Self-management & ehealth: the evidence. Dr. Jaap Trappenburg

Self-management & ehealth: the evidence Dr. Jaap Trappenburg

Self-management is hot!

What s in a name policy The chronic beast is approaching We need more self-management to strike increasing costs self-care shared-care paternalism

What s in a name Capacity Autonomy I am self-managed I want more autonomy

Self-management skills What s in a name Exposure Interventions / programs / support We provide selfmanagement support This will increase your health-related quality of life! stimulus

Self-management as a skill- Definition Self-management refers to the individual s ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition.. Barlow et al. 2002

Which abilities/skills? 1. Problem solving: analyzing situations and finding solutions for present and future 2. Decision making: steps in choice of action 3. Resource utilization: contact resource persons, use of health services 4. Formation of patiënt-provider relationship: active role and collaboration in the plan of care 5. Action planning: day-to-day activities and prevention of symptoms 6. Self-tailoring: self-monitoring of condition such as symptom monitoring Bourbeau et al. Patient Educ Couns 2004

Definition: self-management intervention Active stimulation of symptom monitoring or Transfer of information Enhancing problem solving skills (= anticipation) or Self-management Self-treatment interventions aim to equip Enhancing dietary intake or Enhancing smoking cessation General approach for each component should be enhancing patients active role and responsibility in plan of care patients with Resource skills to actively utilization 1 participate in the management of their chronic condition through at Stress / symptom + least 2 knowledge management acquisition and symptom monitoring, medication Enhancing management, decisionmaking or changing their health physical activity or behavior in order to function optimally. or Enhancing medication adherence

RCT s self-management (year)

Evidence for self-management Etc.

Evidence for self-management Chronic disease Metaanalysis Arthritis / Du et al. Chronic musculoskeletal 2011 pain # Included RCT s / patients 19/? Arthritis-related pain 4 months 6 months 12 months Key significant findings Disease specific outcomes Patient Reported Outcomes Healthcare utilization parameter pooled result parameter pooled result parameter pooled result SMD: -0.23 [-0.36,-0.10] SMD: -0.29 [-0.41,-0.17] SMD: -0.14 [-0.23,-0.04] Arthritis-related disability 12 months SMD: -0.17 [-0.27,-0.07] Asthma Gibson et al. 2003 36/4593 Nocturnal asthma Peak Flow (l/min) RR: 0.67 [0.56,0.79] WMD: 0.18 [0.07,0.29] HRQoL miscellaneous WMD: 0.29 [0.11,0.47] Hospitalization ER visits Days off work RR: 0.64 [0.50-0.82] RR: 0.82 [0.73,0.94] WMD: -0.18 [-0.28,-0.09] CHF COPD Jovicic et al. 2006 Effing et al. 2007 6/857 1-year readmission -all cause -CHF-related 15/2239 Dyspnea Borg scale WMD: -0.53 [-0.96,-0.10] HRQoL SGRQ total SMD: -2.58 [-5.14,-0.02] OR: 0.59 [0.44,0.88] OR: 0.44 [0.27,0.71] 1 respiratory-related hospital admission/year OR: 0.64 [0.47,0.89] DMII DMII not using insuline Hypertension Deakin et al. 2009 Malanda et al. 2012 Chodosh et al 2005 11/1532 HbA1c (%) 4-6 months 12-14 months 2 years FB glucose (mmol/l) 12-14 months Weight (kg) 12-14 months SBP (mmhg) 4-6 months WMD: -1.35 [-1.93,-0.78] WMD: -0.82 [-0.99,-0.65] WMD: -0.97 [-1.40,-0.54] WMD: -1.17 [-1.63,-0.72] WMD: -1.61 [-2.97,-0.25] WMD: -5.37 [-9.53,-1.21] 12/3259 HbA1c (%) 6 months WMD: -0.26 [-0.39,-0.13] 13/? SBP (mmhg) DBP (mmhg) PES: -0.39 [-0.51,-0.28] PES: -0.51 [-0.73,-0.30] Diabetes knowledge WMD: 1.0 [0.7, 1.2] Diabetes medication OR: 11.8 [5.2,26.9] Trappenburg et al. Patient Education Counseling 2013 Patients on longterm oral anticoagulation Garcia- Alamino et al. 2012 18/4723 Thromboembolic events All-cause mortality RR: 0.50 [0.36,0.69] RR: 0.64 [0.46,0.89]

