Academic Appointments

Professional Education

  • DrPH, UC Berkeley Public Health, Health Education (1980)
  • MS, UC San Francisco, Nursing (1968)
  • BS, Boston University, Nursing (1964)

Community and International Work

  • Expert Patient Internet Project, England


    Patient Education Chronic Disease

    Partnering Organization(s)

    National Health Service England

    Populations Served

    Chronic Disease Pts England



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Outcomes (behavior, health status, health care utilization) of community based chronic disease patient education in English and Spanish.
Ongoing studies include small group diabetes self-management for Spanish speakers. Internet self-management for chronic disease, arthritis, and diabetes (3 separtate projects). Low cost mailed arthritis programs for Spanish Speakers and evaluation of an Internet based chronic disease self management program for the National Health Service (Expert Patient Program) in the UK.

Clinical Trials

  • A National Study of the Chronic Disease Self-Management Program Not Recruiting

    This survey will address important research, practice, and policy questions: How does Chronic Disease Self-Management Program (CDSMP) impact participants' general health, their health behaviors, and their need for health care utilization? Who benefits most from the CDSMP program? Are predicted gains maintained over a six and twelve month period? Can critical clinical changes be seen for those who are diabetic?

    Stanford is currently not accepting patients for this trial.

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  • Active Living Tool Kit for Chronic Conditions Not Recruiting

    The development and pilot testing of a self-management program that would be delivered in a one time mailing.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kate Lorig, DrPH, 650-723-7935.

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  • Arthritis Self-Management Education Program Not Recruiting

    We will develop brief versions of the classic 6-week Arthritis Self-Management Program and evaluate their effectiveness.

    Stanford is currently not accepting patients for this trial.

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  • Building Better Caregivers Online: An Online Workshop for Caregivers of Those With Traumatic Brain Injury, Post Traumatic Stress Disorder, or Alzheimer's or Other Dementia Not Recruiting

    The workshop is a 6-week online workshop for caregivers of people with traumatic brain injury, post traumatic stress disorder, or dementia. It is being conducted jointly by the Stanford Patient Education Research Center and the VA Greater Los Angeles Healthcare System and is supported by a grant from the Department of Veterans Affairs, Patient Care Services, Office of Care Management and Social Work. The goal of the study is to determine whether an online caregiver education and support workshop can have lasting beneficial effects in helping caregivers improve their self-management of health skills, stress, and improve their caregiving abilities.

    Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.

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  • Building Better Caregivers: Development and Evaluation Not Recruiting

    The program consists of a 6-week small-group workshop for caregivers of people with memory problems. The goal of the study is to evaluate in a one year longitudinal study, program effectiveness in reducing caregiver stress, depression, fatigue, burden, days lost from work and improving sleep, healthful behaviors and self-efficacy

    Stanford is currently not accepting patients for this trial.

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  • Cancer: Thriving and Surviving Online Workshop and Study for Cancer Survivors Not Recruiting

    Cancer: Surviving and Thriving is a 6-week workshop for cancer survivors. The overall goal of the study is to determine whether an online cancer survivor education and support workshop can have lasting beneficial effects in helping survivors improve their self-management of health skills and quality of life.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kathryn Plant, MPH, 650-723-4863.

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  • Development and Evaluation of A Mailed Arthritis Self-Management Program Not Recruiting

    The purpose of this study is twofold, to develop and test the effectiveness of a mailed arthritis self-management education intervention.

    Stanford is currently not accepting patients for this trial.

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  • Doctors and Web-based Self-management Support Pilot Study Not Recruiting

    Doctors and web-based self-management support pilot study will test whether health professionals' observation of an online patient workshop on self-management of diabetes and participation in structured learning sessions on self-management strategies will change the attitudes and confidence of physicians and other health professionals regarding their willingness and ability to perform self-management interventions with patients. If this pilot suggests that attitudes and confidence levels can change, we hope to launch a larger study to examine this method of learning and its effectiveness in more detail.

    Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.

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  • English Diabetes Self-Management Program Not Recruiting

    We propose a diabetes self-management program evaluation and dissemination project with three components. 1. A six-month randomized trial to evaluate the effect of a community-based small group Diabetes Self Management Program (DSMP) on the health related quality of life, metabolic control and health care utilization of people with type 2 diabetes. 2. A long-term (12 month) longitudinal evaluation of the same program. 3. Two 5 day workshops to train others in California in how to lead and administer the program.

    Stanford is currently not accepting patients for this trial. For more information, please contact kate lorig, (650) 725 - 4617.

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  • Healthier Living Canada Not Recruiting

    This study will evaluate the effectiveness of an online Chronic Disease Self-Management Program for participants in Canada living with chronic health conditions. This pilot will look for improvements in health status, health behaviors and health care utilization.

    Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, MPH, 650-723-7935.

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  • Healthier Living With Arthritis Online Program Not Recruiting

    Individuals with with arthritic conditions (rheumatoid arthritis, osteoarthritis, or fibromyalgia) and internet and email access were randomized to receive an internet-based arthritis self-management program (treatment group) or to continue with usual care (control group). Questionnaires measuring health indicators, health behaviors, self efficacy and health care utilization were administered at baseline, six months and one year after the course. It was hypothesized that those participating in the course would have better outcomes than the control group at six months and one year.

    Stanford is currently not accepting patients for this trial.

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  • Improving Self Management Skills of Older Adults With Diabetes Not Recruiting

    The study will help determine if the Better Choices Better Health Diabetes program (community-based or online, also known as the Diabetes Self-Management Program) improves the hbA1C of people with Type-II diabetes. The investigators will also examine 1) symptoms (fatigue, sleep, low blood sugar symptoms, depression, shortness of breath), 2) healthy behaviors (blood sugar monitoring; taking medications as prescribed; getting eye, foot, kidney and cholesterol exams; and activity), 3) the use of health care services. This project is a translational study to demonstrate the effectiveness of the intervention in the context of a major insurer.

    Stanford is currently not accepting patients for this trial.

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  • Internet Chronic Disease Self-Management Program for Australia Not Recruiting

    The Internet Chronic Disease Self-Management Program (ICDSMP) is a pilot study of our existing, previous approved, Chronic Disease Self-Management Program Online. The online programme will be offered to 300 people with chronic disease in South Australia and evaluated for effectiveness, as well as satisfaction of both the South Australian peer facilitators and the participants with chronic disease. All participants will be recruited by the State of South Australia, after which they will complete informed consent and a questionnaire on a secure website housed at Stanford. They will take a 6-week online self-management program in groups of 20-25, and they fill our additional online questionnaires at 6 month and one year.

    Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.

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  • Internet Diabetes Self-Management Not Recruiting

    Diabetes is a growing health problem causing personal suffering, comorbid conditions, premature death, and high costs to the individual, the health care system and society. Many of these problems can be prevented or delayed by controlling the disease. This in turn requires daily self-management by patients. We will evaluate an Internet based small group Diabetes Self-Management Program. This program will be adapted from the Chronic Disease Self-Management Program Online, already developed and currently being evaluated by the investigators. Participants with type 2 diabetes will be randomized to participate in the Internet Program or serve as controls continuing with usual care. Treatment subjects will participate in a structured 6 week interactive web-based online class with 20-24 other participants and 2 trained peer moderators. If successful, this project will result in a new and effective means of reaching the CDC objective and more importantly in improving the quality of life and health status of people with diabetes while reducing health care utilization and thus costs.

    Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.

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  • Internet Diabetes Self-Management Workshop Not Recruiting

    The purpose of this study is to determine of the effectiveness of an Internet based Diabetes Self-Management workshop for people with type II diabetes. Half of the people who complete the workshop will be invited to continue their education by participating in a email discussion group. Thus, we will be able to learn both the efficacy of the original program as well as its efficacy when reinforced by the discussion group. Diabetes is a disease that must be managed day by day by the individual with the disease. Although we know a great deal about the self-management of type II diabetes, most self-management is less than optimal. In addition, most people with diabetes do not have an opportunity to participate in formal diabetes education. This study will determine if an Internet delivered educational workshop will help people with diabetes manage their disease. Thus we will be measuring changes in behaviors, changes in symptoms and changes in HbA1c, blood pressure, cholesterol, and weight. If successful the workshop will serve as a prototype for Internet diabetes education.

    Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.

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  • Low Back Pain Patient Education Evaluation Not Recruiting

    Back pain is one of the most common of all symptoms. It is also a great cause of days lost from work and visits to health care providers. This study will develop and evaluate an approach to low back pain that allows subjects to talk with each other and with health professionals via an Internet discussion group. Results we will look at include health behaviors, such as exercise; health status, such as pain and disability; and health care use, such as number of visits to doctors and other health care providers. Anyone 18 years old or older who lives in the United States and has ongoing Internet access can take part in the study. All subjects must have back pain and meet the eligibility criteria listed below.

    Stanford is currently not accepting patients for this trial.

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  • Patient Education in Rheumatoid Arthritis and Osteoarthritis Not Recruiting

    This project will evaluate the effectiveness and general usefulness of two arthritis patient education programs. The first, the Arthritis Self-Management Program, is a 6-week, community-based program taught in small groups by peer leaders. The second, the Self-Managed Arthritis Relief Therapy (SMART) Program, is a computer-driven program delivered through the mail. Participants in this project are people with rheumatoid arthritis or osteoarthritis who are taking part in the larger long-term studies being conducted by ARAMIS (the Arthritis, Rheumatism and Aging Medical Information System).

    Stanford is currently not accepting patients for this trial.

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  • Spanish Diabetes Self-Management Program Not Recruiting

    Type II diabetes is a growing health concern for Latinos who not only have a higher incidence of the disease but also suffer great morbidity. At the same time due to poverty, language, low literacy and lack of continuity of care, this population is largely excluded from current diabetes education programs. To assist with this problem we propose to evaluate 1) a community-based, peer-led Spanish Diabetes Self-Management Program that is culturally appropriate and acceptable based on self-efficacy theory, and 2) the effects of long-term, self-tailored educational reinforcement offered by means of automated telephone disease management messages. Should this research be successful it will provide an evidenced based public health diabetes education model for use with Latino populations throughout the United States.

    Stanford is currently not accepting patients for this trial.

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2018-19 Courses

All Publications

  • International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering. Pain medicine (Malden, Mass.) Darnall, B. D., Juurlink, D., Kerns, R. D., Mackey, S., Van Dorsten, B., Humphreys, K., Gonzalez-Sotomayor, J. A., Furlan, A., Gordon, A. J., Gordon, D. B., Hoffman, D. E., Katz, J., Kertesz, S. G., Satel, S., Lawhern, R. A., Nicholson, K. M., Polomano, R. C., Williamson, O. D., McAnally, H., Kao, M., Schug, S., Twillman, R., Lewis, T. A., Stieg, R. L., Lorig, K., Mallick-Searle, T., West, R. W., Gray, S., Ariens, S. R., Sharpe Potter, J., Cowan, P., Kollas, C. D., Laird, D., Ingle, B., Julian Grove, J., Wilson, M., Lockman, K., Hodson, F., Palackdharry, C. S., Fillingim, R. B., Fudin, J., Barnhouse, J., Manhapra, A., Henson, S. R., Singer, B., Ljosenvoor, M., Griffith, M., Doctor, J. N., Hardin, K., London, C., Mankowski, J., Anderson, A., Ellsworth, L., Davis Budzinski, L., Brandt, B., Harkootley, G., Nickels Heck, D., Zobrosky, M. J., Cheek, C., Wilson, M., Laux, C. E., Datz, G., Dunaway, J., Schonfeld, E., Cady, M., LeDantec-Boswell, T., Craigie, M., Sturgeon, J., Flood, P., Giummarra, M., Whelan, J., Thorn, B. E., Martin, R. L., Schatman, M. E., Gregory, M. D., Kirz, J., Robinson, P., Marx, J. G., Stewart, J. R., Keck, P. S., Hadland, S. E., Murphy, J. L., Lumley, M. A., Brown, K. S., Leong, M. S., Fillman, M., Broatch, J. W., Perez, A., Watford, K., Kruska, K., Sophia You, D., Ogbeide, S., Kukucka, A., Lawson, S., Ray, J. B., Wade Martin, T., Lakehomer, J. B., Burke, A., Cohen, R. I., Grinspoon, P., Rubenstein, M. S., Sutherland, S., Walters, K. R., Lovejoy, T. 2018

    View details for DOI 10.1093/pm/pny228

    View details for PubMedID 30496540

  • Development and Pilot of a Patient Satisfaction Scale in Rheumatology Valenzuela, A., Sheth, K., Shoor, S., Ritter, P. L., Lorig, K. WILEY. 2018
  • Evaluation of a Diabetes Self-Management Program: Claims Analysis on Comorbid Illnesses, Health Care Utilization, and Cost JOURNAL OF MEDICAL INTERNET RESEARCH Turner, R. M., Ma, Q., Lorig, K., Greenberg, J., DeVries, A. R. 2018; 20 (6): e207


    An estimated 30.3 million Americans have diabetes mellitus. The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality of life for people who either have or are at risk for diabetes mellitus, and hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative.The aim of this study was to evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to diabetes mellitus, health care utilization, and cost.A propensity score matched two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment were used for outcome variables. The intervention cohort included diabetes mellitus patients who were recruited to a diabetes self-management program. Control cohort subjects were identified from the HealthCore Integrated Research Environment by at least two diabetes-associated claims (International Classification of Diseases-Ninth Revision, ICD-9 250.xx) within 2 years before the program launch date (October 1, 2011-September 30, 2013) but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and postintervention all-cause and diabetes-related utilization and costs. Cost outcomes are reported as least squares means. Repeated measures analyses (generalized estimating equation approach) were conducted for utilization, comorbid conditions, and costs.The program participants who were identified in HealthCore Integrated Research Environment claims (N=558) were matched to a control cohort of 1669 patients. Following the intervention, the self-management cohort experienced significant reductions for diabetes mellitus-associated comorbid conditions, with the postintervention disease burden being significantly lower (mean 1.6 [SD 1.6]) compared with the control cohort (mean 2.1 [SD 1.7]; P=.001). Postintervention all-cause utilization was decreased in the intervention cohort compared with controls with -40/1000 emergency department visits vs +70/1000; P=.004 and -5780 outpatient visits per 1000 vs -290/1000; P=.001. Unadjusted total all-cause medical cost was decreased by US $2207 in the intervention cohort compared with a US $338 decrease in the controls; P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was -US $815 (P=.049).Patients in the BCBH-D program experienced reduced all-cause health care utilization and costs. Direct cost savings were US $815. Although encouraging, given the complexity of the patient population, further study is needed to cross-validate the results.

    View details for DOI 10.2196/jmir.9225

    View details for Web of Science ID 000436201400002

    View details for PubMedID 29934284

  • Comparative Efficacy and Mechanisms of a Single-Session Pain Psychology Class in Chronic Low Back Pain: Study Protocol for a Randomized Controlled Trial Trials Darnall, B., Siadni, M., Roy, A., Kao, M., Sturgeon, J., Cook, K., Lorig, K., Burns, J., Mackey, S. 2018: 165


    The Institute of Medicine (IOM) reported that chronic pain affects about 100 million U.S. adults, with chronic low back pain (CLBP) cited as the most prevalent type. Pain catastrophizing is a psychological construct shown to predict the development and trajectory of chronic pain and patient response to pain treatments. While effective treatment for pain catastrophizing typically includes eight-session groups of cognitive behavioral therapy (CBT), a single-session targeted treatment class yielded promising results which, if replicated and extended, could prove to efficiently and cost-effectively reduce pain catastrophizing. In this trial, we seek to determine the comparative efficacy of this novel single-session pain catastrophizing class to an eight-session course of pain CBT and a single-session back pain health education class. We will also explore the psychosocial mechanisms and outcomes of pain catastrophizing treatment.In this trial we will randomize 231 individuals with CLBP to one of three treatment arms: (1) pain-CBT (eight weekly 2-h group sessions with home exercises and readings); (2) a single 2-h pain catastrophizing class; or (3) a single 2-h back pain health education class (active control). For the primary outcome of pain catastrophizing, the trial is designed as a non-inferiority test between pain-CBT and the single-session pain catastrophizing class, and as a superiority test between the single-session pain catastrophizing class and the health education class. Team researchers masked to treatment assignment will assess outcomes up to six months post treatment.If the single-session targeted pain catastrophizing class is found to be an effective treatment for patients with CLBP, this low cost and low burden treatment could dismantle many of the current barriers and burdens of effective pain care. Further, elucidation of the mechanisms of pain catastrophizing treatments will facilitate future research on the topic as well as further development and refinement of, NCT03167086 . Registered on 22 May 2017.

    View details for DOI 10.1186/s13063-018-2537-3

    View details for PubMedCentralID PMC5838852

  • Development and Validation of a Rheumatologist Satisfaction with Practice Scale -"the Rheumatologist Satisfaction Scale" (RSS) Sheth, K., Valenzuela, A., Shoor, S., Ritter, P. L., Lorig, K. WILEY. 2017
  • Commentary on "Evidence-Based Self-management Programs for Seniors and Other With Chronic Diseases": Patient Experience-Patient Health-Return on Investment. The Journal of ambulatory care management Lorig, K. 2017; 40 (3): 185-188

    View details for DOI 10.1097/JAC.0000000000000204

    View details for PubMedID 28570356

  • Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services BMC PSYCHIATRY Valimaki, M., Yang, M., Normand, S., Lorig, K. R., Anttila, M., Lantta, T., Pekurinen, V., Adams, C. E. 2017; 17


    People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar NCT02724748 . Registered on 25(th) of April 2016.

    View details for DOI 10.1186/s12888-017-1266-6

    View details for Web of Science ID 000398423500002

    View details for PubMedID 28372555

  • Soliciting and Responding to Patients' Questions about Diabetes Through Online Sources. Diabetes technology & therapeutics Crangle, C. E., Bradley, C., Carlin, P. F., Esterhay, R. J., Harper, R., Kearney, P. M., Lorig, K., McCarthy, V. J., McTear, M. F., Tuttle, M. S., Wallace, J. G., Savage, E. 2017


    When patients cannot get answers from health professionals or retain the information given, increasingly they search online for answers, with limited success. Researchers from the United States, Ireland, and the United Kingdom explored this problem for patients with type 2 diabetes mellitus (T2DM). In 2014, patients attending an outpatient clinic (UK) were asked to submit questions about diabetes. Ten questions judged representative of different types of patient concerns were selected by the researchers and submitted to search engines within trusted and vetted websites in the United States, Ireland, and the United Kingdom. Two researchers independently assessed if answers could be found in the three top-ranked documents returned at each website. The 2014 search was repeated in June, 2016, examining the two top-ranked documents returned. One hundred and sixty-four questions were collected from 120 patients during 12 outpatient clinics. Most patients had T2DM (95%). Most questions were about diabetes (N = 155) with the remainder related to clinic operation (N = 9). Of the questions on diabetes, 152 were about T2DM. The 2014 assessment found no adequate answers to the questions in 90 documents (10 questions, 3 websites, 3 top documents). In the 2016 assessment, 1 document out of 60 (10 questions, 3 websites, 2 top documents) provided an adequate answer relating to 1 of the 10 questions. Available online sources of information do not provide answers to questions from patients with diabetes. Our results highlight the urgent need to develop novel ways of providing answers to patient questions about T2DM.

