NIHR Signal Self-care support for children with long-term conditions may reduce emergency costs

Published on 27 March 2018

Helping children and parents to manage long-term conditions like asthma may reduce their need for emergency care, and is unlikely to reduce children’s quality of life.

This NIHR review found that structured professional help with self-care, including online support, provision of care plans, case management and face-to-face education, was linked to small increases in quality of life scores and fewer emergency department visits. However, there was no clear evidence that supported self-care reduced hospital admissions or overall costs.

Most of the 97 studies reviewed included children with asthma (66 studies) or mental health conditions (18 studies). Not all were high-quality studies, and the review covered very different interventions, which makes it hard to compare approaches.

The findings suggest there is little chance of self-care support causing harm to children with long-term conditions, although that could not be definitively ruled out. However, there is also little evidence that supported self-care can make a substantial difference to healthcare costs.

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Why was this study needed?

In the UK, 15% of children aged between 11 and 15 experience a long-term illness or disability, and 10% have a mental health problem. As many long-term conditions are life-long, these children represent substantial ongoing health costs for the NHS. Finding ways of reducing their healthcare needs, without compromising their health or quality of life, could have a positive impact on future NHS demand.

Self-care support is where healthcare professionals help people take control of their illness. This is through education, improving skills and helping them to develop psychological and social resources.

Previous research into self-care support has tended to look at clinical outcomes, often in the short to medium term.

This study intended to explore the effects of self-care support on children’s quality of life and healthcare costs.

What did this study do?

This systematic review and meta-analysis included 97 studies, 14 from the UK.

They assessed 114 different interventions. They ranged from one to several educational or psychological sessions at school, home or hospital, to full multi-disciplinary case management. The support was provided by nurses, social workers, psychologists and teachers. Only 4% of the support was just through technology, the rest involved face-to-face sessions. Most self-care support interventions also involved the child’s adult caregiver. The average age of the child was 10 years.

The researchers plotted the effect of supported self-care on quality of life and healthcare use, to demonstrate whether one came at the expense of the other.

Though 88 of the studies were randomised controlled trials, only 37 were judged as high quality.

What did it find?

  • Self-care support was linked to small improvements in quality of life (effect size ‑0.17, 95% confidence interval [CI] -0.23 to -0.11; 77 comparisons).
  • Self-care support was also linked to small reductions in emergency department visits (effect size -0.11, 95% CI ‑0.17 to ‑0.04; 57 comparisons).
  • There was no difference in hospital admissions (effect size -0.05, 95% CI -0.12 to 0.03; 65 comparisons).
  • Health services costs also did not differ (effect size -0.11, 95% CI -0.47 to 0.25; 10 comparisons). There was comparatively little data looking at health service costs, and these results varied greatly between studies. The cost of the interventions was not provided.

What does current guidance say on this issue?

Self-care support is advocated for children with asthma in the SIGN/BTS 2016 asthma management guideline and NICE 2017 guideline. Self-management education should include a written personalised asthma action plan. This is completed by the GP or asthma nurse with the child if over the age of five and family and carers where appropriate. This should be supported by a regular professional review.

Regular support and education to improve self-management are integral to the provision of diabetes care to young people as outlined in the NICE 2015 guideline.

What are the implications?

Though this study did not find that self-care support for children with long-term conditions made a significant impact on future healthcare costs, it is difficult to form any firm conclusions. This is because there has been a recent emphasis on education about the long-term condition, triggers and best self-management, so this is likely to be a component of usual care.  

The huge range of interventions, intensity, setting and type of healthcare professional providing the increased support in these studies also reduces the ability to pinpoint which aspects may be most important.

Continuing use of self-care support, as advocated by current guidelines, is unlikely to compromise care. Optimal levels of support are likely to differ between individuals and type of long-term condition.

Citation and Funding

Bee P, Pedley R, Rithalia A, et al. Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis. Health Serv Deliv Res. 2018;6(3).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme.

Bibliography

NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: National Institute for Health and Care Research; 2017.

NICE. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. NG18. London: National Institute for Health and Care Research; 2016.

SIGN. British guideline on the management of asthma. SIGN 153. Scotland: Scottish Intercollegiate Guidelines Network; 2016.

Why was this study needed?

