To integrate or not to integrate? Future considerations for chronic disease self-management programs in the health care system

Objective: The growing burden of chronic disease and the increasing realisation that the current health system is ill equipped to deal with this trend has resulted in a health policy shift away from the traditional medical model to a more patient centred approach. As such, chronic disease self-management programs (CDSMP) have emerged as a potentially important component within this approach. Policy and program trends at the international level highlight several critical factors that need to be considered by governments and health care providers alike if CDSMP are to be integrated within the broader health system. This study reviewed international and local policy literature and sought perspectives from key stakeholders to determine the value and potential for integrating a generic group-based CDSMP into the care continuum.
Method: Prominent self-management policies were identified through a comprehensive literature search. Interviews were conducted with policy makers across Australia (n=20), health practitioners (n=20) and consumers (n=42) purposefully recruited from metropolitan and rural Victoria, representing key demographics of interest including low socioeconomic areas.
Results: Whilst CDSMP were viewed as having significant potential to be integrated into the health sector it was identified that the delivery and content of CDSMP needs to be flexible in order to address the needs of people across the disease, age and care continuums. Critical issues to be addressed if CDSMP are to be successfully integrated include increasing the profile of self-management; actively engaging and training health practitioners in self-management and overcoming system barriers such as lack of integrated referral pathways and networks.
Discussion: Policy directions at the national level suggest that self-management will be a centrepiece in forthcoming chronic disease initiatives. International evidence has highlighted the requirement for a ‘suite’ of programs to adequately cater to different stages of the disease continuum, age groups, ethnic backgrounds and sociogeographical areas. Furthermore engagement with key stakeholders (particularly GPs) is identified as critical to ensure the successful integration of CDSMP into the health system.
Conclusion: Evidence suggests that CDSMP is an important facet in improving care of people with chronic conditions. Findings from this study suggest that current infrastructure and policy direction, which have been found to be critical factors in facilitating integration of CDSMP into the health sector, are either absent or inadequate in Victoria. CDSMPs are currently lacking a sustainable workforce, referral infrastructure and specific policy. Such factors need to be addressed before the integration of CDSMP can be considered across the healthcare continuum in Victoria.

Who benefits most from participating in chronic disease self-management programs?

Objectives: To quantify the benefits that people receive from participating in self-management courses and identify subgroups that benefit most.
Research Design: People with a wide range of chronic conditions attending self-management courses (N=1,341 individuals) were administered the generic Health Education Impact Questionnaire (HEI-Q). Data were collected before the first session (baseline) and at the end of courses (follow-up) resulting in 842 complete responses. The median (interquartile range) age was 64 (54 to 73) years and most participants were female (75%). Outcomes were categorized as Substantial improvement (Effect Size, ES ≥ 0.5), Minimal/No change (ES -0.49 to 0.49) and Substantial decline (ES ≤ -0.5).
Results: On average, one third of participants reported substantial benefits after attending a self-management course. Proportions of participants reporting substantial benefits ranged from 49% in Skill and technique acquisition to 27% in Health service navigation. Stratification by gender, age and education showed that younger participants were more likely to benefit, particularly young women. No further subgroup differences were observed.
Conclusions: Given that the health of people with chronic diseases tends to decline, this evaluation is reassuring in that about one third of participants coming from a wide range of backgrounds receive substantial improvements in their self-management skills.

Risk factors for chronic insomnia following hospitalisation

Aim. This paper reports a study whose purpose was to determine whether there is an increase in the incidence of chronic insomnia following hospitalization and, if so, to identify patients at risk.

Background. The consequences of difficulty sleeping in hospital have received scant attention from clinicians or researchers. Implicit in this lack of interest is the assumption that difficulty in sleeping is a transient reaction to hospitalization that will resolve on discharge, an assumption not empirically supported. It has been argued that in susceptible people this type of temporary disruption to sleep can be the catalyst for the development of chronic insomnia.

Method. Established sleep and depression rating instruments were used to monitor the sleep of 57 cardiac and 29 orthopaedic patients after elective surgery (n = 86), recruited through a hospital preadmission clinic.

Results. Preadmission chronic insomnia of 10% was consistent with general population prevalence estimates of 6–12%. Three months after discharge the incidence had almost doubled to 19%. Sixty-one per cent of this variance could be explained by hyperarousal, sleep hygiene issues, and dysfunctional cognitions about sleep. Depression was found to be a salient predictor but not an independent risk factor. Age, sex, and hospital-related data, such as score for difficulty sleeping in hospital, proved to be statistically insignificant.

Conclusions. The results support the role of hyperarousal and dysfunctional sleep attitudes and behaviours as stronger predictors of chronic insomnia than patient demographics or environmental issues. Given that most of the patients were ambivalent about how they slept in hospital, with high satisfaction (71%) in the presence of significant disruption (63%), preadmission sleep education given to these patients prior to admission potentially contributed to the development of more realistic expectations of the quality of in-hospital sleep.

Optimising care for people with chronic disease : foreword

Chronic disease self-management emerged as an organised, formal entity in Australia in the 1980s, when a specific group-based program was introduced from the United States. This program, the Stanford Arthritis Self-Management Course, was promulgated in Australia and other countries by its creator, Professor Kate Lorig of Stanford University. The program showed much early promise, particularly with its dissemination and uptake by an enthusiastic non-government sector. Over subsequent years it has matured, and many other programs endeavouring to support patients to engage in self-management have been developed. In some ways, chronic disease self-management has become mainstream.1-3