    View details for DOI 10.1089/dia.2016.0291

    View details for PubMedID 28221815

  • Cost-Effectiveness of the Hepatitis C Self-Management Program. Health education & behavior Groessl, E. J., Sklar, M., Laurent, D. D., Lorig, K., Ganiats, T. G., Ho, S. B. 2017; 44 (1): 113-122


    Despite the emergence of new hepatitis C virus (HCV) antiviral medications, many people with chronic HCV know little about their disease, are at risk for transmitting HCV to others, and/or are not considered good treatment candidates. Self-management interventions can educate HCV-infected persons, improve their quality of life, and prepare them for treatment.A cost-effectiveness analysis of the HCV Self-Management Program is presented.Effectiveness data in quality-adjusted life years (QALYs) were derived from the previously published prospective, randomized controlled trial ( n = 134). Health care utilization was abstracted from medical records in 2011 for the 12 months before and after study enrollment. Intervention costs were tracked from the payer's perspective and combined with health care costs. Sensitivity analyses were used to examine assumptions. Data were analyzed in 2014.Estimated intervention costs including organizational overhead were $1,760 per 6-week workshop, or $229/person. Health care costs were $815 lower/person for self-management participants, resulting in a cost savings of $586/person. Self-management participants had an average net gain of 0.02975 QALYs after 1 year. When removing inpatient substance use treatment days from analyses, costs were similar between groups, producing an incremental cost-effectiveness ratio of $6,218/QALY. Sensitivity analyses showed that the results and conclusions change little when assumptions were varied.When compared to information-only, the HCV Self-Management Program led to more QALYs and cost savings in the randomized controlled trial. Independent of health care costs, the intervention is low-cost and educates HCV-infected individuals about antiviral treatment and avoiding viral transmission. Low-cost interventions that can enhance the outcomes derived from expensive antiviral treatments should be studied further.

    View details for DOI 10.1177/1090198116639239

    View details for PubMedID 27206463

  • A Diabetes Self-Management Program: 12-Month Outcome Sustainability From a Nonreinforced Pragmatic Trial JOURNAL OF MEDICAL INTERNET RESEARCH Lorig, K., Ritter, P. L., Turner, R. M., English, K., Laurent, D. D., Greenberg, J. 2016; 18 (12): 54-64


    Diabetes self-management education has been shown to be effective in controlled trials. The 6-week Better Choices, Better Health-Diabetes (BCBH-D) self-management program was also associated with an improvement in health outcomes in a 6-month translation study.The objective of this study was to determine whether a national translation of the BCBH-D self-management program, offered both Web-based and face-to-face, was associated with improvements in health outcomes (including HbA1c) and health behaviors (including recommended medical tests) 1 year after intervention.Web-based programs were administered nationally, whereas face-to-face workshops took place in Atlanta, Indianapolis, and St Louis. Self-report questionnaires were either Web-based or administered by mail, at baseline and 1 year, and collected health and health-behavior measures. HbA1c blood samples were collected via mailed kits. A previous 6-month study found statistically significant improvements in 13 of 14 outcome measures, including HbA1c. For this study, paired t test compared baseline with 1-year outcomes. Subgroup analyses determined whether participants with specific conditions improved (high HbA1c, depression, hypoglycemia, nonadherence to medication, no aerobic exercise). The percentage of participants with improvements in effect size of at least 0.4 in at least 1 of the 5 measures was calculated.A total of 857 participants with 1-year data (69.7% of baseline participants) demonstrated statistically significant 1-year improvements in 13 of 15 outcome measures; 79.9% (685/857) of participants showed improvements in effect size of 0.4 or greater in at least 1 of the 5 criterial measures.Participants had small but significant benefits in multiple measures. Improvements previously noted at 6 months were maintained or amplified at 1 year.

    View details for DOI 10.2196/jmir.6484

    View details for Web of Science ID 000391065600005

    View details for PubMedID 27979790

    View details for PubMedCentralID PMC5200842

  • Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization. A Randomized Study. American journal of respiratory and critical care medicine Benzo, R., Vickers, K., Novotny, P. J., Tucker, S., Hoult, J., Neuenfeldt, P., Connett, J., Lorig, K., McEvoy, C. 2016; 194 (6): 672-680


    Hospital readmission for chronic obstructive pulmonary disease (COPD) has attracted attention owing to the burden to patients and the health care system. There is a knowledge gap on approaches to reducing COPD readmissions.To determine the effect of comprehensive health coaching on the rate of COPD readmissions.A total of 215 patients hospitalized for a COPD exacerbation were randomized at hospital discharge to receive either (1) motivational interviewing-based health coaching plus a written action plan for exacerbations (the use of antibiotics and oral steroids) and brief exercise advice or (2) usual care.We evaluated the rate of COPD-related hospitalizations during 1 year of follow-up. The absolute risk reductions of COPD-related rehospitalization in the health coaching group were 7.5% (P = 0.01), 11.0% (P = 0.02), 11.6% (P = 0.03), 11.4% (P = 0.05), and 5.4% (P = 0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. The odds ratios for COPD hospitalization in the intervention arm compared with the control arm were 0.09 (95% confidence interval [CI], 0.01-0.77) at 1 month postdischarge, 0.37 (95% CI, 0.15-0.91) at 3 months postdischarge, 0.43 (95% CI, 0.20-0.94) at 6 months postdischarge, and 0.60 (95% CI, 0.30-1.20) at 1 year postdischarge. The missing value rate for the primary outcome was 0.4% (one patient). Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire emotional score (emotion and mastery domains) and physical score (dyspnea and fatigue domains) (P < 0.05). There were no differences between groups in measured physical activity at any time point.Health coaching may represent a feasible and possibly effective intervention designed to reduce COPD readmissions. Clinical trial registered with (NCT01058486).

    View details for DOI 10.1164/rccm.201512-2503OC

    View details for PubMedID 26953637

  • Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Benzo, R., Vickers, K., Novotny, P. J., Tucker, S., Hoult, J., Neuenfeldt, P., Connett, J., Lorig, K., McEvoy, C. 2016; 194 (6): 672-680
  • Intervention to Improve Quality of life for African-AmericaN lupus patients (IQAN): study protocol for a randomized controlled trial of a unique a la carte intervention approach to self-management of lupus in African Americans BMC HEALTH SERVICES RESEARCH Williams, E. M., Lorig, K., Glover, S., Kamen, D., Back, S., Merchant, A., Zhang, J., Oates, J. C. 2016; 16


    Systemic Lupus Erythematosus (lupus) is a chronic autoimmune disease that can impact any organ system and result in life-threatening complications. African-Americans are at increased risk for morbidity and mortality from lupus. Self-management programs have demonstrated significant improvements in health distress, self-reported global health, and activity limitation among people with lupus. Despite benefits, arthritis self-management education has reached only a limited number of people. Self-selection of program could improve such trends. The aim of the current study is to test a novel intervention to improve quality of life, decrease indicators of depression, and reduce perceived and biological indicators of stress in African-American lupus patients in South Carolina.In a three armed randomized, wait list controlled trial, we will evaluate the effectiveness of a patient-centered 'a-la-carte' approach that offers subjects a variety of modes of interaction from which they can choose as many or few as they wish, compared to a 'set menu' approach and usual care. This unique 'a-la-carte' self-management program will be offered to 50 African-American lupus patients participating in a longitudinal observational web-based SLE Database at the Medical University of South Carolina. Each individualized intervention plan will include 1-4 options, including a mail-delivered arthritis kit, addition and access to an online message board, participation in a support group, and enrollment in a local self-management program. A 'set menu' control group of 50 lupus patients will be offered a standardized chronic disease self-management program only, and a control group of 50 lupus patients will receive usual care. Outcomes will include changes in (a) health behaviors, (b) health status, (c) health care utilization, and (d) biological markers (urinary catecholamines).Such a culturally sensitive educational intervention which includes self-selection of program components has the potential to improve disparate trends in quality of life, disease activity, depression, and stress among African-American lupus patients, as better outcomes have been documented when participants are able to choose/dictate the content and/or pace of the respective treatment/intervention program. Since there is currently no "gold standard" self-management program specifically for lupus, this project may have a considerable impact on future research and policy decisions.NCT01837875 ; April 18, 2013.

    View details for DOI 10.1186/s12913-016-1580-6

    View details for Web of Science ID 000380648700010

    View details for PubMedID 27485509

  • Leveraging Administrative Data for Program Evaluations: A Method for Linking Data Sets Without Unique Identifiers EVALUATION & THE HEALTH PROFESSIONS Lorden, A. L., Radcliff, T. A., Jiang, L., Horel, S. A., Smith, M. L., Lorig, K., Howell, B. L., Whitelaw, N., Ory, M. 2016; 39 (2): 245-259


    In community-based wellness programs, Social Security Numbers (SSNs) are rarely collected to encourage participation and protect participant privacy. One measure of program effectiveness includes changes in health care utilization. For the 65 and over population, health care utilization is captured in Medicare administrative claims data. Therefore, methods as described in this article for linking participant information to administrative data are useful for program evaluations where unique identifiers such as SSN are not available. Following fuzzy matching methodologies, participant information from the National Study of the Chronic Disease Self-Management Program was linked to Medicare administrative data. Linking variables included participant name, date of birth, gender, address, and ZIP code. Seventy-eight percent of participants were linked to their Medicare claims data. Linking program participant information to Medicare administrative data where unique identifiers are not available provides researchers with the ability to leverage claims data to better understand program effects.

    View details for DOI 10.1177/0163278714547568

    View details for Web of Science ID 000376186900006

    View details for PubMedID 25139849

  • Characteristics of the Spanish- and English-Language Self-Efficacy to Manage Diabetes Scales DIABETES EDUCATOR Ritter, P. L., Lorig, K., Laurent, D. D. 2016; 42 (2): 167-177
  • Characteristics of the Spanish- and English-Language Self-Efficacy to Manage Diabetes Scales. Diabetes educator Ritter, P. L., Lorig, K., Laurent, D. D. 2016; 42 (2): 167-177


    The purpose of this study was to examine the characteristics of the Spanish-language diabetes self-efficacy scale (DSES-S) and the English-language version (DSES).This study consists of secondary data from 3 randomized studies that administered the DSES-S and DSES at 2 time points. The scales consist of 8 Likert-type 10-point items. Principal component analysis was applied to determine if the scales were unitary or consisted of subscales. Univariate statistics were used to describe the scales. Sensitivity to change was measured by comparing randomized treatment with control groups, where the treatment included methods designed to enhance self-efficacy. General linear models were used to examine the association between the scales and the 8 medical outcomes after controlling for demographic variables.Principal component analysis indicated that there were 2 subscales for both versions: self-efficacy for behaviors and self-efficacy to manage blood levels and medical condition. The measures had similar means across the 3 studies, high internal consistent reliability, values distributed across the entire range, and they showed no evidence of floor effects and little evidence of ceiling effects. The measures were sensitive to change. They were associated with several health indicators and behaviors at baseline, and changes were associated with changes in health measures.The self-efficacy measures behaved consistently across the 3 studies and were highly reliable. Associations with medical indicators and behaviors suggested validity, although further study would be desirable to compare other measures of self-efficacy for people with type 2 diabetes. These brief scales are appropriate for measuring self-efficacy to manage diabetes.

    View details for DOI 10.1177/0145721716628648

    View details for PubMedID 26846336

  • Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study. Journal of medical Internet research Lorig, K., Ritter, P. L., Turner, R. M., English, K., Laurent, D. D., Greenberg, J. 2016; 18 (6)


    Diabetes self-management education has been shown to be effective in controlled trials. However, few programs that meet American Association of Diabetes Educators standards have been translated into widespread practice.This study examined the translation of the evidence-based Better Choices, Better Health-Diabetes program in both Internet and face-to-face versions.We administered the Internet program nationally in the United States (n=1010). We conducted face-to-face workshops in Atlanta, Georgia; Indianapolis, Indiana; and St. Louis, Missouri (n=232). Self-report questionnaires collected health indicator, health behavior, and health care utilization measures. Questionnaires were administered on the Web or by mail. We determined hemoglobin A1c (HbA1c) from blood samples collected via mailed kits. Paired t tests determined whether changes between baseline and 6 months differed significantly from no change. Subgroup analyses determined whether participants with specific conditions benefited (high HbA1c, depression, hypoglycemia, nonadherence to medication taking, and no aerobic exercise). We calculated the percentage of participants with improvements of at least 0.4 effect size in at least one of the 5 above measures.Of the 1242 participants, 884 provided 6-month follow-up questionnaires. There were statistically significant improvements in 6 of 7 health indicators (including HbA1c) and in 7 of 7 behaviors. For each of the 5 conditions, there were significant improvements among those with the condition (effect sizes 0.59-1.1). A total of 662 (75.0%) of study participants improved at least 0.4 effect size in at least one criterion, and 327 (37.1%) improved in 2 or more.The Diabetes Self-Management Program, offered in two modes, was successfully disseminated to a heterogeneous national population of members of either insured or administered health plans. Participants had small but significant benefits in multiple measures. The program appears effective in improving diabetes management.

    View details for DOI 10.2196/jmir.5568

    View details for PubMedID 27342265

  • National study of chronic disease self-management: 6-month and 12-month findings among cancer survivors and non-cancer survivors PSYCHO-ONCOLOGY Salvatore, A. L., Ahn, S., Jiang, L., Lorig, K., Ory, M. G. 2015; 24 (12): 1714-1722

    View details for DOI 10.1002/pon.3783

    View details for Web of Science ID 000368435000017

  • Can a Box of Mailed Materials Achieve the Triple Aims of Health Care? The Mailed Chronic Disease Self-Management Tool Kit Study. Health promotion practice Lorig, K., Ritter, P. L., Moreland, C., Laurent, D. D. 2015; 16 (5): 765-774


    Not all patients with chronic conditions are able or willing to participate in small-group or Internet self-management programs. Based on the Arthritis Mailed Took Kit Program and the Chronic Disease Self-Management Program, a mailed Chronic Disease Self-Management Tool Kit, delivered in a onetime mailing, was developed as an alternative mode of delivery. Kits were mailed to a national sample of 255 participants with varying chronic conditions and evaluated in a longitudinal (6-month) trial. Outcomes reflected the triple aims of health care. At 6 months, participants demonstrated better health care indicators, better health indicators, and less health care utilization. There were significant improvements in two health care indicators and six health indicators and reductions in physician visits. Follow-up response rate was high (85%). There were no significant baseline differences between responders and nonresponders. Subgroup analyses were performed for a number of subgroups, including those with arthritis (58%) and/or depression (43%), and for African Americans (14%). Subgroups demonstrated improvements equal to or better than the overall group. The Mailed Chronic Disease Self-Management Tool Kit represents a third mode, along with small groups and Internet, of delivering self-management patient education, and appears to contribute to meeting the triple aims of health care for those who actively chose this mode of delivery.

    View details for DOI 10.1177/1524839915571633

    View details for PubMedID 25690615

  • Dissecting an Online Intervention for Cancer Survivors: Four Exploratory Analyses of Internet Engagement and Its Effects on Health Status and Health Behaviors HEALTH EDUCATION & BEHAVIOR Chen, Z., Koh, P. W., Ritter, P. L., Lorig, K., Bantum, E. O., Saria, S. 2015; 42 (1): 32-45


    The Internet has been used extensively to offer health education content and also for social support. More recently, we have seen the advent of Internet-based health education interventions that combine content with structured social networking. In many ways this is the Internet equivalent to small group interventions. While we have some knowledge about the efficacy of these interventions, few studies have examined how participants engage with programs and how that might affect outcomes. This study seeks to explore (a) the content of posts and (b) the nature of participant engagement with an online, 6-week workshop for cancer survivors and how such engagement may affect health outcomes. Using methodologies related to computational linguistics (latent Dirichlet allocation) and more standard statistical approaches, we identified (a) discussion board themes; (b) the relationship between reading and posting messages and outcomes; (c) how making, completing, or not completing action plans is related to outcome; and (d) how self-tailoring relates to outcomes. When considering all posts, emotional support is a key theme. However, different sets of themes are expressed in the first workshop post where participants are asked to express their primary concern. Writing posts was related to improved outcomes, but reading posts was less important. Completing, but not merely making, action plans and self-tailoring are statistically associated with future positive health outcomes. The findings from these exploratory studies can be considered when shaping future electronically mediated social networking interventions. In addition, the methods used here can be used in analyzing other large electronically mediated social-networking interventions.

    View details for DOI 10.1177/1090198114550822

    View details for Web of Science ID 000347981700005

    View details for PubMedID 25288489

  • Workshop characteristics related to chronic disease self-management education program attendance. Frontiers in public health Smith, M. L., Ory, M. G., Jiang, L., Lorig, K., Kulinski, K. P., Ahn, S. 2015; 3: 19-?


    Using the national dissemination of Chronic Disease Self-Management Education (CDSME) programs, the purposes of this study were to (1) document intervention attendance rates as related to the number of participants enrolled in the workshop and (2) compare the relationship between workshop attendance and workshop size by delivery site rurality and type. Data were analyzed from the first 100,000 middle-aged and older adults who participated in CDSME workshops spanning 45 states, Puerto Rico, and the District of Columbia as part of the American Recovery and Reinvestment Act of 2009 Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative. Descriptive statistics are reported for all participants, then separately by each delivery site type. Ratios between the number of workshop participants and the number of workshop sessions attended were calculated and graphed based on the rurality of delivery and separately for the leading five delivery site types. Associations between the number of workshop participants and the number of sessions attended differed by delivery site rurality and type. Findings have implications for participant retention and workshop delivery costs, which can assist program deliverers to strategically plan implementation efforts in their areas.

    View details for DOI 10.3389/fpubh.2015.00019

    View details for PubMedID 25964943

  • Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program. Frontiers in public health Jiang, L., Zhang, B., Smith, M. L., Lorden, A. L., Radcliff, T. A., Lorig, K., Howell, B. L., Whitelaw, N., Ory, M. G. 2015; 3: 222-?


    To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization.Retrospective observational study.We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119).Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson's correlation coefficient were used to evaluate concordance.The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69-0.79), moderate concordance for ED care utilization (κ = 0.45-0.61), and generally low agreement for number of physician visits (κ ≤ 0.31).Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.

