans.

Of the 231 patients (aged over 60 years and with two or more chronic conditions) who completed the trial, 114 had been assigned to receive the CDSMS program, and 117 were assigned to the control group, receiving positive attention and education. Participants in both groups received three home visits and four follow-up phone calls from a clinician with qualifications in nursing or psychology during the 6-month study period.

The researchers found no differences between the two groups in terms of specific health outcome measures.

Scientia Professor Mark Harris, executive director of the Centre for Primary Health Care and Equity at the University of New South Wales, said that the study provided evidence that chronic disease management programs could be effective in patients with multiple chronic conditions.

“One of the problems we have, particularly in elderly Australians, is that many people don’t have one chronic condition, they have multiple conditions. Over the age of 60 years, the number of people with multiple chronic conditions rises,” he said, adding that many chronic disease management programs focused on a single condition.

“For these patients, you can’t just run a program necessarily that’s going to deal with their diabetes if it doesn’t also deal with their arthritis.”

He said the CDSMS program’s focus on problem-solving, goal-setting and self-care addressed factors that affected most chronic conditions.

Professor Paul Glasziou, professor of Evidence-Based Medicine at Bond University, welcomed the findings, but said that more work was needed before such a program was ready for national rollout.

“It’s a top-quality study, which I think is an important step forward, but I don’t think, at the moment, it is a sufficiently streamlined and complete solution to the problem,” he said.

Professor Glasziou said that the program had a positive effect on the primary outcome of self-reported health, but fell short when it came to specific health outcomes.

He said that it would be interesting to build on this program by integrating specific condition management with the generic approaches trialled in the study.

“You do need some generic [interventions], but that needs to link in with the specific measures you know will help the patient as well,” he said.

“The researchers used a generic goal-setting process, but within each disease category there are [measures] that are very helpful to people that are sometimes counter-intuitive. For example, breathlessness is a key symptom in both heart failure and chronic obstructive airways disease, and patients with both conditions are often afraid of exercise because it makes them breathless. But, in fact, that’s exactly what they need to do, they need to exercise and get fitter.”

Professor Mieke van Driel, head of the Primary Care Clinical Unit and the discipline of General Practice at the University of Queensland, said that the study highlighted the importance of patient-centred goal-setting.

“The idea of goal-setting and discussing with patients what actually matters to them [is crucial],” said Professor van Driel, who also practises in an Indigenous medical service.

“All of our diabetes guidelines speak about the importance of keeping the glycated haemoglobin (HbA_1C) [level] under a certain threshold, but patients may have other things that matter to them and will motivate them to improve their lifestyle. HbA_1C might not mean anything to them; they don’t see it, they don’t feel it.

“There needs to be a shift in thinking to be more patient-goal oriented, rather than biomedical-goal oriented, and to integrate these patient conversations and goals into day-to-day practice.”

Professor van Driel said that chronic disease management in primary care had evolved in the years since the completion of the study’s trial period on 2010, and team-based care was now more common.

“Nowadays, in most practices, chronic disease management is done in a team involving practice nurses, allied health professionals and, in Indigenous health, Indigenous health workers and liaison people,” she said.

While all the experts acknowledged that the study intervention’s benefits were relatively modest, Professor van Driel said that the population included in the study (participants with multiple chronic conditions with low education attainment) was a particularly difficult group to manage.

“There is a lot of complexity in this group of patients that’s not only related to the disease, but also to the social and socio-economic context in which they live,” she said.

Professor Harris said that the findings added “another little piece in the evidence jigsaw” supporting CDSMS programs.

“Viewed in the context of other research over the past 20 years, this shows that [CDSMS] programs are useful and effective, and they can provide greater benefit in older people with multiple morbidities than education alone.”

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