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Ashdown H, Steiner M. Delivering high value therapies in COPD: the secret is in the marketing. Eur Respir J 2019; 53:53/4/1900215. [PMID: 31023865 DOI: 10.1183/13993003.00215-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Helen Ashdown
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Michael Steiner
- Institute for Lung Health, Leicester Biomedical Research Centre - Respiratory, University of Leicester, Glenfield Hospital, Leicester, UK
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52
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Liang J, Abramson MJ, Russell G, Holland AE, Zwar NA, Bonevski B, Mahal A, Eustace P, Paul E, Phillips K, Cox NS, Wilson S, George J. Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial. Eur Respir J 2019; 53:13993003.01530-2018. [PMID: 30792342 DOI: 10.1183/13993003.01530-2018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/25/2019] [Indexed: 12/31/2022]
Abstract
We evaluated the effectiveness of an interdisciplinary, primary care-based model of care for chronic obstructive pulmonary disease (COPD).A cluster randomised controlled trial was conducted in 43 general practices in Australia. Adults with a history of smoking and/or COPD, aged ≥40 years with two or more clinic visits in the previous year were enrolled following spirometric confirmation of COPD. The model of care comprised smoking cessation support, home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase). Main outcomes included changes in St George's Respiratory Questionnaire (SGRQ) score, COPD Assessment Test (CAT), dyspnoea, smoking abstinence and lung function at 6 and 12 months.We identified 272 participants with COPD (157 intervention, 115 usual care); 49 (31%) out of 157 completed both HMR and HomeBase. Intention-to-treat analysis showed no statistically significant difference in change in SGRQ at 6 months (adjusted between-group difference 2.45 favouring intervention, 95% CI -0.89-5.79). Per protocol analyses showed clinically and statistically significant improvements in SGRQ in those receiving the full intervention compared to usual care (difference 5.22, 95% CI 0.19-10.25). No statistically significant differences were observed in change in CAT, dyspnoea, smoking abstinence or lung function.No significant evidence was found for the effectiveness of this interdisciplinary model of care for COPD in primary care over usual care. Low uptake was a limitation.
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Affiliation(s)
- Jenifer Liang
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Michael J Abramson
- Dept of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Grant Russell
- Southern Academic Primary Care Research Unit, Dept of General Practice, Monash University, Melbourne, Australia
| | - Anne E Holland
- Discipline of Physiotherapy, La Trobe University, Alfred Health, and Institute for Breathing and Sleep, Melbourne, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Billie Bonevski
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Ajay Mahal
- The Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | | | - Eldho Paul
- Dept of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Narelle S Cox
- Discipline of Physiotherapy, La Trobe University and Institute for Breathing and Sleep, Melbourne, Australia
| | - Sally Wilson
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.,Dept of Infrastructure Engineering, The University of Melbourne, Melbourne, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia .,Dept of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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53
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Ferrone M, Masciantonio MG, Malus N, Stitt L, O'Callahan T, Roberts Z, Johnson L, Samson J, Durocher L, Ferrari M, Reilly M, Griffiths K, Licskai CJ. The impact of integrated disease management in high-risk COPD patients in primary care. NPJ Prim Care Respir Med 2019; 29:8. [PMID: 30923313 PMCID: PMC6438975 DOI: 10.1038/s41533-019-0119-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 02/26/2019] [Indexed: 12/23/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) have a reduced quality of life (QoL) and exacerbations that drive health service utilization (HSU). A majority of patients with COPD are managed in primary care. Our objective was to evaluate an integrated disease management, self-management, and structured follow-up intervention (IDM) for high-risk patients with COPD in primary care. This was a one-year multi-center randomized controlled trial. High-risk, exacerbation-prone COPD patients were randomized to IDM provided by a certified respiratory educator and physician, or usual physician care. IDM received case management, self-management education, and skills training. The primary outcome, COPD-related QoL, was measured using the COPD Assessment Test (CAT). Of 180 patients randomized from 8 sites, 81.1% completed the study. Patients were 53.6% women, mean age 68.2 years, post-bronchodilator FEV1 52.8% predicted, and 77.4% were Global Initiative for Obstructive Lung Disease Stage D. QoL-CAT scores improved in IDM patients, 22.6 to 14.8, and worsened in usual care, 19.3 to 22.0, adjusted difference 9.3 (p < 0.001). Secondary outcomes including the Clinical COPD Questionnaire, Bristol Knowledge Questionnaire, and FEV1 demonstrated differential improvements in favor of IDM of 1.29 (p < 0.001), 29.6% (p < 0.001), and 100 mL, respectively (p = 0.016). Compared to usual care, significantly fewer IDM patients had a severe exacerbation, -48.9% (p < 0.001), required an urgent primary care visit for COPD, -30.2% (p < 0.001), or had an emergency department visit, -23.6% (p = 0.001). We conclude that IDM self-management and structured follow-up substantially improved QoL, knowledge, FEV1, reduced severe exacerbations, and HSU, in a high-risk primary care COPD population. Clinicaltrials.gov NCT02343055.