    View details for DOI 10.3389/fpubh.2015.00222

    View details for PubMedID 26501047

  • Adaptation of the Chronic Disease Self-Management Program for Cancer Survivors: Feasibility, Acceptability, and Lessons for Implementation JOURNAL OF CANCER EDUCATION Risendal, B., Dwyer, A., Seidel, R., Lorig, K., Katzenmeyer, C., Coombs, L., Kellar-Guenther, Y., Warren, L., Franco, A., Ory, M. 2014; 29 (4): 762-771
  • Adaptation of the chronic disease self-management program for cancer survivors: feasibility, acceptability, and lessons for implementation. Journal of cancer education Risendal, B., Dwyer, A., Seidel, R., Lorig, K., Katzenmeyer, C., Coombs, L., Kellar-Guenther, Y., Warren, L., Franco, A., Ory, M. 2014; 29 (4): 762-771


    Self-management in chronic disease has been shown to improve patient-reported and health care-related outcomes. However, relatively little information about its utility in cancer survivorship is known. We evaluated the feasibility and acceptability of the delivery of an adaptation of the evidence-based Chronic Disease Self-management Program (Stanford) called Cancer Thriving and Surviving (CTS). Triangulated mixed methods were used to capture baseline characteristics and post-program experiences using a combination of closed- and open-ended survey items; emergent coding and simple descriptive statistics were used to summarize the data. Twenty-seven workshops were delivered by 22 CTS leaders to 244 participants between August 2011 and January 2013 in a variety of settings (48 % community, 30 % health care, 22 % regional/community cancer center). Representing a variety of cancer types, about half the participants were 1-3 years post-diagnosis and 45 % were 4 or more years from diagnosis. Program attendance was high with 84 % of participants attending four or more of the six sessions in the workshop. Overall, 95 % of the participants were satisfied with the program content and leaders, and would recommend the program to friends and family. These results confirm the feasibility and acceptability of delivery of a high-fidelity, peer-led model for self-management support for cancer survivors. Expansion of the CTS represents a powerful tool toward improving health-related outcomes in this at-risk population.

    View details for DOI 10.1007/s13187-014-0652-8

    View details for PubMedID 24903138

  • Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program. Translational behavioral medicine Ritter, P. L., Ory, M. G., Laurent, D. D., Lorig, K. 2014; 4 (4): 398-406


    Depression often accompanies chronic illness. Study aims included determining (1) the level of current depression (Patient Health Questionnaire (PHQ)-8 ≥ 10) for two sets of Chronic Disease Self-Management Programs (CDSMP) participants; (2) if depression or other outcomes improved for those with PHQ-8 ≥ 10; and (3) if outcomes differed for participants with or without depression. This study utilized longitudinal secondary data analysis of depression cohorts (PHQ-8 ≥ 10) from two independent translational implementations of the CDSMP, small-group (N = 175) and Internet-based (N = 110). At baseline, 27 and 55  % of the two samples had PHQ-8 10 or greater. This decreased to 16 and 37  % by 12  months (p < 0.001). Both depressed and non-depressed cohorts demonstrated improvements in most 12-month outcomes (pain, fatigue, activity limitations, and medication adherence). The CDSMP was associated with long-term improvements in depression regardless of delivery mode or location, and the programs appeared beneficial for participants with and without depression.

    View details for DOI 10.1007/s13142-014-0277-9

    View details for PubMedID 25584089

  • National Study of Chronic Disease Self-Management: Age Comparison of Outcome Findings HEALTH EDUCATION & BEHAVIOR Ory, M. G., Smith, M. L., Ahn, S., Jiang, L., Lorig, K., Whitelaw, N. 2014; 41: 34S-42S
  • The components of action planning and their associations with behavior and health outcomes. Chronic illness Lorig, K., Laurent, D. D., Plant, K., Krishnan, E., Ritter, P. L. 2014; 10 (1): 50-59


    Based on the works of Kiesler and Bandura, action plans have become important tools in patient self-management programs. One such program, shown effective in randomized trials, is the Internet Chronic Disease Self-Management Program. An implementation of this program, Healthy Living Canada, included detailed information on action plans and health-related outcome measures.Action plans were coded by type, and associations between action plans, confidence in completion and completion were examined. Numbers of Action Plans attempted and competed and completion rates were calculated for participants and compared to six-month changes in outcomes using regression models.Five of seven outcome measures significantly improved at six-months. A total of 1136 action plans were posted by 254 participants in 12 workshops (mean 3.9 out of 5 possible); 59% of action plans involved exercise, 16% food, and 14% role management. Confidence of completion was associated with completion. Action plan completion measures were associated with improvements in activity limitation, aerobic exercise, and self-efficacy. Baseline self-efficacy was associated with at least partial completion of action plans.Action planning appears to be an important component of self-management interventions, with successful completion associated with improved health and self-efficacy outcomes.

    View details for DOI 10.1177/1742395313495572

    View details for PubMedID 23838837

  • Surviving and Thriving With Cancer Using a Web-Based Health Behavior Change Intervention: Randomized Controlled Trial JOURNAL OF MEDICAL INTERNET RESEARCH Bantum, E. O., Albright, C. L., White, K. K., Berenberg, J. L., Layi, G., Ritter, P. L., Laurent, D., Plant, K., Lorig, K. 2014; 16 (2)

    View details for DOI 10.2196/jmir.3020

    View details for Web of Science ID 000332397500009

    View details for PubMedID 24566820

  • Effectiveness of the Chronic Disease Self-Management Program for Persons with a Serious Mental Illness: A Translation Study COMMUNITY MENTAL HEALTH JOURNAL Lorig, K., Ritter, P. L., Pifer, C., Werner, P. 2014; 50 (1): 96-103


    Evaluation of evidence-based interventions in new settings and new populations is the hallmark of successful translation. We evaluated the Chronic Disease Self-Management Program in persons with serious mental illness who were receiving care through Michigan Community Mental Health Services (N = 139). At 6-months, participants demonstrated improvements in health indicators (fatigue, quality of life, sleep, depression, health distress, and days health bad) and health behaviors (medical adherence and communication with doctor). The program was successfully administrated in a "real world" setting and continues to be used. In addition, the program appears to be an effective resource for people with serious mental illness.

    View details for DOI 10.1007/s10597-013-9615-5

    View details for Web of Science ID 000330123500014

    View details for PubMedID 23748554

  • Evidence-based leadership council - a national collaborative. Frontiers in public health Haynes, M., Hughes, S., Lorig, K., Simmons, J., Snyder, S. J., Steinman, L., Wilson, N., DiStefano, R., Raymond, J., FallCreek, S., Pelaez, M. B., Smith, D. 2014; 2: 136-?

    View details for DOI 10.3389/fpubh.2014.00136

    View details for PubMedID 25964895

    View details for PubMedCentralID PMC4410421

  • Chronic disease self-management program in the workplace: opportunities for health improvement. Frontiers in public health Smith, M. L., Wilson, M. G., DeJoy, D. M., Padilla, H., Zuercher, H., Corso, P., Vandenberg, R., Lorig, K., Ory, M. G. 2014; 2: 179-?


    Disease management is becoming increasingly important in workplace health promotion given the aging workforce, rising chronic disease prevalence, and needs to maintain a productive and competitive American workforce. Despite the widespread availability of the Chronic Disease Self-Management Program (CDSMP), and its known health-related benefits, program adoption remains low in workplace settings. The primary purpose of this study is to compare personal and delivery characteristics of adults who attended CDSMP in the workplace relative to other settings (e.g., senior centers, healthcare organizations, residential facilities). This study also contrasts characteristics of CDSMP workplace participants to those of the greater United States workforce and provides recommendations for translating CDSMP for use in workplace settings. Data were analyzed from 25,664 adults collected during a national dissemination of CDSMP. Only states and territories that conducted workshops in workplace settings were included in analyses (n = 13 states and Puerto Rico). Chi-squared tests and t-tests were used to compare CDSMP participant characteristics by delivery site type. CDSMP workplace participant characteristics were then compared to reports from the United States Bureau of Labor Statistics. Of the 25,664 CDSMP participants in this study, 1.7% (n = 435) participated in workshops hosted in worksite settings. Compared to CDSMP participants in non-workplace settings, workplace setting participants were significantly younger and had fewer chronic conditions. Differences were also observed based on chronic disease types. On average, CDSMP workshops in workplace settings had smaller class sizes and workplace setting participants attended more workshop sessions. CDSMP participants in workplace settings were substantially older and a larger proportion were female than the general United States workforce. Findings indicate opportunities to translate CDSMP for use in the workplace to reach new target audiences.

    View details for DOI 10.3389/fpubh.2014.00179

    View details for PubMedID 25964909

  • The role of session zero in successful completion of chronic disease self-management program workshops. Frontiers in public health Jiang, L., Smith, M. L., Chen, S., Ahn, S., Kulinski, K. P., Lorig, K., Ory, M. G. 2014; 2: 205-?


    The Chronic Disease Self-Management Program (CDSMP) has been widely disseminated among various racial and ethnic populations. In addition to the six required CDSMP workshop sessions, the delivery sites have the option to offer a Session Zero (or zero class), an information session offered prior to Session One as a marketing tool. Despite assumptions that a zero class is helpful, little is known about the prevalence of these additional sessions or their impact on retaining participants in CDSMP workshops. This study aims to describe the proportion of CDSMP workshops that offered Session Zero and examine the association between Session Zero and workshop completion rates.Data were analyzed from 80,987 middle-aged and older adults collected during a two-year national dissemination of CDSMP. Generalized estimating equation regression analyses were conducted to assess the association between Session Zero and successful workshop completion (attending four or more of the six workshop sessions).On average, 21.04% of the participants attended workshops that offered Session Zero, and 75.33% successfully completed the CDSMP workshop. The participants of the workshops that offered Session Zero had significantly higher odds of completing CDSMP workshops than those who were not offered Session Zero (OR = 1.099, P = <0.001) after controlling for participants' demographic characteristics, race, ethnicity, living status, household income, number of chronic conditions, and workshop delivery type.As one of the first studies reporting the importance of an orientation session for participant retention in chronic disease management intervention projects, our findings suggest offering an orientation session may increase participant retention in similar translational efforts.

    View details for DOI 10.3389/fpubh.2014.00205

    View details for PubMedID 25964918

  • Setting the stage: measure selection, coordination, and data collection for a national self-management initiative. Frontiers in public health Kulinski, K. P., Boutaugh, M., Smith, M. L., Ory, M. G., Lorig, K. 2014; 2: 206-?


    This paper describes the history and rationale behind the development of a centralized data collection system for the national rollout of the Chronic Disease Self-Management Program (CDSMP) through the American Recovery and Reinvestment Act of 2009 Communities Putting Prevention to Work: CDSMP initiative. In addition to justifying the need for solutions to the burgeoning burden of chronic disease in the United States, this paper provides details about CDSMP and related self-management education programs, including their structure, facilitator training, and effectiveness. These topics set the stage for the processes and procedures to create and manage the database for use at the national, state, and local levels. Furthermore, this paper describes the processes related to selecting variables, coordinating data collection, and utilizing data to inform research and policy.

    View details for DOI 10.3389/fpubh.2014.00206

    View details for PubMedID 25964919

  • Linking evidence-based program participant data with medicare data: the consenting process and correlates of retrospective participant consents. Frontiers in public health Ritter, P. L., Ory, M. G., Smith, M. L., Jiang, L., Alonis, A., Laurent, D. D., Lorig, K. 2014; 2: 176-?


    As part of a nation-wide study of the Chronic Disease Self-Management Program (National Study), older participants were asked to consent to have their Medicare data matched with study data. This provided an opportunity to examine the consenting process and compare consenters, refusers, and non-responders. We compared the three groups on a large number of variables. These included demographic, National Study participation, health indicator, health behavior, and health-care utilization variables. We assessed differences in 6-month change scores for time-varying variables. We also examined whether asking participants to consent prior to the final questionnaire impacted completion of that questionnaire. Of 616 possible participants, 42% consented, 44% refused, and 14% failed to respond. Differences by ethnicity were found, with Hispanics more likely to consent. There was a consistent tendency for those who participated most in the National Study to consent. With the exception of number of chronic diseases, there was no evidence of health indicators or health behaviors being associated with consenting. Participants with more physician visits and more nights in the hospital were also more likely to consent. Those asked to consent before the 12-month follow-up questionnaire were less likely to complete that questionnaire than those who were asked after. Fewer than half consented to link to their Medicare data. The greater willingness to consent by those who participated most suggests that willingness to consent may be part of program engagement. Consenters had more diseases, more MD visits, and more nights in the hospital, suggesting that greater contact with the medical system may be associated with willingness to consent. This indicates that examinations of Medicare data based only on those willing to consent could introduce bias. Asking for consent appears to reduce participation in the larger study.

    View details for DOI 10.3389/fpubh.2014.00176

    View details for PubMedID 25964908

  • Meeting the challenge of cancer survivorship in public health: results from the evaluation of the chronic disease self-management program for cancer survivors. Frontiers in public health Risendal, B. C., Dwyer, A., Seidel, R. W., Lorig, K., Coombs, L., Ory, M. G. 2014; 2: 214-?


    Self-management has been identified as an important opportunity to improve health outcomes among cancer survivors. However, few evidence-based interventions are available to meet this need.The effectiveness of an adapted version of the Chronic Disease Self-Management Program for cancer survivors called Cancer Thriving and Surviving was evaluated in a randomized trial. Outcomes were assessed at baseline and 6-months post program via written survey among 244 participants in Colorado. Repeated measures analysis was used to analyze pre/post program change.Statistically significant improvement was observed among those in the intervention in the following outcomes: Provider communication (+16.7% change); depression (-19.1%); energy (+13.8%); sleep (-24.9%) and stress-related problems (-19.2%); change over time was also observed in the controls for energy, sleep, and stress-related outcomes though to a lesser degree. Effect sizes of the difference in change over time observed indicate a net beneficial effect for provider communication (0.23); and decreases in depression (-0.18); pain (-0.19); problems related to stress (-0.17); and sleep (-0.20).Study data suggest that the self-management support from adaptation of the CDSMP can reach and appeal to cancer survivors, improves common concerns in this population, and can fill an important gap in meeting the ongoing need for management of post-diagnosis issues in this growing segment of the U.S. population.

    View details for DOI 10.3389/fpubh.2014.00214

    View details for PubMedID 25964922

  • Surviving and thriving with cancer using a Web-based health behavior change intervention: randomized controlled trial. Journal of medical Internet research Bantum, E. O., Albright, C. L., White, K. K., Berenberg, J. L., Layi, G., Ritter, P. L., Laurent, D., Plant, K., Lorig, K. 2014; 16 (2)


    Given the substantial improvements in cancer screening and cancer treatment in the United States, millions of adult cancer survivors live for years following their initial cancer diagnosis and treatment. However, latent side effects can occur and some symptoms can be alleviated or managed effectively via changes in lifestyle behaviors.The purpose of this study was to test the effectiveness of a six-week Web-based multiple health behavior change program for adult survivors.Participants (n=352) were recruited from oncology clinics, a tumor registry, as well as through online mechanisms, such as Facebook and the Association of Cancer Online Resources (ACOR). Cancer survivors were eligible if they had completed their primary cancer treatment from 4 weeks to 5 years before enrollment. Participants were randomly assigned to the Web-based program or a delayed-treatment control condition.In total, 303 survivors completed the follow-up survey (six months after completion of the baseline survey) and participants in the Web-based intervention condition had significantly greater reductions in insomnia and greater increases in minutes per week of vigorous exercise and stretching compared to controls. There were no significant changes in fruit and vegetable consumption or other outcomes.The Web-based intervention impacted insomnia and exercise; however, a majority of the sample met or exceeded national recommendations for health behaviors and were not suffering from depression or fatigue at baseline. Thus, the survivors were very healthy and well-adjusted upon entry and their ability to make substantial health behavior changes may have been limited. Future work is discussed, with emphasis placed on ways in which Web-based interventions can be more specifically analyzed for benefit, such as in regard to social NCT00962494; (Archived by WebCite at

    View details for DOI 10.2196/jmir.3020

    View details for PubMedID 24566820

  • Chronic disease self-management program: insights from the eye of the storm. Frontiers in public health Lorig, K. 2014; 2: 253-?

    View details for DOI 10.3389/fpubh.2014.00253

    View details for PubMedID 25964929

    View details for PubMedCentralID PMC4410327

  • Closing the Disparity Gap: The Work of the Administration on Aging GENERATIONS-JOURNAL OF THE AMERICAN SOCIETY ON AGING Boutaugh, M. L., Jenkins, S. M., Kulinski, K. P., Lorig, K. R., Ory, M. G., Smith, M. L. 2014; 38 (4): 107-118
  • National dissemination of chronic disease self-management education programs: an incremental examination of delivery characteristics. Frontiers in public health Smith, M. L., Ory, M. G., Ahn, S., Kulinski, K. P., Jiang, L., Horel, S., Lorig, K. 2014; 2: 227-?


    With a near 20-year developmental history as an evidence-based program, the suite of Chronic Disease Self-Management Education (CDSME) programs were selected in 2010 for grand-scale dissemination in a federally supported initiative to improve the health of older Americans. The primary charge of this national effort was to establish a sustainable program delivery system for empowering American adults with one or more chronic conditions to better manage their health. The current study focused on a series of dissemination and implementation science research questions to: (1) examine the geographic distribution of participation in this initiative across the Unites States; (2) describe workshop characteristics engaged to reach program participants in various settings; and (3) describe personal characteristics of the first 100,000 participants. Each subsequent entering cohort was descriptively examined to indicate whether there was constancy or change in delivery sites and populations reached over time. Findings show a strengthening of the workshop delivery infrastructure in that it took 9.4 months to reach the first 25,000 participants in 853 counties compared to 5.4 months to reach the last 25,000 participants in 1,109 counties. The workshop delivery characteristics and participant characteristics remained relatively consistent across increments of 25,000 participants reached, although general trends were observed for some variables. For example, after reaching the first 25,000 participants, subsequent groups of 25,000 participants were reached more quickly. Additionally, workshops were increasingly delivered in ZIP Codes with higher percentages of families residing below the federal poverty line. As more participants were reached, more participants with chronic conditions were enrolled. This national translational study illustrates the rapid expansion of CDSME programs throughout the United States and capability to reach diverse populations in a variety of settings.

