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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Response to Bodenheimer, Kennedy, and Lorig
A response to Jerant et al.
Reply to Jerant
Issues to consider concerning the take up of CDSMP by health services
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Anthony F. Jerant, Sacramento, USA Associate Professor, UC Davis School of Medicine, Peter Franks
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While we are gratified to see interest in our study, we wish to clarify two points. First, Lorig and Bodenheimer suggest we painted an overly pessimistic picture of peer-led self-management interventions. We placed our findings in the context of the overall research evidence regarding effects of such interventions on mental and physical health status and health care utilization. These are the outcomes of greatest interest to health systems considering whether to devote precious resources to specific programs. We concluded the effects of our program on these outcomes were modest and short-lasting, consistent with prior literature. Others have reached similar conclusions. A 2007 Cochrane systematic review of peer-led self-management interventions (17 RCTs [7442 patients], including 7 of the CDSMP), summarized: “…these programmes may lead to modest, short-term improvements in patients' confidence to manage their condition and perceptions of their own health…whilst there were small improvements in pain, disability, fatigue and depression, the improvements were not clinically important. The programmes did not improve quality of life, alter the number of times patients visited their doctor or reduce the amount of time spent in hospital.”[1] The review concluded, “Overall there appears to be a mismatch between the available RCT evidence in support of these interventions and the enthusiasm with which they have been adopted by healthcare providers and consumers.”[1] Second, Kennedy and Bodenheimer suggest the modest effects of our intervention may have been due to the lack of group interaction. While we agree this is possible, strong indirect evidence suggests it is unlikely. Kennedy incorrectly states that a “negative” study of an Internet CDSMP variant also lacked a group component; actually, there was prominent group interaction in the form of moderated Internet bulletin board discussion groups.[2] Additionally, the Cochrane review did not find group programs more effective than others.[1] Finally, no RCTs have compared group with one-to-one delivery. Thus, aside from personal convictions regarding what Bodenheimer calls the “crucial group dynamic component of the CDSMP”, no research evidence supports the necessity of group interaction. We agree striving to optimize patient self-management is important. However, an evidence-oriented approach is needed to rationally inform health care policy, since every intervention has an opportunity cost – the lost opportunity to invest in the next best alternative.[3] To paraphrase Bodenheimer and Lorig, putting an overly positive spin on peer-led self- management is not helpful in moving the field of chronic illness care forward – and could end up holding the field back. References
Competing interests: None declared |
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Thomas Bodenheimer, San Francisco CA Physician at UCSF
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The article by Jerant et al. (Ann Fam Med 2009;7:319-327) represents an addition to the burgeoning literature on chronic disease self-management support, and specifically on the well-known Chronic Disease Self- Management Program (CDSMP). The CDSMP has traditionally been conducted with groups of patients, whose interactions with one another may be the most important feature of this highly innovative self-management support concept. The Jerant paper reported on the CDSMP conducted with a peer facilitator working one-on-one with a patient. The authors gave a negative twist to their conclusion even though some outcomes did improve for a limited period of time. It seems surprising that any positive outcome, even temporary, was achieved without the crucial group dynamic component of the CDSMP. More surprising was that the authors used the occasion of their study to raise doubts about the entire endeavor of peer-led, group-based, chronic disease self-management. A vibrant new phenomenon has appeared in the health care universe: the cluster of innovations involving peer support, group- based chronic disease care, chronic disease self-management in general, and the CDSMP in particular. The literature describing and evaluating these innovations provides examples demonstrating effectiveness of this broad range of novel interventions that encourage patients to become active partners in the management of their chronic conditions [1-4]. This cluster of innovations needs responsible evaluation that encourages healthcare organizations to implement those elements that work. Painting this entire arena of care with an negative brush does not help to move this field forward. References
Competing interests: None declared |
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Kate R Lorig, Palo Alto USA Professor Emeritu Stanford University
