Building Evidence for Cost-effectiveness of Self-management Interventions in Chronic Care - Acknowledging Context and Mechanisms

Involving the chronically ill in the management of their own health is proposed to improve the cost-effectiveness of chronic care by improving health outcomes and diminishing the need and demand for care provided by professionals. Despite high expectations, empirical evidence of the cost-effectiveness of self-management remains scant. This may be due to the methodological challenges posed by the often complex nature of the self-management interventions and difficulty in operationalizing their outcomes. In this study, two empirical evaluations with distinct designs were applied to gain understanding of the methodological considerations related to the cost-effectiveness evaluation of chronic care self-management interventions. Realist evaluation approach was applied to acknowledge the contextual factors and the mechanisms that induce the economic and health outcomes of a self-management intervention. The findings of a retrospective cohort analysis with interviews showed that the present administrative and clinical data that is routinely collected in primary care does not reflect the mechanism of self-management interventions, that is, the improvement in patients' ability to manage their condition. A Finnish translation of Patient Activation Measure (PAM), a viable instrument for assessing the effectiveness of self-management interventions, was validated and used as a measure for effectiveness in the second part of this study. A quasi-experiment on the effectiveness and economic outcomes of a novel self-management intervention, an electronic patient portal, showed that providing chronically ill patients with access to their own health records and secured messaging with the care provider may increase patient activation at an acceptable cost to the health care provider, and therefore be cost-effective. More research is needed to validate the acceptable thresholds for investments in patient activation. The benefits of an electronic patient portal are dependent on the mechanisms that its functionalities generate, and on the contextual factors such as the characteristics of the patients and the health care professionals using it, the health care system that it is adopted in, and its implementation in the organization. The empirical evidence from the two studies showed that realist evaluation can complement the traditional outcome trials in the pursuit of accumulating knowledge on cost-effectiveness of complex health care interventions, such as self-management interventions.