Transcript Effectiveness

Choice, Risk, and
Accountability
Jim Phillips & Bob Sang
[How] Can Expert
Patients Help Provide
Solutions for PCTs’
Priority Challenges?
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Improving Effectiveness is Key
PREVENTION
INFORMED
PROMOTION
BETTER
OUTCOMES
EQUITABLE
INTERACTION
ACCESS
RECOVERY
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IMPROVED
EFFICIENCY
So, “Why Bother?”
• Section 11
• “Choice”
• The Evidence …….
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Confident, knowledgeable patients
have fewer hospitalisations and enjoy
improved health status
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Benefits of self management/self care
evidence from around the world
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Doctor visits reduced by 30 to 40%
Reduction in outpatient visits by 17%
Hospital length of stay reduced by 50%
Angina attacks reduced by 50%
Improved health risk scores for heart attacks and diabetes
Improved health status, such as increased fitness, improved
mobility
• Reduction in stress and anxiety
• Days off work reduced by 50%
• Increase in medicine compliance to 85%
Average cost: savings ratio = 1 : 1.5 to 10 (Lorig KR, Sobel DS, Effective Clin Practice 2001;4:256-262)
i.e. for every £100 spent, savings = £150 to £1000 net of risks
Above figures supplied by Department of Economic and Operational Research (EOR)
DoH. A a range of studies are listed in appendix slides. There is a further
discussion on self management research and evidence on the Expert Patients
Programme web site.
www.expertpatients.nhs.uk
The key findings so far –
EPP emerging trends
 10% more take medicine as prescribed
 30% of the people showed significant reduction in
feeling of depression
 30% showed reduction in feeling of “lacking in
energy”
 felt intensity of pain, breathlessness, tiredness and
depression less for 20 to 30% of the people
 increase in confidence levels for 30 to 50% of the
people that they would not let pain, breathlessness,
tiredness or depression interfere with their lives
 9% fewer visits to GPs
These are emerging findings from the internal audit of the Expert Patient program being carried out by the DoH and are
based on the first PCTs to join the pilot at 4 month follow up a. Whilst provisional and not part of a RCT they clearly show
a trend in line with the evidence base from the US and Kaiser Permanente. A full write up of these will be provided on the
Expert patients web site.
www.expertpatients.nhs.uk
The key findings so farEPP the emerging trends
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6% fewer visits to A&E
9% fewer visits to outpatients
15% increase in visits to pharmacists
17% reduction in number of days off work (by 204 days)
6% increase in number of people using health
information
 30% increase in number of people feeling better
prepared for consultations with care professionals.
These are emerging findings from the internal audit of the Expert Patient program being carried out by the DoH and are
based on the first PCTs to join the pilot at 4 month follow up a. Whilst provisional and not part of a RCT they
clearly show a trend in line with the evidence base from the US and Kaiser Permanente. A full write up of these will
be provided on the Expert patients web site.
www.expertpatients.nhs.uk
Living with Chronic Disease
3 Key Tasks
• Managing the illness
• Taking medications
• Changing diet and exercise
• Managing symptoms of pain, fatigue, insomnia,
shortness of breath, etc.
• Making best use of health care available
• Managing daily activities and roles
• Maintaining roles as spouse, parent, employment,
etc.
• Managing the emotional changes
• Managing anger, fear, depression, anxiety, etc.
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From Expert Patients Program leaders manual
person and professional in
partnership
• Be aware of the possible
social/psychological/physical impact of condition
• Identify lifestyle and psychological barriers to
managing condition
• Identify behaviour changes needed (diet, exercise)
• determine the areas in which changes are
possible
• Identify system determinates- CHOICE
• develop care plan and goals based on persons
ability to engage.
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Empowering
Doctor
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good listener
clear communicator
works in partnership
resource facilitator
monitors condition
outward focused
problem solver
validates patients
experience
 honest
 nurturers respect
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Expert Patient
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good listener
clear communicator
works in partnership
resource finder
monitors condition
outward focussed
problem solver
maintains physical and
emotional well being
 partner in care
 confident
25% decrease in
professional care
20% care managed by health
system
80% of symptoms and
care are self managed
5% increase in self managed
care
Kemper D et al 1992. see also Williams JD, Danaher K, 1978
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Improved efficiency
Attitudes
Beliefs
Moods
Health
Behavior
Change
Health
Outcomes
Effectiveness
Adapted from Lorig K, Arthritis and
Rheumatism. 1989;32:91-95
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“Everyone else – the professionals, my
children and my friends – feel they’re being
very open and up-front referring to me as
disabled and discussing how I’m going to
cope not doing the things I used to.
