Key messages
Despite a vast literature on the topic of patient self-management, evidence on the association between training of health professionals in patient self-management with measured patient health outcomes was rare prior to and up to 2 years after its incorporation into the WONCA Europe definition of general practice.
However, the limited available evidence suggests that specific training programmes for primary care health professionals (a) may improve and support patient competencies for self-management and (b) may improve quality of life for patients with chronic conditions.
Background
The European Definition of General Practice by the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) in the European Region, lists 12 characteristics within six core competencies to define the activities of general practice / family medicine (GP/FM) [
1]. The twelfth characteristic of general practice “
Promotion of patient empowerment and self-management” was officially approved in 2011 [
1]. It follows therefore, that European family physicians agree that among the various disciplines of medicine, GP/FM has a key role in harnessing patient autonomy to develop their expertise in managing their own health and wellness [
2].
Promoting patient self-management (PSM) in the European definition of General Practice is listed under the core competency of “Patient-centered care”, in keeping with scientific evidence on patient empowerment within general practice [
3]. The concept of patient empowerment for patient self-management in chronic conditions has been further explored by the European Society for Quality and Safety in General Practice (EQuiP) [
4].
The World Health Organisation (WHO) defines chronic conditions as those that encompass disability and disease that people ‘live with’ for extended periods of time [
5]. They include non-communicable diseases (NCD), such as cardiovascular diseases, cancers, respiratory diseases and diabetes, and are associated with lifestyle factors and patient behaviours and account for 70% of deaths globally (40 million deaths) in 2017 [
6]. By 2030, the total annual number of NCD deaths is projected to increase to 52 million per year [
6]. This escalation of the prevalence of chronic conditions is a significant factor in the increasingly heavy workload in family medicine internationally, which is also increasing in complexity as people live longer often with multiple co-existing chronic conditions.
By definition, chronic disease is not reversible or curable [
6]. The Chronic Care Model (CCM) [
7] is an internationally accepted model for the management of NCD and specifies self-management support as a key component. Patient self-management can be described as
“a set of tasks and processes that are used by a patient to maintain wellness in the presence of an ongoing illness [
8]
and it may also encompass prevention...” [
9]. In addition to knowledge of the disease and treatment options, patient self-management
“involves active involvement in decision making, coping with signs and symptoms of disease, making lifestyle changes and managing the impact of the disease on life” [
10].
The benefits of supporting patients to implement and maintain self-management skills have been shown to improve patients’ self-care and more appropriate utilisation of health services [
11‐
13]. Improved patient self-management can also reduce health care costs through fewer outpatient visits [
14‐
17] and fewer hospital admissions [
18‐
20]. Lifestyle interventions by patients have been shown to have clinical benefit in a wide range of conditions such as diabetes, coronary heart disease, heart failure, and rheumatoid arthritis [
21].
In the Chronic Care Model, achieving optimum outcomes for patients requires a productive interaction between “an informed activated patient and a prepared proactive practice team” [
22]. Many studies focus on the role of
patient education in self-management, yet no systematic reviews are published on whether
clinician education to improve patient self-management has an effect on patient outcomes. A preliminary literature review [
23] indicated that effective patient self-management support would require specific training of primary care health professionals. Education and training have been identified as a potential way of engaging primary care clinicians in patient self-management support [
24]. However, though existing studies suggest that health professional training is associated with better uptake and implementation of patient self-management programs [
9,
14,
25,
26], it is not clear which type of professional training this might involve, or whether it actually improved patient outcomes.
The primary aim of this systematic review was to examine the effectiveness of educational interventions for primary care professionals that are designed to improve their support for patient self-management of chronic conditions and improve patient outcomes. The timeframe was specifically chosen in order to establish if this evidence was available prior to and up to 2 years after the concept of patient empowerment for self-management was introduced into the WONCA Europe definition of general practice. Furthermore, this systematic review was used to inform the subsequent project work packages, which included the creation of an online educational module and its evaluation.
Methods
A systematic review was undertaken using the PRISMA guidelines [
27] and follows the methodology outlined in the PROSPERO registered protocol (Database registration number: CRD42013004418) [
28].
