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A Systematic Review and Methodological Critique of the Literature

Asra Warsi, BA; Philip S. Wang, MD, DrPH; Michael P. LaValley, PhD; Jerry Avorn, MD; Daniel H. Solomon, MD, MPH

Arch Intern Med. 2004;164:1641-1649.

Background  Self-management programs have been widely reported to help patients manage symptoms and contain utilization of health care resources for several chronic conditions, but to date no systematic review across multiple chronic diseases has been reported. We evaluated the efficacy of patient self-management educational programs for chronic diseases and critically reviewed their methodology.

Methods  We searched MEDLINE and HealthSTAR for the period January 1, 1964, through January 31, 1999, then hand searched the reference section of each article for other relevant publications. We included studies if a self-management education intervention for a chronic disease was reported, a concurrent control group was included, and clinical outcomes were evaluated. Two authors reviewed each study and extracted the data on clinical outcomes.

Results  We included 71 trials of self-management education. Trial methods varied substantially and were suboptimal. Diabetic patients involved with self-management education programs demonstrated reductions in glycosylated hemoglobin levels (summary effect size, 0.45; 95% confidence interval [CI], 0.17-0.74); diabetic patients had improvement in systolic blood pressure (summary effect size, 0.20; 95% CI, 0.01-0.39); and asthmatic patients experienced fewer attacks (log rate ratio, 0.59; 95% CI, 0.35-0.83). Although we found a trend toward a small benefit, arthritis self-management education programs were not associated with statistically significant effects. Evidence of publication bias existed.

Conclusions  Self-management education programs resulted in small to moderate effects for selected chronic diseases. In light of evidence of publication bias, further trials that adhere to a standard methodology would help clarify whether self-management education is worthwhile.

From the Divisions of Pharmacoepidemiology and Pharmacoeconomics (Ms Warsi and Drs Wang, Avorn, and Solomon) and Rheumatology, Immunology, and Allergy (Dr Solomon), Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, and Boston University School of Public Health, Boston (Dr LaValley). The authors have no relevant financial interest in this article.

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