Self ManagementSeeking the views of health professionals on translating chronic disease self-management models into practice
Introduction
Chronic disease (CD) is estimated to account for almost 80% of the total burden of disease and injury in Western countries [1], [2], [3]. Active partnership between health professionals and health service users have been associated with patients’ adherence to and satisfaction with treatment, and is seen as the central tenet of the management of CD [4]. In particular, an emphasis on self-management (SM), individual empowerment and patient-professional partnering in chronic illness management, has resulted in the development of a variety of generic and disease-specific SM models aimed to reduce health related costs and assist patients to develop skills and techniques to enhance their self-care, thereby improving patient outcomes (see [5], [6], [7] for recent reviews).
The SM models differ in a number of ways, such as mode of participant recruitment, delivery format, location, therapeutic approach and facilitator. In addition to traditional models of CDSM such as the Stanford Chronic Disease Self-Management Program (CDSMP) [8], more recent initiatives include individual-focussed strategies such as telephone coaching, health coaching and motivational interviewing [9], [10]. Alternative strategies that encompass both individual and group formats include internet based disease-specific CDSM courses, such as those promoted by the NSW Arthritis Foundation [11] and more recently by the National Health Service Expert Patients Program (EPP) [12]. Regardless of their design, common principles shared by the majority of SM approaches include linkage with community based resources, a client-centred collaborative approach, structured patient support such as goal setting and care plans, disease information and educational materials [13].
Evidence for the efficacy of SM models is mixed. A number of clinical trials have reported positive results [8], [14], [15]. For example, Lorig et al. [8] reported on findings from a Randomised Controlled Trial (RCT) of the CDSMP, which found significant improvements in self-reported health, amount of exercise and a reduction in hospitalisations. However, patients reported no differences in pain/physical discomfort, shortness of breath or psychological well-being compared to wait-list control subjects. Despite the positive findings reported by some clinical trials, questions remain regarding the efficacy of CDSM programs when adopted in everyday clinical practice [16], [17], [18], [19], [20]. For instance, in their recent 12-month RCT of an arthritis lay-led SM program, Buszewicz et al. found an increase in patient self-efficacy, but no significant reduction in health care utilisation, health related quality of life, or psychological health [16]. In addition, Kennedy et al. reported the findings of a national evaluation of the EPP, which again demonstrated modest gains in self-efficacy, but no significant reduction in health service utilisation [21]. Results such as these have led researchers to question the effectiveness of SM programs and their sustainability when translated into everyday practice [6], [16].
When efficacy studies have demonstrated evidence-based success, but failed to effectively replicate those results in clinical practice, concerns have been raised regarding program translation and external validity [22], [23], [24], [25], [26], [27]. It has been argued that disease-specific clinical trials commonly focus on the experiences and outcomes of the service user, usually concerned with only one chronic condition; rather than the reality of significant co-morbidities, regularly faced by patients and health professionals [28], [29]. When adapting to primary care settings, SM programs have faced setbacks and required various trade-offs sometimes resulting in “inadequate integration into primary care” [6, p. 84], leading to the recommendation that decisions regarding future study design be made in the context of patient, clinician and clinic preferences [30], [31].
Relatively little work specifically considers the views of clinicians and other health professionals with respect to the use of CDSM in their practice across a full range of chronic illnesses and yet, such perspectives are vital to the successful integration of CDSM programs into the workplace. Some studies have been conducted in the US and UK, either focusing on a specific chronic illness [32], [33] or professional discipline [34], [35], [36]. For instance, Blakeman et al. interviewed 16 British General Practitioners (GPs) regarding their perspectives on their involvement in the facilitation of CDSM [34]. They found that although GPs valued increased patient involvement, they were not convinced of the efficacy or applicability of CDSM programs, expressing a general reticence to refer patients; a major impediment to the successful inclusion of CDSM in patient care. Even fewer studies have focussed on the relevant issue of training and how this may influence the way in which SM models are applied in clinical practice [37], [38].
In summary, adequate translation of CDSM programs to the broader health care system requires a multidisciplinary approach, co-ordination of multiple health care services and engagement of both patients and health service professionals. Currently, few studies, and none in Australia, have examined the views and experiences of a broad range of professionals involved in the provision of CDSM assistance and advice, in the workplace. This qualitative study aims to address this gap in the current literature and contribute to the translation debate by asking health workers, who are either directly involved with, or manage staff who work with, patients with a broad range of chronic illnesses, specific questions about what elements of SM they use in their clinical practice, whether or not the clinicians had received formal SM training and what elements of CDSM were not considered useful.
Section snippets
Study setting and recruitment of participants
This Australian study was conducted within the State of Victoria's largest metropolitan health care service provider, which supports a greater population of 1.235 million people. The organisation was undergoing a large-scale health system re-design known then as Hospital Admission Risk Program Chronic Disease Management (HARP CDM). The major focus of HARP CDM was to “develop preventive models of care involving hospitals and community agencies which focused on people with chronic and complex
Response rates and characteristics of participants
Of the original 48 participants approached, 8 could not be contacted or were on leave, 5 refused to participate (1 cited work commitments, the remainder gave no reason) and 2 were no longer in the relevant role. Thirty-three individuals agreed to participate and provided informed consent, although 2 failed to arrive for interview and could not be re-booked, resulting in 31 interviewees (65% participation rate).
The majority of the participants were female (81%, see Table 1), within the 40–60
Discussion
The current qualitative study provides valuable insights from a multidisciplinary group of health professionals on using CDSM in the workplace. Clinicians in the current study reported using CDSM techniques in an eclectic fashion, focussing on five key elements: collaborative care; self-responsibility; individual situation; structured support, and linkage with health care networks. The findings have implications for training of health professionals and how evidence-based practice translates to
Conflict of interest
The authors state that there are no conflicts of interest.
Acknowledgements
The authors would like to thank Greg Young, Christine Jones and the HARP CDM Management Group for their support of the study, as well as the individuals who kindly agreed to be interviewed. The authors also thank the following Deakin University staff: Judy Buckingham, Sophia Liddy and Gay Magilton for their assistance with data collection. The views expressed in this paper are the views of the authors and not that of the health care provider.
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