The prevalence of chronic diseases, such as osteoarthritis, is increasing in western countries where there is an ageing population. This has led to public and governmental concerns about both the associated morbidity and the high costs of medical and social care for patients with these conditions.
Self-management programmes have been taken up enthusiastically as a solution to this problem. They provide a combination of education and problem-solving techniques that aim to improve patients’ ability to manage their condition and interact better with doctors, resulting in improvements in confidence, quality of life and possibly reducing the use of healthcare resources.
There are a variety of models but the best known, developed by Dr Kate Lorig at Stanford, USA, involves a group intervention of six sessions run by lay facilitators who themselves have arthritis, with no health professionals involved.
Arthritis self-management programmes have been widely evaluated and found to have benefits including reduced pain and depression, increased exercise-capacity, better communication with doctors and increased self-efficacy (a concept that refers to the patient’s capacity to manage their disease). In some cases self-management has reduced health costs.
However, there have been some queries about the small numbers in some of the studies, the relatively short follow-up times and the use of self-report and non-validated measures.
Comparison across a range of studies is difficult because of the variety of interventions and the outcome measures used.
The UK government is keen on the idea of self-management for patients in primary care. It established a number of Expert Patient Programme (EPP) pilot schemes, which were introduced by 100 primary care services in 2001. EPP is a generic self-management programme for patients with a variety of chronic diseases including arthritis. It evolved from the original arthritis self-management programme.
Since the pilot phase of the EPP there have been two large randomised trials of self-management programmes in the UK. The first examined the effects of an arthritis-specific self-management programme on patients with osteoarthritis.
It showed a positive trend across all measures, but the only significantly positive outcomes at one year’s follow-up were reduction in anxiety and improvement in arthritis self-efficacy. There was no difference in rates of GP attendance.
Uptake was poorer than expected, with only just over half the intervention group attending the four or more sessions.
The DoH also commissioned a randomised trial to evaluate the generic EPP. It showed a moderate improvement in self-efficacy and small positive effects on energy, psychological well-being and health distress. There was no difference in health service use.
Although the results of these trials indicate a slight general benefit to participants, much of the impact appears to be on psychological well-being and perceived self-efficacy.
Publicity around self-management courses often quotes case histories of patients whose lives have been dramatically changed as a result of taking part. Those strongly motivated to volunteer are probably more likely to benefit.
Given the trial results, arthritis self-management programmes may be more beneficial for those with a stronger psychological component to their symptoms.
Broader approach needed
It is always difficult to assess which interventions are worth funding.
Given the limited benefit seen in UK trials, it is important to consider which patients are likely to attend and benefit before recommending that current self-management programmes are offered to all.
Such a ‘one size fits all’ approach is unlikely to achieve the government’s aims of empowering all patients to be ‘self-managers’ and reduce their healthcare costs. Patients may be demoralised by taking part in an intervention they do not find helpful.
Many clinicians and researchers are starting to suggest a broader approach to the question of self-management, with a variety of interventions available to suit different patients’ needs. For example, there is evidence of positive clinical benefit from some disease-specific programmes in asthma and diabetes, while pain and disability in osteoarthritis may respond better to exercise programmes involving health professionals. There is also some evidence supporting approaches that involve both patients and clinicians. Current programmes often fail to include the socially disadvantaged or ethnic minorities.
Unfortunately, the current UK trend is to roll out generic self-management programmes relatively uncritically.
The government recently transferred responsibility for the EPP to a limited Community Interest Company, which aims to provide the intervention for 100,000 patients by 2012. This may make it difficult to determine which are the most effective components of the current intervention and which types of patients are most likely to benefit from such an approach.
Dr Buszewicz is a GP assistant in North London and Senior Lecturer in Primary Care at University College London