    View details for DOI 10.3389/fpubh.2014.00227

    View details for PubMedID 25964923

  • The impact of chronic disease self-management programs: healthcare savings through a community-based intervention BMC PUBLIC HEALTH Ahn, S., Basu, R., Smith, M. L., Jiang, L., Lorig, K., Whitelaw, N., Ory, M. G. 2013; 13


    Among the most studied evidence-based programs, the Chronic Disease Self-Management Program (CDSMP) has been shown to help participants improve their health behaviors, health outcomes, and reduce healthcare utilization. However, there is a lack of information on how CDSMP, when nationally disseminated, impacts healthcare utilization and averts healthcare costs. The purposes of this study were to: 1) document reductions in healthcare utilization among national CDSMP participants; 2) calculate potential cost savings associated with emergency room (ER) visits and hospitalizations; and 3) extrapolate the cost savings estimation to the American adults.The national study of CDSMP surveyed 1,170 community-dwelling CDSMP participants at baseline, 6 months, and 12 months from 22 organizations in 17 states. The procedure used to estimate potential cost savings included: 1) examining the pattern of healthcare utilization among CDSMP participants from self-reported healthcare utilization assessed at baseline, 6 months, and 12 months; 2) calculating age-adjusted average costs for persons using the 2010 Medical Expenditure Panel Survey; 3) calculating costs saved from reductions in healthcare utilization; 4) estimating per participant program costs; 5) computing potential cost savings by deducting program costs from estimated healthcare savings; and 6) extrapolating savings to national populations using Census data combined with national health statistics.Findings from analyses showed significant reductions in ER visits (5%) at both the 6-month and 12-month assessments as well as hospitalizations (3%) at 6 months among national CDSMP participants. This equates to potential net savings of $364 per participant and a national savings of $3.3 billion if 5% of adults with one or more chronic conditions were reached.Findings emphasize the value of public health tertiary prevention interventions and the need for policies to support widespread adoption of CDSMP.

    View details for DOI 10.1186/1471-2458-13-1141

    View details for Web of Science ID 000329305900002

    View details for PubMedID 24314032

  • Successes of a National Study of the Chronic Disease Self-Management Program Meeting the Triple Aim of Health Care Reform MEDICAL CARE Ory, M. G., Ahn, S., Jiang, L., Smith, M. L., Ritter, P. L., Whitelaw, N., Lorig, K. 2013; 51 (11): 992-998


    Emerging health care reform initiatives are of growing importance amidst concerns about providing care to increasing numbers of adults with multiple chronic conditions. Evidence-based self-management strategies are recognized as central to managing a variety of chronic diseases by improving the medical, emotional, and social role management demands of chronic conditions.To examine the effectiveness of the Chronic Disease Self-Management Program (CDSMP) among a national sample of participants organized around the Triple Aim goals of better health, better health care, and better value in terms of reduced health care utilization.Utilizing data collected from small-group CDSMP workshops, baseline, 6-month, and 12-month assessments were examined using 3 types of mixed-effects models to provide unbiased estimates of intervention effects.Data were analyzed from 1170 community-dwelling CDSMP participants.Triple Aim-related outcome measures: better health (eg, self-reported health, pain, fatigue, depression), better health care (eg, patient-physician communication, medication compliance, confidence completing medical forms), and better value [eg, reductions in emergency room (ER) visits and hospitalizations in the past 6 mo].Significant improvements for all better health and better health care outcome measures were observed from baseline to 12-month follow-up. The odds of ER visits significantly reduced from baseline to 12-month follow-up, whereas significant reductions in hospitalization were only observed from baseline to 6-month follow-up.This National Study of CDSMP (National Study) demonstrates the successful translation of CDSMP into widespread practice and its potential for helping the nation achieve the triple aims of health care reform.

    View details for DOI 10.1097/MLR.0b013e3182a95dd1

    View details for Web of Science ID 000326033800007

    View details for PubMedID 24113813

  • National Study of Chronic Disease Self-Management Six-Month Outcome Findings JOURNAL OF AGING AND HEALTH Ory, M. G., Ahn, S., Jiang, L., Lorig, K., Ritter, P., Laurent, D. D., Whitelaw, N., Smith, M. L. 2013; 25 (7): 1258-1274


    To investigate how the Chronic Disease Self-Management Program (CDSMP) changes health outcomes, lifestyle behaviors, and health care service utilization over a 6 month period.The participants were 1,170 adults enrolled in the National Study of CDSMP in 2010-2012 (M age=65.4 years). Six-month assessments were available for 903 participants. Linear mixed models and generalized linear mixed models were used to assess the changes between baseline and 6-month assessment for primary and secondary outcomes among CDSMP participants.Social/role activities limitations, depression, and communication with physicians improved significantly from baseline to 6-month follow-up. Study participants reported significant improvements in more physical activity and less emergency room (ER) visits and hospitalization during that period.Nationally, CDSMP not only improves health outcomes and lifestyle behaviors but also decreases costly ER visits and hospitalization. Geriatricians and other primary care providers should be encouraged to refer patients with chronic conditions to such self-management programs.

    View details for DOI 10.1177/0898264313502531

    View details for Web of Science ID 000324317900009

    View details for PubMedID 24029414

  • Effectiveness of a Generic Chronic Disease Self-Management Program for People With Type 2 Diabetes A Translation Study DIABETES EDUCATOR Lorig, K., Ritter, P. L., Ory, M. G., Whitelaw, N. 2013; 39 (5): 655-663


    PurposeThe purpose of the study was to determine the feasibility and efficacy of a generic chronic disease self-management program for people with type 2 diabetes.MethodsEnglish-speaking adults with type 2 diabetes who were part of a larger US national translation study of the Stanford Chronic Disease Self-Management Program (CDSMP) were invited to be part of the current study. In addition to completing self-report questionnaires, participants submitted blood samples at baseline, 6 months, and 12 months. Of the 114 participants, half had A1C values between 6% and 6.9% and half had values of 7.0% or more.ResultsAdults with diabetes successfully participated in CDSMP workshops in a community health setting. Participants demonstrated statistically significant improvements in health indicators and behaviors but no reductions in health care utilization. Participants with A1C of 7% and above had A1C reductions at 6 months, with smaller reductions at 12 months. Those with baseline A1C less than 7% had no changes in A1C at 6 or 12 months.ConclusionsThe results suggest that the CDSMP is a useful and appropriate program for lowering A1C among those with A1C above 7% and for improving health status for people with diabetes, regardless of their A1C.

    View details for DOI 10.1177/0145721713492567

    View details for Web of Science ID 000324832200008

    View details for PubMedID 23782621

  • Coding and Evaluating Facilitator Posts for an Online Cancer Survivor Workshop JOURNAL OF PSYCHOSOCIAL ONCOLOGY Gits, A. A., Ritter, P. L., Plant, K., Lorig, K. 2013; 31 (2): 219-234


    One-hundred and forty-five people attended six online cancer survivor workshops. Each workshop was monitored by two facilitators, who generated a total of 1,537 online posts. The authors developed a scheme for coding facilitator posts, combining grounded codes with categories developed by Spiegel and Classen for coding therapist responses in cancer support groups. Participants received a mean of 10.6 facilitator posts. Improvement in two health outcomes (practice of mental relaxation and illness intrusiveness) were significantly correlated with supportive posts and total number of posts. The coding scheme was easily applied and appears reliable. The data suggests that more facilitation is better.

    View details for DOI 10.1080/07347332.2012.761321

    View details for Web of Science ID 000316331100007

    View details for PubMedID 23514256

  • Development and Feasibility of a Self-management Intervention for Chronic Obstructive Pulmonary Disease Delivered With Motivational Interviewing Strategies JOURNAL OF CARDIOPULMONARY REHABILITATION AND PREVENTION Benzo, R., Vickers, K., Ernst, D., Tucker, S., McEvoy, C., Lorig, K. 2013; 33 (2): 113-122


    Self-management is proposed as the standard of care in chronic obstructive pulmonary disease (COPD), but details of the process and training required to deliver effective self-management are not widely available. In addition, recent data suggest that patient engagement and motivation are critical ingredients for effective self-management. This article carefully describes a self-management intervention using motivational interviewing skills, aimed to increase engagement and commitment in severe COPD patients.The intervention was developed and pilot tested for fidelity to protocol, for patient and interventionist feedback (qualitative) and effect on quality of life. Engagement between patient and interventionists was measured by the Working Alliance Inventory. The intervention was refined on the basis of the results of the pilot study and delivered in the active arm of a prospective randomized study.The pilot study suggested improvements in quality of life, fidelity to theory, and patient acceptability. The refined self-management intervention was delivered 540 times in the active arm of a randomized study. We observed a retention rate of 86% (patients missing or not available for only 14% the scheduled encounters).A self-management intervention that includes motivational interviewing as the way if guiding patients into behavior change is feasible in severe COPD and may increase patient engagement and commitment to self-management. This provides a very detailed description of the process for the specifics of training and delivering the intervention, which facilitates replicability in other settings and could be translated to cardiac rehabilitation.

    View details for DOI 10.1097/HCR.0b013e318284ec67

    View details for Web of Science ID 000315595600008

    View details for PubMedID 23434613

  • The South Australia Health Chronic Disease Self-Management Internet Trial HEALTH EDUCATION & BEHAVIOR Lorig, K., Ritter, P. L., Plant, K., Laurent, D. D., Kelly, P., Rowe, S. 2013; 40 (1): 67-77


    To evaluate the effectiveness of an online chronic disease self-management program for South Australia residents.Data were collected online at baseline, 6 months, and 12 months. The intervention was an asynchronous 6-week chronic disease self-management program offered online. The authors measured eight health status measures, seven behaviors, and four utilization measures; self-efficacy; and health care satisfaction.Two hundred fifty-four South Australian adults with one or more chronic conditions completed baseline data. One hundred forty-four completed 6 months and 194 completed 1 year. Significant improvements (p < .05) were found at 6 months for four health status measures, six health behaviors, self-efficacy, and visits to emergency departments. At 12 months, five health status indicators, six health behaviors, self-efficacy, and visits to emergency departments remained significant. Satisfaction with health care trended toward significance.The peer-led online program was both acceptable and useful for this population. It appeared to decrease symptoms, improve health behaviors, self-efficacy, and reduce health care utilization up to 1 year. This intervention also has large potential implications for the use of a public health education model for reaching large numbers of people. It demonstrates that an Internet self-management program, which includes social media, can reach rural and underserved people as well as be effective and reduce health care costs. If this intervention can be brought to scale, it has the potential for improving the lives of large numbers of people with chronic illness. It represents a way the medical care and public health sectors can interact.

    View details for DOI 10.1177/1090198112436969

    View details for Web of Science ID 000330294000009

    View details for PubMedID 22491008

  • Web-based self-management support training for health professionals: A pilot study PATIENT EDUCATION AND COUNSELING Yank, V., Laurent, D., Plant, K., Lorig, K. 2013; 90 (1): 29-37


    To evaluate a web-based self-management training for health professionals. Patients spend 99% of their time outside the healthcare system. Thus self-management support from health professionals is central to optimal care. Our objective was to teach health professionals the skills to provide this support.Primary care residents and practicing providers enrolled in six groups. Each group received four web-based interactive training sessions derived from self-efficacy theory. Retrospective-pre/post assessed changes in self-management beliefs and confidence. Wilcoxon signed-rank tests with Bonferroni correction compared responses. Focus groups solicited qualitative feedback.Fifty-seven residents and providers across the United States enrolled. Residents demonstrated positive changes on all belief questions (P 0.001-0.012). Practicing providers had a non-significant positive change on one and significant changes on the remainder (P 0.001-0.018). Both types of participants demonstrated significant increases on confidence questions regarding their ability to support self-management (P<0.01 for all). Participants described learned techniques as being useful, reducing burnout, and increasing acceptance of patient involvement in care planning.The web-based self-management support training for health professionals was feasible and changed beliefs and confidence.The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.

    View details for DOI 10.1016/j.pec.2012.09.003

    View details for Web of Science ID 000314012100006

    View details for PubMedID 23031610

  • Patient-Centered Care: Depends on the Point of View HEALTH EDUCATION & BEHAVIOR Lorig, K. 2012; 39 (5): 523-525
  • Peer education for secondary stroke prevention in inner-city minorities: Design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial CONTEMPORARY CLINICAL TRIALS Goldfinger, J. Z., Kronish, I. M., Fei, K., Graciani, A., Rosenfeld, P., Lorig, K., Horowitz, C. R. 2012; 33 (5): 1065-1073


    The highest risk for stroke is among survivors of strokes or transient ischemic attacks (TIA). However, use of proven-effective cardiovascular medications to control stroke risk is suboptimal, particularly among the Black and Latino populations disproportionately impacted by stroke.A partnership of Harlem and Bronx community representatives, stroke survivors, researchers, clinicians, outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial. Using data from focus groups with stroke survivors, they tailored a peer-led, community-based chronic disease self-management program to address stroke risk factors. PRAISE will test, in a randomized controlled trial, whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control, lipid control, and use of antithrombotic medications.Of the 582 survivors of stroke and TIA enrolled thus far, 81% are Black or Latino and 56% have an annual income less than $15,000. Many (33%) do not have blood pressures in the target range, and most (66%) do not have control of all three major stroke risk factors.Rates of stroke recurrence risk factors remain suboptimal in the high risk, urban, predominantly minority communities studied. With a community-partnered approach, PRAISE has recruited a large number of stroke and TIA survivors to date, and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities.

    View details for DOI 10.1016/j.cct.2012.06.003

    View details for Web of Science ID 000308049800026

    View details for PubMedID 22710563

    View details for PubMedCentralID PMC3408803

  • Diabetes Mellitus in Older People: Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION Sinclair, A., Morley, J. E., Rodriguez-Manas, L., Paolisso, G., Bayer, T., Zeyfang, A., Bourdel-Marchasson, I., Vischer, U., Woo, J., Chapman, I., Dunning, T., Meneilly, G., Rodriguez-Saldana, J., Gutierrez Robledo, L. M., Cukierman-Yaffe, T., Gadsby, R., Schernthaner, G., Lorig, K. 2012; 13 (6): 497-502


    Diabetes mellitus is a highly prevalent metabolic condition in ageing societies associated with high levels of morbidity, multiple therapies, and functional deterioration that challenges even the best of health care systems to deliver high-quality, individualized care. Most international clinical guidelines have ignored the often-unique issues of frailty, functional limitation, changes in mental health, and increasing dependency that characterize many aged patients with diabetes. A collaborative Expert Group of the IAGG and EDWPOP and an International Task Force have explored the key issues that affect diabetes in older people using a robust method comprising a Delphi process and an evidence-based review of the literature. Eight domains of interest were initially agreed and discussed: hypoglycemia, therapy, care home diabetes, influence of comorbidities, glucose targets, family/carer perspectives, diabetes education, and patient safety. A set of "consensus" statements was produced in each domain of interest. These form a foundation for future policy development in this area and should influence the clinical behavior and approach of all health professionals engaged in delivering diabetes care to older people.

    View details for DOI 10.1016/j.jamda.2012.04.012

    View details for Web of Science ID 000305948700005

    View details for PubMedID 22748719

  • Building Better Caregivers: A Pilot Online Support Workshop for Family Caregivers of Cognitively Impaired Adults JOURNAL OF APPLIED GERONTOLOGY Lorig, K., Thompson-Gallagher, D., Traylor, L., Ritter, P. L., Laurent, D. D., Plant, K., Thompson, L. W., Hahn, T. J. 2012; 31 (3): 423-437
  • The dos and don'ts of patient engagement in busy office practices. The Journal of ambulatory care management Hibbard, J., Lorig, K. 2012; 35 (2): 129-132

    View details for DOI 10.1097/JAC.0b013e3182496647

    View details for PubMedID 22415286

  • UH Cancer Center Hotline: Recruiting cancer survivors for an online health-behavior change intervention: are different strategies more beneficial? Hawaii medical journal Layi, G., Albright, C. A., Berenberg, J., Plant, K., Ritter, P., Laurent, D., Lorig, K., Bantum, E. O. 2011; 70 (10): 222-223

    View details for PubMedID 22162599

  • Effectively translating diabetes prevention: a successful model in a historically underserved community TRANSLATIONAL BEHAVIORAL MEDICINE Horowitz, C. R., Eckhardt, S., Talavera, S., Goytia, C., Lorig, K. 2011; 1 (3): 443-452


    Lifestyle interventions can prevent diabetes through weight loss, but they are rarely translated for use in underserved communities. The aim of this study was to describe how a community-academic partnership formed and developed a program to address local health disparities by developing a low-cost, culturally and economically appropriate, peer-led community-based diabetes prevention program. Using a participatory approach, the partnership chose to focus on diabetes prevention, and co-developed all intervention, recruitment, research, and evaluation strategies. The partnership's philosophy to maintain high clinical and scientific standards paired with their ability to represent and engage the community facilitated the development of a randomized controlled trial that achieved statistically significant and sustained weight loss, and the recruitment of a largely Spanish-speaking, low income, uninsured population. The success of this intervention lies in the partnership's commitment to the community, co-ownership of research, and a careful balance between academic rigor and community engagement and relevance.

    View details for DOI 10.1007/s13142-011-0067-6

    View details for Web of Science ID 000209412100014

    View details for PubMedID 22189897

    View details for PubMedCentralID PMC3242468

  • Cancer Health Empowerment for Living without Pain (Ca-HELP): Effects of a tailored education and coaching intervention on pain and impairment PAIN Kravitz, R. L., Tancredi, D. J., Grennan, T., Kalauokalani, D., Street, R. L., Slee, C. K., Wun, T., Oliver, J. W., Lorig, K., Franks, P. 2011; 152 (7): 1572-1582


    We aimed to determine the effectiveness of a lay-administered tailored education and coaching (TEC) intervention (aimed at reducing pain misconceptions and enhancing self-efficacy for communicating with physicians) on cancer pain severity, pain-related impairment, and quality of life. Cancer patients with baseline "worst pain" of ≥4 on a 0-10 scale or at least moderate functional impairment due to pain were randomly assigned to TEC or enhanced usual care (EUC) during a telephone interview conducted in advance of a planned oncology office visit (265 patients randomized to TEC or EUC; 258 completed at least one follow-up). Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 6, and 12 weeks. Mixed effects regressions were used to evaluate the intervention adjusting for patient, practice, and site characteristics. Compared to EUC, TEC was associated with increased pain communication self-efficacy after the intervention (P<.001); both groups showed significant (P<.0001), similar, reductions in pain misconceptions. At 2 weeks, assignment to TEC was associated with improvement in pain-related impairment (-0.25 points on a 5-point scale, 95% confidence interval -0.43 to -0.06, P=.01) but not in pain severity (-0.21 points on an 11-point scale, -0.60 to 0.17, P=.27). The improvement in pain-related impairment was not sustained at 6 and 12 weeks. There were no significant intervention by subgroup interactions (P>.10). We conclude that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in pain severity.

