Internationally, innumerable randomized controlled trials (RCTs) evaluated the efficacy of SME programs for chronic diseases. One of the first RCTs done in the United States provided 1,140 outpatients with chronic heart disease, lung disease, stroke, or arthritis either SME or placement on the SME course wait list.17 Outpatients receiving SME exhibited statistically significant improvements in self-reported health status and behaviors and spent fewer nights in the hospital, with no difference in outpatient visits between groups. A 2-year longitudinal follow-up study of the intervention patients revealed decreased health-care use with fewer emergency services, hospitalizations, and outpatient visits.18 Unfortunately, this may simply reflect improved disease control after multiple initial physician visits and other unmeasured interventions (such as concomitant PR) to optimize therapy. More recently, a large RCT in the United Kingdom randomized 5,599 patients with chronic diseases, including COPD, to an SME program, with no significant differences in the primary outcomes of self-efficacy, QOL, or shared decision-making or in secondary outcomes of general health, social or role limitations, or various psychologic and functional measures.19 The earlier, effective study by Lorig and colleagues17 implemented a time- and resource-intensive educational program, whereas Kennedy and colleagues19 weaved both the facilitator training and patient education into the pre-existing practice system, to enhance scalability. The latter approach likely limited the intensity of the intervention but more closely resembled real-world conditions and may be a more compelling result.