Two specialist subject librarians assisted in the development of the search strategy designed to identify internationally recognised terminology in peer-reviewed journals. Full details of this strategy are available in the published protocol [
28]. Six databases were searched - Cochrane Library, PubMed, ERIC, EMBASE, CINAHL and PsycINFO - in addition to Web searches, Hand searches and Bibliographies. Articles published in advance of September 1st, 2013 were included in the review, with the search conducted by GD and PP. The full search terms and sample search are shown in ‘Additional file
1’. The timeframe was deliberately chosen in order to coincide with the inclusion of the concept of patient empowerment in WONCA Europe’s definition of general practice. It was also the first work package of a larger project. It is intended to repeat the systematic review in 2018.
Selection criteria
Studies with the following designs were included: systematic reviews, randomized controlled trials (RCTs), controlled clinical trials, interrupted time series, and controlled before and after studies.
Participants were physicians in primary care settings, other clinicians in primary care settings and patients 18+ years with chronic conditions in primary care settings. Included interventions had an educational focus designed to train primary care clinicians to support patient self-management. This review was concerned with all chronic conditions as they occur generically in the primary care setting, rather than focusing on any one specific chronic condition. Only articles including reference to patient outcomes, measured using validated measurement scales, were included. The primary patient outcome was change in patients’ self-management behaviours; the secondary outcomes were changes in physical health measures, health behaviours including medical adherence and compliance, service utilisation, psychological health, psycho-social function (e.g. Quality of Life, SF36, SF12) physical functioning and knowledge.
The eligibility of studies was determined using the inclusion and exclusion criteria listed in the registered proposal and shown in Table
1.
Table 1
Inclusion and exclusion criteria
English papers | Non- English papers | Eng |
Adults (18+) | Study population < 18 | Age |
Primary Care/Community | Secondary Care/Hospital | Not PC |
Chronic conditions, chronic illness, chronic disease, non-communicable disease (NCD) | Acute conditions | Acute |
Study Type- Systematic reviews, meta- analysis, RCTs, controlled clinical trials, interrupted time series. Controlled before and after studies | Study Type- Qualitative studies, populations studies, surveys, cross sectional, uncontrolled before and after studies (cohort) | Study |
Education and training of primary care Health Professionals for patient education in promoting change, behaviour change, lifestyle change, patient engagement, patient empowerment, motivational skills, patient collaboration, patient adherence and compliance, Patient self-management, decision making, patient problem- solving | Not education/training of health care professionals | Int |
Not primary care health professionals | Pop |
Primary outcome measures not included | Out |
Direct patient education only | Edu |
Continuing education / CME / Lifelong learning / Evidence based medicine | Guideline adherence, clinical performance | Guid |
All studies published to September 2013 | Organisational interventions | Org |
Financial changes and incentives | Fi |
Regulatory interventions | Reg |
All abstracts were reviewed using the RefWorks package to categorise the abstracts identified by the search. The initial review of abstracts was undertaken by SB with 10% of same re-checked by AR. The full text articles of all those considered to be of possible relevance to the systematic review were read independently by SB, JG and CC and categorised using the same exclusion reasons. Disagreements were reviewed by AR. The final list of full text articles were then reviewed by JG to confirm relevance. The quality assessment and extraction of thematic content of the final list of articles applicable to the systematic review question were considered by CC and AR.
Quality assessment
We assessed risk of bias and overall quality of individual studies using the Quality of Assessment Tool for Quantitative Studies [
29] (Tables
2,
3 and
4). For each study, reviewers rated six components (selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts) leading to an overall methodological quality rating for each study of strong, moderate, or weak, with strong quality indicating a low risk of bias. Reviewers resolved rating disagreements through discussion.
