With the ageing of populations, chronic conditions are a significant concern. Self-management is a crucial strategy to address this challenge due to its potential for improving outcomes and reducing costs.
COMPAR-EU aimed to identify, compare, and rank the most effective and cost-effective SMIs for adults in Europe and make them available to relevant stakeholders. We focused on four high-priority chronic conditions: diabetes mellitus type 2, heart failure, chronic obstructive pulmonary disease, and obesity.
Main findings and results per phase:
Development of a taxonomy
A taxonomy for SMIs was developed and validated in co-creation with international experts.
This taxonomy contributes to building a common framework for patient self-management research and practice and facilitates implementation and improvement of patient empowerment interventions and comparative effectiveness research on SMIs.
Eliciting patients' priorities and preferences
We have identified and prioritised a set of core outcomes (COS) for the four diseases. These COS contribute to the consistency in measuring and reporting outcomes across trials. They will also contribute to more personalised health care and more informed health decisions in clinical practice as patients' preferences are more systematically included. A database of tools used to measure the outcomes in our COS has been prepared and integrated into an interactive repository (
https://platform.self-management.eu/tools(se abrirá en una nueva ventana)).
Data search, extraction, and synthesis of evidence
We have summarised the evidence of SMIs organised by condition, outcome, and population subgroups, including the quality of the evidence and strength of the recommendations. An interactive repository of interventions has been created to facilitate access to existing and tested interventions
https://platform.self-management.eu/interventions(se abrirá en una nueva ventana) Many RCTs are poorly described missing details about design, components, and comparison groups. Insufficient and heterogeneous reporting complicates the replication of successful interventions.
Results of the network meta-analysis (NMA)
SMIs are generally effective, as derived from the pairwise meta-analysis comparing SMIs versus usual care. We applied standard and component NMA to explore SMI.
The best interventions or components remain unclear for many outcomes due to the high uncertainty in the estimates.
For several outcomes across the diseases, there was an indication for subgroup differences according to the different variables examined (intensity, health literacy level, gender, comorbidities, and socio-economic minority status). However, due to significant uncertainty and heterogeneity levels encountered, the results are not conclusive.
Cost-effectiveness of best-performing SMIs
Newly developed health economic models were used to extrapolate the short-term SMI effectiveness data from the NMA to long-term outcomes regarding prevented complications/hospitalisations, change in life expectancy, quality-adjusted life-years and lifetime healthcare and total costs.
Results for all SMIs combined versus usual care showed that on the patient level, the gain life expectancy and quality-adjusted life-years were highest for heart failure, followed by obesity, COPD and diabetes. On a population level, the potential was highest for obesity because of the large (younger) target population in the different countries.
There is a potential for SMIs to be cost-effective, especially in obesity, but also COPD and heart failure. This potential, however, largely depends on the actual costs of providing effective SMIs.
Contextual factors analysis of SMIs
We identified many contextual factors across the four chronic diseases that play a role in the successful implementation of SMIs, and that are partly interrelated. Most important is to ensure that the content of SMIs and the communication with professionals are tailored to patient's preferences, needs and circumstances.
Development of tailored decision-making tools: the COMPAR-EU platform
We developed four interlinked and interactive decision-making tools:
1. Summary of findings tables containing the evidence of effects, certainty of the evidence, and a plain-language summary.
2. Evidence to decision frameworks to summarise key results, such as evidence of effects, cost-effectiveness, contextual factors, and patient's values and preferences.
3. Recommendations for the use and implementation of SMI.
Recommendations were conditional in favour of using SMIs, due to the low certainty of the evidence. If implemented, SMIs should be of high intensity (> ten hours) and include education and monitoring plus behavioural techniques (either action-based or emotional-based) and/or social support as main components.
4. Patient decision aids for the four chronic conditions.
Dissemination and exploitation
Implementation of SMIs requires efforts at different levels. At the individual level, patients' needs and characteristics should be considered, and decision tools introduced to those most motivated, with efforts to support those most in need. Patients should be guided, and caregivers should be involved. At the organisational level, high-level leadership and opinion leaders should lead the effort, and teams require continuous training on using SMIs. Implementation is further facilitated by maintaining interoperability with information systems or (mHealth) applications. At the macro level, purchasers of health services should be involved early on, and the implementation should be guided by policies and financial incentives linked to the implementation of SMIs and SMIs outcomes.
