Table 6.
Summary description of studies on self-management in the reviewed randomized controlled trials of electronic symptom reportinga.
| Patient group | Trial and countryb |
Participant characteristicsc |
Study characteristicsd |
Health service innovation: self-management |
Main findings and research targetse |
| Respiratory and lung disease | |||||
| DeVito Dabbs et al [65]; USA | 34 lung transplant recipients; >18 (mean 56) years; female 40% | Design: P + 2; outside/home Duration: the first 2 months after discharge |
Early self-care behaviors and follow-up after lung transplant Intervention: Pocket Personal Assistant for Tracking Health (Pocket PATH): In addition to standard care, patients used a handheld device to record health data, review data trends by using the screens and graphs, and follow feedback instructions regarding reporting changes to their transplant coordinator. Control: Used standard paper-and-pencil logs to record data. Both groups were instructed to contact their transplant coordinator for any clinical questions or issues. Follow-up was identical. |
Several primary outcomes: Patients in the Pocket PATH group showed significantly higher ratings of self-care agency, performed self-care behaviors at significantly higher rates, and reported significantly better health-related quality of life than standard-care controls. Research targets: Health benefits, patient centeredness |
|
| Yardley et al [66]; UK | 714 participants with minor respiratory symptoms; 18–79 years (62.1% were <25); female 72.3% | Design: P + 2; outside/home Duration: 1 access + follow-up after 48 hours (332) and 4 weeks (214) |
Web-based intervention providing tailored advice for self-management of minor respiratory symptoms Intervention: Web-based Internet Doctor-provided tailored computer-generated advice for minor respiratory symptoms (cough, sore throat, fever, and runny or stuffy nose). Participants could access 3 main pages: (1) diagnostic pages asking a series of questions about symptoms, and a complex algorithm providing appropriate tailored advice on whether they needed to contact health services (+ options to possible diagnoses), (2) treatment pages providing information about medication for symptoms, (3) Common Questions section addressing common concerns and misconceptions about symptoms and treatment. Control group got access to a static webpage providing the best existing patient information. |
Several primary outcomes: 1 month later the Internet Doctor resulted in higher levels of enablement (median 3 and 2, respectively; P = .03), and 11.6% (11) of participants consulted their doctor or used other health care services (mainly NHS Direct) for their symptoms, compared with a substantially greater proportion (21, 17.6%) in the control group (P = .22). Secondary: The Internet Doctor resulted in higher levels of satisfaction than the control information (mean 6.58 and 5.86, respectively; P = .002). Understanding of illness improved in the 48 hours following use of the Internet Doctor webpages, whereas it did not improve in the control group (mean change from baseline 0.21 and –0.06, respectively; P = .05). Research targets: Patient centeredness, resource utilization (for health professionals) |
|
| van der Meer et al [67]; the Netherlands | 200 asthma patients from 37 general practices and 1 academic outpatient department; 18–50 (mean in intervention: 36, in control: 37) years; females 69.5% | Design: P + 2; outside/home Duration: 12 months |
Internet-based self-management plus education compared with usual care The Internet-based self-management program included weekly asthma-control monitoring and treatment advice, online and group education (face-to-face), and Web communication with a specialized asthma nurse, as an adjunct to usual care. Patients completed an electronic questionnaire on the website weekly and instantly received automated feedback on the state of their asthma control, along with advice on how to adjust their treatment (increasing or decreasing; contact asthma nurse). Control group: Usual physician-provided care according to Dutch general practice guidelines. |
Primary: Asthma-related quality-of-life improvement of 0.5 point or more occurred in 54% and 27% of Internet and usual care patients, respectively (adjusted relative risk 2.00, confidence interval 1.38–3.04). Statistically significant, but not clinically significant. Secondary: Asthma control improved more in the Internet group than in the usual care group (adjusted difference –0.47, confidence interval –0.64 to –0.30). At 12 months, 63% of Internet patients and 52% of usual care patients reported symptom-free days in the previous 2 weeks (adjusted absolute difference 10.9%, confidence interval 0.05%–21.3%). Research target: Health benefits |
|
| Nguyen et al [68]; USA | 50 patients with moderate to severe chronic obstructive pulmonary disease; mean 69.5 years, range ± 8.5; female 44% | Design: P + 2; outside/home Duration: 6 months |