I’d like people to concentrate on what I can
do and explore with me (rather than for me)
the possibilities for what things I can
improve - not how they are going to
deteriorate.”
Participant on expert patient course
www.expertpatients.nhs.uk
Background – supporting evidence see in particular
the work of Lorig K, Fries J and Barlow J
Author and description
Vickery et al
The effect of Self-care interventions on the use of medical
services within a Medicare population
Effectiveness in health outcomes and health service utilisation
Doctor visits reduced 31%
Lorig et al
Can a back pain e-mail discussion group improve health
status and lower health care costs (unpublished)
Doctor visits decreased 46%
Participants had improvements in pain, disability, and role function
and health distress.
Swindon Communication project trust (SCAMP) Project
report
Very high user satisfaction. Has been effective in decreasing social
isolation.
Lorig et al
Evidence suggesting that a chronic disease self
management programme can improve health status while
reducing hospitalisation
Improved self-confidence, social role, exercise.
Reduced fatigue, health service use
Montgomery et al
Patient education and health promotion can be effective in
Parkinson’s disease: a randomised control trial.
Clinical improvement 10%: days confined to home decreased 28%.
Doctors visits reduced 24%, hospitalisation decreased by 50%
Fries et al
Randomised control trial of cost reductions from a health
education programme
Improved health risk scorers. Improved medical care utilisation.
Levin R
A randomised control trial comparing a Cognitive
behavioural angina management programme with a
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education
session
Reduced anxiety depression. Reduced frequency of angina attacks
and use of glyceryl trinitrate. Positive changes to diet and exercise
Author and description
Effectiveness in health outcomes and health service
utilisation
Fries J et al
Patient education in arthritis: Randomised controlled trial
of a mail delivered programme.
Decrease in pain, improvement in function, increased self efficacy
and exercise. Days of work or confined to home reduced 52%.
improvements last up to one year
E Grossel T Cronan Cost analysis of self management
program for people with chronic illness
Improved heath status and self-efficacy.
Most effective was a combination of education and support group.
This fits in well with the proposal to develop Self-care networks
Leigh P
Randomised controlled study of a retiree health
promotion program
7% decrease in physician visits.
50% participation in programme and 85% retention of
participants.
Improved health status and behaviours
Fries J
Health risk changes with a low cost individualised health
promotion program: effects up to 30 months
Progressive health improvements particularly around changes
over time in diet and exercise, improvements in cholesterol levels
and stress
Moore j et al
Effect of a Self-care book on physician visits
Total medical visits reduced by 7.5%
Lorig et al
A work place health education programme that reduces
outpatient visits.
Overall reduction of 7.2% in visits to outpatients. With 17% in
reduction found in one group
Barlow & Barefoot (1996)
Increase in exercise exercised. Reduction in depression and
increased self confidence
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Author and description
Effectiveness in health outcomes and health service utilisation
Barlow et al. (1998a & 1998b)
Significant improvements on pain, depression, anxiety, illness
acceptance, self-efficacy, cognitive symptom management &
communication with physician. Changes still apparent 12 months
on.
Barlow et al. (1999)
At 4 months: significant improvements on pain, self-efficacy,
cognitive symptom management & communication with physician.
Also, significant improvements on exercise and relaxation.
Braden, C (1991) Whether SLE education intervention
changes patterns of learned response.
Participants demonstrated a significant change in learned response
over time with uncertainty & depression (both decreasing) and
enabling skills, self-efficacy & self-worth (all increasing) contributing
to the significant change over time.
Significant improvements over time in knowledge, range and
number of rest, relaxation, heat & exercise activities.
Cohen et al. (1986) Comparison of lay-instructed and
health professional-instructed versions of the ASMP and
compare outcomes against a control group.
Increased knowledge & exercise. No differences in outcome
measures between groups led by lay people and professionals.
Lorig et al. (1986) To compare lay-taught and health
professional-taught versions of the ASMP and compare
outcomes against a control group.
Improvements in exercise, relaxation, knowledge. Less disability.
No difference whether lay or professionally led
Lorig et al. (1999) To evaluate the an arthritis Self-care
intervention among Spanish speaking participants.
At 12 months compared with baseline: significant effects on pain,
disability, general health, depression, self-efficacy, exercise.
Lorig & Holman (1989) To evaluate the effects of
reinforcement efforts on ASMP outcomes.
significant improvements on pain (20%), depression (13%), &
physician visits (35%).
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Author and description
Effectiveness in health outcomes and health service utilisation
Barlow et al. (1998a & 1998b)
Significant improvements on pain, depression, anxiety, illness
acceptance, self-efficacy, cognitive symptom management &
communication with physician. Changes still apparent 12 months
on.
