CADENZA Community Project: Chronic Disease Self-Management Programme Evaluation of CADENZA Community Project: Chronic Disease Self-Management Programme 流金頌社區計劃－ 「活得自在」健康生活行動 評估報告

Introduction 引言

Prevalence of chronic diseases in older adults 長者慢性病的患病率 More than 700,000 older adults in Hong Kong have one or more chronic disease 超過700,000在港的長者有一種或多種慢性病 (Census & Statistics Department, 2005)

Burden of chronic diseases 慢性病造成的負擔 Healthcare system: increase healthcare expenditure, overload healthcare services 醫療系統︰增加醫療開支，使醫療服務超出負荷 Patients: lack of self-management knowledge and skills, lack of support in the community, multiple morbidities in older adults 病人︰缺乏自我管理疾病知識和技巧，缺乏社區支援，老年人普遍患有多種病患

Chronic Disease Self-Management Programme (CDSMP) 「慢性疾病自我管理課程」 A widely accepted education programme developed by Dr. Kate Lorig and colleagues at Stanford University 由史丹福大學 Dr. Kate Lorig 和其研究人員建立的一個病人教育課程 Attempted to improve confidence, health-related behaviours, health status and reduce healthcare utilization 嘗試改善病患者的信心，與健康有關的行為，健康狀況，及降低醫療服務的使用

Features of CDSMP 課程特點 Generic, non disease-specific Community-based Teach “self-management toolbox” Lay persons with chronic diseases as programme leaders 課程適合患有各種慢性病的人士 在社區內推行，教授自我管理的工具及技巧，並由有慢性病的病患者帶領課程

CADENZA Community Project 流金頌社區計劃 “CADENZA: A Jockey Club Initiative for Seniors” supported a CDSMP programme conducted by the Salvation Army 「流金頌︰賽馬會長者計劃新里程」支持由救世軍推行的「活得自在」自我管理生活課程 The effectiveness of the programme was evaluated by the Cadenza Research Team working with Dr. Elsie Hui of Shatin Hospital 沙田醫院的高級醫生許鷗思醫生與流金頌的研究團隊合作評估課程的成效

Project partners and work flow 計劃伙伴和工作流程 CADENZA research team 流金頌研究團隊 The Salvation Army 救世軍 Shatin Hospital 沙田醫院 Steering Committee 統籌委員會 Evaluation 評估 CDSMP in community elderly centres 在社區老人中心舉辦課程 Leaders training 組長訓練 Professional staff and Elder lay leaders 職員及長者組長 Professional staff-led programme 由職員組長帶領課程 Elder lay-led Programme 由長者組長帶領課程

Programme format 形式 6 sessions, 2.5 hours each, 1 session per week 課程有 6堂，每堂 2.5小時，每周 1堂 10-12 participants per group 每組 10-12個參加者 Held in community elderly centres of various NGOs in NTE districts 在新界東多個屬非政府機構的社區老人中心舉行 Led by 2-3 trained professional staff or elder lay leaders 由 2-3位受過訓練的職員或長者組長帶領課程

Features of leaders training 組長訓練的特點 All professional staff and elder lay leaders underwent 4-days leaders training 所有職員組長和長者組長進行 4天的組長訓練 Skills were practiced in real situation by leading “placement groups” 帶領「實習小組」，實踐組長技巧 Guidance was provided by experienced master trainers and leaders (coaching team) 有經驗的組長（支援隊）會提供指導

Methodology 評估方法 Compare the changes in health outcomes of CDSMP participants (study group) with those did not join the programme (control group) at 6 months 比較課程參加者（研究組）與未有接受課程的參加者（對照組）於 6個月後在健康方面的變化 Compare the effectiveness between programmes led by professional staff and elder lay leaders 比較由職員組長及長者組長領導課程的成效 Please refer to our publication for the details 詳情請參閱我們的報告書 (Woo et al, 2009)

Findings 評估結果

Participants 參加者 n=112 (86.82%) n=112 (82.35%) n=103 (79.84%) n=107 Study group participants 研究組 n=265 Control group participants 對照組 n=302 Baseline 基礎 Staff-led CDSMP 職員擔任課程組長 n=129 Elder lay-led CDSMP 長者擔任課程組長 n=136 Drop-out 棄權例數 n=17 Drop-out 棄權例數 n=24 Lost to follow-up 遺失例數 n=58 Finished 6 weeks CDSMP 完成 6周課程 n=112 (86.82%) n=112 (82.35%) Lost follow-up 遺失例數 n=9 Lost follow-up 遺失例數 n=5 Finished 6 months follow-up 完成 6個月訪問 n=103 (79.84%) n=107 (78.68%) n=244 (80.79%)