    View details for DOI 10.1016/j.pain.2011.02.047

    View details for Web of Science ID 000291474000022

    View details for PubMedID 21439726

  • Moderators of chronic disease self-management programs: who benefits? Chronic illness Ritter, P. L., Lee, J., Lorig, K. 2011; 7 (2): 162-172


    The Stanford University Chronic Disease Self-Management Program (CDSMP) has resulted in moderate beneficial outcomes in randomized controlled trials. A study of a modified CDSMP in England suggested that younger participants, those with lower initial self-efficacy and those with greater depression benefited most from the program.Using data from previous CDSMP programs in English and Spanish, we examined whether there were statistically significant interactions between baseline statuses (demographic, disease and health status variables) and randomization (intervention or usual-care control) in estimating 6-month changes in health status (health distress, activity limitation/role function, self-efficacy and self-reported general health). If an interaction was found, post hoc examinations of the relationships between the baseline variables and outcomes determined the directions of the relationships.Six moderating variables were found in the original English-language CDSMP and three in the Spanish program. Each moderator was specific to only one outcome within only one of the two studies.There were no consistent moderating effects across four outcomes and two programs and little evidence to suggest that any groups should be targeted for program recruitment. The CDSMP appears to remain useful to a wide range of people with chronic illness.

    View details for DOI 10.1177/1742395311399127

    View details for PubMedID 21357642

  • The internet diabetes self-management workshop for American Indians and Alaska Natives. Health promotion practice Johnson, V. B., Lorig, K. 2011; 12 (2): 261-270


    Type 2 diabetes disproportionately affects American Indians and Alaska Natives (AI/ANs). In the larger population, patient self-management has become an increasing focus of the health care system to help reduce the impact of diabetes. However, little is known about patient self-management programs designed for AI/ANs. This study reports on the feasibility of implementing the Stanford Internet Diabetes Self-Management Workshop within the AI/AN population using a participatory research approach. This is a continuation of self-management studies to assist in meeting the needs of both patients and the health care system for health services that are effective (evidence based), efficient, and culturally appropriate. To our knowledge, this is the first study examining the effectiveness of an Internet-based diabetes patient self-management program among AI/ANs. This article reports on a pilot for a larger randomized study that is ongoing.

    View details for DOI 10.1177/1524839909335178

    View details for PubMedID 20534807

  • Self-Management: Enabling and Empowering Patients Living With Cancer as a Chronic Illness CA-A CANCER JOURNAL FOR CLINICIANS McCorkle, R., Ercolano, E., Lazenby, M., Schulman-Green, D., Schilling, L. S., Lorig, K., Wagner, E. H. 2011; 61 (1): 50-62


    With recent improvements in the early detection, diagnosis, and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this article, self-management interventions that enable patients and families to participate in managing their care along this continuum are reviewed. Randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer care continuum are reviewed, and the Chronic Care Model is presented as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. It is concluded that the need for a common language with which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually agreed upon care plans that enable and empower patients to care for themselves in the way they prefer.

    View details for DOI 10.3322/caac.20093

    View details for Web of Science ID 000286448800006

    View details for PubMedID 21205833

    View details for PubMedCentralID PMC3058905

  • Online Diabetes Self-Management Program A randomized study DIABETES CARE Lorig, K., Ritter, P. L., Laurent, D. D., Plant, K., Green, M., Jernigan, V. B., Case, S. 2010; 33 (6): 1275-1281


    We hypothesized that people with type 2 diabetes in an online diabetes self-management program, compared with usual-care control subjects, would 1) demonstrate reduced A1C at 6 and 18 months, 2) have fewer symptoms, 3) demonstrate increased exercise, and 4) have improved self-efficacy and patient activation. In addition, participants randomized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement.A total of 761 participants were randomized to 1) the program, 2) the program with e-mail reinforcement, or 3) were usual-care control subjects (no treatment). This sample included 110 American Indians/Alaska Natives (AI/ANs). Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups.At 6 months, A1C, patient activation, and self-efficacy were improved for program participants compared with usual care control subjects (P < 0.05). There were no changes in other health or behavioral indicators. The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects. The subgroup with initial A1C >7% demonstrated stronger improvement in A1C (P = 0.01). At 18 months, self-efficacy and patient activation were improved for program participants. A1C was not measured. Reinforcement showed no improvement.An online diabetes self-management program is acceptable for people with type 2 diabetes. Although the results were mixed they suggest 1) that the program may have beneficial effects in reducing A1C, 2) AI/AN populations can be engaged in and benefit from online interventions, and 3) our follow-up reinforcement appeared to have no value.

    View details for DOI 10.2337/dc09-2153

    View details for Web of Science ID 000279304300024

    View details for PubMedID 20299481

  • The Health and Recovery Peer (HARP) Program: A peer-led intervention to improve medical self-management for persons with serious mental illness SCHIZOPHRENIA RESEARCH Druss, B. G., Zhao, L., von Esenwein, S. A., Bona, J. R., Fricks, L., Jenkins-Tucker, S., Sterling, E., DiClemente, R., Lorig, K. 2010; 118 (1-3): 264-270


    Persons with serious mental illnesses (SMI) have elevated rates of comorbid medical conditions, but may also face challenges in effectively managing those conditions.The study team developed and pilot-tested the Health and Recovery Program (HARP), an adaptation of the Chronic Disease Self-Management Program (CDSMP) for mental health consumers. A manualized, six-session intervention, delivered by mental health peer leaders, helps participants become more effective managers of their chronic illnesses. A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care.At six month follow-up, participants in the HARP program had a significantly greater improvement in patient activation than those in usual care (7.7% relative improvement vs. 5.7% decline, p=0.03 for group *time interaction), and in rates of having one or more primary care visit (68.4% vs. 51.9% with one or more visit, p=0.046 for group *time interaction). Intervention advantages were observed for physical health related quality of life (HRQOL), physical activity, medication adherence, and, and though not statistically significant, had similar effect sizes as those seen for the CDSMP in general medical populations. Improvements in HRQOL were largest among medically and socially vulnerable subpopulations.This peer-led, medical self-management program was feasible and showed promise for improving a range of health outcomes among mental health consumers with chronic medical comorbidities. The HARP intervention may provide a vehicle for the mental health peer workforce to actively engage in efforts to reduce morbidity and mortality among mental health consumers.

    View details for DOI 10.1016/j.schres.2010.01.026

    View details for Web of Science ID 000278214500038

    View details for PubMedID 20185272

  • Some not so random thoughts about participation. The Journal of ambulatory care management Lorig, K. 2009; 32 (4): 278-279

    View details for DOI 10.1097/JAC.0b013e3181ba6e4c

    View details for PubMedID 19888000

  • Mail-Delivered Arthritis Self-Management Tool Kit: A Randomized Trial and Longitudinal Followup ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH Goeppinger, J., Lorig, K. R., Ritter, P. L., Mutatkar, S., Villa, F., Gizlice, Z. 2009; 61 (7): 867-875


    To determine the effectiveness of an intervention Tool Kit of arthritis self-management materials to be sent once through the mail, and to describe the populations reached.Spanish speakers (n = 335), non-Hispanic English-speaking African Americans (n = 156), and other non-Hispanic English speakers (n = 404) were recruited separately and randomized within each of the 3 ethnic/racial categories to immediately receive the intervention Tool Kit (n = 458) or to a 4-month wait-list control status (n = 463). At the end of 4 months, controls were sent the Tool Kit. All subjects were followed in a longitudinal study for 9 months. Self-administered measures included health status, health behavior, arthritis self-efficacy, medical care utilization, and demographic variables. Using analyses of covariance and t-tests, analyses were conducted for all participants and for Spanish- and English-language groups.At 4 months, comparing all intervention subjects with randomized wait-list controls, there were significant (P < 0.01) benefits in all outcomes except medical care utilization and self-rated health. The results were maintained at 9 months compared with baseline. On average, the Tool Kit reached persons ages 50-56 years with 12-15 years of schooling. There were few differences between English- and Spanish-language participants in either the effectiveness or reach variables.A mailed Arthritis Self-Management Tool Kit proved effective in improving health status, health behavior, and self-efficacy variables for up to 9 months. It also reached younger persons in both English- and Spanish-language groups and Spanish speakers with higher education levels than previous studies of the small-group Arthritis Self-Management Program.

    View details for DOI 10.1002/art.24587

    View details for Web of Science ID 000268151100002

    View details for PubMedID 19565554

  • Community-Based Peer-Led Diabetes Self-management A Randomized Trial DIABETES EDUCATOR Lorig, K., Ritter, P. L., Villa, F. J., Armas, J. 2009; 35 (4): 641-651


    The purpose of this study is to determine the effectiveness of a community-based diabetes self-management program comparing treatment participants to a randomized usual-care control group at 6 months.A total of 345 adults with type 2 diabetes but no criteria for high A1C were randomized to a usual-care control group or 6-week community-based, peer-led diabetes self-management program (DSMP). Randomized participants were compared at 6 months. The DSMP intervention participants were followed for an additional 6 months (12 months total). A1C and body mass index were measured at baseline, 6 months, and 12 months. All other data were collected by self-administered questionnaires.At 6 months, DSMP participants did not demonstrate improvements in A1C as compared with controls. Baseline A1C was much lower than in similar trials. Participants did have significant improvements in depression, symptoms of hypoglycemia, communication with physicians, healthy eating, and reading food labels (P < .01). They also had significant improvements in patient activation and self-efficacy. At 12 months, DSMP intervention participants continued to demonstrate improvements in depression, communication with physicians, healthy eating, patient activation, and self-efficacy (P < .01). There were no significant changes in utilization measures.These findings suggest that people with diabetes without elevated A1C can benefit from a community-based, peer-led diabetes program. Given the large number of people with diabetes and lack of low-cost diabetes education, the DSMP deserves consideration for implementation.

    View details for DOI 10.1177/0145721709335006

    View details for Web of Science ID 000268306800009

    View details for PubMedID 19407333

  • Content and Frequency of Writing on Diabetes Bulletin Boards: Does Race Make a Difference? JOURNAL OF MEDICAL INTERNET RESEARCH Case, S., Jernigan, V., Gardner, A., Ritter, P., Heaney, C. A., Lorig, K. R. 2009; 11 (2)


    Diabetes-related disparities are well documented among racial minority groups in the United States. Online programs hold great potential for reducing these disparities. However, little is known about how people of different races utilize and communicate in such groups. This type of research is necessary to ensure that online programs respond to the needs of diverse populations.This exploratory study investigated message frequency and content on bulletin boards by race in the Internet Diabetes Self-Management Program (IDSMP). Two questions were asked: (1) Do participants of different races utilize bulletin boards with different frequency? (2) Do message, content, and communication style differ by race? If so, how?Subjects were drawn by purposeful sampling from participants in an ongoing study of the effectiveness of the IDSMP. All subjects had completed a 6-week intervention that included the opportunity to use four diabetes-specific bulletin boards. The sample (N = 45) consisted of three groups of 15 participants, each who self-identified as American Indian or Alaskan Native (AI/AN), African American (AA), or Caucasian, and was stratified by gender, age, and education. Utilization was assessed by counting the number of messages per participant and the range of days of participation. Messages were coded blindly for message type, content, and communication style. Data were analyzed using descriptive and nonparametric statistics.In assessing board utilization, AAs wrote fewer overall messages (P = .02) and AIs/ANs wrote fewer action planning posts (P = .05) compared with Caucasians. AIs/ANs logged in to the program for a shorter time period than Caucasians (P = .04). For message content, there were no statistical (P

    View details for DOI 10.2196/jmir.1153

    View details for Web of Science ID 000274632700006

    View details for PubMedID 19632975

  • The Expert Patients Programme online, a 1-year study of an Internet-based self-management programme for people with long-term conditions. Chronic illness Lorig, K. R., Ritter, P. L., Dost, A., Plant, K., Laurent, D. D., McNeil, I. 2008; 4 (4): 247-256


    Evaluate the effectiveness of an online self-management programme (EPP Online) for England residents with long-term conditions.A prospective longitudinal study. Data were collected online at baseline, 6 and 12 months. The intervention was an asynchronous 6-week chronic-disease self-management programme offered online. We measured seven health status measures (health distress, self-rated health, illness intrusiveness, disability, fatigue, pain and shortness of breath), four behaviours (aerobic exercise, stretching exercise, stress management and communications with physician), and five utilization measures (GP visits, pharmacy visits, PT/OT visits, emergency visits and hospitalizations). We also measured self-efficacy and satisfaction with the health care system.A total of 568 completed baseline data: 546 (81%) completed 6 months and 443 (78%) completed 1 year. Significant improvements (p < 0.01) were found at 6 months for all variables except self-rated health, disability, stretching, hospitalizations and nights in hospital. At 12 months only decrease in disability, nights in hospital and hospitalizations were not significant with reduction in visits to emergency departments being marginally significant (p = 0.012). Both self-efficacy and satisfaction with the health care system improved significantly.The peer-led online programme conditions appears to decrease symptoms, improve health behaviours, self-efficacy and satisfaction with the health care system and reducing health care utilization up to 1 year.

    View details for DOI 10.1177/1742395308098886

    View details for PubMedID 19091933

  • Perceived control moderated the self-efficacy-enhancing effects of a chronic illness self-management intervention. Chronic illness Jerant, A., Moore, M., Lorig, K., Franks, P. 2008; 4 (3): 173-182


    Identifying moderators of the effects of self-efficacy-enhancing interventions could improve their efficiency. We examined the effects of a home-based variant of the Chronic Disease Self-Management Program on self-efficacy, and explored the moderating effects of perceived control over self-management (PCSM).In a randomized controlled trial, patients (N= 415) aged>40 years with various chronic conditions plus basic activity impairment and/or significant depressive symptoms were randomized to one of three groups: intervention provided in homes or by telephone, v. usual care control. We used mixed effects linear models for repeated measures to examine effects on self-management self-efficacy at 6-month follow-up and explore moderation by PCSM.Only the home intervention had a significant self-efficacy-enhancing effect (Wald test, chi( 2) = 13.8, p = 0.008; effect size = 0.3). The effect was moderated by PCSM, considered as a continuous [effective in subjects with lower PCSM (Wald test, chi(2) = 13.4, p = 0.009)] or categorical (effective only for subjects in the lowest tercile) variable.People with lower PCSM appear more likely to experience enhanced self-efficacy from chronic illness self-management training than those with higher PCSM. These findings, although preliminary, suggest that office-based measurement of PCSM might identify those chronically ill patients likely to benefit most from self-management training.

    View details for DOI 10.1177/1742395308089057

    View details for PubMedID 18796506

  • The Internet-based Arthritis Self-Management Program: A one-year randomized trial for patients with arthritis or fibromyalgia ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH Lorig, K. R., Ritter, P. L., Laurent, D. D., Plant, K. 2008; 59 (7): 1009-1017


    To determine the efficacy of an Internet-based Arthritis Self-Management Program (ASMP) as a resource for arthritis patients unable or unwilling to attend small-group ASMPs, which have proven effective in changing health-related behaviors and improving health status measures.Randomized intervention participants were compared with usual care controls at 6 months and 1 year using repeated-measures analyses of variance. Patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia and Internet and e-mail access (n = 855) were randomized to an intervention (n = 433) or usual care control (n = 422) group. Measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy.At 1 year, the intervention group significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found.The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.

    View details for DOI 10.1002/art.23817

    View details for Web of Science ID 000257602000015

    View details for PubMedID 18576310

  • Spanish diabetes self-management with and without automated telephone reinforcement - Two randomized trials DIABETES CARE Lorig, K., Ritter, P. L., Villa, F., Piette, J. D. 2008; 31 (3): 408-414


    To determine 1) whether participants in the Spanish Diabetes Self-Management Program (SDSMP), when compared at 6 months to randomized control subjects, would demonstrate improvements in health status, health behaviors, and self-efficacy; and 2) whether SDSMP participants receiving monthly automated telephone reinforcement would maintain improvements at 18 months better than those not receiving reinforcement.A total of 567 Spanish-speaking adults with type 2 diabetes were randomized to a usual-care control group or 6-week community-based, peer-led SDSMP. SDSMP participants were re-randomized to receive 15 months of automated telephone messages or no reinforcement. A1C was measured at baseline and 6 and 18 months. All other data were collected by self-administered questionnaires.At 6 months SDSMP participants compared with control subjects demonstrated improvements in A1C (-0.4%), health distress, symptoms of hypo- and hyperglycemia, and self-efficacy (P < 0.05). At 18 months all improvements persisted (P < 0.05). SDSMP participants also demonstrated improvements in self-rated health and communication with physicians, had fewer emergency room visits (-0.18 visits in 6 months, P < 0.05), and trended toward fewer visits to physicians. At 18 months the only difference between reinforced and nonreinforced participants was increased glucose monitoring for the reinforcement group.The SDSMP demonstrated effectiveness in lowering A1C and improving health status. Reinforcement did not add to its effectiveness. Given the high needs of the Spanish-speaking population, the SDSMP deserves consideration for implementation.

    View details for DOI 10.2337/dc07-1313

    View details for Web of Science ID 000253801100006

    View details for PubMedID 18096810

  • Participation in patient self-management programs ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH Bruce, B., Lorig, K., Laurent, D. 2007; 57 (5): 851-854


    Participation in evidenced-based arthritis self-management programs (SMPs) has not been well documented. The purpose of this study was to investigate the participation rate and participant characteristics in a closed cohort of subjects in a geographic region where arthritis SMPs have been offered multiple times and continuously for 2 decades.Data were from osteoarthritis (OA) and rheumatoid arthritis subjects participating in the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) who resided in the San Francisco (SF) Bay area who had responded to questions about ever participating in an SMP. Differences between participants and nonparticipants were examined by t-tests and chi-square tests.Questions added to the Health Assessment Questionnaire were returned by 1,176 patients; 618 resided in the SF Bay area. Of the SF Bay area sample, 41.9% had participated in an SMP. Small group SMPs, which had been offered multiple times, in diverse settings, continuously over the past 2 decades, were attended by the highest proportion (28%) of participants. Characteristics of participants and nonparticipants in the SF Bay area were similar ( approximately 70 years old, 15 years of education, and the majority had OA [ approximately 72%]). However, a higher proportion of participants were white (88% versus 82%; P = 0.046) and female (82% versus 73%; P < 0.05).When arthritis SMPs were offered multiple times in diverse settings and continuously over many years, >40% of the cohort was reached. More research is needed with larger samples and different geographic regions to identify participation rates in more diverse populations.

    View details for DOI 10.1002/art.22776

    View details for Web of Science ID 000247129900022

    View details for PubMedID 17530686

  • Does self-management lead to sustainable health benefits in people with arthritis? A 2-year transition study of 452 Australians JOURNAL OF RHEUMATOLOGY Osborne, R. H., Wilson, T., Lorig, K. R., McColl, G. J. 2007; 34 (5): 1112-1117


    To evaluate the Arthritis Self-Management Course (ASMC) when applied in a nationwide context.Four hundred fifty-two people who participated in the ASMC across Australian states took part in a longitudinal followup study. ASMC is a 6 week, 2 h group educational program designed to assist people with chronic illness to better manage their condition. Measures of program effectiveness included health status and service utilization. Data were collected on 3 occasions: before intervention (baseline) and 6 months and 2 years after the program.Several indicators of health status showed improvement at 6 months following the ASMC. These included reduction in pain (4%; p < 0.001), fatigue (3%; p < 0.01), and health distress (12%; p < 0.001) as well as increase in self-efficacy (6%; p < 0.001). Increased self-efficacy was a significant predictor of positive change in health status. Health-related behaviors such as aerobic exercise also increased, with the proportion of people who did little or no exercise decreasing by up to 8%. These changes were sustained at 2 years. There was an increase in use of analgesics at 6 months and an increase in use of nonsteroidal antiinflammatory drugs at 2 years. No changes in healthcare utilization (physician visits, allied health visits, and hospitalizations) were observed.The ASMC is a widely applied program in which participants benefit through a reduction in pain, fatigue, and health distress. Although the absolute changes in health status are small, the low cost and wide application of the intervention suggests the program may have a substantial public health effect.

