Abstract
Background
Studies show the great potential for self-management to improve health outcomes, yet it is carried out in a limited way by patients and providers. This study investigated the provider perspective of existing self-management support resources in a region of 1.2 million people. Participants included physicians, nurses, nurse practitioners, educators, and program managers.
Methods
Qualitative study using semi-structured, one-on-one interviews. An iterative immersion/crystallization process identified key themes and new questions and was built on a grounded theory approach. Triangulation was used to validate findings by comparing with data from a related provider workshop and presenting significant findings in follow-up interviews with select individuals.
Results
There was a lack of understanding about self-management. Existing programs lacked an evidence-based approach and were often entrenched in a single disease-focus model of care, despite a majority of patients served having multiple chronic conditions. A new approach to self-management support was desired, although often anchored in an old model of revolving doors for patients. Self-management was described as burdensome for patients and providers alike. There was disbelief about program effectiveness and frustration about lack of sustainability.
Interpretation
Understanding the perspectives of providers engaged in self-management support is a critical first step in developing regional strategies for such support programs. A better understanding of the comprehensive and long-term nature of self-management support is needed. System reform promoting integration of services is essential to enable providers to offer patient-centred self-management support.
Key words: Self-management, SMS, chronic disease, co-morbidities
Résumé
Contexte
Des études démontrent l’immense potentiel de l’autogestion des soins pour améliorer les résultats de santé. Pourtant, les patients et les fournisseurs de soins utilisent cette approche de façon limitée. La présente étude s’est penchée sur la perspective du fournisseur de soins quant aux ressources d’appui actuelles en matière d’autogestion dans une région de 1,2 million d’habitants. Les participants englobaient des médecins, du personnel infirmier, des infirmières praticiennes, des pédagogues, et des gestionnaires de programmes.
Méthode
Étude qualitative faisant appel à des entrevues semistructurées et individuelles. Grâce à un processus itératif d’immersion/de cristallisation, fondé sur une approche théorique reposant sur les faits, de nouvelles questions et des sujets-clés ont été identifiés. Nous avons procédé par triangulation pour valider les résultats en établissant des comparaisons avec des données provenant d’un atelier connexe et en présentant les conclusions importantes tirées dans le cadre d’entrevues de suivi avec quelques personnes désignées.
Résultats
On comprend mal ce qu’est l’autogestion des soins. Les programmes actuels n’ont pas une approche fondée sur les preuves et sont souvent limités à un modèle de soins axé sur une seule maladie et cela, même si, en majorité, les patients ciblés sont atteints de plusieurs conditions chroniques. Une nouvelle approche d’appui à l’autogestion est souhaitée, même si l’autogestion est enracinée dans le vieux phénomène de la « porte tournante » pour les patients. Le programme d’autogestion des soins est jugé coûteux tant pour les patients que pour les fournisseurs, et suscite du scepticisme quant à son efficacité et de la frustration face à son manque de viabilité.
Interprétation
Une première étape fondamentale consiste à bien cerner la perspective des fournisseurs qui soutiennent l’autogestion afin d’élaborer des stratégies régionales relatives aux programmes d’appui. Une meilleure connaissance de la nature polyvalente et à long terme de l’appui à l’autogestion est nécessaire. Une réforme du système qui encourage l’intégration des services est indispensable pour permettre aux fournisseurs d’offrir un soutien en autogestion axé sur le patient.
Mots clés: autogestion, soutien de l’autogestion, maladie chronique, comorbidités
Footnotes
Conflict of Interest: None to declare.
Acknowledgements: This research was made possible by funding from the Champlain Local Health Integration Network (LHIN) and the Élisabeth Bruyère Research Institute. In addition, Dr. Clare Liddy is a career scientist funded by the MOHLTC. The authors thank Priyanga Seyon and Jennifer Creer for their help with several drafts of the manuscript.