Dyspnea self-management Intervention: Internet-based (eDSMP) dyspnea self-management Control: Face-to-face dyspnea self-management (fDSMP). The content of the 2 programs was similar, focusing on education, skills training, and ongoing support for dyspnea self-management, including independent exercise. eDSMP participants submitted symptom and exercise information in real time via the PDAf or website. fDSMP paper diaries were mailed weekly. Nurse-provided feedback via email (eDSMP) or telephone (fDSMP), weekly for the first month and then biweekly for the next 5 months. Contacts were expected to be as similar as possible for the 2 groups, except that automated email alerts were sent to the study nurses if worsening of symptoms or reports of not performing exercise for at least 3 consecutive days. |
Primary: Both groups showed similar clinically meaningful changes in dyspnea with activities of daily living after 3 months and sustained these improvements at 6 months. Secondary: Self-reported endurance exercise time (P = .001), physical functioning (P = .04), and self-efficacy for managing dyspnea (P = .02) also showed positive improvements over time in both groups with no significant differences with respect to program modality. Research targets: Health benefits, patient centeredness |
|
| Psychiatry | |||||
| Berger et al [69]; Switzerland | 81 patients with social phobia; 19–62 (mean 37.2) years; female 53.1% | Design: P + 3; outside/home Duration: 10-week treatment + 6-month follow-up |
Internet-based treatments of social phobia Intervention 1: Guided Internet-based self-help program with weekly scheduled email feedback by a therapist and the possibility to ask questions via email (response time maximum 3 days). Intervention 2: Step-up on demand (same as control) but with the possibility to step up to guidance by email (intervention 1) or telephone. Both groups used an online diary to report anxiety-provoking situations, and related thoughts, feelings, and behaviors. Control: Pure self-help program (by Internet) without any therapist support. |
Significant symptom reductions in all 3 treatment groups with large effect sizes for primary measures (self-reported measures of symptoms of social phobia) and for secondary outcome measures (symptoms of depression, interpersonal problems, and general symptomatology). No significant between-group effects were found. No significant difference between the 3 conditions regarding diagnosis-free status, clinical change, dropout rates, or adherence measures such as lessons or exercises completed. High level of patient satisfaction overall, with a significant difference favoring the guided Internet-based self-help group. Research targets: Health benefits, patient centeredness |
|
| Bergstrom et al [70]; Sweden | 113 patients with panic disorder; >18 (mean in intervention: 33.8, in control: 34.6) years; female 61.5% | Design: P + 2; outside/home Duration: 10 weeks + 6-month follow-up |
Internet-based CBTg for patients with panic disorder Intervention: 10 Web-based self-help modules, 1 per week, with information, exercises, and homework assignments, based on established CBT principles. Psychologist provided feedback, gave access to next module, and replied to other messages within 24 hours on regular weekdays. Only email contact. Control: Regular psychiatric care setting. Psychologists presented the same self-help program as above during weekly 2-hour sessions, supported by handouts. Homework assignments were addressed during group sessions. |
Primary: Internet CBT is as effective as the more widely used group CBT. No significant between-group effects were found. Secondary: Internet treatment had superior cost-effectiveness ratios in relation to group treatment at both posttreatment and follow-up. Research targets: Health benefits, health care costs |
|
| Vernmark et al [71]; Sweden | 88 patients with major depression; age range not reported (mean 37); female 68% | Design: P + 3; outside/home Duration: 8 weeks (we don’t report from the 6-month follow-up, since the control group had received guided self-help by this time) |
Internet-administered guided self-help versus individualized email therapy versus waiting lists Intervention 1: Guided self-help included weekly modules and homework assignments. Standard CBT components were presented. Therapists contributed with positive reinforcement on the progress made by participants. Intervention 2: email therapy did not use the self-help texts; all emails were written for the unique patient. The therapists had more or less the same role as in face-to-face psychological treatment. The contents of the email therapy overlapped with the self-help material but were tailored to each participant’s needs. The treatment was based on a protocol manual developed by the team. The third group was a waiting-list control group. Each therapist was responsible for 5 participants in each group. |