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Dr. Jerant and colleagues have presented us with a well-designed and implemented study. Unfortunately, the intervention they chose to investigate was not successful. As someone who helped to design the intervention, I have many thoughts about why it may have failed. Although I was involved in the design, I turned down the opportunity to be a co-author of this article because I do not agree with its conclusion, ”These findings challenge the suggestion, forwarded in several influential blueprints for health system redesign, that wider application of peer-led illness self-management programs would be cost-effective.” Self-Management is a proven and established component of chronic care. It is an essential component of the Chronic Care Model. It is one of the corner stones of the Patient-Centered Medical Home and the Vermont Blueprint for Health. The Stanford model programs are only a small portion of all the successful self-management programs many of which have been shown to affect health status and costs. For just the Stanford programs, we have had many studies, both randomized trials and longitudinal. These have shown consistently that self-management interventions improve health behaviors, improve symptoms and health status, and in some interventions, improve metabolic outcomes. There are also at least six studies that have demonstrated improvements in health care utilization. (1-9) Studies have taken place in countries as diverse as England and China, and in cultures as diverse as Hispanics and people from Bangladesh. Multiple federal agencies have made investments that have advanced the science behind self-management and at least two federal agencies, the Centers for Disease Control and Prevention and the Administration on Aging, are supporting widespread adoption of evidenced based self-management programs. Do we need to know more about these interventions? Do we need to know under what conditions they are successful and under what conditions they are not? Do we need new interventions? The answer to all of these is absolutely yes. However, to suggest that a whole field is suspect because of one failed study is not helpful. Dr. Jerant and his colleagues are to be congratulated on showing us one direction we do not need to pursue. 1. Richardson G, Kennedy A, Reeves D, Bower P, Lee V, Middleton E,
Gardner C, Gately C and Rogers A. Cost Effectiveness of the Expert
Patients Programme (EPP) for Patients with Chronic Conditions. Journal of
Epidemiology and Community Health, 62:361-367, 2008.
Competing interests: I receive royalties from Bull Publications and DeCabo Press |
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Anne Kennedy, UK Researcher University of Manchester, Anne Rogers, Pete Bower, Gerry Richardson
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Variants of the CDSMP courses developed by Lorig and colleagues at Stanford University have now been subjected to a number of trials and evaluations around the world. It is important to have the results of an RCT with predesignated primary outcomes run by researchers independent of the development team and the modest effectiveness achieved in this study is in accord with other research. The important issue raised in this paper is whether the peer-led CDSMP approach should be taken up by health systems. Self-efficacy is the one outcome that shows consistent improvement in trials of CDSMP – but there is a lack of consensus about how important this outcome is for patients, professional and service managers. We have shown that patients value feelings of self-efficacy and are willing to trade it for health-related quality of life.1 Nevertheless, it remains to be seen whether impacts on self-efficacy will attract the interest of those who fund services. We think there are a few additional issues to consider: 1. There is concern that investing in such programmes has the potential to increase inequity – studies have shown that the approach appeals to white, middle class females and that it is difficult to engage people from more disadvantaged sectors of the community.2 2. In the UK, the Expert Patients Programme (the CDSMP was a key element) was initially promoted as a ‘one-size-fits-all’ solution to the provision of self care support in the UK.3 We would agree with the authors that identification of the groups for whom the course works is a priority, so that it can be effectively targeted.4 3. The EPP (and CDSMP) were originally conceived as group therapies. The effectiveness (or lack of effectiveness) in this study may be influenced by the mode of delivery of the intervention; the only other study investigating CDSMP outside a group environment5 also showed very little impact on outcomes. 4. One limitation of the CDSMP is that the intervention is not linked to routine health services provision, which may in part account for the lack of effect on health outcomes and routine utilisation. People with long-term conditions generally expect close contact and support from the health service. We are currently evaluating a primary care based self- management intervention which seeks to link self-management support more closely with routine care for long-term conditions.6 5. There is also a need to think beyond health services provision to take account of how naturally occurring self care resources in communities, the workplace and social networks can be used to provide more tailored, acceptable and appropriate self care support. The role of social determinants and inequalities in shaping behavioural responses and health outcomes is one issue which needs to be considered in approaches to SMS and how information can join up in a recursive way with provision in health service systems. Reference List
Competing interests: None declared |
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