Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is the comparative effectiveness of disease-specific chronic disease self management programs vs. non-disease specific, in particular the Stanford University’s Living Well with Chronic Illnesses and Tomando Control de Salud? Are their particular conditions or diseases that show greater effectiveness over time for improving patient behavior at managing their condition, reducing use of health care system and pharmaceuticals? What self-management programs show greater effectiveness for patients who complete the programs and who sustain behavior modifications emphasized in the program? What difference, if any, is the evidence of the sponsor-organizations’ locations or settings (healthcare-specific settings vs. community settings) have on the improved patient health outcomes over time?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

-Stanford University’s Living Well with Chronic Conditions and Tomando Control de Salud vs. Senior Services of Seattle “Enhance Fitness” vs. other disease-specific programs that address diabetes, heart disease, and obesity, including but not limited to (1) American Diabetes Association's National Standards for Diabetes Self-Management Education (DSME) (2) Balancing Your Life and Diabetes Curriculum – The core diabetes curriculum from the IHS Division of Diabetes

--community-sponsored programs vs. health plan/insurer-sponsored vs. primary care/hospital-sponsored programs

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Men and women with diabetes, obesity, heart disease, asthma, arthritis and other chronic pain conditions.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

African-American, Latino, Asian Pacific Islanders individuals with chronic conditions Medicare, Medicaid and uninsured individuals are of interest.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

--improved and sustained health and behavioral benefits --reduced ED visits

--reduced prescriptions for specific condition, or weight loss for obesity --increased adherence to suggested medications programs and healthy behavior changes --reduced burden on primary care physicians’ office or clinic --achieving and sustaining goals established in self-management program --improved quality of life

Describe any health-related risks, side effects, or harms that you are concerned about.

--continued progression of disease or condition --increased costs to health care system without improving health outcomes --decreasing provider productivity --dissatisfied patients

--increased ‘no show’ appointments --increased risk factors and underlying health disparities and barriers to accessing needed care

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cardiovascular disease, including stroke and hypertension
• Diabetes mellitus
• Obesity
• Pulmonary disease/asthma

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women

Federal Health Care Program

• Medicaid
• Medicare
• Other

Importance

Describe why this topic is important.

As chronic conditions grow in their prevalence and cost to the US healthcare system, patients and payers of all types (public and private/commercial) are struggling to identify cost-effective methods and approaches to improving patient health, redesigning delivery and reimbursement. A range of self management programs are being offered to increase patient activation and to increase patients’ ability to meet goals and improve health, prevent worsening conditions, reduce health care costs, and extend provider capacity on these high need patients. More and more healthcare provider organizations, health plans, high risk pools, and community organizations are offering self management programs for at-risk patients, or even subsidizing the classes as an incentive for patients to participate as part of their health benefit. Furthermore, with clinician workforce shortages from physicians to diabetes educators, self-management programs offer the potential to serve as clinician extenders, so more individuals can participate in self-management programs and hopefully reduce the strain on the limited primary care physicians.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Stanford’s patient education program has existed for over 20 years and claims to be effective. While only part of the full Chronic Care Model, the Stanford programs are growing in reputation, are being customized for Latino culture (not just translating the English program but modified for cultural appropriateness--- see Tomando Control) and numbers of sites offered. Furthermore, Stanford’s Chronic Disease Self Management Programs (CDSMP) also claims as a distinction to be “non-disease specific,” rather than a diabetes only self management program, for example. I am curious about the effectiveness of the broader approach versus the narrower. In addition, with its growing notoriety, discussions have occurred too to incorporate self management programs into reimbursement models as Medicaid and Medicare have struggled to find innovative ways to manage costs. Senior Services of Seattle “Enhance Fitness also claims to be “evidence-based.” A CER or new research on the comparative effectiveness of these disease management programs could offer important information to address the growing impact chronic diseases on the US healthcare system.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Health plans and hospitals are beginning to offer self management courses to their members and patients as part of ongoing care and/or as part of benefit packages. Furthermore, community based organizations are offering disease self management courses to their low-income and uninsured patient populations in addition to providing housing services etc as their clients do not have regular access or a medical home to help manage the chronic condition, so the CBO are trying to provide some additional services to address the health issues of their clients. Good comparative effectiveness research of the success and value of this approach does not exist. Evidence to support disease-specific or non-disease specific programs would help inform coverage decisions, and improve patients’ health outcomes. Evidence to support programs that operation within the current health care system, and those offered in community (non-health care settings) would help inform state and national health care policy addressing chronic conditions and health disparities.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

A CER on this could help inform federal and state health policy addressing chronic conditions and health disparities.

Describe the timeframe in which an answer to your question is needed.

As possible.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

See above.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

A CER on this could help inform federal and state health policy addressing chronic conditions and health disparities.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

OHSU Center for Evidence-based Policy, Portland Oregon