chronic disease self management – a systematic review of proactive telephone applications carly...
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Chronic disease self management – Chronic disease self management – a systematic review of proactive a systematic review of proactive
telephone applicationstelephone applications
Carly MullerCarly MullerDean SchillingerDean Schillinger
Division of General Internal MedicineDivision of General Internal MedicineSan Francisco General HospitalSan Francisco General Hospital
University of California San FranciscoUniversity of California San Francisco
IntroductionIntroduction Chronic disease leads mortality and Chronic disease leads mortality and
morbidity morbidity
Significant potential to reduce the burdenSignificant potential to reduce the burden
Current system can’t meet long term Current system can’t meet long term needsneeds
2. Received and
Reviewed by
patient
3. Response by
patient
4. Received and reviewed
by Health
Professional or automated
system
1. Questions and
information
Proactive telephone supportProactive telephone support
RE-AIMRE-AIM
ReachReachEffectivenessEffectivenessAdoptionAdoption ImplementationImplementationMaintenanceMaintenance
Overall objectiveOverall objective
Undertake a systematic literature of Undertake a systematic literature of proactive use of the telephone to proactive use of the telephone to assist chronic disease self assist chronic disease self management to:management to:
1.1. develop a conceptual schema develop a conceptual schema
2.2. understand their effectivenessunderstand their effectiveness
3.3. understand population-level reachunderstand population-level reach
Inclusion/ExclusionInclusion/Exclusion
InclusionsInclusions All ages All ages individuals with one or more chronic diseasesindividuals with one or more chronic diseases PROACTIVE telephone self management PROACTIVE telephone self management
applicationsapplications
ExclusionsExclusions Telephone solely for data collection interviews or Telephone solely for data collection interviews or
solely for data shuntingsolely for data shunting Intervention groups comprising 10 or fewer Intervention groups comprising 10 or fewer
participantsparticipants Articles in languages other than EnglishArticles in languages other than English
Search strategySearch strategy
+
One of…. and One of…..
Medline 1967-Dec 2006
CINAHL March 1982-
week 50 2006
Psychinfo 1967-week 50
2006
Journals @OVID
Articles identi-fied through snowballing
• chronic disease(s) • disease management • self-care • self-management • self-efficacy
• tele health • tele care • tele monitoring • telephone system (subject heading) • telephone (subject heading)
115 articles in final review pool Representing 92 different studies
404 articles excluded in detailed review
395 articles excluded in abstract review
934 unique citations identified (Unable to locate 20)
Overall intervention descriptionOverall intervention description
115 articles covering 92 studies.
Median intervention sample size = 77
Median intervention duration = 4 months (range 1 day to 2 years).
82% of studies were conducted in the US
Intervention description – primary Intervention description – primary and secondary (N=92)and secondary (N=92)
0%
20%
40%
60%
80%
100%"L
ive"
hea
lth
pro
vider
Auto
mate
dIn
pers
on c
are
Inte
rnet
/w
eb-b
ase
d
Pri
nte
d/re
cord
ed m
ate
rials
Pro
act
ive p
eer
support
Pat
ient
init
iate
d c
alls
% o
f st
udie
s
Secondary intervention
Primary intervention
Conceptual schemaConceptual schema
Peer Support
CaseManagement
“Navigator”
Other
Counseling
Clinicaltreatment
Patient Education
Surveillance
Clinical Governance
Corporate Governance
Recruitment & Assessment
Integration
Quality Assurance & Monitoring
Human resources
Data and Analysis
Conceptual schemaConceptual schema
Peer Support
CaseManagement
“Navigator”
Other
Counseling
Clinicaltreatment
Patient Education
Surveillance
Studies’ condition focus (N=92)Studies’ condition focus (N=92)
Diabetes27%
COPD/Asthma5%
Central Nervous System
4%
Mixed11%
Arthritis3%
Mental Health - general
5%
Mental Health - addiction
13%
Mental Health - dual diagnosis
1%
HIV/AIDS1%
CVD - High Cholesterol
2%
CHF/CVD25%
Cancer3%
Effectiveness (N=75)Effectiveness (N=75) Comparison groups
– 37% multiple interventions, – 51% passive “usual care” – 12% active “usual care”
351 different health outcome measures
Categories: access, self-efficacy, knowledge, behavior, functional outcomes, physiologic outcomes, clinical guidelines, hospital utilization, ED utilization, medical office visits, costs and other healthcare utilization
Effectiveness (N=75)Effectiveness (N=75) Comparison groups
– 37% multiple interventions, – 51% passive “usual care” – 12% active “usual care”
351 different health outcome measures
Categories: access, self-efficacy, knowledge, behavior, functional outcomes, physiologic outcomes, clinical guidelines, hospital utilization, ED utilization, medical office visits, costs and other healthcare utilization
EffectivenessEffectiveness
0
20
40
60
80
100
Self-efficacy Behavior Functionaloutcomes
Physiologicoutcomes
Hospital utilization
Pe
rce
nt
of
ca
teg
ory
Significantly worse
Not significant
Some measures showsignificant improvement, some not significant
Significant improvement
Maintenance of effectMaintenance of effect
RepresentativenessRepresentativeness
Only 7% of articles sampled from a Only 7% of articles sampled from a real world settingreal world setting
Median sample size at intervention Median sample size at intervention completion was only 77completion was only 77
Population vs sample characteristics?Population vs sample characteristics?
EngagementEngagement Very few studies reported on Very few studies reported on
engagement engagement
Median drop out rate was 12%Median drop out rate was 12%
Median # successful calls/pt/month = Median # successful calls/pt/month = 1.7 (N=32)1.7 (N=32)
Median duration per interaction Median duration per interaction =20min (N=19).=20min (N=19).
LimitationsLimitations
Potential for publication bias not Potential for publication bias not evaluatedevaluated
English language onlyEnglish language only
No combined measure of effect size No combined measure of effect size as a meta-analysis was not as a meta-analysis was not undertakenundertaken
ConclusionsConclusions
Evidence insufficiently robustEvidence insufficiently robust
Potentially these services may Potentially these services may deliver superior - or at the very least deliver superior - or at the very least equivalent – outcomesequivalent – outcomes
Focus on patient outcomesFocus on patient outcomes
Policy implicationsPolicy implications
Rigorous and larger scale pilots:Rigorous and larger scale pilots:
$$
Robust specifications Robust specifications
TargetingTargeting
Appropriate financing model Appropriate financing model
Data collection and analysisData collection and analysis
This work would not have been possible This work would not have been possible without the support ofwithout the support of
The Commonwealth FundThe Commonwealth Fund
Assoc Prof Dean SchillingerAssoc Prof Dean SchillingerProf Andy BindmanProf Andy Bindman
Department of Internal MedicineDepartment of Internal MedicineSan Francisco General HospitalSan Francisco General Hospital
University of California San FranciscoUniversity of California San Francisco
Primary Health BranchPrimary Health BranchVictorian Department of Human Services, Victorian Department of Human Services,
AustraliaAustralia
Thank-youThank-you
Research implicationsResearch implications
Future studies should ensure: Future studies should ensure: Key information is included to allow Key information is included to allow
assessment of the generalizability of assessment of the generalizability of results results
Larger sample sizes Larger sample sizes Consistency and reporting on reach Consistency and reporting on reach
and effectiveness measuresand effectiveness measures Long-term monitoringLong-term monitoring Cost effectivenessCost effectiveness