Self-Management Education for Osteoarthritis
Authors: Halsted R. Holman, Kate Lorig
Journal: Annals of Internal Medicine (2006)

Letters18 April 2006Self-Management Education for OsteoarthritisHalsted R. Holman, MD and Kate Lorig, RN, DrPHHalsted R. Holman, MDFrom Stanford University, Stanford, CA 94305.Search for more papers by this author and Kate Lorig, RN, DrPHFrom Stanford University, Stanford, CA 94305.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-144-8-200604180-00014 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:We wish to comment on the quality of the study by Chodosh and colleagues (1) that included our articles. We do not know how our concerns apply to other articles that were analyzed. Also, we discuss only the data on pain (not physical disability) because self-management education for osteoarthritis, unlike that for diabetes and hypertension, does not intend to change the biological abnormality. The goal of treatment is greater comfort and activity for the patient despite physical limitation. Disability may improve minimally but usually worsens over time.A valid meta-analysis must be accurate in its use of data. Beyond that, it should search the relevant databases thoroughly, assess the methodologic quality of the studies being analyzed, and interpret numerical results with common sense and due regard for the broader aspects of the problem (2). This study fails these requirements.First, the authors described the unbiased effect size for pain change in our study (3) as having a positive value that favored no benefit. In reality, the effect size was in the opposite direction, favoring treatment by −0.31 as calculated by the method the authors used (a similar error of direction is made for disability change).Second, the authors used 4 of our studies, one of which contained 2 control–treatment comparisons with small sample sizes (27 to 29 persons per group). They omitted 2 of our randomized, controlled studies (4, 5) with similar designs that were performed in the same time period with larger sample sizes (49 to 189 persons per group). These studies had effect sizes for pain that clearly favored treatment of about −0.36 and −0.41, depending on the calculation method.On the basis of these issues alone, the conclusion that self-management programs for osteoarthritis offer “no clinically beneficial effect” is not legitimate. There are also more problems. The authors included education programs that differed widely: home-based reading with video demonstrations, computer programs, mailed information with audiotapes and telephone calls, and group meetings. Each intervention had different design, content, and facilitators; therefore, the programs are not comparable and the effectiveness of their teaching was not assessed as a condition for selection. The authors also failed to mention that there are other valid methods to assess the benefits of a complex educational program. There are many examples, including 2 longitudinal studies of ours with large sample sizes (113 and 263 persons per group) that had benefits in pain and other outcomes persisting 3 to 4 years (6, 7).Although the goals of self-management have different definitions, none is restricted to pain and physical function (8, 9). Just as osteoarthritis can have many consequences for a person, self-management can have many benefits beyond pain reduction. Some that occur are mood improvement, enhanced perceived self-efficacy to cope with the consequences of chronic handicap, and reduced need for medical services. No mention is made of these benefits or the fact that benefits are additive to those of usual care. Consequently, a conclusion from this study about the value of self-management in osteoarthritis would be invalid.Why is all this important? Study integrity is only part of the answer. The impact of false conclusions can be substantial. Chronic disease is the dominant health care problem today, and effective self-management is an essential part of the solution. We are just beginning to learn how best to instill and maintain patient self-management skills. As we devise and test different methods, it is crucial that we assess each approach without error to select the best ways to improve health care. Failure to do so properly undermines the effort and harms the public good.Halsted R. Holman, MDKate Lorig, RN, DrPHStanford UniversityStanford, CA 94305References1. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143:427-38. [PMID: 16172441] LinkGoogle Scholar2. Greenhalgh T. Papers that summarise other papers (systematic reviews and meta-analyses). BMJ. 1997;315:672-5. [PMID: 9310574] CrossrefMedlineGoogle Scholar3. Lorig K, Lubeck D, Kraines RG, Seleznick M, Holman HR. Outcomes of self-help education for patients with arthritis. Arthritis Rheum. 1985;28:680-5. [PMID: 4004977] CrossrefMedlineGoogle Scholar4. Lorig K, Chastain RL, Ung E, Shoor S, Holman HR. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32:37-44. [PMID: 2912463] CrossrefMedlineGoogle Scholar5. Lorig K, Gonzalez VM, Ritter P. Community-based Spanish language arthritis education program: a randomized trial. Med Care. 1999;37:957-63. [PMID: 10493473] CrossrefMedlineGoogle Scholar6. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis Rheum. 1993;36:439-46. [PMID: 8457219] CrossrefMedlineGoogle Scholar7. Lorig KR, Ritter PL, Laurent DD, Fries JF. Long-term randomized, controlled trials of tailored-print and small-group arthritis self-management interventions. Med Care. 2004;42:346-54. [PMID: 15076811] CrossrefMedlineGoogle Scholar8. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns. 2002;48:177-87. [PMID: 12401421] CrossrefMedlineGoogle Scholar9. Adams K, Greiner A, Corrigan J. Report of a Summit. The First Annual Crossing the Quality Chasm Summit: A Focus on Communities. Washington, DC: National Academies Pr; 2004. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Stanford University, Stanford, CA 94305.Disclosures: Grants received: H.R. Holman (National Institutes of Health, Robert Wood Johnson Foundation, American Lung Association). PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoMeta-Analysis: Chronic Disease Self-Management Programs for Older Adults Joshua Chodosh , Sally C. Morton , Walter Mojica , Margaret Maglione , Marika J. Suttorp , Lara Hilton , Shannon Rhodes , and Paul Shekelle Self-Management Education for Osteoarthritis Joshua Chodosh , Sally C. Morton , Marika J. Suttorp , and Paul G. Shekelle Self-Management Education for Osteoarthritis Halsted R. Holman and Kate Lorig Metrics Cited byOsteoarthritis patients' perceptions of “appropriateness” for total joint replacement surgeryArthritis Self-Management 18 April 2006Volume 144, Issue 8Page: 617KeywordsDatabasesDisabilitiesHealth careHypertensionLongitudinal studiesLungsMedical servicesOsteoarthritisPhysical functioningSoftware tools ePublished: 18 April 2006 Issue Published: 18 April 2006 Copyright & PermissionsCopyright © 2006 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...