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Affiliation(s)
- Madonna Ferrone
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
- Hotel-Dieu Grace Healthcare, Windsor, ON, Canada
| | - Marcello G Masciantonio
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
- Western University, London Health Sciences Centre, London, ON, Canada
| | - Natalie Malus
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
- Western University, London Health Sciences Centre, London, ON, Canada
| | - Larry Stitt
- Lawson Health Research Institute, London, ON, Canada
| | | | - Zofe Roberts
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
| | - Laura Johnson
- Chatham Kent Family Health Team, Chatham, ON, Canada
| | - Jim Samson
- Leamington Family Health Team, Leamington, ON, Canada
| | - Lisa Durocher
- Leamington Family Health Team, Leamington, ON, Canada
| | | | | | | | - Christopher J Licskai
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada.
- Western University, London Health Sciences Centre, London, ON, Canada.
- Lawson Health Research Institute, London, ON, Canada.
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54
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Suzuki K, Kimura T, Uchida S, Katamura H, Tanaka H. The Influence of a Multimodal Health Program with Diet, Art, and Biofield Therapy on the Quality of Life of People in Japan. J Altern Complement Med 2019; 25:336-345. [PMID: 30742776 PMCID: PMC6437628 DOI: 10.1089/acm.2018.0291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To investigate whether the frequency of the practice of each of diet, art, and biofield therapy influences improvement in quality of life (QOL), and to examine whether the simultaneous practice of all three components increasingly improves QOL in a real-world setting. Design: Pre–post-test design using convenience sampling methods. Setting: Home setting. Subjects: A total of 4681 individuals aged 16 years or older who answered the questionnaire appropriately. Intervention: Participants agreed to practice the three components daily and self-evaluated the frequency of their weekly practice for three consecutive months. At the beginning and end of the study, they completed the MOA quality-of-life questionnaire (10-item MOA quality-of-life questionnaire [MQL-10]). Outcome measures: Factors associated with the increase in MQL-10 scores for each component, and the relationship between the simultaneous practice of multiple components and the changes in MQL-10 scores were analyzed. Results: Frequent practice of the diet and/or art components was associated with an increase in the term-end MQL-10 score (p < 0.001); however, receiving biofield therapy frequently was not. Participants' age, gender, and qualification as a practitioner of biofield therapy had no relationship with changes in scores, but the reasons for participation had a significant influence on changes in scores (p < 0.001). Participants who initially did not practice any components frequently but who subsequently increased the number of components and frequency of each practice had a higher likelihood of exhibiting an increase in the term-end score (p < 0.01). Participants who initially practiced all three components frequently but later decreased the number of components practiced frequently had a lower chance of increase and a higher risk of decrease in scores (p < 0.01). Conclusions: The data suggest that the frequent practice of the diet and art components is associated with improvement in QOL. Simultaneous practice of diet, art, and biofield therapy is more likely to improve QOL. (ClinicalTrials.gov NCT01927250)
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Affiliation(s)
- Kiyoshi Suzuki
- Tokyo Ryo-in MOA Takanawa Clinic, Tokyo, Japan
- Research Department, MOA Health Science Foundation, Tokyo, Japan
- Address correspondence to: Kiyoshi Suzuki, MD, PhD, MOA Health Science Foundation, 4-8-10 Takanawa, Minato-ku, Tokyo 108-0074, Japan
| | - Tomoaki Kimura
- Research Department, MOA Health Science Foundation, Tokyo, Japan
| | - Seiya Uchida
- Research Department, MOA Health Science Foundation, Tokyo, Japan
| | - Hiroshi Katamura
- Tokyo Ryo-in MOA Takanawa Clinic, Tokyo, Japan
- Research Department, MOA Health Science Foundation, Tokyo, Japan
| | - Hideaki Tanaka
- Research Department, MOA Health Science Foundation, Tokyo, Japan
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55
