Building Better Caregivers: A Pragmatic 12-Month Trial of a Community-Based Workshop for Caregivers of Cognitively Impaired Adults.

Building Better Caregivers (BBC), a community 6-week, peer-led intervention, targets family caregivers of those with cognitive impairments. BBC was implemented in four geographically scattered areas. Self-report data were collected at baseline, 6 months, and 1 year. Primary outcome were caregiver strain and depression. Secondary outcomes included caregiver burden, stress, fatigue, pain, sleep, self-rated health, exercise, self-efficacy, and caregiver and care partner health care utilization. Paired t tests examined 6 month and 1-year improvements. General linear models examined associations between baseline and 6-month changes in self-efficacy and 12-month primary outcomes. Eighty-three participants (75% of eligible) completed 12-month data. Caregiver strain and depression improved significantly (Effect Sizes = .30 and .41). All secondary outcomes except exercise and caregiver health care utilization improved significantly. Baseline and 6-month improvements in self-efficacy were associated with improvements in caregiver strain and depression. In this pilot pragmatic study, BBC appears to assist caregivers while reducing care partner health care utilization. Self-efficacy appears to moderate these outcomes.

Impact of a Translated Disease Self-Management Program on Employee Health and Productivity: Six-Month Findings from a Randomized Controlled Trial.

Disease management is gaining importance in workplace health promotion given the aging workforce and rising chronic disease prevalence. The Chronic Disease Self-Management Program (CDSMP) is an effective intervention widely offered in diverse community settings; however, adoption remains low in workplace settings. As part of a larger NIH-funded randomized controlled trial, this study examines the effectiveness of a worksite-tailored version of CDSMP (wCDSMP [n = 72]) relative to CDSMP (‘Usual Care’ [n = 109]) to improve health and work performance among employees with one or more chronic conditions. Multiple-group latent-difference score models with sandwich estimators were fitted to identify changes from baseline to 6-month follow-up. Overall, participants were primarily female (87%), non-Hispanic white (62%), and obese (73%). On average, participants were age 48 (range: 23⁻72) and self-reported 3.25 chronic conditions (range: 1⁻16). The most commonly reported conditions were high cholesterol (45%), high blood pressure (45%), anxiety/emotional/mental health condition (26%), and diabetes (25%). Among wCDSMP participants, significant improvements were observed for physically unhealthy days (uΔ = −2.07, p = 0.018), fatigue (uΔ = −2.88, p = 0.002), sedentary behavior (uΔ = −4.49, p = 0.018), soda/sugar beverage consumption (uΔ = −0.78, p = 0.028), and fast food intake (uΔ = −0.76, p = 0.009) from baseline to follow-up. Significant improvements in patient⁻provider communication (uΔ = 0.46, p = 0.031) and mental work limitations (uΔ = −8.89, p = 0.010) were also observed from baseline to follow-up. Relative to Usual Care, wCDSMP participants reported significantly larger improvements in fatigue, physical activity, soda/sugar beverage consumption, and mental work limitations (p < 0.05). The translation of Usual Care (content and format) has potential to improve health among employees with chronic conditions and increase uptake in workplace settings.

Cost-Effectiveness of the Hepatitis C Self-Management Program.

BACKGROUND: 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. PURPOSE: A cost-effectiveness analysis of the HCV Self-Management Program is presented. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

A Diabetes Self-Management Program: 12-Month Outcome Sustainability From a Nonreinforced Pragmatic Trial.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Participants had small but significant benefits in multiple measures. Improvements previously noted at 6 months were maintained or amplified at 1 year.

Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study.

BACKGROUND: 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. OBJECTIVE: This study examined the translation of the evidence-based Better Choices, Better Health-Diabetes program in both Internet and face-to-face versions. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Characteristics of the Spanish- and English-Language Self-Efficacy to Manage Diabetes Scales.

PURPOSE: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Can a Box of Mailed Materials Achieve the Triple Aims of Health Care? The Mailed Chronic Disease Self-Management Tool Kit Study.

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.

The components of action planning and their associations with behavior and health outcomes.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. DISCUSSION: Action planning appears to be an important component of self-management interventions, with successful completion associated with improved health and self-efficacy outcomes.

Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program.

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.

Linking evidence-based program participant data with medicare data: the consenting process and correlates of retrospective participant consents.

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.

National study of chronic disease self-management: six-month outcome findings.

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. DISCUSSION: 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.

The South Australia health chronic disease self-management Internet trial.

OBJECTIVES: To evaluate the effectiveness of an online chronic disease self-management program for South Australia residents. METHOD: 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. RESULTS: 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. DISCUSSION: 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.

Online diabetes self-management program: a randomized study.

OBJECTIVE: 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. RESEARCH DESIGN AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

The Expert Patients Programme online, a 1-year study of an Internet-based self-management programme for people with long-term conditions.

OBJECTIVES: Evaluate the effectiveness of an online self-management programme (EPP Online) for England residents with long-term conditions. METHODS: 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. RESULTS: 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. DISCUSSION: 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.

The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.

Internet-based chronic disease self-management: a randomized trial.

BACKGROUND: 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. OBJECTIVES: We sought to determine the efficacy of the Internet-based CDSMP. DESIGN: We compared randomized intervention participants with usual-care controls at 1 year. We compared intervention participants with the small-group CDSMP at 1 year. SUBJECTS: 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: 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. RESULTS: 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. CONCLUSIONS: 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.

Measurement of pain using the visual numeric scale.

OBJECTIVE: 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions.

OBJECTIVE: 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). METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.

Can a Back Pain E-mail Discussion Group improve health status and lower health care costs?: A randomized study.

BACKGROUND: 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. METHODS: 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. INTERVENTION: 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. MAIN OUTCOME MEASURES: Pain, disability, role function, health distress, and health care utilization. RESULTS: 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). CONCLUSIONS: 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.