計劃伙伴 Project Partners Evaluation of CADENZA Community Project: Chronic Disease Self-Management Programme (CDSMP) Wayne Chan Physiotherapist, CADENZA

計劃伙伴 Project Partners

Evaluation of CADENZA Community Project: Chronic Disease

Self-Management Programme (CDSMP)

Wayne ChanPhysiotherapist, CADENZA

Introduction


Prevalence of chronic diseases in older adultsPrevalence of chronic diseases in older adults

• More than 700,000 older adults in Hong Kong have one or more chronic disease

(Census & Statistics Department, 2005)


Burden of chronic diseasesBurden of chronic diseases

• Healthcare system:– overload healthcare services– increase healthcare expenditure

• Patients:– lack of self-management knowledge and skills– lack of support in the community– comorbidities in older adults


Chronic Disease Self-Management Chronic Disease Self-Management Programme (CDSMP)Programme (CDSMP)

• A widely accepted education programme developed by Dr. Kate Lorig and colleagues at Stanford University

• Attempted to improve self-efficacy, health-related behaviours, health status and reduce healthcare utilization

• Based on self-efficacy theory


What is self-efficacy?What is self-efficacy?

• Self-efficacy is the confidence of individuals in completing a specific task to achieve a desired goal

• Higher self-efficacy indicates greater motivation of individuals to improve their health-related behaviours, which may in turn improve their health status and reduce their reliance on healthcare services

(Bandura, 1997)


Features of CDSMPFeatures of CDSMP

• Generic, non disease-specific• Community-based• “Self-management toolbox” – a set of self-

management skills for managing symptoms, daily problems, and other physical and psychosocial consequences caused by chronic diseases

• Lay persons with chronic diseases as programme leaders


CADENZA Community ProjectCADENZA Community Project

• “CADENZA: A Jockey Club Initiative for Seniors” supported a CDSMP programme conducted by the Salvation Army

• The effectiveness of the programme was evaluated by the Cadenza Research Team working with Dr. Elsie Hui of Shatin Hospital


Project partners and work flowProject partners and work flow

CADENZA research team

The Salvation Army Shatin Hospital

Steering Committee

Leaders trainingCDSMP in community elderly centres

Evaluation

Professional staff and Elder lay leaders

Professional staff-led programme

Elder lay-ledprogramme


Programme formatProgramme format

• 6 sessions, 2.5 hours each, 1 session per week

• 10-12 participants per group

• Held in community elderly centres of various NGOs in NTE districts

• Led by 2-3 trained professional staff or elder lay leaders


Features of leaders trainingFeatures of leaders training

• All professional staff and elder lay leaders underwent 4-days leaders training

• Skills were practiced in real situation by leading “placement groups”

• Guidance was provided by experienced master trainers and leaders (coaching team)


Methodology


MethodologyMethodology

• Compare the changes in health outcomes of CDSMP participants (study group) with those did not join the programme (control group) at 6 months

• Compare the effectiveness between programmes led by professional staff and elder lay leaders

• Please refer to our publication for the details

(Woo et al, 2009)


ParticipantsParticipants

• Eligible participants:– Aged 55 or above– At least one chronic diseases– Living in community– No significant cognitive impairment (AMT ≥ 6)


ProcedureProcedure

Baseline Recruitment in Taipo and Northern districts

Complete baseline assessment

Elder lay-ledprogramme

Professional staff-led programme

Study group participants

Recruitment in Shatin district

Control group participants

6 months Complete 6 months assessment

6 weeks Complete CDSMP


EvaluationEvaluation

• Questionnaire assessment at baseline and 6 months– Four categories of outcomes:

• Self-management behaviours• Self-efficacy• Health status• Health care utilization

• Focus group interview (participants and leaders)


Findings


ParticipantsParticipants

Baseline

Study group participantsn=265

Control group participants n=302

Staff-led CDSMPn=129

Elder lay-led CDSMPn=136

Finished 6 weeks CDSMP

n=103(79.84%)

n=107(78.68%)

n=244(80.79%)

n=112(86.82%)

n=112(82.35%)

Finished 6 months follow-up

Drop-outn=17

Drop-outn=24

Lost follow-upn=5

Lost follow-upn=9

Lost to follow-upn=58


Characteristics of participantsCharacteristics of participants

Characteristics Study (n=210) Control (n=244) P-value

Mean age (SD) 73.17 (8.29) 75.26 (7.90) 0.006

Gender: Female (%) 78.57% 82.38% 0.306

Mean years of education (SD) 3.82 (3.97) 3.96 (4.05) 0.721

Mean number of chronic disease (SD) 2.39 (1.01) 2.39 (1.11) 0.976

Type of chronic disease:

Arthritis (%) 63.81% 70.49% 0.130

Hypertension (%) 61.43% 65.16% 0.410

Diabetes (%) 32.86% 27.46% 0.211

Frailty index level: 0.293

None (%) 37.62% 41.39%

Mild (%) 32.86% 30.33%

Moderate (%) 18.57% 21.72%

Severe (%) 10.95% 6.56%



Outcome changes at 6 monthsOutcome changes at 6 months– self management behaviours and self-efficacy– self management behaviours and self-efficacy

Outcome measures Study (n=210) Control (n=244) P-value

Baseline mean (SD)

Adjusted mean change (SD)

Baseline mean (SD)


Self management behaviours

Exercises (minutes per week)

Stretch and strengthen (0-180) 110.14 (70.61)

+11.26 (4.33) 124.92 (67.11)

-6.37 (3.99) 0.003

Aerobic (0-900) 162.57 (90.18)

+8.05 (5.75) 182.95 (96.88)

-13.55 (5.29) 0.007

Cognitive symptom management (0-5)

0.76 (0.62) +0.36 (0.04) 0.77 (0.60) -0.01 (0.04) <0.0005

Communication with physician (0-5)

1.44 (1.33) +0.45 (0.08) 1.46 (1.21) -0.00 (0.08) <0.0005

Self efficacy

Self efficacy in managing disease in general (0-10)

6.37 (1.83) +0.37 (0.12) 6.28 (2.05) -0.43 (0.11) <0.0005

Self efficacy in managing symptoms (0-10)

5.80 (2.17) +0.44 (0.14) 5.72 (2.43) -0.44 (0.13) <0.0005

Outcome changes at 6 monthsOutcome changes at 6 months– health status– health status


Baseline mean (SD)


Baseline mean (SD)


Health status

Disability (0-3) 0.20 (0.31) -0.02 (0.02) 0.20 (0.83) +0.01 (0.01) 0.157

Social/role activities limitations (0-4)

0.59 (0.72) -0.12 (0.05) 0.63 (0.83) +0.06 (0.05) 0.010

Energy (0-5) 2.91 (1.01) +0.09 (0.06) 2.86 (1.12) -0.04 (0.06) 0.139

Psychological well-being /distress (0-5)

3.51 (0.95) +0.20 (0.05) 3.59 (1.00) +0.05 (0.05) 0.050

Depressive symptom (0-5) 1.19 (0.93) -0.26 (0.06) 1.16 (0.96) -0.05 (0.05) 0.004

Health distress (0-5) 1.20 (1.07) -0.31 (0.06) 1.27 (1.13) -0.09 (0.06) 0.014

Pain and discomfort (0-10) 3.91 (2.56) -0.42 (0.16) 3.96 (2.71) +0.16 (0.15) 0.010

Fatigue (0-10) 3.78 (2.46) -0.11 (0.16) 3.82 (2.54) +0.23 (0.15) 0.116

Shortness of breath (0-10) 1.33 (2.33) +0.13 (0.14) 0.99 (1.93) +0.42 (0.13) 0.141

Self-rated health (1-5) 3.79 (0.77) -0.18 (0.05) 3.86 (0.73) +0.01 (0.04) 0.003


Outcome changes at 6 monthsOutcome changes at 6 months– health care utilization– health care utilization


Baseline mean (SD)


Baseline mean (SD)


Health care utilization

Total physician visits 10.80 (14.06) -1.21 (0.68) 9.51 (11.50) +0.45 (0.63) 0.080

General practitioner visits

6.29 (9.62) -0.89 (0.46) 5.20 (8.92) -0.18 (0.43) 0.264

Other health service visits

4.51 (7.67) -0.33 (0.47) 4.31 (7.18) +0.64 (0.43) 0.140

Emergency room visits 0.40 (1.13) +0.04 (0.06) 0.35 (0.74) -0.02 (0.05) 0.476

Nights in hospital 1.30 (5.08) -0.32 (0.33) 1.16 (4.89) +0.09 (0.31) 0.366


Subgroup analysisSubgroup analysis

• To explore whether participants with different age, educational level and frailty level would have different programme outcomes

• In most of the outcome measures, evidence showing that no significant difference was found in the outcomes of participants from different age groups, educational level and frailty level


Social/role activities limitation was significantly improved in the study group participants within the age group ≥80, effect size=0.087 (moderate to large)

p=0.002




Aerobic exercise was significantly improved in the study group participants in severe frailty level, effect size=0.141 (large)

p=0.034


Comparison of professional staff-led and Comparison of professional staff-led and elder lay-led programmeelder lay-led programme

• In most of the outcome measures, no significant difference was observed between outcomes of the programmes led by professional staff and elder lay-leaders