Random sequence generation (selection bias) | Low - Selection by central permuted block randomisation | Low - Selection by drawing lots |
Allocation Concealment (selection bias) | Low | Unclear-Insufficient information provided |
Blinding of participants and personnel (performance bias) | High – Blinding of participants and personnel was not possible | High – Blinding of participants and personnel was not possible |
Blinding of outcome assessment (detection bias) | High – Self-reported outcomes | High – Self-reported outcomes |
Incomplete outcome data (attrition bias) | Low – Clear participant flow reported | Low – Clear participant flow reported |
Selective reporting (reporting bias) | Low – The published report includes all expected outcomes | Low – The published report includes all expected outcomes |
Other bias | Unclear – but unlikely. Insufficient information to assess whether another important risk of bias exists | Unclear – but possible; no baseline data. Insufficient information to assess whether another important risk of bias exists |
Table 3
Quality assessment using EPHPP tool
Selection Bias 1. Are the individuals selected to participate likely to be representative of the target populations? | Can’t tell = 4 | Can’t tell = 4 |
Selection Bias 2. What percentage of the selected individuals agreed to participate? | Less than 60% agreement = 3 | Can’t tell = 5 |
SELECTION BIAS RATING | WEAK | WEAK |
Study design | Randomized control trial = 1 | Randomized control trial = 1 |
Was the study described as randomized? | Yes | Yes |
Was the method of randomization described? | Yes | Yes |
Was the randomization process appropriate? | Yes | Yes |
Study design rating | Strong | Strong |
Were there important differences between groups prior to the intervention? | No = 2 | No = 2 |
What percentage of relevant confounders were controlled? | N/A | N/A |
Confounders rating | Strong | Strong |
Were the outcome assessors aware of the intervention status of participants? | Can’t tell = 3 | Can’t tell = 3 |
Were the participants aware of the research question? | No = 2 | No = 2 |
Blinding rating | Moderate | Moderate |
Were data collection tools shown to be valid? | Yes = 1 | Yes = 1 |
Were data collections tools shown to be reliable? | Yes = 1 | Yes = 1 |
Data collection rating | Strong | Strong |
Were withdrawals and drop-outs reported in terms of numbers/reasons? | Yes = 1 | Yes = 1 |
Percentage of participants completing the study | 80 = − 100% = 1 | 80 = −100% = 1 |
Withdrawals and drop outs rating | Strong | Strong |
Intervention Integrity: What percentage of participants received the allocated intervention? | 80 = −100% = 1 | 80 = − 100% = 1 |
Was the consistency of the intervention measured | Can’t tell = 3 | Can’t tell = 3 |
Is it likely that subjects received an unintended intervention that may influence results? | No = 5 | No = 5 |
Analyses: Unit of allocation | Practice | Practice |
Unit of analysis | Individual | Individual |
Are the statistical methods appropriate for the study design? | Yes = 1 | Yes = 1 |
Is the analysis performed by intervention allocation status (ITT) rather than actual intervention received? | Yes = 1 | Yes = 1 |
Table 4
Summary of Global rating for Quality using EPHPP Quality Assessment tool
Selection Bias | Weak | Weak |
Study Design | Strong | Strong |
Confounders | Strong | Strong |
Blinding | Moderate | Moderate |
Data Collection Methods | Strong | Strong |
Withdrawals and Dropouts | Strong | Strong |
Global rating | Moderate | Moderate |
Data synthesis
We performed a narrative data synthesis as the clinical heterogeneity and differences in outcomes in the two studies meant meta-analysis would have been inappropriate.
Discussion
Main findings
The key finding of this systematic review is the scarcity of studies that assess the impact on patient outcomes of training primary care clinicians in patient self-management of chronic conditions. This was surprising given that patient self-management is a core element of person-centered healthcare in family practice and given the volume of published material on patient self-management.
This review shows that when health professionals undergo training in empowering patients for self-management of chronic conditions, it is possible to achieve improvement in patients’ self-efficacy, autonomy and motivation to change, functional capacity, pain free days and quality of life.
One study [
30] demonstrated improvement in functional capacity, quality of life scale and a greater number of pain free days reported by patients after six months and after 12 months among those whose primary care clinicians had been given training in motivational interviewing techniques. A second study [
31] showed that patients of the health professionals who participated in specific training programmes were more motivated to change behaviours and were more autonomous in their choice of behavioural changes compared to a control group. These patients were significantly more aware of the importance of controlling their diabetes for specific factors, and had a higher level of perception of having received specific advice from their GP on healthy behaviour changes.