References
- 1.World Health Organization. Facing the Facts: Impact of Chronic Disease in Canada. 2006. [Google Scholar]
- 2.Wagner E, Austin B, Davies C, Hindmarsh M, Scaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20(6):64–78. doi: 10.1377/hlthaff.20.6.64. [DOI] [PubMed] [Google Scholar]
- 3.Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Davies GP, et al. APHCRI Stream Four: A systematic review of chronic disease management. 2006. [Google Scholar]
- 4.BMC Cardiovasc Disord. 2006.
- 5.Lorig K, Holman H. Self-management education: History, definition, outcomes and mechanisms. Ann Behav Med. 2003;26(1):1–7. doi: 10.1207/S15324796ABM2601_01. [DOI] [PubMed] [Google Scholar]
- 6.Canadian Institute for Health Information. Experiences with Primary Health Care in Canada. Ottawa, ON: CIHI; 2009. [Google Scholar]
- 7.Schoen C, Osborn R, How S, Doty MM, Peugh J. In chronic condition: Experiences of patients with complex health care needs, in eight countries. Health Aff. 2009;28(1):w1–w16. doi: 10.1377/hlthaff.28.1.w1. [DOI] [PubMed] [Google Scholar]
- 8.Griffiths CJ, Foster G, Ramsey J, Eldridge S, Taylor S. How effective are expert patient (lay led) education programmes for chronic disease? BMJ. 2007;334:1254–56. doi: 10.1136/bmj.39227.698785.47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Williams A, Harris M, Daffurn K, Davies G, Pascoe A, Zwar N. Sustaining chronic disease management in primary care: Lessons from a demonstrative project. Aust J Public Health. 2007;13(2):121–28. [Google Scholar]
- 10.Tracey J, Bramley D. The acceptability of chronic disease management programs to patients, GPs and practice nurses. N Z Med J. 2003;116(1169):U331. [PubMed] [Google Scholar]
- 11.Patton M. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34(5pt2):1189–208. [PMC free article] [PubMed] [Google Scholar]
- 12.Re-Aim. Checklist for Study or Intervention Planning. 2010. [Google Scholar]
- 13.Glanz K, Lewis F, Rimer B. Evaluation of theory-based interventions: The REAIM Model. In: Glanz K, Lewis F, Rimer B, editors. Health Behavior and Health Education: Theory, Research and Practice. 3rd, ed. San Francisco, CA: John Wiley and Sons; 2002. pp. 531–44. [Google Scholar]
- 14.Glasgow RE, McKay H, Piette J, Reynolds K. RE-AIM framework for evaluation interventions: What can it tell us about approaches to chronic illness management? Patient Educ Couns. 2001;44:119–27. doi: 10.1016/S0738-3991(00)00186-5. [DOI] [PubMed] [Google Scholar]
- 15.Renders C, Valk G, Griffins S, Wagner E, Van Eijk J, Assendelft W. Interventions to improve the management of diabetes in primary care, outpatient and community settings. Diabetes Care. 2001;24(10):1821–33. doi: 10.2337/diacare.24.10.1821. [DOI] [PubMed] [Google Scholar]
- 16.Fan L, Sidani S. Effectiveness of diabetes self-management education intervention elements: A meta-analysis. Can J Diabetes. 2009;33(1):18–26. doi: 10.1016/S1499-2671(09)31005-9. [DOI] [Google Scholar]
- 17.Bains N, Dall K, Hay C, Pacey M, Sarkella J, Ward M. Population Health Profile: Champlain LHIN. 2004. [Google Scholar]
- 18.Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005;3:223–28. doi: 10.1370/afm.272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Valderas J, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: Implications for understanding health and health services. Ann Fam Med. 2009;7:357–63. doi: 10.1370/afm.983. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.van den Akker M, Buntinx F, Metsemakers J, Roos S, Knottnerus J. Multimorbidity in general practice: Prevalence, incidence, and determinants of cooccurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51:367–75. doi: 10.1016/S0895-4356(97)00306-5. [DOI] [PubMed] [Google Scholar]
- 21.Daveluy C, Pica L, Audet N, Courtemanche R, Lapointe F. Enquête sociale et de santé. 2nd, ed. Québec: Institut de la statistique du Québec; 1998. [Google Scholar]
- 22.McGowan P. Self-Management: A Background Paper. 2005. [Google Scholar]