Patient empowerment as a promising avenue towards health and social care integration: results from an overview of systematic reviews of patient empowerment interventions

摘要

Background : The ever increasing complexity of health care paired with the increasing proportion of chronic patients and other factors are clearly exacerbating the need for an all round well coordinated health (and social) system. This need for better integration of services has long sparked the interest for health system research and in the last 15 years this area has expanded and it now includes the increasingly active role of the patients, the field of patient empowerment. Although it has been strongly developed for over a decade now, it is still far from being consistent in terms of conceptualisations, categorisations and analysis. The results from the EMPATHiE project, by conducting a through review of systematic reviews analysing patient empowerment interventions targeting chronic conditions, aims to provide an overview of the field and advance in our common understanding of the role the patients as active players can have in the future developments of an integrated health (and social) systems. Objectives : To identify the effective empowerment interventions targeting chronic patients (chronic respiratory diseases (COPD or Asthma); chronic cardiovascular diseases; diabetes mellitus (type 1 and 2); severe mental illness (schizophrenia or chronic depression); complex patients (multi-morbidity) or health or social professionals working with the described chronic patients). Also we aimed to describe main contextual factors that help or hinder their implementation. Methods : Overview of systematic reviews (SR) of empowerment interventions for patients with chronic conditions from 2000 to 2013 was conducted for EMPATHIE (EU Project on Patient empowerment). Selected articles were extracted collecting intervention characteristics, outcome measures and scientific quality (AMSTAR). The effectiveness of the interventions was measured in terms of patient empowerment related measures, clinical outcomes, quality of life measures and use of health services. The success and failure factors were identified with a mixed methodology: results from meta-analysis and subgroup analysis and qualitative review of the conclusions of the SR’s authors. The interventions and identified factors are categorized by type of intervention, targeted condition, and level of evidence. Results : The search identified 101 SRs of interest (corresponding to more than 2300 individual studies) A descriptive analysis detected that most of the interventions reported in the studies were addressed to patients at micro or meso level. A predominance of interventions targeted diabetic patients (28.7% of SRs), followed at a distance by interventions targeting chronic respiratory conditions (25.7%), cardiovascular (12.9%), mental health conditions (10.9%) and just 1% specifically targeting complex patients. Within a general positive tendency (when compared to usual clinical centred care) some specific interventions emerge as the most effective: self-management support interventions across all conditions and different formats of patient education for diabetic patients. Recent innovative practices (such as virtual interactive platforms and tele-monitoring through smartphones) present a positive tendency, mainly in diabetes and cardiovascular conditions. Finally, systemic changes regarding the model of care (such as the chronic care model), seem to yield positive results. Similar interventions report different levels of effectiveness, which can be partially explained by multiple factors such as targeted condition, specific components of the intervention, patient and provider characteristics, contextual factors and outcome measures used. The study of the effect appears to indicate that, to a significant degree, success and failure factors are related to the targeted behaviour, which in turn is mediated, by the type of condition in which it is applied. Conclusion : Interventions targeting patient empowerment tend to present positive results in several types of outcomes. Self-management support interventions and some type of patient education formats presented the most conclusive evidence in their effectiveness. Recent innovative practices (as IT based platforms) present a positive tendency but still need further research particularly regarding the ideal combination between more traditional care and these innovative practices. Practical implications for policy and clinical organization will be discussed during the presentation. Stronger evaluative work on effectiveness of meso and macro level initiatives of patient empowerment is needed. Overall patient empowerment has opened a promising avenue towards healthcare (and social) integration.