Limitations of the review
Despite much literature on patient self-management in chronic disease, focussing on whether training health professionals regarding patient self-management improves patient outcomes, resulted in only two articles being eligible for inclusion in this systematic review. We are aware that some additional studies have been published more recently on self-management that were outside the chosen search period of this review. We plan to update this review in 2018. However, we feel it is important to publish the findings of this first phase review to highlight that, despite a vast volume of literature on one topic, evidence of impact on patient outcomes is largely lacking during the study period despite the publicity and interest in patient empowerment for self-management in the years leading up to its official inclusion in the European definition in 2011.
The small number of studies included and the range of outcome measures therein made concrete conclusions impossible, both papers describe positive outcomes from teaching motivational interviewing skills to clinicians, but we do not yet know if other approaches would be equally or more effective. The two studies did not report effect sizes, further complicating the interpretation of results. A further limitation is that only articles in English were included, based on available resources.
A total of 1643 patients, 191 clinicians and 164 practices were involved in these studies in two European countries, however further research on this topic is also needed to clarify if other factors are effective in improving patient outcomes other than those involving time constrained clinicians in general practice.
Interpretation of findings in the context of existing evidence
This review has given us concrete evidence of the lack of studies in the English language on improving patient outcomes through training primary care clinicians in patient self-management. Previous studies focus on patient education, group discussion among patients, shared experiences and unstructured acquisition of knowledge during clinical encounters or through leaflets and brochures [
16,
25,
32,
33] rather than on assessing the specific effect of specific clinician training on patient outcomes in this setting. Primary care professionals have a longitudinal relationship with patients in the patient’s own community, are accessible to patients, and though contacts are intermittent, there is coordination and continuity of care. This review suggests that teaching motivational interviewing skills to health professionals in primary care may improve self-efficacy and quality of life in their patients, compared to those patients of clinicians who did not participate in this training. It suggests that the addition of motivational interviewing techniques to usual care may have added benefit for patients over usual care in the primary care setting, however further research is needed to identify if other educational interventions or skills are useful.
Implications for further research
Further research is needed to distil the specific techniques to empower patients for self-management [
34]; to explore and define the various aspects of the concept of patient empowerment [
35]; and the variety of approaches that can be taken by primary care physicians to support patients to self monitor and make decisions about their chronic condition. We also need to identify and address potential barriers for self-management in patients [
36].
Patients with chronic conditions interact over time with many professionals in primary and secondary care. There are many other interventions that may help to improve patient self-management, (for example group education, health coaching, telemedicine, e-health, media led interventions, voluntary associations, sports organisations and community group activities). Additional factors having a potential impact on successful outcomes include patient preferences for individual or group interventions, and patients’ values, goals, level of education and literacy. Patients have increasingly easy and direct access to online resources. We need research to guide both clinicians and patients to know which methods are best used in which settings [
37], and which methods are not suited to particular settings. Careful designs and methods need to be used in future studies to assess the impact of such factors on measuring the outcomes of patient self-management including the Hawthorne effect and language bias. Appropriate assessment tools are required taking account of the integrative model of change appropriate in different settings [
38].
Studies are also needed on evidence for the feasibility of training health professionals in patient self-management approaches including efficient use of resources such as time, people and finance, as research into the value and effectiveness of the various methods that can be used to “empower patients” is still in its infancy [
37].
We also need to promote the inclusion of validated scales and instruments in future research for measurement and comparison of patient outcomes in chronic conditions.
Conclusions
Effective training for healthcare staff in patient self-management support is important in the context of patient centred care, patient outcomes, health care economics, strategy and delivery of healthcare on a global perspective.
This review suggests that primary care health professionals can help to harness patients’ capacity to contribute to improvement of their own health outcomes. Despite increasing literature on patient self-management and on health professional training on this topic, the evidence is very limited on measured patient health outcomes up to two years after patient self-management was incorporated into the WONCA definition of general practice. We plan to undertake a follow-up systematic review to establish if this changes over time or if further research is needed to assure health professionals and policy makers that patient self-management is a worthwhile and effective aspect of general practice.
Acknowledgements
We acknowledge the contributions of Dr. Ernesto Mola (Scientific Interdisciplinary Association of Both Family and Community Medicine (ASSIMEFAC), Lecce, Italy) and Associate Professor John Litt (Flinders University, Adelaide, Australia and Deputy Chair of National Quality Committee RACGP) on the theories and concepts of patient empowerment for self-management which encouraged EQuiP to conduct this research.