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Abstract
Although enthusiasm is growing for self-management programs for chronic conditions,
there are conflicting data regarding their effectiveness and no agreement on their
essential components.
To assess the effectiveness and essential components of self-management programs for
hypertension, osteoarthritis, and diabetes mellitus.
The authors searched multiple sources dated through September 2004, including the
Cochrane Library, MEDLINE, PsycINFO, and Nursing and Allied Health databases, and
bibliographies of 87 previous reviews.
Randomized trials that compared outcomes of self-management interventions with a control
or with usual care for diabetes mellitus, osteoarthritis, or hypertension; outcomes
included hemoglobin A1c level, fasting blood glucose level, weight, blood pressure,
pain, or function.
Two reviewers independently identified trials and extracted data regarding whether
the intervention used tailored adjustments to meet individual patient needs, a group
setting, feedback, and psychological services, and whether the intervention was provided
by the patient's usual physician.
Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis
(26 diabetes studies, 14 osteoarthritis studies, and 13 hypertension studies). Self-management
interventions led to a statistically and clinically significant pooled effect size
of -0.36 (95% CI, -0.52 to -0.21) for hemoglobin A1c, equivalent to a reduction in
hemoglobin A1c level of about 0.81%. Self-management interventions decreased systolic
blood pressure by 5 mm Hg (effect size, -0.39 [CI, -0.51 to -0.28]) and decreased
diastolic blood pressure by 4.3 mm Hg (effect size, -0.51 [CI, -0.73 to -0.30]). Pooled
effects of self-management interventions were statistically significant but clinically
trivial for pain and function outcomes for osteoarthritis. No consistent results supported
any of the 5 characteristics examined as essential for program success.
Studies had variable quality, and possible publication bias was evident.
Self-management programs for diabetes mellitus and hypertension probably produce clinically
important benefits. The elements of the programs most responsible for benefits cannot
be determined from existing data, and this inhibits specification of optimally effective
or cost-effective programs. Osteoarthritis self-management programs do not appear
to have clinically beneficial effects on pain or function.
[1
]From Southern California Evidence-based Practice Center (RAND Health Division), Santa
Monica, and University of California, Los Angeles, and the Greater Los Angeles Veterans
Affairs Healthcare System, Los Angeles, California.