Self-Help Manuals Cut Use of Unneeded Health Care Half of the Time
The Oregon Health Sciences University (OHSU) conducted a review of studies examining the effectiveness of providing patients with self-care manuals as a way to reduce unnecessary use of health care services.
Investigators reported the following findings based on 14 studies:
- Roughly half the people who receive self-care manuals actually use them.
- The combination of a manual and an educational program may increase knowledge and understanding of health care.
- Some reports indicate that people respond differently to illness symptoms after receiving a self-care manual, while others do not.
- People reported increased satisfaction and confidence after receiving a self-care manual.
- Manual users may hesitate to seek health care when it is the right thing to do.
- In roughly half the studies, there was a decline in unnecessary use of health care services after self-care manuals were distributed.
The research team distributed a printed report, Assessment of Self-Care Manuals, to health insurance programs, health care programs, researchers and others.
The Robert Wood Johnson Foundation (RWJF) provided $146,677 in funding from October 1998 to March 2000 to support the study.
Increasingly, organized health systems are providing members with self-care booklets, manuals and other tools as a way of encouraging them to participate actively in their own care and to make appropriate use of medical services. This practice is becoming common because consumers want more information, health care delivery systems are cultivating loyalty in their members, and many believe manuals will reduce inappropriate use of health care services.
RWJF funded previous evaluations by Oregon Health Sciences University (OHSU) researchers of projects that provided manuals to consumers in Idaho (ID#s 027017, 027929) and Oregon (ID# 029783). Following these studies (which found only small changes in health care utilization when self-care manuals were provided), RWJF supported this review by OHSU researchers of studies examining the efficacy of self-care manuals defined as general-purpose (not condition-specific) books or booklets that describe symptoms of common illnesses and give instructions about when and how to self-treat and when to consult a doctor.
OHSU houses one of 12 Evidence-based Practice Centers selected by the U.S. Agency for Healthcare Research and Quality (AHRQ) to provide clinicians and health plans with state-of-the-art scientific information to help them improve the quality of health care. OHSU's Department of Public Health and Preventive Medicine provided general support to the project.
The study used an evidence-based review methodology developed by AHRQ to assess the extent to which the assumed benefits of disseminating self-care manuals have been borne out by research. Working in consultation with an expert panel (see the Appendix), the investigators conducted a systematic search of the scientific literature for evidence that the dissemination of self-care manuals produces changes in patient behavior, their use of health care services, or the cost of care they receive.
They reviewed abstracts of more than 1,400 papers in the medical literature and identified 14 studies (11 of which were randomized controlled trials) that provided evidence regarding the effect of self-care manuals or brochures on health or health outcomes. Some studies examined only the effect of providing a book or booklet, while others combined the manual with some form of educational program, such as a lecture or introductory session.
In the Assessment of Self-Care Manuals, the investigators reported the following findings:
- Self-reported data indicate that roughly half the people who receive self-care manuals actually use them. There appears to be no difference in reported usage among people who receive a self-care manual in the context of a larger educational program and people who receive a manual alone.
- Evidence from two of the 14 studies examined suggests that when a self-care manual is provided in the context of a larger program (e.g., a lecture or introductory session), use of self-care manuals may increase knowledge and understanding of health care.
- While some reports indicate that people respond differently to illness symptoms after receiving a self-care manual, others do not. In one study, for example, families that received a booklet on common childhood illnesses consulted pediatricians less frequently for three of six symptoms covered than did a comparison group of families that did not receive the brochure. But in another study of a different self-care manual, there was no difference in number of consultations between families who received a booklet and those that did not.
- People reported increased satisfaction and confidence from receiving a self-care manual. Virtually every study that assessed how people felt about the self-care manuals found that recipients thought them to be useful and were pleased.
- In the two studies that attempted to evaluate whether self-care manuals reduced or increased patients' appropriate use of health care services, one study found no effect while the other found an adverse effect. That is, manual users hesitated to seek care when that was probably the right thing to do, or when that action was recommend in the manual.
- In roughly half the studies, there was a decline in unnecessary use of health care services after self-care manuals were distributed, as indicated by decreased office visits and other measures. While some projects failed to find a reduction in unnecessary use of medical services, there was too much evidence of reduced utilization to dismiss the hypothesis that it does occur.
