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Electronic letters published:
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Author's response
Elders face Complex Problems in Chronic Disease Self-Management
A Call for Conceptual Clarify
Towards a research agenda on multimorbidity
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Elizabeth A. Bayliss, Denver, CO, USA Clinician Researcher, Kaiser Permanente and UCHSC
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We agree with Dr. Riegel (and Wilson and Cleary) that general health status and physical functioning do not in themselves define QOL, but are contributors to this multidimensional concept. Our choice of ‘barriers’ to investigate came from patients themselves in a previous qualitative investigation that provides a broad working definition of self-management (also briefly footnoted in our figure).(1) Unfortunately we did not have the ability in the current investigation to explore the question of what the mechanisms are behind the barriers’ association with decreased health status and physical functioning. This important question will need to be addressed in future studies in order to design subsequent trials to test new processes of care. Dr. Fortin is correct that we can only generalize our results to populations with the characteristics of our survey respondents. Although we were somewhat reassured that non-respondents to our survey had similar morbidity levels as non-respondents, our respondents were slightly younger than non-respondents. Not only may older persons experience different barriers to self-management, they may prioritize care outcomes differently than younger persons. There are certainly plenty of non-geriatric persons who wrestle with the complexities of managing multimorbidity and their process-of-care needs should be explored as well. We see this investigation as adding piece to the small (but growing) evidence base for providing the best possible care to complex patients. As Mr. Goldstein points out, it will require multidisciplinary teams to deliver ‘best care’ for complex and multimorbid patients. While disease- specific care goals are often still relevant; these goals must be considered in the appropriate context. Nurse care managers will likely play leading roles in determining which patients need what levels of care management at what times; as well as in delivering this care. (1) Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Annals of Family Medicine 2003;1(1):15-21. Competing interests: None declared |
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Perry C. Goldstein, Boca Raton, USA Graduate Student, Christine E. Lynn College of Nursing, Florida Atlantic University
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Congratulations to Drs Bayliss and Steiner and Ms. Ellis on highlighting an important problem in conceptualizing disease self- management in older patients; multifaceted problems require attention to multiple issues including financial, psychosocial and medical concerns. With declining resources and the number of older patients with chronic diseases estimated to grow to 100 million by 2030, it is clear that healthcare providers will need to focus on comprehensive assessments and interventions which enhance effective management of disease in this population(1). Some in the managed care industry have naively suggested that information provided through online, self-management websites may be a cost-effective solution to assist patients in chronic disease management(2). Thankfully, the authors clearly demonstrate that simplistic, single-minded solutions to this complex problem are likely to fail. Dealing with depression, low perceptions of self-efficacy, and being overwhelmed by financial burdens of disease require a multidisciplinary treatment approach; physicians alone cannot be expected to achieve positive outcomes in this situation. Multiple research studies have demonstrated that specially trained nurse practitioners decrease morbidity, enhance quality of life and function as effective “disease managers” working within specialty group practices, assisting patients with medication teaching, depression related to medical illness, and issues related to symptom management(3). I eagerly await further reports from these authors, targeted towards effective methods and systems to reduce barriers to disease self-management which they have so thoughtfully elucidated. References 1.Redman, B.K. (2004). Patient self-management of chronic disease: The health care provider's challenge. Sudbury: Jones and Bartlett. 2.Greenhut, G. (2007).Patients learn chronic disease self-management online. Medscape (Online CME/CE) June 25, 2007. Retrieved January 2, 2008 from: http://www.medscape.com/viewprogram/7315_pnt 3.Goldstein, P.C. (2006). Impact of disease management programs on hospital and community nursing practice. Nursing Economics, 24(6); 308-313. Competing interests: None declared |
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Barbara J. Riegel, Philadelphia, PA Associate Professor, School of Nursing, University of Pennsylvania
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The basic premise of this study is solid—multiple comorbid conditions make it challenging for patients to care for their illnesses, and Bayliss et al are to be commended for calling our attention to this issue. They surveyed a sample of 352 HMO members to quantify the contributions of disease burden and self-management barriers to health status and physical functioning in persons with at least three major illnesses (diabetes, depression, osteoarthritis). Health status and physical functioning are assumed to reflect quality of life (QOL), although the concept of QOL is never defined. The lack of a definition for QOL was problematic for me, as there are numerous definitions of QOL in the literature. For example, Wilson and Cleary1 include health status and physical functioning in their QOL model, but they define QOL as subjective well-being related to how happy or satisfied someone is with life as a whole. This definition suggests that health status and physical functioning contribute to overall QOL but they are not synonymous with it. The emphasis of the study was on identifying which self-management barriers were most predictive of health status and physical functioning. They assessed self-efficacy, health literacy, multiple conditions, feeling overwhelmed by a specific condition, knowledge about conditions, financial constraints, social activity, patient-clinician communication, medication knowledge, medication adherence, compound effects of medications, and demographic characteristics. These are important factors known to influence self-care, so the goal of determining their combined contribution to outcomes is laudable. However, self-management also was never defined. If we assume that the authors are referring to patients’ abilities to follow the treatment plan and manage their illnesses, I have trouble equating medication adherence with the other variables. That is, financial constraints may well influence medication adherence, which may affect health status and physical functioning. If this is the way that the authors conceptualized the process, the analysis used did not do justice to their conceptual model. In summary, this is an important area that needs further study. I would hope that the investigators would continue to work in this area. Future work could be strengthened by defining variables and clearly conceptualizing the processes to be tested. 1. Wilson IB, Cleary PD. Linking clinical variables with health- related quality of life. A conceptual model of patient outcomes. JAMA. 1995;273(1):59-65. Competing interests: None declared |
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Martin Fortin, Saguenay, Canada Family doctor and researcher
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Physicians caring for patients with chronic conditions try to enhance the functional status of these patients, minimize their symptoms, and reduce their disability. But when patients present with multiple chronic conditions, physicians are also facing many other problems such as the risk of poly-medication, difficult self-care, difficulties with observance and difficulty to achieve continuity of care. Implementing interventions addressing all these disease-related problems may give the impression that a comprehensive care is provided. Bayliss and colleagues, however, call our attention to psychosocial factors that affect the overall health status of senior patients with multimorbidity and that may be overseen while managing medical diseases. This widened vision of the problem of multimorbidity gives us a better idea of the complexity of the management of these patients. An interesting aspect of these findings is that many factors pointed out by Bayliss and colleagues are amenable to intervention to improve health outcomes. However, the low response rate in this study is an issue of concern. Previous studies have shown that being a non-respondent is associated with bad outcomes and especially lower functional status among seniors (1). Surveying this population could have revealed different results, opening the door to even more targeted intervention. Surveying younger people would also be very important as they may have different barriers to self management. The prevalence of multimorbidity among younger people is also of concern (2). Bayliss’ paper is a call to continue focussing on this vulnerable population of patients with multimorbidity through longitudinal studies because time is a factor that may influence health outcomes. Cause and effect relationship between variables can only be confirmed by longitudinal designs. The door is open to widen the research agenda on multimorbidity. “The time has come not only to include people of all ages with multimorbidity in research efforts, but also to focus on improving the care of this vulnerable population” (3). References 1. Hebert R, Bravo G, Korner-Bitensky N, Voyer L. Refusal and information bias associated with postal questionnaires and face-to-face interviews in very elderly subjects. J Clin Epidemiol 1996;49:373-81. 2. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3:223-8. 3. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity's many challenges. BMJ 2007;334:1016-7. Competing interests: None declared |
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