    View details for Web of Science ID 000246230700031

    View details for PubMedID 17343319

  • Internet-based chronic disease self-management - A randomized trial MEDICAL CARE Lorig, K. R., Ritter, P. L., Laurent, D. D., Plant, K. 2006; 44 (11): 964-971


    The small-group Chronic Disease Self-Management Program (CDSMP) has proven effective in changing health-related behaviors and improving health statuses. An Internet-based CDSMP was developed to reach additional chronic-disease patients.We sought to determine the efficacy of the Internet-based CDSMP.We compared randomized intervention participants with usual-care controls at 1 year. We compared intervention participants with the small-group CDSMP at 1 year.Nine-hundred fifty-eight patients with chronic diseases (heart, lung, or type 2 diabetes) and Internet and e-mail access were randomized to intervention (457) or usual care control (501).Measures included 7 health status variables (pain, shortness of breath, fatigue, illness intrusiveness, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 3 utilization variables (physician visits, emergency room visits, and nights in hospital), and self-efficacy.At 1 year, the intervention group had significant improvements in health statuses compared with usual care control patients. The intervention group had similar results to the small-group CDSMP participants. Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year.The Internet-based CDSMP proved effective in improving health statutes by 1 year and is a viable alternative to the small-group Chronic Disease Self Management Program.

    View details for Web of Science ID 000241956600002

    View details for PubMedID 17063127

  • Action planning: A call to action JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE Lorig, K. 2006; 19 (3): 324-325

    View details for Web of Science ID 000237804600014

    View details for PubMedID 16672687

  • Self-management education for osteoarthritis - Response ANNALS OF INTERNAL MEDICINE Holman, H. R., Lorig, K. 2006; 144 (8): 618-618
  • Self-management education for osteoarthritis ANNALS OF INTERNAL MEDICINE Holman, H. R., Lorig, K. 2006; 144 (8): 617-617

    View details for Web of Science ID 000237017900010

    View details for PubMedID 16618959

  • Measurement of pain using the visual numeric scale JOURNAL OF RHEUMATOLOGY Ritter, P. L., Gonzalez, V. M., Laurent, D. D., Lorig, K. R. 2006; 33 (3): 574-580


    We introduce the English-language Visual Numeric Scale (VNS) for self-reported pain and examine its psychometric properties; we compare the VNS to the better known Visual Analog Scale (VAS).We developed the VNS, which combines strong visual cues with an 11-point numeric rating scale. The VNS was administered to 2 sets of subjects with arthritis or chronic disease (N = 175, N = 192, respectively) and responses were examined. To compare the VNS to the VAS, we administered both scales to all subjects and used correlations to compare them to each other and to health distress and overall general health scores. A subset of respondents enrolled in an arthritis self-management program were given the VNS 4 months later, and change scores were used to test the sensitivity of the VNS.The VNS had means of 5.4 and 5.6 in the 2 samples, with distributions across the range of possible values. The VNS correlated well with the VAS (r = 0.85) and correlated slightly better than the VAS with the 2 independent health measures. The VNS was more likely to be completed than the VAS and there were fewer coding errors with the VNS. The VNS showed a significant (effect size 0.28) positive change for participants in a self-management course.The VNS appeared to be a valid measure. It was as successful as the VAS in measuring the underlying pain variable. It was easier to administer and code than the VAS, and was sensitive to change in pain.

    View details for Web of Science ID 000235749200023

    View details for PubMedID 16511926

  • A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH Lorig, K., Ritter, P. L., Plant, K. 2005; 53 (6): 950-957


    Both the Arthritis Self-Management Program (ASMP) and the generic Chronic Disease Self-Management Program (CDSMP) have been shown to be successful in improving conditions in patients with arthritis. This study compared the relative effectiveness of the 2 programs for individuals with arthritis.Patients whose primary disease was arthritis were randomized to the ASMP (n = 239) or to the CDSMP (n = 116). Analyses of covariance were used to compare the outcome measures for the 2 programs at 4 months and 1 year. Measures included quality of life outcomes (self reported, health distress, disability, activity limitation, global health, pain, and fatigue), health behaviors (practice of mental stress management, stretching and strength exercise, aerobic exercise), self efficacy, and health care utilization (physician visits and hospitalizations).Both programs showed positive results. The disease-specific ASMP appeared to have advantages over the more generic CDSMP for patients with arthritis at 4 months. These advantages had lessened slightly by 1 year.The disease-specific ASMP should be considered first where there are sufficient resources and participants. However, both programs had positive effects, and the CDSMP should be considered a viable alternative.

    View details for DOI 10.1002/art.21604

    View details for Web of Science ID 000234086100021

    View details for PubMedID 16342084

  • A national dissemination of an evidence-based self-management program: a process evaluation study PATIENT EDUCATION AND COUNSELING Lorig, K. R., Hurwicz, M. L., Sobel, D., Hobbs, M., Ritter, P. L. 2005; 59 (1): 69-79


    While evidence exists regarding the effectiveness of many health education interventions, few of these evidence-based programs have been systematically or widely disseminated. This paper reports on the dissemination of one such intervention, the 6-week peer-led Chronic Disease Self-Management Program, throughout a large health-care system, Kaiser Permanente. We describe the dissemination process and, using qualitative analysis of interviews and surveys, discuss the factors that aided and hindered this process and make recommendations for similar dissemination projects. Six years after the beginning of the dissemination process, the program is integrated in most of the Kaiser Permanente regions and is being offered to several thousand people a year.

    View details for DOI 10.1016/j.pec.2004.10.002

    View details for Web of Science ID 000232860700008

    View details for PubMedID 16198220

  • The impact of a moderated e-mail discussion group on use of complementary and alternative therapies in subjects with recurrent back pain AAPP 2005 Forum/International Conference on Communication in Healthcare Bruce, B., Lorig, K., Laurent, D., Ritter, P. ELSEVIER IRELAND LTD. 2005: 305–11


    The purpose was to examine whether or not participation in an e-mail discussion group would affect use of selected complementary and alternative medicine (CAM) modalities during an Internet-based, 1-year randomized, controlled trial on back pain management.Intervention subjects (n = 190) participated in a closed, moderated e-mail discussion group; control subjects (n = 231) received usual care. At 1 year, we compared CAM use over the previous 6-month period during which intervention subjects had had interactive discussions about them. Differences in CAM use between groups were compared using Chi-square and t-tests.Subjects did not differ statistically between groups (p > 0.05). They were Caucasian (approximately 91%), male (approximately 60%), in their mid-40s, well educated, had approximately 13 years back pain duration, a disability level approximately 10 (Roland-Morris scale: 0-23; 23 = worst), and >80% had used the Internet for greater than a year before the randomized trial. During the study period, only small proportions in either group had initiated use of glucosamine (13% versus 8%), chiropractic services (5% versus 4%), acupuncture (3%, both), yoga (6% versus 4%), or magnets (6%, both).Results suggest that participation in interactive discussions over the Internet about these CAM modalities may not affect their use.

    View details for DOI 10.1016/j.pec.2004.08.012

    View details for Web of Science ID 000231834800011

    View details for PubMedID 16122642

  • Outcomes of border health Spanish/English chronic disease self-management programs DIABETES EDUCATOR Lorig, K. R., Ritter, P. L., Jacquez, A. 2005; 31 (3): 401-409


    The purpose of this study was to evaluate the community-based Chronic Disease Self-management Program (CDSMP) and the Spanish-language version (Tomando Control de Su Salud) programs as delivered in settings along the Texas/New Mexico/Mexico border. The programs had proven effective in randomized trials, and the authors wished to determine if they would be as effective when administered by others to different populations.The El Paso Diabetes Association administered the CDSMP and Tomando to 445 persons with chronic illness (two thirds with diabetes) in Texas, New Mexico, and Mexico. Four-month and 1-year outcomes were compared to baseline using t tests of change scores. Regression models were used to test whether baseline demographics and self-efficacy were associated with positive outcomes of the programs.Participants showed improvements in health behaviors, health status, and self-efficacy at both 4 month and 1 year. Baseline self-efficacy and 4-month change in self-efficacy were significantly associated with improved 1-year outcomes.The CDSMP and Tomando are effective when used in settings other than that of the original study for populations other than those for which they were initially developed.

    View details for DOI 10.1177/0145721705276574

    View details for Web of Science ID 000229360600005

    View details for PubMedID 15919640

  • Internet versus mailed questionnaires: A randomized comparison JOURNAL OF MEDICAL INTERNET RESEARCH Ritter, P., Lorig, K., Laurent, D., Matthews, K. 2004; 6 (3): 19-25


    The use of Internet-based questionnaires for collection of data to evaluate patient education and other interventions has increased in recent years. Many self-report instruments have been validated using paper-and-pencil versions, but we cannot assume that the psychometric properties of an Internet-based version will be identical.To look at similarities and differences between the Internet versions and the paper-and-pencil versions of 16 existing self-report instruments useful in evaluation of patient interventions.Participants were recruited via the Internet and volunteered to participate (N=397), after which they were randomly assigned to fill out questionnaires online or via mailed paper-and-pencil versions. The self-report instruments measured were overall health, health distress, practice mental stress management, Health Assessment Questionnaire (HAQ) disability, illness intrusiveness, activity limitations, visual numeric for pain, visual numeric for shortness of breath, visual numeric for fatigue, self-efficacy for managing disease, aerobic exercise, stretching and strengthening exercise, visits to MD, hospitalizations, hospital days, and emergency room visits. Means, ranges, and confidence intervals are given for each instrument within each type of questionnaire. The results from the two questionnaires were compared using both parametric and non-parametric tests. Reliability tests were given for multi-item instruments. A separate sample (N=30) filled out identical questionnaires over the Internet within a few days and correlations were used to assess test-retest reliability.Out of 16 instruments, none showed significant differences when the appropriate tests were used. Construct reliability was similar within each type of questionnaire, and Internet test-retest reliability was high. Internet questionnaires required less follow-up to achieve a slightly (non-significant) higher completion rate compared to mailed questionnaires.Among a convenience sample recruited via the Internet, results from those randomly assigned to Internet participation were at least as good as, if not better than, among those assigned mailed questionnaires, with less recruitment effort required. The instruments administered via the Internet appear to be reliable, and to be answered similarly to the way they are answered when they are administered via traditional mailed paper questionnaires.

    View details for Web of Science ID 000226554300006

    View details for PubMedID 15471755

  • Patient self-management: A key to effectiveness and efficiency in care of chronic disease PUBLIC HEALTH REPORTS Holman, H., Loric, K. 2004; 119 (3): 239-243

    View details for Web of Science ID 000223958000003

    View details for PubMedID 15158102

  • Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions MEDICAL CARE Lorig, K. R., Ritter, P. L., Laurent, D. D., Fries, J. F. 2004; 42 (4): 346-354


    The objective of this study was to test the effectiveness of a mail-delivered, tailored self-management intervention (SMART) and to compare it with the classic Arthritis Self-Management Program (ASMP).We performed 2 randomized controlled trials: 1) a study of 1090 participants randomized to SMART or USUAL CARE, and 2) a study of 341 participants randomized to SMART or ASMP. Dependent variables included disability, pain, depression, role function, global severity, doctor visits, and self-efficacy. SMART interventions were provided in months 0-18 and not reinforced. Results were assessed at 1, 2, and 3 years using analyses of covariance (ANCOVA).Compared with USUAL CARE, SMART participants at 1 year had decreased disability, improved role function, and increased self-efficacy (all P <0.01). At 2 years, decreases in global severity, doctor visits, and increases in self-efficacy (all P <0.01) were noted. At 3 years without reinforcement, no statistically significant effects remained. Compared with ASMP, SMART at 1 year had greater decreases in disability (P = 0.02) and increases in self-efficacy (P = 0.01). There were no differences at 2 years. At 3 years, role function (P = 0.04) and doctor visit (P = 0.03) were improved in ASMP as compared with SMART. Improvements from baseline were seen for nearly all variables in both groups.A mail-delivered arthritis self-management program, SMART, was similarly effective to the classic ASMP, with slightly better results in the first year and a slightly more rapid attenuation over the next 2 years. Results suggest that both programs are effective, and that the addition of a mail-delivered program could improve accessibility to arthritis self-management treatment.

    View details for DOI 10.1097/07.mlr.0000118709.74348.65

    View details for Web of Science ID 000220475800007

    View details for PubMedID 15076811

  • Taking patient ed to the next level. RN Lorig, K. R. 2003; 66 (12): 35-38

    View details for PubMedID 14725064

  • Hispanic chronic disease self-management - A randomized community-based outcome trial NURSING RESEARCH Lorig, K. R., Ritter, P. L., Gonzalez, V. M. 2003; 52 (6): 361-369


    In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory.This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes.The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests.At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p <.05). At 1 year, the improvements were maintained and remained significantly different from baseline condition.This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.

    View details for Web of Science ID 000186724200003

    View details for PubMedID 14639082

  • Self-management education: History, definition, outcomes, and mechanisms ANNALS OF BEHAVIORAL MEDICINE Lorig, K. R., Holman, H. R. 2003; 26 (1): 1-7


    Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks--medical management, role management, and emotional management--and six self-management skills--problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

    View details for Web of Science ID 000184521900001

    View details for PubMedID 12867348

  • Patient self-management of chronic disease in primary care JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bodenheimer, T., Lorig, K., Holman, H., Grumbach, K. 2002; 288 (19): 2469-2475


    Patients with chronic conditions make day-to-day decisions about--self-manage--their illnesses. This reality introduces a new chronic disease paradigm: the patient-professional partnership, involving collaborative care and self-management education. Self-management education complements traditional patient education in supporting patients to live the best possible quality of life with their chronic condition. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is self-efficacy--confidence to carry out a behavior necessary to reach a desired goal. Self-efficacy is enhanced when patients succeed in solving patient-identified problems. Evidence from controlled clinical trials suggests that (1) programs teaching self-management skills are more effective than information-only patient education in improving clinical outcomes; (2) in some circumstances, self-management education improves outcomes and can reduce costs for arthritis and probably for adult asthma patients; and (3) in initial studies, a self-management education program bringing together patients with a variety of chronic conditions may improve outcomes and reduce costs. Self-management education for chronic illness may soon become an integral part of high-quality primary care.

    View details for Web of Science ID 000179292300031

    View details for PubMedID 12435261

  • Can a Back Pain E-mail Discussion Group improve health status and lower health care costs?: A randomized study. Archives of internal medicine Lorig, K. R., Laurent, D. D., Deyo, R. A., Marnell, M. E., Minor, M. A., Ritter, P. L. 2002; 162 (7): 792-796


    Given the high health care utilization, limited evidence for the effectiveness of back pain interventions, and the proliferation of e-mail health discussion groups, this study seeks to determine if the Internet can be used to improve health status and health care utilization for people with chronic back pain.Randomized controlled trial. Participants included 580 people from 49 states with chronic back pain having at least 1 outpatient visit in the past year, no "red-flag" symptoms, and access to e-mail. Major exclusion criteria included continuous back pain for more than 90 days causing major activity intolerance and/or receiving disability payments.Closed, moderated, e-mail discussion group. Participants also received a book and videotape about back pain. Controls received a subscription to a non-health-related magazine of their choice.Pain, disability, role function, health distress, and health care utilization.At 1-year treatment, subjects compared with controls demonstrated improvements in pain (P =.045), disability (P =.02), role function (P =.007), and health distress (P =.001). Physician visits for the past 6 months declined by 1.5 visits for the treatment group and by 0.65 visits for the control group (P =.07). Mean hospital days declined nearly 0.20 days for the treated group vs and increased 0.04 days for the control group (P =.24).An e-mail discussion group can positively affect health status and possibly health care utilization. It may have a place in the treatment of chronic recurrent back pain.

    View details for PubMedID 11926853

  • Can a back pain e-mail discussion group improve health status and lower health care costs? ARCHIVES OF INTERNAL MEDICINE Lorig, K. R., Laurent, D. D., Deyo, R. A., Marnell, M. E., Minor, M. A., Ritter, P. L. 2002; 162 (7): 792-796
  • Self-care and the doctor-patient relationship. Medical care Shoor, S., Lorig, K. R. 2002; 40 (4): II40-44


    An important factor contributing to the steep rise in health care costs in the late 1960s was a reversal from the predominance of acute illness to that of chronic disease. Beginning with the philosophy of Illich and Levin, and the practical instruments of Fries, Sehnert, Vickery, and Ferguson, a new movement in patient self-care emerged. However, such programs were not integrated into organized medical care plans and though theoretically attractive had not yet proven to improve health or decrease costs.The contributions to the self-care movement made under the intellectual guidance of Halsted Holman and the relevant literature produced are reviewed.While caring for chronic rheumatic diseases, Halsted Holman discovered that patient self-report was a more powerful predictor of outcome than were traditional biologic measures such as anti-DNA antibodies. Realizing the role that patient knowledge of their own disease course might play, he developed the Arthritis Self-Management course, a lay-led self-care program emphasizing patient participation. Holman and colleagues next elucidated the pivotal importance of Bandura's theory of self-efficacy in the improved patient outcomes initially observed. These self-care techniques were woven into the structure of the Midpeninsula Health Service, showing for the first time reductions in subsequent office visits and enhanced quality. In partnership with Kaiser Health Plan, these techniques showed improvements in self-efficacy health behaviors, status, and use in a randomized trial of more than 1,000 patients.Halsted Holman and colleagues have played a seminal role in the translation of academic self-care theory into community practice.

    View details for PubMedID 12064580

  • Self-care and the doctor-patient relationship MEDICAL CARE Shoor, S., Lorig, K. R. 2002; 40 (4): 40-44
  • Partnerships between expert patients and physicians LANCET Lorig, K. 2002; 359 (9309): 814-815

    View details for Web of Science ID 000174329600004

    View details for PubMedID 11897275

  • Effect of a self-management program on patients with chronic disease. Effective clinical practice : ECP Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., Hobbs, M. 2001; 4 (6): 256-262


    For patients with chronic disease, there is growing interest in "self-management" programs that emphasize the patients' central role in managing their illness. A recent randomized clinical trial demonstrated the potential of self-management to improve health status and reduce health care utilization in patients with chronic diseases.To evaluate outcomes of a chronic disease self-management program in a real-world" setting.Before-after cohort study.Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data.The Chronic Disease Self-Management Program is a 7-week, small-group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building.Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires.At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant.We replicated the results of our previous clinical trial of a chronic disease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.

