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%

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ive p

eer

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ient

init

iate

d c

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% 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