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

Introduction 計劃伙伴 Project Partners

Prevalence 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) 計劃伙伴 Project Partners

Burden 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 計劃伙伴 Project Partners

Chronic Disease Self-Management 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 計劃伙伴 Project Partners

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) 計劃伙伴 Project Partners

Features 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 計劃伙伴 Project Partners

CADENZA 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 計劃伙伴 Project Partners

Project partners and work flow CADENZA research team The Salvation ArmyShatin Hospital Steering Committee Leaders trainingCDSMP in community elderly centres Evaluation Professional staff and Elder lay leaders Professional staff-led programme Elder lay-led programme 計劃伙伴 Project Partners

Programme format 6 sessions, 2.5 hours each, 1 session per week 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 計劃伙伴 Project Partners

Features 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) 計劃伙伴 Project Partners

Methodology 計劃伙伴 Project Partners

Methodology 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) 計劃伙伴 Project Partners

Participants Eligible participants: –Aged 55 or above –At least one chronic diseases –Living in community –No significant cognitive impairment (AMT ≥ 6) 計劃伙伴 Project Partners

Procedure BaselineRecruitment in Taipo and Northern districts Complete baseline assessment Elder lay-led programme Professional staff-led programme Study group participants Recruitment in Shatin district Control group participants 6 monthsComplete 6 months assessment 6 weeks Complete CDSMP 計劃伙伴 Project Partners

Evaluation 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) 計劃伙伴 Project Partners

Findings 計劃伙伴 Project Partners

Participants Baseline Study group participants n=265 Control group participants n=302 Staff-led CDSMP n=129 Elder lay-led CDSMP n=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-out n=17 Drop-out n=24 Lost follow-up n=5 Lost follow-up n=9 Lost to follow-up n=58 計劃伙伴 Project Partners

Characteristics of participants CharacteristicsStudy (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% 計劃伙伴 Project Partners

計劃伙伴 Project Partners Outcome changes at 6 months – self management behaviours and self-efficacy Outcome measuresStudy (n=210)Control (n=244)P-value Baseline mean (SD) Adjusted mean change (SD) Baseline mean (SD) Adjusted mean change (SD) Self management behaviours Exercises (minutes per week) Stretch and strengthen (0-180)  (70.61) (4.33) (67.11)-6.37 (3.99)0.003 Aerobic (0-900)  (90.18)+8.05 (5.75) (96.88) (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)< Communication with physician (0-5)  1.44 (1.33)+0.45 (0.08)1.46 (1.21)-0.00 (0.08)< 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)< 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 months – health status Outcome measuresStudy (n=210)Control (n=244)P-value Baseline mean (SD) Adjusted mean change (SD) Baseline mean (SD) Adjusted mean change (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 計劃伙伴 Project Partners

Outcome changes at 6 months – health care utilization Outcome measuresStudy (n=210)Control (n=244)P-value Baseline mean (SD) Adjusted mean change (SD) Baseline mean (SD) Adjusted mean change (SD) Health care utilization Total physician visits  (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 計劃伙伴 Project Partners

Subgroup 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 計劃伙伴 Project Partners

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 Subgroup analysis 計劃伙伴 Project Partners

Subgroup analysis Aerobic exercise was significantly improved in the study group participants in severe frailty level, effect size=0.141 (large) p=0.034 計劃伙伴 Project Partners

Comparison of professional staff-led and elder 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 計劃伙伴 Project Partners

Outcome measuresMean (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)  (81.64) (60.96)0.902 Aerobic (0-900)  (102.16) (109.01)0.538 Cognitive symptom management (0-5)  (0.73)+0.33 (0.73)0.233 Communication with physician (0-5)  (1.40)+0.29 (1.51)0.321 Self efficacy Self efficacy in managing disease in general (0-10)  (1.92)+0.18 (2.04)0.485 Self efficacy in managing symptoms (0-10)  (2.62)+0.41 (2.09)0.486 Comparison of professional staff-led and elder lay-led programme 計劃伙伴 Project Partners

Comparison of professional staff-led and elder lay-led programme Outcome measuresMean (SD)P-value Professional staff-led (n=103) Elder lay-led (n=107) Health status Disability (0-3)  (0.21)+0.01 (0.28)0.149 Social/role activities limitations (0-4)  (0.82)-0.11 (0.67)0.925 Energy (0-5)  (1.02)+0.02 (0.87)0.340 Psychological well-being/distress (0-5)  (0.94)+0.10 (0.79)0.191 Depressive symptom (0-5)  (0.89)-0.19 (0.76)0.196 Health distress (0-5)  (1.07)-0.22 (1.04)0.518 Pain and discomfort (0-10)  (2.81)-0.27 (2.85)0.783 Fatigue (0-10)  (2.74)-0.07 (2.98)0.936 Shortness of breath (0-10)  (2.25)+0.25 (2.08)0.237 Self-rated health (1-5)  (0.74)-0.04 (0.79)0.041 計劃伙伴 Project Partners

Comparison of professional staff-led and elder lay-led programme Outcome measuresMean (SD)P-value Professional staff-led (n=103) Elder lay-led (n=107) Health care utilization Total physician visits  (12.53)-0.25 (11.93)0.143 General practitioner visits  (7.52)-0.89 (7.97)0.444 Other health service visits  (7.68)+0.64 (8.59)0.116 Emergency room visits  (1.32)+0.14 (1.15)0.627 Nights in hospital  (7.47)-0.04 (5.94)0.644 計劃伙伴 Project Partners

Focus 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 計劃伙伴 Project Partners

Discussion 計劃伙伴 Project Partners

Effectiveness 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 計劃伙伴 Project Partners

Effectiveness 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 計劃伙伴 Project Partners

Effect of subgroups on CDSMP outcomes 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 計劃伙伴 Project Partners

Effectiveness 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 計劃伙伴 Project Partners

Recommendation 計劃伙伴 Project Partners

Territory-wide implementation Widespread dissemination of the value of the programme Promote to other districts of Hong Kong 計劃伙伴 Project Partners

Setting up referral systems and coordination Incorporate self-management programmes in community centres Complementing episodic hospital encounters Achieved through setting up referral systems from healthcare sector to NGO partners 計劃伙伴 Project Partners

Promotion of the concepts of elder as human 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 計劃伙伴 Project Partners

Conclusion 計劃伙伴 Project Partners

Conclusion 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 計劃伙伴 Project Partners

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 計劃伙伴 Project Partners