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Navaratnam V, Forrester DL, Eg KP, Chang AB. Paediatric and adult bronchiectasis: Monitoring, cross-infection, role of multidisciplinary teams and self-management plans. Respirology 2018; 24:115-126. [PMID: 30500093 DOI: 10.1111/resp.13451] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 01/21/2023]
Abstract
Bronchiectasis is a chronic lung disease associated with structurally abnormal bronchi, clinically manifested by a persistent wet/productive cough, airway infections and recurrent exacerbations. Early identification and treatment of acute exacerbations is an integral part of monitoring and annual review, in both adults and children, to minimize further damage due to infection and inflammation. Common modalities used to monitor disease progression include clinical signs and symptoms, frequency of exacerbations and/or number of hospital admissions, lung function (forced expiratory volume in 1 s (FEV1 )% predicted), imaging (radiological severity of disease) and sputum microbiology (chronic infection with Pseudomonas aeruginosa). There is good evidence that these monitoring tools can be used to accurately assess severity of disease and predict prognosis in terms of mortality and future hospitalization. Other tools that are currently used in research settings such as health-related quality of life (QoL) questionnaires, magnetic resonance imaging and lung clearance index can be burdensome and require additional expertise or resource, which limits their use in clinical practice. Studies have demonstrated that cross-infection, especially with P. aeruginosa between patients with bronchiectasis is possible but infrequent. This should not limit participation of patients in group activities such as pulmonary rehabilitation, and simple infection control measures should be carried out to limit the risk of cross-transmission. A multidisciplinary approach to care which includes respiratory physicians, chest physiotherapists, nurse specialists and other allied health professionals are vital in providing holistic care. Patient education and personalized self-management plans are also important despite limited evidence it improves QoL or frequency of exacerbations.
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Affiliation(s)
- Vidya Navaratnam
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Child Health Division, Menzies School of Health Research, Darwin, NT, Australia
| | - Douglas L Forrester
- Department of Respiratory Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Kah Peng Eg
- Respiratory and Sleep Unit, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Darwin, NT, Australia.,Department of Respiratory and Sleep Medicine, Children's Health Queensland, Queensland University of Technology, Brisbane, QLD, Australia
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56
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Thom DH, Willard-Grace R, Tsao S, Hessler D, Huang B, DeVore D, Chirinos C, Wolf J, Donesky D, Garvey C, Su G. Randomized Controlled Trial of Health Coaching for Vulnerable Patients with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2018; 15:1159-1168. [PMID: 30130430 PMCID: PMC6321989 DOI: 10.1513/annalsats.201806-365oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 06/28/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Socioeconomically disadvantaged patients with chronic obstructive pulmonary disease (COPD) often face barriers to evidence-based care that are difficult to address in public care settings with limited resources. OBJECTIVES To determine the benefit of health coaching for patients with moderate to severe COPD relative to usual care. METHODS We conducted a randomized controlled trial of 9 months of health coaching versus usual care for English- or Spanish-speaking patients at least 40 years of age with moderate to severe COPD. Primary outcomes were COPD-related quality of life and the dyspnea subscale of the Chronic Respiratory Disease Questionnaire. Secondary outcomes were self-efficacy for managing COPD, exercise capacity (6-min walk test), and number of COPD exacerbations. Additional outcomes were COPD symptoms, lung function (forced expiratory volume in 1 s percent predicted), smoking status, bed days owing to COPD, quality of care (Patient Assessment of Chronic Illness Care), COPD knowledge, and symptoms of depression (Patient Health Questionnaire). Outpatient visits, emergency department