- No study tested the effect of the manual on participant health status to establish whether the overarching goal of improved health status is actually achieved.
- Most of the studies did not evaluate whether the self-care manuals improved the recipients' health care decision-making processes and skills.
Because the review followed guidelines established by AHRQ, Assessment of Self-Care Manuals was approved for publication and dissemination through OHSU's Evidence-based Practice Center. With supplemental communications funding from RWJF, OHSU printed 700 copies of the full report and distributed them to health insurance programs, health care programs, researchers and others.
AHRQ and the Center for the Advancement of Health, a Washington, D.C. nonprofit that promotes research in behavior and medicine, publicized availability of the report. AHRQ is distributing the executive summary of the final project report. The findings were presented at the Qualitative Health Research Conference in Banff, Canada, in April 2000. Project team members are adapting the final report for submission to a professional journal. See the Bibliography for details.
AFTER THE GRANT
One project team member is pursuing a project designed to strengthen the use of self-care manuals among Medicaid patients. Two members of the project team are collaborating on developing a course for medical students on systematic evidence reviews.
GRANT DETAILS & CONTACT INFORMATION
Assessing the Efficacy of Self Management Strategies
Oregon Health and Sciences University (Portland, OR)
Dates: October 1998 to March 2000
Merwyn R. Greenlick, Ph.D.
Expert Panel Members and Peer Reviewers
National Expert Panel
Russell Glasgow, Ph.D.
AMC Cancer Research Center
Peter Juhn, M.D.
Care Management Institute
Donald W. Kemper, M.S.I.E., M.P.H.
Kate Lorig, Ph.D.
Stanford Patient Education Research Center
Palo Alto, Calif.
Michael Von Korff, Sc.D.
Center for Health Studies
Group Health Cooperative of Puget Sound
Local Expert Panel
Bruce Bayley, Ph.D.
Center for Outcomes Research and Education
Providence Health System
Certified Diabetes Educator
Michael J. Garland, D.Sc.Rel.
Professor, Vice Chair
Public Health and Preventive Medicine
Oregon Health Sciences University
Nancy Guenther, M.P.H.
Don Thieman, M.D.
Regence Blue Cross Blue Shield
Jacqueline Besteman, J.D., M.A.
EPC Project Officer
Center for Practice and Technology Assessment
Agency for Health Care Policy and Research
Barbara B. Fleming, M.D., Ph.D.
Senior Medical Advisor
Division of Ambulatory Post Acute Care
Health Care Financing Administration
James F. Fries, M.D.
Medicine/Immunology and Rheumatology
Stanford University Medical Center
Palo Alto, Calif.
Jeffrey Harris, M.D., M.P.H.
Division of Prevention Research and Analytic Methods
Epidemiology Program Office
Centers for Disease Control and Prevention
San Francisco, Calif.
Lowell S. Levin, Ed.D., M.P.H.
Epidemiology and Public Health
New Haven, Conn.
Marcia Ory, Ph.D., M.P.H.
Chief, Social Science Research on Aging
William Rakowski, Ph.D.
Associate Professor of Medical Science
Department of Community Health
C. Scott Smith, M.D.
Veterans Affairs Medical Center
Diana Storz, R.N., B.S.N.
Supervisor, Health Care Management
Regence Blue Cross Blue Shield of Oregon and HMO Oregon
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Carney N, Greenlick M, Austin D, Nygren P, Hibbard J and Helfand M. Assessment of Self-Care Manuals. Portland, Ore.: Oregon Health Sciences University, Department of Public Health and Preventive Medicine and Evidence-based Practice Center, 2000.
Carney N, Greenlick MR, Austin DF, Nygren P, Hibbard JH and Helfand M, et al. "Assessment of Self-Care Manuals." Portland, Ore.: Oregon Health Science University, 2000.
Presentations and Testimony
Carney N "Assessment of Self-Care Manuals," at the Qualitative Health Research Conference, April 58, 2000, Banff, Canada.
Report prepared by: Susan Baird Kanaan
Reviewed by: Richard Camer
Reviewed by: Robert Narus
Program Officer: C. Tracy Orleans