In the UK, 15% of children aged between 11 and 15 experience a long-term illness or disability, and 10% have a mental health problem. As many long-term conditions are life-long, these children represent substantial ongoing health costs for the NHS. Finding ways of reducing their healthcare needs, without compromising their health or quality of life, could have a positive impact on future NHS demand.

Self-care support is where healthcare professionals help people take control of their illness. This is through education, improving skills and helping them to develop psychological and social resources.

Previous research into self-care support has tended to look at clinical outcomes, often in the short to medium term.

This study intended to explore the effects of self-care support on children’s quality of life and healthcare costs.

What did this study do?

This systematic review and meta-analysis included 97 studies, 14 from the UK.

They assessed 114 different interventions. They ranged from one to several educational or psychological sessions at school, home or hospital, to full multi-disciplinary case management. The support was provided by nurses, social workers, psychologists and teachers. Only 4% of the support was just through technology, the rest involved face-to-face sessions. Most self-care support interventions also involved the child’s adult caregiver. The average age of the child was 10 years.

The researchers plotted the effect of supported self-care on quality of life and healthcare use, to demonstrate whether one came at the expense of the other.

Though 88 of the studies were randomised controlled trials, only 37 were judged as high quality.

What did it find?

  • Self-care support was linked to small improvements in quality of life (effect size ‑0.17, 95% confidence interval [CI] -0.23 to -0.11; 77 comparisons).
  • Self-care support was also linked to small reductions in emergency department visits (effect size -0.11, 95% CI ‑0.17 to ‑0.04; 57 comparisons).
  • There was no difference in hospital admissions (effect size -0.05, 95% CI -0.12 to 0.03; 65 comparisons).
  • Health services costs also did not differ (effect size -0.11, 95% CI -0.47 to 0.25; 10 comparisons). There was comparatively little data looking at health service costs, and these results varied greatly between studies. The cost of the interventions was not provided.

What does current guidance say on this issue?

Self-care support is advocated for children with asthma in the SIGN/BTS 2016 asthma management guideline and NICE 2017 guideline. Self-management education should include a written personalised asthma action plan. This is completed by the GP or asthma nurse with the child if over the age of five and family and carers where appropriate. This should be supported by a regular professional review.

Regular support and education to improve self-management are integral to the provision of diabetes care to young people as outlined in the NICE 2015 guideline.

What are the implications?

Though this study did not find that self-care support for children with long-term conditions made a significant impact on future healthcare costs, it is difficult to form any firm conclusions. This is because there has been a recent emphasis on education about the long-term condition, triggers and best self-management, so this is likely to be a component of usual care.  

The huge range of interventions, intensity, setting and type of healthcare professional providing the increased support in these studies also reduces the ability to pinpoint which aspects may be most important.

Continuing use of self-care support, as advocated by current guidelines, is unlikely to compromise care. Optimal levels of support are likely to differ between individuals and type of long-term condition.

Citation and Funding

Bee P, Pedley R, Rithalia A, et al. Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis. Health Serv Deliv Res. 2018;6(3).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme.

Bibliography

NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: National Institute for Health and Care Research; 2017.

NICE. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. NG18. London: National Institute for Health and Care Research; 2016.

SIGN. British guideline on the management of asthma. SIGN 153. Scotland: Scottish Intercollegiate Guidelines Network; 2016.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Published on 26 January 2018

Bee P, Pedley R, Rithalia A, Richardson G, Pryjmachuk S, Kirk S & Bower P.

Health Services and Delivery Research Volume 6 Issue 3 , 2018

Background Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems. Objectives To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people. Design Systematic review with meta-analysis. Population Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression). Intervention Self-care support in health, social care, educational or community settings. Comparator Usual care. Outcomes Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs. Design Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs. Data sources MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015. Methods We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity). Results Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings. Limitations Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded. Conclusions Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs. Future work Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

One would think that the best model of care for children with long-term conditions such as asthma is one where the patient and their family uses a self-care support package as well as conventional medicines.

Surprisingly little is known about the effectiveness of such a model, and this study shows this approach produces small but worthwhile improvements in quality of life and possibly a reduced need for emergency treatment for asthma. However, what makes an optimal, cost-effective self-care intervention package remains to be fully defined. 

Overcoming this challenge should further improve the health of children with asthma and other long-term conditions.

Professor Ian Hall, Director, NIHR Nottingham Biomedical Research Centre