Trying to tackle chronic disease with web-based interventions

By: Perry Payne, Jr., MD/JD/MPP

Researchers estimate that half of Americans will suffer from a chronic disease before 2020, a startling fact that begs for innovation in order to prevent this occurrence or at least manage these diseases when they occur.

Patient Activation Measure is a valid, highly reliable scale developed by researchers at the University of Oregon that measures the extent to which:

patients know how to manage their condition,
have the skills and behavioral repertoire to manage their condition, and
have the confidence that they can collaborate with their health providers, maintain functioning, and access appropriate and high quality care.

Researchers in Coral Springs, Florida recently published the first study showing a change in patient activation as a result of a web-based intervention for people with chronic conditions. Read below to see what they learned and what the limitations are of this positive finding.

Prior self-management interventions, which supplement ongoing care by health professionals, have been associated with patient activation–a predictor of health outcomes. However, these have been done mainly in face-to-face settings or by telephone.

While, it would seem that websites, mobile apps, and similar technologies should be useful tools for helping people who have chronic diseases, the current evidence in this area of research is sparse. One prior randomized controlled trial by Lorig, et al reported a significant improvement in patient activation among patients with diabetes. The researchers sought to build on this study and increase the number of high quality studies which assess the effectiveness of web-based interventions.

Goal of study

The objective of the study was to explore whether a web-based intervention had any effect on patient activation levels for patients with chronic diseases. The web based intervention provides patients with access to self-management materials. Patient activation was measured as “attitudes toward knowledge, skills and confidence in self-managing health.”

The stated hypothesis of the study is that

“patients given access to a web-based intervention designed to support self-management in the context of a person’s particular chronic disease would demonstrate positive change in patient activation levels compared with control group participants.”

There was also a secondary hypothesis that “patients beginning at a lower stage of patient activation development would demonstrate greater change in patient activation than would participants starting at higher stages.”

Methods

This study was a prospective, randomized study conducted over a 12 week period. The participants were patients at Carolinas Health Care System, a regional health care system in North Carolina. The patients were aged 18-64 and were selected from a database of individuals seen by 300 physicians with a diagnosis of asthma, hypertension, or diabetes. Patients had at least one of these conditions. They also needed to have a history of visiting a physicians in the past 2 years but not in the last 180 days.

Selected patients were sent a personalized invitation to participate in the study and those that consented were randomly assigned to either an intervention or a control group.

The intervention group had access to MyHealth Online, an online patient portal with interactive health applications. With MyHealthOnline, people can also book doctor’s appointments, request prescription renewals, and view/pay their bills. The health applications are designed to advance the user’s knowledge by providing “evidence-based information on the patient’s specific condition, self-management guidelines, and options for problem solving and treatment.”

The control group has access to a health education website, but not MyHealth Online. Patient activation levels were assessed in both groups, pre and post the intervention with a 13 item patient activation measure (PAM-13). The PAM-13 was created to “elicit responses from a person about his or her attitudes toward knowledge, skills, and confidence in self-managing health.” The information used in the study was self-reported by participants and collected using an online survey.

Results

201 participants enrolled in the study. 57% had hypertension. 70% had a doctor visit in the last 6 months. The web-based intervention had a positive and significant effect on patient activation in the intervention group versus the control group. A small, but significant difference existed for the post-test activation scores of the two groups, except for people who started out at a high level of patient activation. Hence, the web-based intervention appears to be most useful for those who are in the early stages of patient activation.

Limitations

There were a number of limitations to this study. First, the data was self-reported which may have led to some degree of bias among participants. Perhaps, they wanted strongly for the web-based approach to work and their bias affected response to questions. Also, the study participants were not reflected of the country’s diversity. Over 95% of the participants went to college. The group contains only a few people from minority groups. This is an ongoing problem with web-based interventions.

The second limitation is the attrition rate in the intervention group which was 41%. This level was much higher than what other web-based intervention studies have reported.

A third limitation was that the specific functions of the MyHealthOnline website and its perceived value by patients was not studied. Since the actual tool being used was not fully evaluated, this creates a difficult choice for future researchers who may want to study this or another online or mobile intervention for helping manage chronic disease.

Next steps

This study appears to be the first to show a change in patient activation as a result of a web-based intervention for people with chronic conditions. This is an important finding because patient activation is associated with better adherence to health professional recommendations and thereby better health outcomes. The findings of the study are focused on a web intervention, but likely will translate to mobile technologies which can be accessed even more frequently. The results of the study also demonstrate one strategy for addressing the challenge of distributing self-management support to a large population of patients.

The authors of the study indicate that developing a web-based intervention for a specific stage of patient activation may increase the effectiveness of these interventions. In addition, the researchers note that in order for web-based interventions to reach their full potential, studies need to show that the technology can produce benefits over a sustained period and in a diverse population.