visits, and hospitalizations were assessed by review of medical records. Generalized linear modeling was used to adjust for baseline values and account for clustering by clinic. RESULTS Of 192 patients enrolled, 158 (82%) completed 9 months of follow-up. There were no significant differences between study arms for the primary or secondary outcomes. At 9 months, patients in the coached group reported better quality of care (mean Patient Assessment of Chronic Illness Care score, 3.30 vs. 3.18; adjusted P = 0.02) and were less likely to report symptoms of moderate to severe depression (Patient Health Questionnaire score, ≥15) than those in the usual care arm (6% vs. 20%; adjusted P = 0.01). During the study, patients in the coaching arm had 48% fewer hospitalizations related to COPD (0.27/patient/yr vs. 0.52/patient/yr), but this difference was not significant in the adjusted analysis. CONCLUSIONS These results help inform expectations regarding the limitations and benefits of health coaching for patients with COPD. They may be useful to health policy experts in assessing the potential value of reimbursement and incentives for health coaching-type activities for patients with chronic disease. Clinical trial registered with www.clinicaltrials.gov (NCT02234284).
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Affiliation(s)
| | | | - Stephanie Tsao
- San Francisco Department of Public Health, San Francisco, California; and
| | | | | | | | | | | | - DorAnne Donesky
- University of California San Francisco at Mount Zion Sleep Disorders Center, San Francisco, California
| | - Chris Garvey
- Department of Physiological Nursing, and
- University of California San Francisco at Mount Zion Sleep Disorders Center, San Francisco, California
| | - George Su
- Pulmonology, Critical Care, Allergy and Sleep Medicine Program, Department of Medicine, University of California, San Francisco, San Francisco, California
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57
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Henoch I, Löfdahl CG, Ekberg-Jansson A. Influences of patient education on exacerbations and hospital admissions in patients with COPD - a longitudinal national register study. Eur Clin Respir J 2018; 5:1500073. [PMID: 30083305 PMCID: PMC6070991 DOI: 10.1080/20018525.2018.1500073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/05/2018] [Indexed: 01/05/2023] Open
Abstract
Introduction: Chronic obstructive pulmonary disease (COPD) contributes to impaired health-related quality of life (HRQoL). Patient education and smoking cessation programs are recommended to reduce the number of exacerbations and hospitalizations, but the effects of such programs have yet to be explored in larger samples. Objective: The aim was to explore the longitudinal effects of patient education and smoking cessation programs on exacerbations and hospital admissions in patients with COPD. Design: This is a register study where data from the Swedish National Airway Register, including 20,666 patients with COPD, were used. Baseline measures of demographic, disease-related, and patient-reported variables were compared with a follow-up, 10-30 months after baseline. Descriptive statistics and changes between baseline and follow-up were calculated. Results: Comparing those not participating in education programs to those who did, HRQoL deteriorated significantly between baseline and follow-up in non-participants; there was no change in either exacerbations or hospitalizations in either group; there was a significant difference in baseline HRQoL between the two, and, when controlling for this, there was no significant change (p = 0.73). Patients who participated in smoking cessation programs were younger than the non-participants; mean 66.0 (standard deviations (SD) 7.8) vs. mean 68.1 (SD 8.8), p = 0.006. Among participants in smoking cessation programs, the proportion with continued smoking decreased significantly, from 76% to 66%, p < 0.001. Exacerbations at follow-up were predicted by FEV1% of predicted value and exacerbations at baseline. Hospital admissions at follow-up were predicted by baseline FEV1% of predicted value and exacerbations at baseline. Conclusions: To prevent exacerbations and hospital admissions, treatment and prevention must be prioritized in COPD care. Patient education and smoking cessation programs are beneficial, but there is a need to combine them with other interventions.