Barlow et al. (1999)
At 4 months: significant improvements on pain, self-efficacy,
cognitive symptom management & communication with physician.
Also, significant improvements on exercise and relaxation.
Braden, C (1991) Whether SLE education intervention
changes patterns of learned response.
Participants demonstrated a significant change in learned response
over time with uncertainty & depression (both decreasing) and
enabling skills, self-efficacy & self-worth (all increasing) contributing
to the significant change over time.
Significant improvements over time in knowledge, range and
number of rest, relaxation, heat & exercise activities.
Cohen et al. (1986) Comparison of lay-instructed and
health professional-instructed versions of the ASMP and
compare outcomes against a control group.
Increased knowledge & exercise. No differences in outcome
measures between groups led by lay people and professionals.
Lorig et al. (1986) To compare lay-taught and health
professional-taught versions of the ASMP and compare
outcomes against a control group.
Improvements in exercise, relaxation, knowledge. Less disability. No
difference whether lay or professionally led
Lorig et al. (1999) To evaluate the an arthritis Self-care
intervention among Spanish speaking participants.
At 12 months compared with baseline: significant effects on pain,
disability, general health, depression, self-efficacy, exercise.
Lorig & Holman (1989) To evaluate the effects of
reinforcement efforts on ASMP outcomes.
significant improvements on pain (20%), depression (13%), &
physician visits (35%).
www.expertpatients.nhs.uk
Author and description
Effectiveness in health outcomes and health service utilisation
Lorig et al. (1993)
To evaluate the effects of the ASMP outcomes over a 4
year period.
Significantly less pain ( 19% -22%); fewer visits to physicians (42%
-44%); improved self efficacy (17% -34%).
Simeoni et al. (1995)
To evaluate the effectiveness of a community based
arthritis education programme.
At 6 months compared with baseline:
Group 1: significantly increased knowledge & satisfaction with
physical ability.
Bailey et al. (1999)
community service asthma education programme with
respect to improving asthma knowledge, promoting
compliance with medication and morbidity reduction.
Significantly increased knowledge, better compliance with
medication, lower symptom severity.
Boulet et al. (1995)
Program for asthmatics with respect to increase in
knowledge of asthma and self-management skills.
Emphasis on criteria recognition for control or loss of
control.
Significantly higher knowledge, quality of life (symptoms &
emotions); significantly lower ER visits, work absenteeism.
Charlton et al. (1990)
To evaluate a peak flow and a symptoms only selfmanagement plan for controlling asthma.
Significant reductions in salbutamol treatment.
Significant reductions in doctor consultations, oral steroid use.
Improvements were broadly consistent for both adults & children
Choy et al. (1999)
Pilot study to evaluate hospital based education
programme with respect to self-management skills &
morbidity with a group of low socioeconomic status &
education level.
At 12 months compared with baseline:
Significant improvement on hospitalisations, family physician visits,
Accident & Emergency visits, patients self-rating of their asthma
control.
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Author and description
Effectiveness in health outcomes and health service
utilisation
D’Souza et al.(1998)
To assess the effectiveness of the ‘credit card plan’ 6
month community based asthma programme, 2 yrs
after the end of the programme with respect to GP
visits, hospital visits & admissions, & asthma
morbidity.
At 18 months & 30 months:
Significantly fewer patients making routine GP visits,
emergency visits to GP & being woken most nights by asthma
during previous 12 months.
Gillies et al. (1996)
to determine the effect of introducing an action plan to
children with mild to moderate asthma, who have
never used a plan before.
Second 8 weeks of plan compared with prior to plan:
significant improvement for nights woken, days on steroids,
days on reliever inhalers, nebuliser use, GP visits, days out of
action.
Parents: 90% of parents felt plan had led to overall
improvement in their management of the child’s asthma; 88%
more confidence in managing child’s asthma.
Jenkinson et al. (1988)
To evaluate effects on self-management of book, tape
& book with tape given to patients by GP with no other
intervention.
Significant improvement in knowledge; reduced perceived
disability (significance not reported).
Kotses et al. (1996)
To compare the effectiveness of personalized selfmanagement programs based on patient recording
procedures with that of an established group asthma
self-management program, the Wheezers Anonymous
program
Significant improvement in morning peak flow.
Significant improvement in morning asthma attacks. For both
group and those using personalized plans
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Author and description
Effectiveness in health outcomes and health service
utilisation
J.Fries et al
Reducing need and demand for medical services
in high risk groups
Physician use decreased .8 visits in 6 months,
illness duration reduced .9 days
Vickery et al
Effect of Self-care education programme on
medical visits
Total medical visits reduced 17%, visits for minor illnesses
decreased 31%
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