UK: Whole System Demonstrator Multi-center cluster randomized trial in patients with COPD, diabetes and irritable bowel syndrom; n = 5599 Practice level training in a whole systems approach to self-management support Regular care (normal access) 12 months Kennedy et al. BMJ 2013

Self-management in COPD Substantial number of non-responders

Example: 3x Living well with COPD Canada 2007 The Netherlands 2012 N = 191 Recruitment: Secondary care > 1 hospital admision / last year Age: 69 ± 7 years FEV1lit: 0.99 ± 0.32 liters Low education: 77% N = 110 Recruitment: Primary care Age: 64 ± 9 years FEV1pred: 66 ± 17% Low education: 55% Admissions: -39% SGRQ: -3.5 (-6.5 to -0.5) Cost-savings: $2,149 Unscheduled contacts: 1.09 (0.42 to 2.81) CRQ: 0.22 ( 0.49 to 0.042) Bourbeau et al. Arch Int med 2003 Bischoff et al. BMJ 2012

Self-management is harmless? N= 426 Age 66 years FEV1: 38% pred Self-management 4 individual 90-minute weekly sessions Monthly telephonic reinforcement for 3 months Multiple topics + action plan (self-treatment) Regular care

Heterogeneity in content

So what do we know Heterogeneous programs Heterogeneous patients Large variance in effect size One size does not fit all

Tailored self-management Tailored self-management Etc

Disease management Self Patient E-learning Self-monitoring Decision making E-consultation Casemanagement EPD Surveillance Selfmanagement Case-management education Telemedicine E-therapy Monitoring Decision support Provider Care intensity / costs

Evidence for telehealth (meta-analysis) COPD Polisena et al. 2010 Telemonitoring or Telephone support McLean et al. 2011 Healthcare at a distance Low number of trials Low quality of trials Effects: None CHF Anker et al. 2011 Telemonitoring (invasive + non-invasive) Moderate number of trials Moderate to good quality of trials Effects: mortality, hospitalizations Diabetes Polisena et al. 2011 Telemonitoring or Telephone support Moderate to high number of trials Low to moderate quality of trials Effects: Glycaemic control, unscheduled healthcare contacts

Whole System Demonstrator Trial Pragmatic multi-center (n=238 GP s) cluster randomized trial, DM II, CHF, COPD; n = 3230 Philips Motiva Personal Healthcare System Tunstall RTX 3370 Viterion V100 Regular UK primary care 12 months Minimisation: practice size, disease prevalence, and other characteristics. Steventon et al. BMJ 2012

Results Steventon et al. BMJ 2012 (incremental costs 92.000 per QALY)

Mayo Clinics Multi-center randomized trial, patients at risk for hospitalization (frail elderly: incl. COPD, CHF) ; n = 205 Intel-GE Regular care (normal access) 12 months Takahashi et al. Arch Int Med 2012

Negative / adverse effects

Conclusion & recommendations Grote heterogeniteit in interventies, uitkomsten, populaties en resultaten. Samengeteld is hierdoor de bewijskracht voor (kosten-reductie van) zelfmanagement programma s en telehealth te diffuus om nu over te kunnen gaan tot grootschalige implementatie. Zelfmanagement/zelfzorg & telehealth (telemonitoring) zijn niet per definitie risicioloos. Er is te weinig kennis beschikbaar over welke programma karakteristieken de grootste effecten sorteren (Wat werkt?). Te weinig kennis over patiënt-gerelateerde factoren om onderscheid te kunnen maken in (Bij wie werkt wat?): non-responders van responders Compliantie van non-compliantie TAILORING!! Echter, bovenstaande kennis is nodig om inhoud, modus en dosis op maat te kunnen aanpassen aan de individuele patiënt en zodoende grotere effecten te sorteren. Complexe interventies dienen ontwikkeld en geëvalueerd te worden volgens pre-gespecificeerde kwaliteitsstandaarden: Non-inferioriteit (en kosten-neutraliteit) is de minimale ondergrens voor grootschalige implementatie.

TASTE: Research agenda

Thank you for your attention!

Etc. IPD meta-analysis Would you be willing to share your data? Study 1: exposure X COPD n = 22 CHF n = 33 Study 2: exposure X Success = f(exposure patient characteristics (effect modifiers)) Study 3: exposure Y