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Affiliation(s)
- Ingela Henoch
- Research and Development Department, Angered Hospital, Gothenburg, Sweden
- The Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Claes-Göran Löfdahl
- Research and Development Department, Angered Hospital, Gothenburg, Sweden
- Department of Respiratory Medicine and Allergology, Clinical Sciences, University of Lund, Lund, Sweden
| | - Ann Ekberg-Jansson
- Department of Research and Development, Region Halland, Sweden
- The Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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58
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Koolen EH, van der Wees PJ, Westert GP, Dekhuijzen R, Heijdra YF, van 't Hul AJ. The COPDnet integrated care model. Int J Chron Obstruct Pulmon Dis 2018; 13:2225-2235. [PMID: 30050295 PMCID: PMC6056161 DOI: 10.2147/copd.s150820] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Introduction This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options. Theory and methods The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems. Results An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care. Discussion In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care. Conclusion Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.
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Affiliation(s)
- Eleonore H Koolen
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Philip J van der Wees
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Richard Dekhuijzen
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Yvonne F Heijdra
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Alex J van 't Hul
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
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59
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Koolen EH, van der Wees PJ, Westert GP, Dekhuijzen R, Heijdra YF, van 't Hul AJ. Evaluation of the COPDnet integrated care model in patients with COPD: the study protocol. Int J Chron Obstruct Pulmon Dis 2018; 13:2237-2244. [PMID: 30050296 PMCID: PMC6056168 DOI: 10.2147/copd.s153992] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Projections on the future suggest a further rise in the prevalence of patients with COPD, and in COPD related morbidity, mortality, and health care costs worldwide. Given the substantial impact on the individual and on society, it is important to establish a care process that maximizes outcomes in relation to the costs and efforts made. In an attempt to bridge this gap, we set out to develop an evidence-based model of integrated care for patients with COPD, named the COPDnet integrated care model. Purpose The current study protocol sets out to 1) evaluate the feasibility of employing the COPDnet model in present real-life care within the context of the Dutch health care system, 2) explore the potential health status benefits, and 3) analyze the costs of care of this model. Patients and methods In this prospective study, feasibility and health status changes will be evaluated with an experimental before and after study design. The costs of the diagnostic trajectory will be calculated according to a standard economic health care evaluation approach. Furthermore, the feasibility and cost of care studies will comprise both quantitative and qualitative data collection. For the studies on the feasibility and change in health status, all new patients qualifying for shared care by primary and secondary care professionals according to the Dutch Standard of Care for COPD, and patients referred by their general practitioners to one of the COPDnet hospitals will be included. To evaluate the feasibility and costs of care, semi-structured interviews will be held with patients, hospital personnel, health care professionals in the affiliated primary care region, and hospital and primary care group managers. Conclusions The COPDnet integrated care model for COPD patients has been designed according to the current insights regarding effective care for patients with a chronic condition in general, and for patients with COPD in particular. It will be evaluated for its feasibility, potential health status benefits, and the costs of care of the diagnostic trajectory in secondary care.
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Affiliation(s)
- Eleonore H Koolen
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Philip J van der Wees
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Richard Dekhuijzen
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Yvonne F Heijdra
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Alex J van 't Hul
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
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60
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Kalter-Leibovici O, Benderly M, Freedman LS, Kaufman G, Molcho Falkenberg Luft T, Murad H, Olmer L, Gluch M, Segev D, Gilad A, Elkrinawi S, Cukierman-Yaffe T, Chen B, Jacobson O, Key C, Shani M. Disease Management plus Recommended Care versus Recommended Care Alone for Ambulatory Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2018; 197:1565-1574. [PMID: 29494211 PMCID: PMC6009010 DOI: 10.1164/rccm.201711-2182oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/26/2018] [Indexed: 11/16/2022] Open
Abstract
Rationale: The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain.Objectives: To study the effect of disease management (DM) added to recommended care (RC) in ambulatory patients with COPD.Measurements and Main Results: In this trial, 1,202 patients with COPD (age, ≥40 yr), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists, inhaled long-acting bronchodilators and corticosteroids, smoking cessation intervention, nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and by remote contacts with the patients between these visits, included patient self-care education, monitoring patients' symptoms and adherence to treatment, provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 patients (47.2%) in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95% confidence interval, 0.77-1.08).Conclusions: DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory patients with COPD.
