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Studies examine barriers to self-management for patients with chronic illness and interventions that improve care

About half of the population in the United States (90 million people) live with one or more chronic illnesses such as diabetes, arthritis, depression, or congestive heart failure. A common aim of care models, such as the Chronic Care Model, is to involve patients in their care and to encourage them to follow sometimes complex self-care regimens to better manage their illness. A new study supported by the Agency for Healthcare Research and Quality (HS13603) identified several barriers to patient self-management. These ranged from depression and difficulty exercising to fatigue, pain, and financial problems. A second AHRQ-supported study (HS00059 and HS14151) found that interventions that contained at least one element of the Chronic Care Model improved outcomes and care for the chronically ill. Both studies are discussed here.

Jerant, A.F., von Friederichs-Fitzwater, M.M., and Moore, M. (2005, June). "Patients' perceived barriers to active self-management of chronic conditions." Patient Education and Counseling 57, pp. 300-307.

Active self-management of chronic diseases often includes exercise and diet to reduce blood sugar, high blood pressure, and arthritic symptoms. Discussions with 54 chronically ill people in 10 focus groups revealed their thoughts about barriers to active self-management of their illnesses. The focus groups addressed perceived barriers to active self-management and to self-management support services and resources.

Focus group participants cited depression, pain, problems controlling weight, difficulty exercising regularly, and fatigue as barriers to self-management. They also cited lack of support from family, financial problems, and poor communication with physicians. Some felt rushed through doctor visits so that they could not gain adequate understanding of their diseases and how best to manage them.

The most common barriers to accessing self-management support resources, such as local cardiac rehabilitation programs or fitness centers, were lack of awareness of the resources, physical symptoms that limited mobility, transportation problems, and cost or lack of insurance coverage for certain resources. The researchers suggest that many of these barriers could be overcome through home-delivered programs, in which most participants expressed interest.

Tsai, A.C., Morton, S.C., Mangione, C.M., and Keeler, E.B. (2005, August). "A meta-analysis of interventions to improve care for chronic illnesses." The American Journal of Managed Care 11, pp. 478-488.

The Chronic Care Model (CCM) is aimed at improving the primary care of patients with chronic illnesses by fostering more productive interactions between prepared, proactive clinical teams and well-informed, motivated patients. The CCM identifies six elements deemed to be essential for providing high quality care to patients with chronic diseases: delivery system design (for example, care delivery/coordination and care management roles), self-management support (patient education and collaborative decisionmaking with patients), decision support (provider education and expert consultation support), clinical information systems for care management, community resources for patients and community, and health care organization (leadership support and provider participation). According to this study, clinical interventions that contain at least one element of the CCM improve outcomes and care for the chronically ill.

Researchers identified recently published systematic reviews and meta-analyses of four chronic illnesses: asthma, congestive heart failure (CHF), non-insulin dependent diabetes, and depression. They extracted data on clinical outcomes, quality of life, and processes of care for a meta-analysis of 112 studies: asthma, 27 studies; CHF, 21 studies; depression, 33 studies; and diabetes, 31 studies. The researchers found that interventions with at least one CCM element had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied.

For example, interventions with at least one CCM element directed at diabetes care led to a 0.30 percent to 0.47 percent reduction in HbA1c (blood glucose) levels. Interventions directed at CHF led to a 5.6- to 6.7-point improvement in Chronic Heart Failure Questionnaire responses, slightly less than the 7- to 9-point difference that is regarded as a minimal clinically important difference on that scale.

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