    View details for PubMedID 11769298

  • Chronic disease self-management program - 2-year health status and health care utilization outcomes MEDICAL CARE Lorig, K. R., Ritter, P., Stewart, A. L., Sobel, D. S., Brown, B. W., Bandura, A., Gonzalez, V. M., Laurent, D. D., Holman, H. R. 2001; 39 (11): 1217-1223


    To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization.Longitudinal design as follow-up to a randomized trial.Community.Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data.Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured.Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes.A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.

    View details for Web of Science ID 000171821000008

    View details for PubMedID 11606875

  • Self-reports of health care utilization compared to provider records JOURNAL OF CLINICAL EPIDEMIOLOGY Ritter, P. L., Stewart, A. L., Kaymaz, H., Sobel, D. S., Block, D. A., Lorig, K. R. 2001; 54 (2): 136-141


    This study compares self-reports of medical utilization with provider records. As part of a chronic disease self-management intervention study, patients completed self-reports of their last six months of health care utilization. A subgroup of patients was selected from the larger study and their self-reports of utilization were compared to computerized utilization records. Consistent with earlier studies, patients tended to report less physician utilization than was recorded in the computerized provider records. However, they also tended to report slightly more emergency room visits than were reported in the computerized utilization records. There was no association between demographic or health variables and the tendency toward discrepancy between self-report and computerized utilization record reports. However, there was a tendency for the discrepancy to increase as the amount of record utilization increased. Thus, the likelihood of bias caused by differing demographic factors is low, but researchers should take into account that underreporting occurs and is likely to increase as utilization increases.

    View details for Web of Science ID 000166819400006

    View details for PubMedID 11166528

  • The perils and pitfalls of comparing UK and US samples of people enrolled in an arthritis self-management program: The case of the Center for Epidemiological Studies-Depression (CES-D) Scale ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH Barlow, J. H., Wright, C. C., Lorig, K. 2001; 45 (1): 77-80

    View details for Web of Science ID 000171814800011

    View details for PubMedID 11308065

  • A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting PAIN Moore, J. E., von Korff, M., Cherkin, D., Saunders, K., Lorig, K. 2000; 88 (2): 145-153


    Back pain is a significant health care problem that has been managed unsatisfactorily in primary care settings. Providers typically address medical issues but do not adequately address patient concerns or functional limitations related to back pain. We evaluated a brief intervention for primary care back pain patients designed to provide accurate information about back pain, instill attitudes favorable towards self care, reduce fears and worries, assist patients in developing personalized action plans to manage their back pain, and improve functional outcomes. Patients enrolled in a large health maintenance organization were invited to participate in an educational program to improve back pain self care skills 6-8 weeks after a primary care back pain visit. Patients (n=226) were randomly assigned to a Self Care intervention or to Usual Care, and were assessed at baseline, 3-, 6-, and 12-months. The intervention involved a two-session Self Care group and an individual meeting and telephone conversation with the group leader, a psychologist experienced in chronic pain management. The intervention was supplemented by educational materials (book and videos) supporting active management of back pain. The control group received usual care supplemented by a book on back pain care. Participants assigned to the Self Care intervention showed significantly greater reductions in back-related worry and fear-avoidance beliefs than the control group. Modest, but statistically significant, effects on pain ratings and interference with activities were also observed.

    View details for Web of Science ID 000165119100005

    View details for PubMedID 11050369

  • Assessing patients' views of clinical changes - Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Holman, H., Bloch, D. A., Lorig, K., Laurent, D., Fischer, D., Stewart, A. L. 2000; 283 (14): 1825-1825
  • Capturing the patient's view of change as a clinical outcome measure JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Fischer, D., Stewart, A. L., Bloch, D. A., Lorig, K., Laurent, D., Holman, H. 1999; 282 (12): 1157-1162


    Measurement of change in patients' health status is central to both clinical trials and clinical practice. Trials commonly use serial measurements by the patients at 2 points in time while clinicians use the patient's retrospective assessment of change made at 1 point in time. How well these measures correlate is not known.To compare the 2 methods in measurement of changes in pain and disability.Longitudinal survey of patients starting new therapy for chronic arthritis in 1994 and 1995. Surveys were completed at baseline (before intervention) and at 6 weeks and 4 months.Community health education program and university medical and orthopedic services.A total of 202 patients undertaking self-management education (n = 140), therapy with prednisone or methotrexate (n = 34), or arthroplasty of the knee or hip (n = 28).Concordance between serial (visual analog scale for pain and Health Assessment Questionnaire for disability) and retrospective (7-point Likert scale) measures, sensitivities of these measures, and their correlation with patients' satisfaction with the change (7-point Likert scale).When change was small (education group), serial measures correlated poorly with retrospective assessments (eg, r=0.13-0.21 at 6 weeks). With greater change, correlations improved (eg, r = 0.45-0.71 at 6 weeks). Average agreement between all pairs of assessments was 29%. Significant lack of concordance was confirmed in all 12 comparisons by McNemar tests (P = .02 to <.001) and by t tests (P = .03 to <.001). Retrospective measures were more sensitive to change than serial measures and correlated more strongly with patients' satisfaction with change.The 2 methods for measuring health status change did not give concordant results. Including patient retrospective assessments in clinical trials might increase the comprehensiveness of information gained and its accord with clinical practice.

    View details for Web of Science ID 000082596200031

    View details for PubMedID 10501119

  • Community-based Spanish language arthritis education program - A randomized trial MEDICAL CARE Lorig, K., Gonzalez, V. M., Ritter, P. 1999; 37 (9): 957-963


    To determine 4-month and 1-year health-related outcomes of a 6-week, lay-led, and community-based arthritis self-management program for Spanish-speaking participants and to determine the role of self-efficacy in predicting health status for this population.Three hundred and thirty one subjects were randomized to the program or to a 4-month wait list control group. One hundred ninety eight subjects continued in a 1-year longitudinal study. Data were collected via mailed questionnaires with telephone follow up.At 4 months, treatment subjects, compared with controls, demonstrated positive changes in exercise, disability, pain, and self-efficacy (P < 0.05). At 1 year, compared with baseline, treatment subjects demonstrated improvements in exercise, general health, disability, pain, self-efficacy, and depression (P < 0.05). Baseline and 4-month changes in self-efficacy predicted health status at 1 year.Spanish-speaking participants of an arthritis self-management program demonstrate short- and long-term benefits (improved health behaviors, health status, and self-efficacy).

    View details for Web of Science ID 000082515500011

    View details for PubMedID 10493473

  • Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization - A randomized trial MEDICAL CARE Lorig, K. R., Sobel, D. S., Stewart, A. L., Brown, B. W., Bandura, A., Ritter, P., Gonzalez, V. M., Laurent, D. D., Holman, H. R. 1999; 37 (1): 5-14


    This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities.The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured.Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being.An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.

    View details for Web of Science ID 000077870400002

    View details for PubMedID 10413387

  • Arthritis self-management program variations: Three studies ARTHRITIS CARE AND RESEARCH Lorig, K., Gonzalez, V. M., Laurent, D. D., Morgan, L., Laris, B. A. 1998; 11 (6): 448-454


    1) Determine strengths and weaknesses of the Arthritis Self-Management Program (ASMP). 2) Compare 3- and 6-week ASMP. 3) Evaluate 1.5-hour arthritis program.Study 1: Qualitative methods incorporating incomplete block design. Study 2: Comparison of 3- and 6-week outcomes. Study 3: Pretest/posttest comparison.Study 1: Pain management, exercise, and sharing ranked as the most useful aspects of the ASMP. Nutrition, medications, and making decisions about nontraditional treatments ranked least useful. Study 2: Six-week ASMP subjects improved pain, health distress, illness impact, exercise, cognitive pain management, self-efficacy, and reduced visits to physicians (P < 0.05). Three-week subjects improved health distress, cognitive pain management, and self-efficacy (P < 0.05). Study 3: Improved knowledge, self-efficacy, and pain (P < 0.05).The traditional 6-week ASMP is more effective than a 3-week version. A 1.5-hour community program is effective in increasing knowledge, self-efficacy, and contact with the Arthritis Foundation.

    View details for Web of Science ID 000077922300003

    View details for PubMedID 10030176

  • A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care SPINE von Korff, M., Moore, J. E., Lorig, K., Cherkin, D. C., Saunders, K., Gonzalez, V. M., Laurent, D., Rutter, C., Comite, F. 1998; 23 (23): 2608-2615


    Randomized, controlled trial.To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations.Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated.Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care.Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls.Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.

    View details for Web of Science ID 000077366200015

    View details for PubMedID 9854760

  • Patient retrospective evaluation of change: An appropriate outcome measure for clinical trials? Fischer, D., Stewart, A. L., Bloch, D. A., Lorig, K., Laurent, D., Holman, H. R. WILEY-BLACKWELL. 1998: S229–S229
  • Psychosocial factors associated with youth involvement in community activities promoting heart health HEALTH EDUCATION & BEHAVIOR Altman, D. G., Feighery, E., Robinson, T. N., Haydel, K. F., Strausberg, L., Lorig, K., Killen, J. D. 1998; 25 (4): 489-500


    This study examined factors that influence youth participation in heart disease prevention activities among 2,609 ninth graders in six inner-city public high schools. Constructs derived from social cognitive, empowerment, and community development theories informed the conceptual framework employed. Study participants were diverse with respect to gender, ethnicity, parent education, acculturation, and academic achievement. Perceived incentive value, self-efficacy, outcome expectancies, sense of community, and perceived policy control were all significantly associated with participation in community activities promoting heart health. In multivariate analyses, perceived incentive value, defined as the extent to which participants valued a heart-healthy environment, was most strongly associated with community participation, accounting for 11.9% of the total variance. These findings have implications for designing school curricula and after-school and community programs targeting adolescents' involvement in health advocacy activities.

    View details for Web of Science ID 000074933300007

    View details for PubMedID 9690106

  • Arthritis self-efficacy scales measure self-efficacy ARTHRITIS CARE AND RESEARCH Lorig, K., Holman, H. 1998; 11 (3): 155-157

    View details for Web of Science ID 000075123400001

    View details for PubMedID 9782806

  • Pilot randomized trial of education to improve self-management skills of men with symptomatic HIV/AIDS XIth International Conference on AIDS Gifford, A. L., Laurent, D. D., Gonzales, V. M., Chesney, M. A., Lorig, K. R. LIPPINCOTT WILLIAMS & WILKINS. 1998: 136–44


    To evaluate the acceptability, practicality, and short-term efficacy of a health education program to improve disease self-management in patients with symptomatic HIV/AIDS.Randomized controlled trial, baseline and 3-month follow-up questionnaire assessments.San Francisco Bay communities.Seventy-one men with symptomatic HIV or AIDS were randomly assigned to a seven-session group educational intervention (N=34) or a usual-care control group (N=37).Interactive health education groups were used to teach wide-ranging disease self-management skills and information: symptom assessment and management, medication use, physical exercise, relaxation, doctor-patient communication, and nutrition. Each group was led by two trained peer-leaders (one of whom was HIV-positive) recruited from the community.The primary outcome of interest was symptom status. Secondary outcomes were self-efficacy and health behaviors. Analysis of covariance was used to compare experimental and control group mean outcomes, adjusting for baseline value differences.The symptom severity index (number of symptoms moderate or greater severity) decreased in the experimental, and increased in the control group (-0.9 versus +0.5; p < .03). Pain, fatigue, and psychological symptoms were not significantly different between groups. Self-efficacy for controlling symptoms improved in the experimental, and decreased in the control group (+4 versus -7; p < .02). Changes in stress/relaxation exercises and HIV/AIDS knowledge were not different between groups. A trend was shown toward more frequent physical exercise in the experimental group compared with less in the control group (+1.3 versus -0.5 times/week; p=.06).Health education emphasizing self-management skills for HIV/AIDS patients can be implemented and evaluated and was accepted by patients, peer-leaders, and health care providers. Whether this educational program can lead to prolonged improvement in HIV symptoms and behaviors can be adequately addressed only by a larger trial of longer duration.

    View details for Web of Science ID 000074168900005

    View details for PubMedID 9637578

  • [Chronic disease self-management: a model for tertiary prevention]. Kango kenkyu. The Japanese journal of nursing research LORING, K. 1998; 31 (1): 23-29

    View details for PubMedID 10437456

  • Cultural diversity issues in the development of valid and reliable measures of health status ARTHRITIS CARE AND RESEARCH Gonzalez-Calvo, J., Gonzalez, V. M., Lorig, K. 1997; 10 (6): 448-456


    The development of instruments for use in culturally diverse settings and populations really involves much more than mere translation. Measurements must be tested for content validity and appropriate meaning among members of the group to be studied. Attention to issues of validity, reliability, and cross-cultural differences will lead to effective assessment, culturally competent health care, and the enhancement of the client/provider relationship. The concerns surrounding the use of quantitative measurement in diverse cultural groups are substantial. While the refinement of scales to meet the needs of various groups is a challenging task, such effort is essential to the diagnosis of disease, determination of health status, and the measurement of health outcomes in the diverse subgroups of this country's population.

    View details for Web of Science ID 000071345500012

    View details for PubMedID 9481237

  • Overcoming barriers to successful aging - Self-management of osteoarthritis WESTERN JOURNAL OF MEDICINE Holman, H. R., Lorig, K. R. 1997; 167 (4): 265-268

    View details for Web of Science ID A1997YB46400012

    View details for PubMedID 9348758

  • Comparison of three methods of data collection in an urban Spanish-speaking population NURSING RESEARCH Lorig, K., Gonzalez, V. M., Ritter, P., DEBREY, V. N. 1997; 46 (4): 230-234

    View details for Web of Science ID A1997XP68000008

    View details for PubMedID 9261297

  • Interventions to reduce the impact of chronic disease: community-based arthritis patient education. Annual review of nursing research Goeppinger, J., Lorig, K. 1997; 15: 101-122


    Systematic development and testing of the efficacy of educational interventions to improve functioning, prevent disability, and reduce the impact of chronic disease has been limited, perhaps because many chronic diseases disable, do not kill, and because they are managed largely within home, work, and community environments and not within the medical care system. Until recently, these factors contributed to a paucity of arthritis educational interventions. But since the impetus provided by the establishment of the Multipurpose Arthritis Centers Program of the NIH (1977), a number of arthritis patient education programs have been established and evaluated. This chapter summarizes findings from community-based arthritis patient education studies conducted between 1980 and 1995, critiques the methods of these studies, and provides guidance for state-of-the-art community-based intervention research aimed at reducing the individual and social impact of arthritis and other chronic diseases.

    View details for PubMedID 9262789

  • Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison with nonsteroidal antiinflammatory drug treatment ARTHRITIS CARE AND RESEARCH SuperioCabuslay, E., Ward, M. M., Lorig, K. R. 1996; 9 (4): 292-301


    To compare the effects of education interventions and nonsteroidal antiinflammatory drug (NSAID) treatment on pain and functional disability in patients with osteoarthritis (OA), and on pain, functional disability, and tender joint counts in patients with rheumatoid arthritis (RA).Two meta-analyses were performed: one of controlled trials of patient education interventions and one of placebo-controlled trials of NSAID treatments.Nineteen patient education trials comprised of 32 treatment arms and 28 NSAID trials comprised of 46 treatment arms were included. The weighted average effect size for pain was 0.17 in the education trials and 0.66 in the NSAID trials. The average effect size for functional disability was 0.03 in the education trials and 0.34 in the NSAID trials; effects of education were much larger in RA studies than in OA studies. In RA studies, the average effect size for the tender joint count was 0.34 in the education trials and 0.43 in the NSAID trials. Because most patients in the education trials were being treated with medications, the effect sizes of these trials represent the additional, or marginal, effects of patient education interventions beyond those achieved by medication.Based on this meta-analysis, patient education interventions provide additional benefits that are 20-30% as great as the effects of NSAID treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60-80% as great as NSAID treatment in reduction in tender joint counts in RA.

    View details for Web of Science ID A1996WM82600013

    View details for PubMedID 8997918

  • Chronic disease self-management - A model for tertiary prevention AMERICAN BEHAVIORAL SCIENTIST Lorig, K. 1996; 39 (6): 676-683


    To produce Spanish versions of common arthritis outcome measures: the Health Assessment Questionnaire (HAQ) Disability Scale, the Center for Epidemiologic Studies Depression Scale (CES-D), the Medical Outcomes Study (MOS) Pain Severity Scale, the Arthritis Self-Efficacy Scale for Pain and Other Symptoms (with the addition of 2 new items), the Visual Analogue Pain Scale, the MOS Self-Rated Health Item, and a Physical Activities Scale that would be usable by most Hispanics living in the US. We tested these translated measures for reliability and, where appropriate, validity.Instruments were translated and back translated by bilingual persons from 5 different countries of origin. Translators met to resolve variations in translation. The instruments were then administered to Hispanic arthritis patients in 6 geographic locations (5 in the United States and 1 in Latin America). All instruments underwent standard psychometric testing. As appropriate, the sample was stratified by level of acculturation, nation of origin, and geographic location.The translated instruments, with slight modification, met acceptable levels of reliability and validity. They are understood and easily usable by diverse Spanish-speaking populations.The availability of these translated outcome measures should enable investigators to include monolingual Spanish-speakers into their studies, and should facilitate study of cross-cultural differences with respect to these specific outcomes.

    View details for Web of Science ID A1995TA57400009

    View details for PubMedID 7575693

  • A research agenda for health education among underserved populations HEALTH EDUCATION QUARTERLY Marin, G., Burhansstipanov, L., Connell, C. M., Gielen, A. C., HelitzerAllen, D., Lorig, K., Morisky, D. E., Tenney, M., Thomas, S. 1995; 22 (3): 346-363


    This article summarizes the outcome of health education efforts among populations that, due to their cultural heritage, have received limited services. The literature reviewed shows that programs found to be effective in one population cannot be assumed to be equally effective with a different population. An argument is made for the design of culturally appropriate and group-specific interventions which would properly serve the various underserved populations. Research needs to be conducted to identify appropriate approaches and intervention strategies, as well as the group-specific sociopsychological characteristics (attitudes, norms, values, expectancies) that are related to health-damaging and protective behaviors.

    View details for Web of Science ID A1995UD81100007

    View details for PubMedID 7591789

  • Arthritis self-help course. HMO practice Lorig, K. 1995; 9 (2): 60-61

    View details for PubMedID 10143154



    This article discusses the use of balanced incomplete block design for process evaluation and presents a case study of its use. This technique produces a weighted ranking of program elements, showing the relative importance of each element and allowing comparison of process and content elements. The article presents a case study in which the technique was used to evaluate the Chronic Disease Self-Management Program. Participants and lay course leaders were asked to rank 13 course elements for their helpfulness. The most valued element, sharing or unstructured interactions among participants, was not an explicitly planned part of the intervention. Some of the elements least valued (nutrition, use of community resources, and medication use) are elements most emphasized by the health care system and by patient education. We found that balanced incomplete block design was easy to administer and tally. The results could be readily applied to program redesign and to needs assessment.