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Affiliation(s)
- Ofra Kalter-Leibovici
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Benderly
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Laurence S. Freedman
- Biostatistics Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Galit Kaufman
- Northern District, Maccabi Health Care Services, Haifa, Israel
| | | | - Havi Murad
- Biostatistics Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Liraz Olmer
- Biostatistics Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Meri Gluch
- Tel-Aviv District, Clalit Health Services, Tel-Aviv, Israel
| | - David Segev
- Sharon-Shomron District, Clalit Health Services, Hadera, Israel
| | - Avi Gilad
- Central District, Clalit Health Services, Tel-Aviv, Israel
| | - Said Elkrinawi
- Pulmonary Institute, Soroka Medical Center, Beer-Sheva, Israel
| | - Tali Cukierman-Yaffe
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Endocrinology Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Baruch Chen
- Department of Pulmonology, Meir Medical Center, Kfar-Saba, Israel
| | | | - Calanit Key
- Community Division, Clalit Health Services, Tel-Aviv, Israel
| | - Mordechai Shani
- Medical Research Infrastructure Development and Health Services Fund, Chaim Sheba Medical Center, Tel-Hashomer, Israel; and
| | - for the Chronic Obstructive Pulmonary Disease Community Disease Management (COPD-CDM) Investigators
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Biostatistics Unit, Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer, Israel
- Northern District, Maccabi Health Care Services, Haifa, Israel
- Community Division, Clalit Health Services, Tel-Aviv, Israel
- Tel-Aviv District, Clalit Health Services, Tel-Aviv, Israel
- Sharon-Shomron District, Clalit Health Services, Hadera, Israel
- Central District, Clalit Health Services, Tel-Aviv, Israel
- Pulmonary Institute, Soroka Medical Center, Beer-Sheva, Israel
- Endocrinology Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pulmonology, Meir Medical Center, Kfar-Saba, Israel
- MOR Institute for Medical Data, Bnei Brak, Israel
- Medical Research Infrastructure Development and Health Services Fund, Chaim Sheba Medical Center, Tel-Hashomer, Israel; and
- Clinical Research Institute, Kaplan Medical Center, Rechovot, Israel
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61
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Euceda G, Kong WT, Kapoor A, Hokanson JE, Dilauro P, Ogunnaike R, Chronakos J. The Effects of a Comprehensive Care Management Program on Readmission Rates After Acute Exacerbation of COPD at a Community-Based Academic Hospital. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:185-192. [PMID: 30584582 DOI: 10.15326/jcopdf.5.3.2017.0177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is one of the leading causes of hospitalization in the United States. Prior investigations suggest clinical and physiological parameters are important determinants for AECOPD readmissions. Strategies aimed at addressing these factors have not resulted in a major reduction of readmissions. We compared patients readmitted after an index AECOPD admission with non-readmitted patients. Patients' age, gender, body mass index, comorbidities (obstructive sleep apnea, chronic hypercapnia, congestive heart failure, lung cancer, pulmonary arterial hypertension, pneumonia, interstitial lung disease, atrial fibrillation, musculoskeletal disorders, cognitive disorders, and anxiety disorders), substance abuse and smoking status were assessed. Some 272 patients were included: 20 patients were readmitted within 30 days of their index hospitalization; 252 patients were not readmitted within 30 days of their index admission. Readmitted patients were significantly more likely to have pneumonia than non-readmitted patients (30.0% versus 13.1%, p<0.05). No statistically significant difference was seen with respect to other clinical comorbidities. Patients readmitted within 30 days were significantly more likely than non-readmitted patients to have safety issues at home (80.0% versus. 39.3%, p<0.001), anxiety (60.0% versus 29.8%, p<0.01), and lack of transportation (35.0% versus 15.5%, p<0.05). Implementation of a comprehensive care management program (CCMP) was associated with a reduction in readmissions from 21.5% to 13.6% (p<0.01, 95% confidence interval [CI] 2.08-12.45). A CCMP can reduce readmissions through attention to social variables, optimization of in-hospital care, improved coordination of pre- and post-discharge, a system to better identify problems after discharge, and an office setup that accommodates same-day visits.
