Adults with 1+ Chronic Conditions Secondary Prevention
In recent years, there have been two major trends in studies of effective interventions for individuals with chronic disorders. The first is the development of effective technological interventions (e.g., eHealth and mHealth), which enable self-monitoring and guided adherence to drug and rehabilitation regimes. The second, and more prominent, is the development of educational and social interventions, which have been repeatedly shown to be effective in improving not only the patient's self-care, but improving their emotional well-being as well.
COPD MAINTENANCE THERAPY
- In the US, an estimated 14% of adults over the age of 40 suffer from chronic obstructive pulmonary disease (COPD).
- The costs of COPD increased 38% in a 20-year period, largely due to increased hospital admissions, which accounted for $3.2-3.8 billion in increased costs.
- Drug maintenance therapy has been shown in two clinical trials to reduce the incidence of exacerbations by 16-17%, the most important factor leading to hospitalization, but is only used by 30-35% of those with COPD.
- A review of COPD maintenance therapy concludes, "Earlier diagnosis and the earlier initiation of treatment can improve patient outcomes and lessen the financial burden associated with this disease."
- A nurse practitioner created the mI SMART intervention, which combines a HIPAA-compliant, "web-based, structure of mHealth sensors (portable health monitors) and mobile devices to treat and monitor multiple chronic conditions."
- In a 12-week study of "impoverished adults... with at least one chronic condition, a minimum of 3rd grade reading level, and without dementia/psychosis," the effectiveness of this intervention was tested.
- The average blood glucose levels in the trial group were reduced from 201.93 to 146.79 mmol/L.
- The average systolic blood pressure reduced from 134.24 to 118.93 mmHg and diastolic blood pressure reduced from 88.79 to 83.62 mmHg.
- The average body weight reduced from 218 to 207 lbs.
- The study concludes, "The change in focus to preventative, health maintenance, and routine chronic illness care specific to individualized patient needs may improve outcomes leading to decreased burden and complexity for both patients and practices."
Note that this report easily could have been dominated with other mHealth (mobile health) and eHealth interventions, such as for helping HIV patients to self-monitor in a Vancouver study.
IMPROVING MEDICATION MANAGEMENT
- It is estimated that 30-50% of the 117 million people in the US with a chronic health condition fail to take their medication as prescribed.
- Common reasons for medicine non-adherence "include forgetting, running out of medication, or being careless about the medication-dosing schedule."
- A recent study tested whether 30 minutes of occupational therapy intervention (specifically, the Integrative Medication Self-Management Intervention, or IMedS) was effective in improving medication adherence.
- Subjectively, 90% of participants in the study indicated that "additional medication management services would be beneficial," especially in the cases of the elderly, those on multiple medications, and those on a new drug regime.
- 55% of those in the occupational therapy intervention group (OTIG) reported improved ability to manage their medications compared to 30% of the control group.
- 66% of OTIG participants implemented new strategies to manage their medication regimes while only 40% of the control group did the same.
- In addition, on average, OTIG participants implemented two new strategies while the average control group participant implemented only one.
- In fact, average adherence in the control group actually decreased from a baseline mean of 88.74 to 86.06 while the OTIG group increased from 98.58 to 98.95, according to actual diaries that participants maintained during the study.
- Interestingly, even control group participants indicated that keeping a medication diary during the study "helped them to better take their medications."
- While the study itself does not directly deal with the issue of improved outcomes or costs as a result of the intervention, given that the CDC estimates that "direct health care costs associated with non-adherence have grown to approximately $100–$300 billion of U.S. health care dollars spent annually," any improvement in patient adherence would have a clear direct cost benefit.
COPD EDUCATION-SUPPORT INTERVENTION
- In a year-long study, COPD patients were enrolled in a 9-month educational program delivered by advanced practice registered nurses (APRNs), followed by a 3-month period with no contact.
- In the first 3-month period, participants met with APRNs every 10-14 days for a 60-90 minute educational session, followed by six months of regular phone calls and/or emails.
- The control group received only written information packets.
- Of particular note, "Memory enhancement methods were built into the teaching materials and delivery of the intervention" and the "intervention was adapted from Stuifbergen’s health promotion in chronic illness intervention which focuses on enhancing self-efficacy and has successfully utilized an educational and skill-building program with supportive phone follow-up."
- As a result, "The intervention group showed significant improvements in functional status, self-efficacy and quality of life (Kansas City Cardiomyopathy Questionnaire-KCCQ); metamemory Change and Capacity subscales (Metamemory in Adulthood Questionnaire-MIA); self-care knowledge (HF Knowledge Test-HFKT); and self-care (Self-Care in Heart Failure Index—SCHFI)." The control group either remained static or actually decreased in their scores.
PEER-LED, TELEPHONE-BASED EMPOWERMENT INTERVENTION
- In a study of patients with chronic spinal cord injuries, trained health coaches were assigned to provide telephone support and education over a 6-month period "on a tapered call schedule."
- Participants reported significantly greater increase (7.029) in their Patient Activation Measure (PAM) scores, a measure of "health self-management," compared to the control group "with a trend toward significance at 4 months." (See here for more information about PAM scores.)
- Participants also showed a "greater decrease in social/role activity limitations," made more use of available services, and had greater life satisfaction than the control group. (Statistical summaries available at the source.)
Given the potential scope of this project, we began by conducting a quick search of Google's scholar database for likely keyword combinations in order to determine how many potential papers would need to be screened if we were to attempt an exhaustive evaluation. Unfiltered for time, there were 3.5 million potential papers. Even narrowing down the field to the last two years, there were still nearly 100,000, obviously far too many to even scan within the limitations of a single Wonder request. We found similar numbers when attempting to limit the field to systematic reviews of the available literature.
Simply put, there are far too many positives in any time-span to collate the papers into anything approximating a "top" list. (We understand that this would be a step beyond the report criteria.) Moreover, many papers (particularly the most recent) are publicly available in abstract only. The abstracts generally give too little information to evaluate how significant the impact of a given intervention is on health outcomes, hospitalizations, and/or cost savings really is. Finally, some results reported in various papers are given in terms of statistical significance and/or in highly technical language which we are not entirely comfortable parsing.
Therefore, while the examples we have chosen certainly demonstrate quantifiable significant impacts, time constraints mean that the sample of papers and articles reviewed is simply too small (particularly given how many we were forced to pass over due to only being available in abstract) and the methods of determining impact too diverse to say with any certainty that our examples above particularly stand out in this field.
Due to the nature of academic publishing, in which research generated a decade ago may still be cited as current unless superseded by a later study, and the need to find papers released into the public domain, we have set aside Wonder's normal criterion of citing only those works published in the last two years. While our usual methodology is meant to ensure that we bring only the most up-to-date information available into our briefs, in this case, reaching further back had a distinct advantage: By utilizing Google Scholar's ability to show which later papers cited a given work, we could ensure that the effectiveness of a given intervention had not been called into question by later research and, if later research proved to verify or expand upon the original, we could cite the more recent work.
The examples given in our findings, therefore, have been verified to be effective (quantitatively) and have not been called into question by later research, ensuring that these examples meet all the project criteria. Where possible, we have sought out recent non-academic articles commenting on the studies in question in order to better understand the significance of the intervention. In order to avoid cluttering our source list, we have cited only those which provided the most pertinent details of each intervention.