Effects of Self-Management Support on Structure, Process, and Outcomes Among Vulnerable Patients With Diabetes
A three-arm practical clinical trial
- Dean Schillinger, MD,1,2,
- Margaret Handley, PHD2,3,
- Frances Wang, MS1,2 and
- Hali Hammer, MD3
- 1Division of General Internal Medicine, University of California, San Francisco, San Francisco, California;
- 2University of California San Francisco Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California;
- 3Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California.
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The views presented here are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.
- Corresponding author: Dean Schillinger, dschillinger{at}medsfgh.ucsf.edu.
Abstract
OBJECTIVE Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model.
RESEARCH DESIGN AND METHODS A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic).
RESULTS Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (−1.7 days, P = 0.05) and the GMV group (−2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change.
CONCLUSIONS Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life.
Footnotes
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The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
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- Received April 23, 2008.
- Accepted December 24, 2008.
- © 2009 by the American Diabetes Association.
