بررسی برنامه های مزمن بیماری خودمدیریتی (CDSMP) در میان افراد مسن بیمار در هلند

Many chronically ill older patients in the Netherlands have a combination of more than one chronic disease. There is therefore a need for self-management programs that address general management problems, rather than the problems related to a specific disease. The Chronic Disease Self-Management Program (CDSMP) seems to be very suitable for this purpose. In evaluations of the program that have been carried out in the United States and China, positive effects were found on self-management behaviour and health status. However, the program has not yet been evaluated in the Netherlands. Therefore, the aim of this study was to evaluate the short-term and longer-term effects of the program among chronically ill older people in the Netherlands. One hundred and thirty-nine people aged 59 or older, with a lung disease, a heart disease, diabetes, or arthritis were randomly assigned to an intervention group (CDSMP) or a control group (care-as-usual). Demographic data and data on self-efficacy, self-management behaviour and health status were collected at three measurement moments (baseline, after 6 weeks, and after 6 months). The patients who participated rated the program with a mean of 8.5 points (range 0–10), and only one dropped out. However, our study did not yield any evidence for the effectiveness of the CDSMP on self-efficacy, self-management behaviour or health status of older patients in the Netherlands. Because the patients who participated were very enthusiastic, which was also indicated by very high mean attendance (5.6 out of 6 sessions) and only one dropout, it seems too early to conclude that the program is not beneficial for these patients.

It may be questioned whether the current Dutch medical care system, with its main focus on acute care and cure, is sufficiently responsive to chronically ill patients who often will have no hope of recovery, but have to cope with an incurable long-term disease. As in other Western societies, the number of chronically ill older people in the Netherlands is increasing. Older people are often not only confronted with a chronic disease, but also with comorbidity (Westert, Satariano, Schellevis, & van den Bos, 2001). The impact of chronic conditions on health is substantial, it varies according to condition, and it usually affects all aspects of functioning and well-being (Baanders, Calsbeek, Spreeuwenberg, & Rijken, 2003; Gijsen et al., 2001; Heijmans, Rijken, Schellevis, & van den Bos, 2003; Kempen, Jelicic, & Ormel, 1997; Kempen, Ormel, Brilman, & Relyveld, 1997; Ormel, Kempen, Brilman, & Van Sonderen, 1996; Stewart, Greenfield, Hays, Wells, Rogers et al., 1989). Chronic diseases may lead to disabilities, which can have a negative effect on the ability of older people to care for themselves (Fried & Guralnik, 1997). This increase in the number of older people with chronic conditions implies a need for new means of delivering care, and teaching patients self-management behaviour to cope with their disease could be an element in these new means. However, because many older patients have a combination of more than one chronic disease, there is a need for self-management programs that focus less on the problems related to one specific disease, and more on general management problems that are the same for patients with different chronic conditions, such as fatigue, pain, anxiety, etc. One program that meets these criteria is the Chronic Disease Self-Management Program (CDSMP), which was developed by Lorig and co-workers at Stanford University in America. To our knowledge, it is the only self-management program for (older) people with more than one chronic disease. The CDSMP has been evaluated in the United States and in China (Fu, Fu, McGowan, Shen, Zhu et al., 2003; Lorig, Ritter, Stewart, Sobel, Brown et al., 2001; Lorig, K.R., et al., 1999; Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001). The study samples in these evaluations mainly involved older adults (mean age 64.2, range 40–90), and mainly concerned patients with heart disease, lung disease, diabetes, or arthritis. In all evaluations, except for one, self-efficacy was measured. Other outcome measures were self-management behaviour, health status, and health care utilization. However, there was no standard measurement of outcome variables such as self-efficacy and health status. The CDSMP has been found to be effective in maintaining and improving these abovementioned outcomes, although not consistently so in all studies. The effect sizes of most of these outcomes were small to moderate. The CDSMP has not yet been evaluated in the Netherlands. The aim of the present study was to evaluate the short-term and longer-term effects of the CDSMP among chronically ill older people in the Netherlands. Knowing from previous studies that the program can have positive effects on self-efficacy, self-management behaviour, and health status, we expect to find positive effects in our sample of patients aged 59 and older with one or more chronic diseases.

Description of sample Of the 361 patients who were personally invited to participate in the outpatient clinic, 94 (26%) agreed to participate. We analysed the non-participants and found that they were more restricted in their mobility, lived further away from the location of the intervention and had a partner more often, compared to the participants (Elzen, Slaets, Snijders, & Steverink, 2007, submitted). No differences were found in level of education, age, or gender. Another 50 participants were recruited through public announcements. Of the 144 patients who were included in the study, 136 completed the first post-intervention measurement (T1). Of these, 50% (n=68) had been assigned to the intervention group. As shown in Table 1, no significant differences in the basic patient characteristics were found at baseline. No group differences were found on any of the measurement scales. Table 1. Patient characteristics Variable Intervention Control p-value a N (%) M (SD) Range N (%) M (SD) Range N 68 68 Age 68.2 (6.0) 59–84 68.5 (6.6) 59–87 .775 Gender 25 (36.8) 25 (36.8) 1.0 Male Partner 45 (66.2) 40 (58.8) .376 Disease Diabetes 23 (33.8) 21 (30.9) .375 Lung disease 22 (32.4) 16 (23.5) Arthritis 20 (29.4) 26 (38.2) Heart disease 3 (4.4) 5 (7.4) Self-efficacy 57.5 (10.6) 56.4 (10.9) .555 Self-management behavior Exercise 170.6 (112.5) 160.8 (118.8) .624 Cognitive symptom-management — — — Communication 2.2 (1.1) 2.6 (1.3) .081 Health status Physical component 35.4 (10.9) 36.8 (10.5) .897 Mental component 46.8 (10.1) 48.0 (9.9) .751 a P-value of t-tests, χ2-tests, or Mann-Whitney test. Table options Fig. 1 is a flow diagram of the sample and drop-outs. As can be seen, relatively few patients dropped out after inclusion. Of the eight patients who did not complete the first post-intervention questionnaire, two withdrew from the study after randomisation. This concerned a couple who had been assigned to the intervention group, and the husband had suffered a heart attack. Six patients in the control group did not return the first post-intervention questionnaire: one patient had died, one wrote to say that the study did not meet her expectations, and four gave no specific reason. Five of the drop-outs had diabetes, two had arthritis, and one had a lung disease. The eight drop-outs did not differ significantly from the other participants at baseline. Full-size image (40 K) Fig. 1. Flow diagram of the drop-out of participants. Figure options Seven patients (six in control group and one in the intervention group) did not complete the second post-intervention questionnaire, leaving 129 participants in the study (67 in the intervention group and 62 in the control group). Of the six drop-outs in the control group, one had developed a brain tumour and was unable to complete the questionnaire, one had died, and four persons gave no specific reason. One patient in the intervention group did not complete the questionnaire because she no longer thought it was of any use. Of these seven drop-outs, four had diabetes, two had a lung disease, and one had a heart disease. At T1 these drop-outs had returned their questionnaire significantly later than the other participants (z=−3.269, p=.001), and had a significantly lower score for the physical functioning component of the RAND-36 (z=−2.546, p=.011). The drop-outs also had a significantly lower score for exercise (z=−2.695, p=.007), but a significantly higher score for cognitive symptom-management (z=−2.138, p=.033).