Characteristics of participants 參加者的基本狀況 Study 研究組 (n=210) Control 對照組 (n=244) P-value P值 Mean age (SD) 平均年齡 (標準差) 73.17 (8.29) 75.26 (7.90) 0.006* Gender: Female (%) 性別: 女性 (%) 78.57% 82.38% 0.306 Mean years of education (SD) 平均受教育年數 (標準差) 3.82 (3.97) 3.96 (4.05) 0.721 Mean number of chronic disease (SD) 平均慢性病數目 (標準差) 2.39 (1.01) 2.39 (1.11) 0.976 Type of chronic disease: 慢性病類型: Arthritis 關節炎 (%) 63.81% 70.49% 0.130 Hypertension 高血壓 (%) 61.43% 65.16% 0.410 Diabetes 糖尿病 (%) 32.86% 27.46% 0.211 Frailty index level: 虛弱程度: 0.293 None 無 (%) 37.62% 41.39% Mild 輕度 (%) 30.33% Moderate 中度 (%) 18.57% 21.72% Severe 重度 (%) 10.95% 6.56%

Outcome changes at 6 months – self management behaviours and self-efficacy 6 個月後評估變化 – 自我管理行為及信心 Outcome measures 成效評估 Study 研究組 (n=210) Control 對照組 (n=244) P-value P值 % Improvement 改善比率 Baseline mean (SD) 基礎評估均值 (標準差) Adjusted mean change (SD) 調正均數變化 Self management behaviours 自我管理行為 Exercises (minutes per week) 運動 (分鐘/每週) Stretch and strengthen (0-180)  伸展及負重運動 110.14 (70.61) +11.26 (4.33) 124.92 (67.11) -6.37 (3.99) 0.003 16.01* Aerobic (0-900)  帶氧運動 162.57 (90.18) +8.05 (5.75) 182.95 (96.88) -13.55 (5.29) 0.007 13.29* Cognitive symptom management (0-5) 應付症狀 0.76 (0.62) +0.36 (0.04) 0.77 (0.60) -0.01 (0.04) <0.0005 48.69* Communication with physician (0-5) 與醫生溝通 1.44 (1.33) +0.45 (0.08) 1.46 (1.21) -0.00 (0.08) 31.25* Self efficacy 自我管理信心 Self efficacy in managing disease in general (0-10) 管理整體疾病的信心 6.37 (1.83) +0.37 (0.12) 6.28 (2.05) -0.43 (0.11) 12.56* Self efficacy in managing symptoms (0-10) 管理症狀的信心 5.80 (2.17) +0.44 (0.14) 5.72 (2.43) -0.44 (0.13) 15.17*

Outcome changes at 6 months – health status 6 個月後評估變化 – 健康狀況 Outcome measures 成效評估 Study 研究組 (n=210) Control 對照組 (n=244) P-value P值 % improvement 改善比率 Baseline mean (SD) 基礎評估均值 (標準差) Adjusted mean change (SD) 調正均數變化 (標準差) Health status 健康狀況 Disability (0-3)  身體機能 0.20 (0.31) -0.02 (0.02) 0.20 (0.83) +0.01 (0.01) 0.157 Social/role activities limitations (0-4)  社交及日常生活的限制 0.59 (0.72) -0.12 (0.05) 0.63 (0.83) +0.06 (0.05) 0.010* 30.51 Energy (0-5)  能量 2.91 (1.01) +0.09 (0.06) 2.86 (1.12) -0.04 (0.06) 0.139 Psychological well-being/distress (0-5)  心理狀況 3.51 (0.95) +0.20 (0.05) 3.59 (1.00) +0.05 (0.05) 0.050* 4.27 Depressive symptom (0-5)  抑鬱症狀 1.19 (0.93) -0.26 (0.06) 1.16 (0.96) -0.05 (0.05) 0.004* 17.65 Health distress (0-5)  疾病的困擾 1.20 (1.07) -0.31 (0.06) 1.27 (1.13) -0.09 (0.06) 0.014* 18.33 Pain and discomfort (0-10)  疼痛與不適 3.91 (2.56) -0.42 (0.16) 3.96 (2.71) +0.16 (0.15) 14.83 Fatigue (0-10)  疲勞 3.78 (2.46) -0.11 (0.16) 3.82 (2.54) +0.23 (0.15) 0.116 Shortness of breath (0-10)  氣喘 1.33 (2.33) +0.13 (0.14) 0.99 (1.93) +0.42 (0.13) 0.141 Self-rated health (1-5)  整體健康 3.79 (0.77) -0.18 (0.05) 3.86 (0.73) +0.01 (0.04) 0.003* 5.01

Outcome changes at 6 months – health care utilization 6 個月後評估變化 – 醫療服務的使用 Outcome measures 成效評估 Study 研究組 (n=210) Control 對照組 (n=244) P-value P值 Baseline mean (SD) 基礎評估均值 (標準差) Adjusted mean change (SD) 調正均數變化 (標準差) Health care utilization 醫療服務的使用 Total physician visits  求診總次數 10.80 (14.06) -1.21 (0.68) 9.51 (11.50) +0.45 (0.63) 0.080 General practitioner visits  家庭醫生求診次數 6.29 (9.62) -0.89 (0.46) 5.20 (8.92) -0.18 (0.43) 0.264 Other health service visits  其他醫療服務使用 4.51 (7.67) -0.33 (0.47) 4.31 (7.18) +0.64 (0.43) 0.140 Emergency room visits  急症室 0.40 (1.13) +0.04 (0.06) 0.35 (0.74) -0.02 (0.05) 0.476 Nights in hospital  住院日數 1.30 (5.08) -0.32 (0.33) 1.16 (4.89) +0.09 (0.31) 0.366

