برنامه ریزی مجدد رابطه بین آموزش خودمدیریتی شرایط بلندمدت و استفاده از خدمات بهداشتی و درمانی

Encouraging self-management has been viewed as one means of reducing health service utilisation and contributing to improved demand management. However, the processes and imputed relationship between self-management education skills and health service contact are poorly understood. This paper reports on data from an embedded qualitative study which ran alongside a randomised controlled trial in England designed to test the clinical and cost effectiveness of a self-care support policy which found no statistically significant reductions in health service utilisation. Drawing on concepts from the sociology of chronic illness, analyses suggest that the biographical and social context relevant to individuals’ experience of living with a long-term condition, history of health service utilisation, and relationships with health professionals are relevant to understanding the impact of self-management education and related policies aimed at bringing about changes in service use. Our study suggests that future health policy assumptions about utilisation in the context of chronic disease management and self-care support polices may benefit by acknowledging the complex, contextual and recursive nature of health service utilisation operating in the life worlds of patients’ experience of living with a long-term condition.

The prevalence of long-term conditions has been identified as a key factor placing increased demand on health services and requiring active management to prevent the costs of health services spiralling out of control. Policies for managing long-term conditions increasingly envisage their care being based around three tiers: case management for patients with multiple, complex conditions; disease management for patients at some risk, through guideline-based programmes in primary care ( Department of Health, 2005a; Wagner et al., 2001); and self-care support for low risk patients (70–80% of those with long-term conditions). Self-care has been defined as ‘the care taken by individuals towards their own health and well being: it comprises the actions they take to lead a healthy lifestyle; to meet their social, emotional and psychological needs; to care for their long-term condition; and to prevent further illness or accidents’ ( Department of Health, 2005b). One of the aims of top-down policy programmes of self-management support has been to contribute to more effective chronic disease management. Self-management education has also been identified as having a key role to play in utilisation reduction and containing health care spending ( Department of Health (1999) and Department of Health (2005b)). However, the evidence supporting the impact of self-management and other chronic disease management initiatives on health service utilisation is more equivocal than policy statements often imply ( Roland, Dusheiko, Gravelle, & Parker, 2005) and the mechanisms underlying the purported relationship between increases in self-care activities and a reduction in utilisation remain under-explored. In this paper we argue that utilisation needs to be understood more broadly as part of a complex pre-existing relationship that individuals have with health care services. Drawing on a longitudinal qualitative study embedded within an RCT of a national programme of self-care support in England ( Department of Health, 2001), the aim of this paper is to illuminate the nature and the processes of utilisation which accompany self-management skills-training by exploring the way in which patients related to services prior and subsequent to participation in a self-care intervention. The Expert Patients Programme (EPP) is an anglicised version of the Chronic Disease Self-Management Programme (CDSMP) developed in the USA (Lorig et al., 1999) (also being implemented in the US and Australia). One of the primary outcome measures used to judge the effectiveness of these interventions is an impact on utilisation: “Confident, knowledgeable patients practicing self-management will experience improved health status and will utilise fewer health care resources” (Lorig et al., 1999). Some self-management interventions have reported significant impacts on health services utilisation. For example, an RCT of self-management in inflammatory bowel disease (Kennedy et al., 2004) found that following the intervention, patients made significantly fewer hospital visits at one year follow-up (difference −1.04 (95% confidence interval (CI) −1.43 to −0.65); p<0.001). Furthermore, an RCT of self-management in irritable bowel syndrome ( Robinson et al., 2006) found that at one year, patients in the intervention group had a 60% reduction in primary care consultations (p<0.001). For others the impact on utilisation has been more equivocal. A trial of the CDSMP ( Lorig et al., 1999) carried out in the USA found that compared with a control group, the intervention group reported no significant changes in the physician visits but there were fewer episodes of hospitalisation and nights spent in hospital. However, evidence for utilisation change from other CDSMP trials appears to be the weakest of all outcome improvements ( Fu et al., 2003; Lorig, Ritter, & Gonzalez, 2003). Trial outcomes measure changes in the levels of utilisation but tell us little about the purported mechanisms and processes. Trial measures of utilisation are particularly limited because they fail to take into account people's existing relationships and past experiences of health services and the way in which these might feed into current and future patterns of service use. There is also uncertainty about the extent to which self-care acts as an alternative or supplement to, formally provided services and the relationship between health services utilisation, self-care and living with a chronic condition. By contrast, studies of help-seeking and sociological research on the experience of living with a chronic illness point to the complexities of specifying a relationship between illness behaviour and health care utilisation.

The findings of this study suggest that an understanding of the relationship between utilisation and self-management education requires moving beyond viewing outcomes in terms of increases or decreases in utilisation. Rather there is a need to view it as dynamic and part of a broader system mediated by patient's life world experience of chronic illness and trajectories of utilisation. Services and the support provided by health professionals, and the self-care that patients perform for themselves, are intrinsically linked, in that the way a person manages their condition is shaped by contact with services. The design of self-care interventions is tied into the services patients are already negotiating their through. Policy initiatives, in the area of self-management education and chronic disease management seeking to link the provision of self-care with a reduction in demand, need to acknowledge the complex and contextual nature of health service utilisation.