Outcome measures Mean (SD) P-value

Professional staff-led (n=103)

Elder lay-led (n=107)

Self management behaviours

Exercises (minutes per week)

Stretch and strengthen (0-180) +14.42 (81.64) +13.32 (60.96) 0.902

Aerobic (0-900) +11.21 (102.16) +22.29 (109.01) 0.538

Cognitive symptom management (0-5) +0.40 (0.73) +0.33 (0.73) 0.233

Communication with physician (0-5) +0.55 (1.40) +0.29 (1.51) 0.321

Self efficacy

Self efficacy in managing disease in general (0-10)

+0.37 (1.92) +0.18 (2.04) 0.485

Self efficacy in managing symptoms (0-10) +0.24 (2.62) +0.41 (2.09) 0.486







Health status

Disability (0-3) -0.04 (0.21) +0.01 (0.28) 0.149

Social/role activities limitations (0-4) -0.07 (0.82) -0.11 (0.67) 0.925

Energy (0-5) +0.10 (1.02) +0.02 (0.87) 0.340

Psychological well-being/distress (0-5) +0.29 (0.94) +0.10 (0.79) 0.191

Depressive symptom (0-5) -0.32 (0.89) -0.19 (0.76) 0.196

Health distress (0-5) -0.28 (1.07) -0.22 (1.04) 0.518

Pain and discomfort (0-10) -0.36 (2.81) -0.27 (2.85) 0.783

Fatigue (0-10) +0.05 (2.74) -0.07 (2.98) 0.936

Shortness of breath (0-10) -0.05 (2.25) +0.25 (2.08) 0.237

Self-rated health (1-5) -0.26 (0.74) -0.04 (0.79) 0.041






Health care utilization

Total physician visits -2.63 (12.53) -0.25 (11.93) 0.143

General practitioner visits -1.16 (7.52) -0.89 (7.97) 0.444

Other health service visits -1.48 (7.68) +0.64 (8.59) 0.116

Emergency room visits -0.11 (1.32) +0.14 (1.15) 0.627

Nights in hospital -0.53 (7.47) -0.04 (5.94) 0.644


Focus group interviewFocus group interview

• Participants perceived that disease prevention services and education for older adults with chronic diseases were insufficient

• CDSMP helped the participants and leaders to modify their lifestyles, gain self-management skills, and strengthen their psychosocial support

• CDSMP could relieve the burden of chronic diseases on the current healthcare services and should be disseminated in the community level


Discussion


Effectiveness of CDSMPEffectiveness of CDSMP

• Evidence showing that CDSMP has beneficial effects in older adults with chronic diseases– Improved self-management behaviours– Improved self-efficacy– Improved health status

• Effects lasted for at least 6 months


Effectiveness of CDSMPEffectiveness of CDSMP

• Trends of reduction in total physician visits and nights in hospital

• Further study is needed in frailer patients who are heavy consumers of healthcare services and in-patient beds


Effect of subgroups on CDSMP Effect of subgroups on CDSMP outcomesoutcomes

• Participants from different age groups, educational level and frailty level could benefit equally from CDSMP

• Advanced age, low education and high level of frailty should not be excluded from self-management interventions


Effectiveness of elder lay leadersEffectiveness of elder lay leaders

• Evidence showing that the effectiveness of programmes led by elder lay leaders is similar to professional staff leaders

• Elder lay-leaders could be trained to teach CDSMP effectively


Recommendation


Territory-wide implementationTerritory-wide implementation

• Widespread dissemination of the value of the programme

• Promote to other districts of Hong Kong


Setting up referral systems and Setting up referral systems and coordinationcoordination

• Incorporate self-management programmes in community centres

• Complementing episodic hospital encounters

• Achieved through setting up referral systems from healthcare sector to NGO partners


Promotion of the concepts of elder as Promotion of the concepts of elder as human capitalhuman capital

• Being lay leaders could satisfy the desire of older adults after retirement to continue to contribute to society

• Taking part in volunteer work can promote their own health and social benefits as well


Conclusion


ConclusionConclusion

• High prevalence of chronic diseases and conditions in older adults create huge burden on individuals and healthcare system

• CDSMP could reduce the burden by enhancing self-efficacy and motivation, and improving health status of those with chronic diseases

• Training lay leaders could be cost-effective and sustainable means of promoting self-management concept in our community


What’s next?What’s next?

• Diffusion of innovation– Disseminate the programme– Incorporate into regular service

• As a part of primary care services in Jockey Club CADENZA Hub


Documents

計劃伙伴 Project Partners Evaluation of CADENZA Community Project: Chronic Disease Self-Management Programme (CDSMP) Wayne Chan Physiotherapist, CADENZA