Implications (1) 評估結果的意義 (1) Evidence showing that CDSMP has beneficial effects in older adults with chronic diseases 證據顯示課程對患有慢性病的老年人裡有顯著的成效 Improved self-management behaviours 改善自我管理行為 Improved self-efficacy 改善自我管理的信心 Improved health status 改善健康狀況 Effects lasted for at least 6 months 成效持續至少 6 個月

Subgroup analysis 子群分析 To explore whether participants with different age, educational level and frailty level would have different programme outcomes 分析課程對不同年齡，教育程度及虛弱程度的參加者是否有不同效果 In most of the outcome measures, evidence showing that no significant difference was found in the outcomes of participants from different age groups, educational level and frailty level 在大多數評估項目中，證據顯示課程對不同年齡，教育程度和虛弱程度的參加者的成效沒有明顯的分別

Subgroup analysis 子群分析 Aerobic exercise was significantly improved in the study group participants in severe frailty level 在帶氧運動的評估中，屬重度虛弱程度的研究組參加者有顯著的進步

Implications (2) 評估結果的意義 (2) Participants from different age groups, educational level and frailty level could benefit equally from CDSMP 來自不同的年齡，教育程度和虛弱程度的參加者都能同樣從中得益 Advanced age, low education and high level of frailty should not be excluded from self-management interventions 年紀較大，教育程度偏低及身體較虛弱的長者都一樣可以參加自我管課程，獲得課程帶來的益處

在大多數評估項目中，職員組長及長者組長帶領的課程的成效沒有明顯分別 Comparison of professional staff-led and elder lay-led programme 比較職員組長及長者組長帶領的課程的成效 In most of the outcome measures, no significant difference was observed between outcomes of the programmes led by professional staff and elder lay-leaders 在大多數評估項目中，職員組長及長者組長帶領的課程的成效沒有明顯分別

Implications (3) 評估結果的意義 (3) Evidence showing that the effectiveness of programmes led by elder lay leaders is similar to professional staff leaders 證據顯示長者組長帶領的課程跟職員組長的課程成效相近 Elder lay-leaders could be trained to teach CDSMP effectively 受過訓練的長者組長可以有效地帶領課程

Focus group interview 聚焦小組 Participants perceived that disease prevention services and education for older adults with chronic diseases were insufficient 參加者認為提供給患有慢性病的長者的疾病預防服務和教育並不足夠 CDSMP helped the participants and leaders to modify their lifestyles, gain self-management skills, and strengthen their psychosocial support 課程幫助參加者和組長改善生活模式，裝備自我管理技巧，及加強心理社交上的支援 CDSMP could relieve the burden of chronic diseases on the current healthcare services and should be disseminated in the community level 課程能夠減低慢性病對醫療服務的負擔，應該在社區層面上推廣出去

Recommendation 建議

Territory-wide implementation 地區性的實施 Widespread dissemination of the value of the programme 廣泛的推廣傳播課程的價值 Promote to other districts of Hong Kong 把課程推展至香港其他地區

Setting up referral systems and coordination 建立轉介系統和協調工作 Incorporate self-management programmes in community centres 把自我管理課程編入社區老人中心的服務 Complementing episodic hospital encounters 配合及彌補醫院較斷續、欠連貫的服務 Achieved through setting up referral systems from healthcare sector to NGO partners 需建立的轉介系統，從醫療部門轉介病患者到非政府機構的合作伙伴

Promotion of the concepts of elder as human capital 推廣長者重要的人力資本 Being lay leaders could satisfy the desire of older adults after retirement to continue to contribute to society 已退休的長者成為課程組長，可以滿足他們要繼續為社會作出貢獻的願望 Taking part in volunteer work can promote their own health and social benefits as well 參加義工工作能促進他們自己的健康和社交生活

Conclusion 結論

Conclusion 結論 High prevalence of chronic diseases and conditions in older adults create huge burden on individuals and healthcare system 大部份長者都患有慢性病，慢性病在個人和醫療系統上形成巨大的負擔 CDSMP could reduce the burden by enhancing self-efficacy and motivation, and improving health status of those with chronic diseases 「活得自在」自我管理生活課程能透過提升信心和推動力，改善患者的健康狀況，從而降低醫療系統的負擔 Training lay leaders could be cost-effective and sustainable means of promoting self-management concept in our community 訓練患有慢性病的長者成為組長，可能是一個低成本，有效和可持續的方法於社區裡推廣自我管理的概念