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計劃伙伴 Project Partners
Evaluation of CADENZA Community Project: Chronic Disease
Self-Management Programme (CDSMP)
Wayne ChanPhysiotherapist, CADENZA
Introduction
計劃伙伴 Project Partners
Prevalence of chronic diseases in older adultsPrevalence 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)
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Burden of chronic diseasesBurden 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
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Chronic Disease Self-Management Chronic Disease Self-Management Programme (CDSMP)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
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What is self-efficacy?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)
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Features of CDSMPFeatures 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
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CADENZA Community ProjectCADENZA 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 flowProject partners and work flow
CADENZA research team
The Salvation Army Shatin Hospital
Steering Committee
Leaders trainingCDSMP in community elderly centres
Evaluation
Professional staff and Elder lay leaders
Professional staff-led programme
Elder lay-ledprogramme
計劃伙伴 Project Partners
Programme formatProgramme format
• 6 sessions, 2.5 hours each, 1 session per week
• 10-12 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
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Features of leaders trainingFeatures 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)
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Methodology
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MethodologyMethodology
• 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)
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ParticipantsParticipants
• Eligible participants:– Aged 55 or above– At least one chronic diseases– Living in community– No significant cognitive impairment (AMT ≥ 6)
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ProcedureProcedure
Baseline Recruitment in Taipo and Northern districts
Complete baseline assessment
Elder lay-ledprogramme
Professional staff-led programme
Study group participants
Recruitment in Shatin district
Control group participants
6 months Complete 6 months assessment
6 weeks Complete CDSMP
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EvaluationEvaluation
• 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)
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Findings
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ParticipantsParticipants
Baseline
Study group participantsn=265
Control group participants n=302
Staff-led CDSMPn=129
Elder lay-led CDSMPn=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-outn=17
Drop-outn=24
Lost follow-upn=5
Lost follow-upn=9
Lost to follow-upn=58
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Characteristics of participantsCharacteristics of participants
Characteristics Study (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%
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計劃伙伴 Project Partners
Outcome changes at 6 monthsOutcome changes at 6 months– self management behaviours and self-efficacy– self management behaviours and self-efficacy
Outcome measures Study (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) 110.14 (70.61)
+11.26 (4.33) 124.92 (67.11)
-6.37 (3.99) 0.003
Aerobic (0-900) 162.57 (90.18)
+8.05 (5.75) 182.95 (96.88)
-13.55 (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) <0.0005
Communication with physician (0-5)
1.44 (1.33) +0.45 (0.08) 1.46 (1.21) -0.00 (0.08) <0.0005
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) <0.0005
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 monthsOutcome changes at 6 months– health status– health status
Outcome measures Study (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 monthsOutcome changes at 6 months– health care utilization– health care utilization
Outcome measures Study (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 10.80 (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
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Subgroup analysisSubgroup 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
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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 analysisSubgroup analysis
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Subgroup analysisSubgroup analysis
Aerobic exercise was significantly improved in the study group participants in severe frailty level, effect size=0.141 (large)
p=0.034
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Comparison of professional staff-led and Comparison of professional staff-led and elder lay-led programmeelder 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
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Outcome measures Mean (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) +14.42 (81.64) +13.32 (60.96) 0.902
Aerobic (0-900) +11.21 (102.16) +22.29 (109.01) 0.538
Cognitive symptom management (0-5) +0.40 (0.73) +0.33 (0.73) 0.233
Communication with physician (0-5) +0.55 (1.40) +0.29 (1.51) 0.321
Self efficacy
Self efficacy in managing disease in general (0-10)
+0.37 (1.92) +0.18 (2.04) 0.485
Self efficacy in managing symptoms (0-10) +0.24 (2.62) +0.41 (2.09) 0.486
Comparison of professional staff-led and Comparison of professional staff-led and elder lay-led programmeelder lay-led programme
計劃伙伴 Project Partners
Comparison of professional staff-led and Comparison of professional staff-led and elder lay-led programmeelder lay-led programme
Outcome measures Mean (SD) P-value
Professional staff-led (n=103)
Elder lay-led (n=107)
Health status
Disability (0-3) -0.04 (0.21) +0.01 (0.28) 0.149
Social/role activities limitations (0-4) -0.07 (0.82) -0.11 (0.67) 0.925
Energy (0-5) +0.10 (1.02) +0.02 (0.87) 0.340
Psychological well-being/distress (0-5) +0.29 (0.94) +0.10 (0.79) 0.191
Depressive symptom (0-5) -0.32 (0.89) -0.19 (0.76) 0.196
Health distress (0-5) -0.28 (1.07) -0.22 (1.04) 0.518
Pain and discomfort (0-10) -0.36 (2.81) -0.27 (2.85) 0.783
Fatigue (0-10) +0.05 (2.74) -0.07 (2.98) 0.936
Shortness of breath (0-10) -0.05 (2.25) +0.25 (2.08) 0.237
Self-rated health (1-5) -0.26 (0.74) -0.04 (0.79) 0.041
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Comparison of professional staff-led and Comparison of professional staff-led and elder lay-led programmeelder lay-led programme
Outcome measures Mean (SD) P-value
Professional staff-led (n=103)
Elder lay-led (n=107)
Health care utilization
Total physician visits -2.63 (12.53) -0.25 (11.93) 0.143
General practitioner visits -1.16 (7.52) -0.89 (7.97) 0.444
Other health service visits -1.48 (7.68) +0.64 (8.59) 0.116
Emergency room visits -0.11 (1.32) +0.14 (1.15) 0.627
Nights in hospital -0.53 (7.47) -0.04 (5.94) 0.644
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Focus group interviewFocus 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
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Discussion
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Effectiveness of CDSMPEffectiveness 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
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Effectiveness of CDSMPEffectiveness 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
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Effect of subgroups on CDSMP Effect of subgroups on CDSMP outcomesoutcomes
• 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
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Effectiveness of elder lay leadersEffectiveness 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
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Recommendation
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Territory-wide implementationTerritory-wide implementation
• Widespread dissemination of the value of the programme
• Promote to other districts of Hong Kong
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Setting up referral systems and Setting up referral systems and coordinationcoordination
• Incorporate self-management programmes in community centres
• Complementing episodic hospital encounters
• Achieved through setting up referral systems from healthcare sector to NGO partners
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Promotion of the concepts of elder as Promotion of the concepts of elder as human capitalhuman 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
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Conclusion
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ConclusionConclusion
• 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
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What’s next?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
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