Primary: Both the email therapy and the self-help groups improved in symptom reduction compared with the waiting-list condition (P = .002 and P = .06). The 2 treatments did not differ (P = .41). At posttreatment 34.5% of the guided self-help group, 30% of the email therapy group, and 13.8% of the waiting-list group reached the criteria of high-end state functioning (P = .17), (Beck Depression Inventory score <9). Research target: Health benefits |
|
| Oerlemans et al [72]; the Netherlands | 76 irritable bowel syndrome patients; age range not reported; mean in intervention: 35.9, for control: 40.6 years; female in intervention: 91.9%, in control: 76.9% | Design: P + 2; outside/mobile Duration: 4 weeks + 3-month follow-up |
Intervening on cognitions and behavior in irritable bowel syndrome Intervention: Patients received standard care supplemented with a 4-week CBT e-intervention on PDAs. Patients completed 3 diaries daily. The data were immediately accessible to the psychologist, who during weeks 2–4 sent situational feedback based on CBT via text message. Feedback was standardized through a developed protocol. Control: Received standard care consisting of reassurance, dietary advice, and education from their general practitioner. |
Several primary outcomes: No significant differences between groups for dysfunctional cognitions. Between-group comparisons after 4 weeks showed more overall quality-of-life improvement, more improvement in catastrophizing thoughts, and more pain improvement in the intervention group. Only improvement in catastrophizing thoughts persisted in the long term. The eHealth intervention seems feasible, since all intervention group patients completed the diaries 3 times a day for 4 weeks. Research target: Health benefits |
|
| Diabetes | Glasgow et al [73] and Williams et al [74]; USA | 52 primary care physicians, 886 type 2 diabetes patients; >25 (mean in intervention: 61.48, in control: 64.63) years; female in intervention: 52.3%, in control: 50% ([73]) | Design: C + 2; inside clinic Duration: 12 months |
Interactive computer technology to assist patients and clinicians in emphasizing patient-centered communication and improved quality of care Computer-assisted intervention patients were asked to come 30 minutes early to 2 diabetes-related visits scheduled 6 months apart to complete a touch-screen assessment procedure and set self-management goals, received computer- tailored feedback and individualized action plans, received a printout on general health risks, met with a care manager, and received follow-up phone calls from care manager (nurse or medical assistant). Physician and care manager received printout of patient’s needs, self-management goals, and areas the patient wished to discuss. Control patients also completed touch-screen assessment procedure, received printout on general health risks, but did not set self-management goals, meet with a care manager, or receive follow-up phone calls. |
Glasgow et al [73]: Primary: Significantly improved both the laboratory assays and patient-centered aspects of diabetes care that patients received compared with those in the control condition. Secondary: Overall improvement in lipids, glycated hemoglobin, quality of life, and depression scores; between-condition differences were not significant. Williams et al [74]: Unclear primary outcome. The intervention increased patient perception of autonomy support relative to a computer-based control condition (P < .05). Change in perceived competence partially mediated the effects of increased autonomy support on the change in lipids, diabetes distress, and depressive symptoms. The construct of autonomy support was separate from that of patient satisfaction. Research targets: Health benefits, patient centeredness |
a Articles were identified in a comprehensive search in Medline, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and IEEE Xplore from 1990 to November 2011, and were published in the time period 2002–2011.
b Main author, main reference. References with and between them are articles that belong to the same study.
c Number of clinicians, number of patients with diagnosis, age range (mean) of patients, percentage female patients.
d Design (P = parallel group design, CO = crossover, C = cluster, F = factorial, O = other, U = unclear; + number of study arms), where symptom reporting took place (outside or in the home; or inside a clinic), and duration of intervention.
e Main findings are in general presented as in the original article and refer to primary outcome if clearly defined and secondary outcomes considered relevant for the scope of the study. Research targets refers to the six areas of health service quality defined by the Institute of Medicine [43].
f Personal digital assistant.
g Cognitive behavioral therapy.