    View details for Web of Science ID A1995TB46400005

    View details for PubMedID 7622388



    Arthritis is a chronic disease that is estimated to affect 14.5% of the American population and is the leading cause of functional dependency in the activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) in all persons over the age of 65 years. Clinical studies have shown that medical care, including the use of medications, can offer a 20-50% improvement in reported arthritis symptoms. Data from patient education studies suggest that a further improvement of 15-30% is attainable through patient education interventions. This literature review has been completed to update the reviews of patient education studies by Lorig and Riggs in 1983 and Lorig, Konkol, and Gonzalez in 1987. More specifically, the objectives of this review are: (1) to provide a summary of arthritis patient education studies published or presented since 1987; (2) to summarize the findings concerning the effectiveness of arthritis patient education studies which attempt to change knowledge, behavior, psychosocial status, and health status; (3) to discuss shifting trends in observed outcomes of arthritis patient education studies; and (4) to discuss implications for the future.

    View details for Web of Science ID A1994PL31300002

    View details for PubMedID 7862599

  • Arthritis and musculoskeletal patient education standards. Arthritis Foundation. Arthritis care and research Burckhardt, C. S., Lorig, K., Moncur, C., Melvin, J., Beardmore, T., Boyd, M., BOUTAUGH, M. 1994; 7 (1): 1-4

    View details for PubMedID 7918719

  • BIOPSYCHOSOCIAL CONTRIBUTIONS TO THE MANAGEMENT OF ARTHRITIS DISABILITY - BLUEPRINTS FROM AN NIDRR-SPONSORED CONFERENCE ARTHRITIS AND RHEUMATISM Parker, J. C., Bradley, L. A., DEVELLIS, R. M., Gerber, L. H., Holman, H. R., Keefe, F. J., Lawrence, T. S., Liang, M. H., Lorig, K. R., Nicassio, P. M., Revenson, T. A., Rogers, M. P., Wallston, K. A., Wilson, M. G., Wolfe, F. 1993; 36 (7): 885-889


    The contributions of MACs and RRTCs to the generation of arthritis-related biopsychosocial research over the last 15 years have been enormous. However, the assimilation of biopsychosocial concepts into mainstream clinical practice, professional education, and public awareness will require a sustained national effort.

    View details for Web of Science ID A1993LM08000002

    View details for PubMedID 8318036



    To estimate when a difference in disability symptoms is sufficiently large to be important to individual patients.Cross-sectional analysis of two groups: derivation set (n = 46) and validation set (n = 57).The Arthritis Foundation, Northern California Chapters.Volunteer sample of patients with arthritis who live in the community.We applied the Stanford Health Assessment Questionnaire to assess the functional status of individuals. Participants then conducted one-on-one conversations with each other and rated whether their disability was "much better" "somewhat better," "about the same," "somewhat worse," or "much worse" relative to each person they met. For every conversation we calculated the difference between the two participants' health assessment questionnaire scores and linked the difference to the subjective comparison ratings of each individual in the pair.Health assessment questionnaire score differences were significantly correlated with subjective comparison ratings (correlation coefficient, .41; 95% confidence interval, 0.31 to 0.50). We estimated that health assessment questionnaire scores needed to differ by about 0.19 units for average respondents to stop rating themselves as "about the same" and start rating themselves as "somewhat better" (95% confidence interval, 0.10 to 0.28). Analysis of a second group of patients revealed a similar threshold (mean, 0.23 units; 95% confidence interval, 0.13 to 0.23). In both groups, health assessment questionnaire score differences were imperfect predictors of individual ratings and the threshold for less disabled participants tended to be lower than the threshold for more disabled participants.Some statistically significant differences in functional status scores may be so small that they represent trivial degrees of symptom relief. An awareness of the smallest difference in symptom scores that is important to patients can provide a rough guide to help clinicians interpret the medical literature.

    View details for Web of Science ID A1993LG14100007

    View details for PubMedID 8507124



    Medical self-care has always been a primary means of caring for health problems. Educational materials and interventions have been used for centuries to improve the quality of medical self-care. However, relatively few studies have been undertaken to examine the effects of these interventions on the health of the individual or on the use of professional services. This review was undertaken to provide (1) a summary of studies describing the practice of medical self-care and (2) a summary of studies evaluating the impact of medical self-care interventions to improve self-initiated responses to symptoms. In addition, we summarize the effectiveness of those self-care interventions.

    View details for Web of Science ID A1993LM14700004

    View details for PubMedID 8337202



    To determine the effects of the Arthritis Self-Management Program 4 years after participation in it.Valid self-administered instruments were used to measure health status, psychological states, and health service utilization.Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient.Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.

    View details for Web of Science ID A1993KW02600002

    View details for PubMedID 8457219


    View details for Web of Science ID A1993KM03500003

    View details for PubMedID 8444622



    Although the integration of health education theory with practice has always been taught, this linkage has not always occurred as a systematic part of program or theory development. This paper reflects the 12-year experience of one health education program which started from a base not soundly grounded in theory and moved to one tightly linked with theory. Throughout this process, outcome data were collected allowing for evaluations of both practice and theory.

    View details for Web of Science ID A1992JJ52800006

    View details for PubMedID 1517098



    Although social and behavioral science theories are claimed to be able to contribute greatly to the effectiveness of health education programs, most practitioners in the profession seem to doubt this, and very few ever deliberately use theories in their work. Some reasons for such diverse views reside in the nature of the theories, in the very different roles they play in the worlds of theory-minded and practice-oriented health educators, respectively, in widespread unrealistic expectations of what theories can and cannot contribute to practice, and in lack of appropriate training in theories and their uses. Suggestions are offered to both practicing and academic health educators on ways to bridge the gap between the two camps, to render theories more useful to practitioners, and to train practitioners and health education students to appreciate the potentials of theories and to acquire skills needed to utilize such potentials.

    View details for Web of Science ID A1992JJ52800002

    View details for PubMedID 1517094

  • Obstacles to and future goals of ten comprehensive community health promotion projects. Journal of community health Altman, D. G., Endres, J., Linzer, J., Lorig, K., Howard-Pitney, B., Rogers, T. 1991; 16 (6): 299-314


    Over 100 project staff, community coalition members, and other representatives from 10 comprehensive community health promotion projects in the western United States were surveyed two years into a three year funding cycle about: (1) the problems or obstacles they judged as preventing successful completion of their current goals and objectives, and (2) future goals and objectives they envisioned for their projects. The key issues confronting respondents were diverse, although issues around the process of implementing community health promotion programs were cited more frequently than issues related to the content of health promotion. When respondents were asked to prioritize Future Goals in the second survey, consensus across communities was obtained despite broad differences in the type of community surveyed and the health problem targeted. This study identifies the common organizational and community development problems faced by newly emerging community health promotion programs and has implications for other communities involved in designing, implementing, and evaluating community-wide health promotion programs.

    View details for PubMedID 1774346

  • Four psychosocial theories and their application to patient education and clinical practice. Arthritis care and research Gonzalez, V. M., Goeppinger, J., Lorig, K. 1990; 3 (3): 132-143


    Although the development of theoretically based and empirically verified practice guidelines is now possible, some health education practice still remains uninformed by this research-based knowledge. This article describes four psychosocial theories that have been useful in our practices: self-efficacy, stress and coping, learned helplessness, and social support. The theories are introduced and compared; practical suggestions for their use in the development of health education interventions are then discussed. Skills mastery, modeling, reinterpretation of physical signs and symptoms, and persuasion are presented as ways of enhancing self-efficacy. Some similar strategies are presented as examples of coping techniques, including positive reappraisal or reinterpretation. Other coping strategies such as confronting, distancing, self-care, seeking social support, accepting responsibility, escape avoidance or ignoring, problem solving, activity, distraction, self-talk, and prayer are also introduced. Cognitive restructuring is examined most fully as an example of an intervention strategy derived from learned helplessness theory. And finally, five strategies for fostering positive social support are presented: enhancing personal networks, linking volunteers, establishing mutual aid networks, identifying and supporting neighborhood helpers, and community empowerment.

    View details for PubMedID 2285752

  • Impact of juvenile arthritis on families. An educational assessment. Arthritis care and research Konkol, L., Lineberry, J., Gottlieb, J., Shelby, P. E., MILLER, J. J., Lorig, K. 1989; 2 (2): 40-48


    State of the art patient education programs have as their goals changes in behaviors, coping styles, health status, and/or costs. The accomplishment of these goals often involves not only the patient but also his or her whole family. This is especially true if the patient is a child. Based on this premise, we undertook an educational needs assessment of 50 children with juvenile arthritis (JA) and their families. Through utilization of a grounded theory methodology, open-ended questionnaires were completed by JA children, their parents, and their siblings. The resulting analysis suggests (1) the need for family-based education, (2) differing needs of various family members, and (3) several hypotheses for further study.

    View details for PubMedID 2487692


    View details for Web of Science ID A1989BQ46H00024

    View details for PubMedID 2517854



    Evaluation of the Arthritis Self-Management Course revealed significant positive changes in the practice of behaviors that were taught and in health outcomes. However, utilizing a variety of statistical techniques, we were able to demonstrate only weak associations between changes in behavior and changes in health status. This suggests the need to examine the mechanisms by which health education affects health status.

    View details for Web of Science ID A1989R917000015

    View details for PubMedID 2912467



    There is evidence that the psychological attribute of perceived self-efficacy plays a role in mediating health outcomes for persons with chronic arthritis who take the Arthritis Self-Management Course. An instrument to measure perceived self-efficacy was developed through consultation with patients and physicians and through study of 4 groups of patients. Tests of construct and concurrent validity and of reliability showed that the instrument met appropriate standards. Health outcomes and self-efficacy scores improved during the Arthritis Self-Management Course, and the improvements were correlated.

    View details for Web of Science ID A1989R917000006

    View details for PubMedID 2912463



    An underlying assumption of self-care interventions is that they are most effective when reinforced. To test this assumption, 8 months after baseline, 589 subjects who had taken a 6-week Arthritis Self-management Course (ASMC) were randomized to (1) receive a bi-monthly arthritis newsletter, (2) attend a new 6-week Arthritis Reinforcement Course (ARC) or (3) receive no reinforcement. Between 8 and 20 months there were no significant differences among the three randomized groups. The results were unaltered by inclusion of assumed data of no change for the 46 subjects who did not complete the full 20-month study. Between baseline and 20 months all participants reduced their pain by 20%, depression by 14%, and visits to physicians by 35% (P less than 0.01). There were no trends toward loss of these effects over time. These findings indicate that the effects of a self-care intervention were sustained over 20 months and that the tested forms of reinforcement did not alter those effects.

    View details for Web of Science ID A1989AB72800012

    View details for PubMedID 2665110



    The psychometric properties of two self-administered measures of function were examined: the Disability Score of the Health Assessment Questionnaire (HAQ) and the Total Health Score of the Arthritis Impact Measurement Scales (AIMS). Data from 140 respondents were analyzed. Respondents had diagnoses of osteoarthritis, rheumatoid arthritis, or diabetes mellitus; resided in rural and urban areas; and were for the most part elderly, female, and white, with educational levels of high school or below. Reliabilities (test-retest and internal consistency) of both measures were high. The concurrent validity also was high. Content analysis suggested the HAQ represented the scope of nursing practice better than the AIMS. An exploratory principal components analysis confirmed that the HAQ is relevant to nursing practice.

    View details for Web of Science ID A1988Q134200006

    View details for PubMedID 3175056



    This experiment tested a cognitive-behavioral rheumatoid arthritis treatment designed to confer skills in managing stress, pain, and other symptoms of the disease. We hypothesized that a mediator of the magnitude of treatment effects might be enhancement of perceived self-efficacy to manage the disease. It was predicted that the treatment would reduce arthritis symptoms and possibly would improve both immunologic competence and psychological functioning. The treatment provided instruction in self-relaxation, cognitive pain management, and goal setting. A control group received a widely available arthritis helpbook containing useful information about arthritis self-management. We obtained suggestive evidence of an enhancement of perceived self-efficacy, reduced pain and joint inflammation, and improved psychosocial functioning in the treated group. No change was demonstrated in numbers or function of T-cell subsets. The magnitude of the improvements was correlated with degree of self-efficacy enhancement.

    View details for Web of Science ID A1988R935000004

    View details for PubMedID 3063517



    Arthritis is one of the most prevalent chronic diseases and the number one disabler of the elderly. Even though arthritis is a major cause of morbidity and a contributor to early mortality, relatively few studies have been undertaken to examine effects of arthritis patient education. This review was undertaken to (1) provide a summary of arthritis patient education studies, (2) summarize the effectiveness of arthritis patient education in changing knowledge, behavior, psychological status, and health status, (3) address critical issues/problems in arthritis patient education study methodology, and (4) suggest guidelines for future design, implementation, and evaluation of arthritis patient education programs. In addition, we discuss implications of past studies for future practice.

    View details for Web of Science ID A1987L236200002

    View details for PubMedID 10302113



    Meta-analysis is a technique which combines data from several properly and similarly designed controlled studies so as to increase the power of the relevant statistical analysis. Fifteen studies on the effects of psychoeducational interventions on disability, pain and depression in individuals with chronic rheumatoid arthritis or osteoarthritis were analyzed by this method. The results indicate that patient education can indeed contribute to improving the health status of such patients.

    View details for Web of Science ID A1987K038300009

    View details for PubMedID 3656305


    View details for Web of Science ID A1987P837800001

    View details for PubMedID 3509747



    A four session multidisciplinary workshop was held to teach Veterans Administration (VA) Medical Center staff basic patient education design principles. During the sessions, staff, working in teams, designed patient education programs on a wide variety of health care topics. Guidance to teams was provided at each step of program development so that at the end of the workshop, programs were ready for implementation. Medical Center standards for patient education and documentation were integrated into program designs.

    View details for Web of Science ID A1986E474400006

    View details for PubMedID 10279102



    One hundred subjects with arthritis were randomized into lay-taught, or professional-taught 12-h arthritis self-management courses, or a control group. Outcomes, knowledge, exercise, relaxation, disability, pain, and number of physician visits were measured aat baseline and 4 months. Professional-taught groups demonstrated greater knowledge gain while lay-taught groups had greater changes in relaxation (p less than .01) and a tendency toward less disability. Although it is impossible to draw definitive conclusions, this study suggests that lay leaders can teach arthritis self-management courses with results similar to those achieved by professionals.

    View details for Web of Science ID A1986E027400017

    View details for PubMedID 3772925



    Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.

    View details for Web of Science ID A1985AKL3600011

    View details for PubMedID 4004977



    By definition, the objective of health education is to change health behavior. One assumption underlying this objective is that changed health behaviors will result in improved health status. Both the objective and its assumption are based largely on experience with acute health problems. However, health education is now changing its focus towards chronic diseases. This paper examines a number of chronic disease health education studies. Investigation reveals that although there is often an improvement in health status, the associations between changed health behaviors and improved health status are not clear and at times do not appear to exist. In light of this evidence, the authors suggest that there is, in some cases, a need to reevaluate the assumptions that underlie health education and a need in health education programs to study factors other than, or in addition to, behavior change as mediators of health status.

    View details for Web of Science ID A1985ASE7800002

    View details for PubMedID 4055384



    A workplace health education program aimed at reducing unnecessary outpatient visits was offered through 22 California employers. A total of 5,200 employees attended a presentation, received self-help books, and completed self-administered questionnaires. All visits for their households were monitored for up to 15 months. The study utilized a quasi-experimental staggered intervention design involving eight different cohorts, before/after comparisons, with statistical adjustment for seasonality and other intervening variables. Visit rates for households insured only by Blue Cross of California were reduced by 17% (P = 0.001), or 2.0 visits per household per year. For all participants, the reduction was 7.2% (P = 0.06), or 0.8 visits. Reductions were seen for all age and educational strata. The program was most effective among households with first dollar fee-for-service insurance coverage. Households with insurance requiring co-payments had less reduction. No reduction was seen among health maintenance organization (HMO) members. The study concludes that a minimal cost, self-care workplace intervention can reduce outpatient visits by important magnitudes.

    View details for Web of Science ID A1985AQW7400003

    View details for PubMedID 4033235

  • Reasons for the lack of association between changes in health behavior and improved health status: an exploratory study. Pat. Educ. & Counsel. Lorig K, Lenker S, Gallagher D. 1984; 2 (6): 69-72

    View details for Web of Science ID A1984TN31400002

    View details for PubMedID 6500266



    Ninety-eight Caucasian patients, 46 Spanish speaking patients, and 50 physicians (mainly rheumatologists) took part in surveys of salient beliefs about arthritis and its treatment. The beliefs of Caucasian patients and those of physicians were similar. However, beliefs of physicians about patients' beliefs and actual patient beliefs diverged as did the beliefs of Caucasian and Spanish speaking patients. These results suggest that arthritis education and treatment should be based on patients' perceptions rather than on physicians' beliefs about patients' perceptions.

    View details for Web of Science ID A1984SF48800017

    View details for PubMedID 6699837



    There are several lessons to be learned from the ASM experience. First, and most outstanding, is the willingness of large numbers of people across the United States to participate in both the ASM course and the research. Second, we have found that lay leaders can be trained to offer a rather complex arthritis course. They have proved to be reliable and, most important, are acceptable to the public and most health professionals. When their acceptance has been questioned, it is usually by persons with little or no experience with either the course or the lay leaders. Third, a national organization, in this case the Arthritis Foundation, has been able to disseminate the course widely and, to some extent, to conduct evaluations. From the national evaluation experience, we have learned that local areas are much more interested in service than evaluation and almost too readily accept an unproven yet hopeful arthritis education program. However, this acceptance of a new innovation before thorough testing is no different than that seen with other new medical technologies from medication to coronary bypass. Finally and most intriguing, we have found that such standard arthritis treatments as exercise and relaxation seem to directly contribute only slightly to the reductions in pain experienced by ASM participants. This unexpected lack of correlation has led us to begin studying other mediating factors such as self-efficacy, depression or both.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1984TY94500009

    View details for PubMedID 6569531



    Persons with arthritis who attended a 12-hour self-management course generally showed improved health behaviors and improved health status. However, no association was found between the two. We therefore interviewed 54 course participants to determine factors that were associated with positive and negative health-status outcomes. Persons having positive outcomes indicated that they had more control over their disease and had a positive emotional status. Persons with negative outcomes indicated a lack of control and generally had a negative emotional status. These differences were statistically significant.

    View details for Web of Science ID A1984TH91600007

    View details for PubMedID 10268098