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Affiliation(s)
- Glenda Euceda
- Department of Internal Medicine, Danbury Hospital, Western Connecticut Health Network, Danbury
| | - Wing-Tai Kong
- Department of Internal Medicine, Danbury Hospital, Western Connecticut Health Network, Danbury
| | - Amber Kapoor
- Department of Research and Innovation, Danbury Hospital, Western Connecticut Health Network, Danbury
| | - John E Hokanson
- Department of Research and Innovation, Danbury Hospital, Western Connecticut Health Network, Danbury
| | - Patricia Dilauro
- Section of Pulmonary Medicine, Department of Internal Medicine, Danbury Hospital, Western Connecticut Health Network, Danbury
| | - Rahila Ogunnaike
- Department of Internal Medicine, Danbury Hospital, Western Connecticut Health Network, Danbury
| | - John Chronakos
- Section of Pulmonary Medicine, Department of Internal Medicine, Danbury Hospital, Western Connecticut Health Network, Danbury
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Ware P, Ross HJ, Cafazzo JA, Laporte A, Seto E. Implementation and Evaluation of a Smartphone-Based Telemonitoring Program for Patients With Heart Failure: Mixed-Methods Study Protocol. JMIR Res Protoc 2018; 7:e121. [PMID: 29724704 PMCID: PMC5958281 DOI: 10.2196/resprot.9911] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/02/2018] [Accepted: 03/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Meta-analyses of telemonitoring for patients with heart failure conclude that it can lower the utilization of health services and improve health outcomes compared with the standard of care. A smartphone-based telemonitoring program is being implemented as part of the standard of care at a specialty care clinic for patients with heart failure in Toronto, Canada. Objective The objectives of this study are to (1) evaluate the impact of the telemonitoring program on health service utilization, patient health outcomes, and their ability to self-care; (2) identify the contextual barriers and facilitators of implementation at the physician, clinic, and institutional level; (3) describe patient usage patterns to determine adherence and other behaviors in the telemonitoring program; and (4) evaluate the costs associated with implementation of the telemonitoring program from the perspective of the health care system (ie, public payer), hospital, and patient. Methods The evaluation will use a mixed-methods approach. The quantitative component will include a pragmatic pre- and posttest study design for the impact and cost analyses, which will make use of clinical data and questionnaires administered to at least 108 patients at baseline and 6 months. Furthermore, outcome data will be collected at 1, 12, and 24 months to explore the longitudinal impact of the program. In addition, quantitative data related to implementation outcomes and patient usage patterns of the telemonitoring system will be reported. The qualitative component involves an embedded single case study design to identify the contextual factors that influenced the implementation. The implementation evaluation will be completed using semistructured interviews with clinicians, and other program staff at baseline, 4 months, and 12 months after the program start date. Interviews conducted with patients will be triangulated with usage data to explain usage patterns and adherence to the system. Results The telemonitoring program was launched in August 2016 and patient enrollment is ongoing. Conclusions The methods described provide an example for conducting comprehensive evaluations of telemonitoring programs. The combination of impact, implementation, and cost evaluations will inform the quality improvement of the existing program and will yield insights into the sustainability of smartphone-based telemonitoring programs for patients with heart failure within a specialty care setting.
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Affiliation(s)
- Patrick Ware
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Audrey Laporte
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Canadian Centre for Health Economics, Toronto, ON, Canada
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
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63
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Wu CX, Hwang CH, Tan WS, Tai KP, Kwek LSL, Chee TG, Choo YM, Phng FWL, Chua GSW. Effectiveness of a chronic obstructive pulmonary disease integrated care pathway in a regional health system: a propensity score matched cohort study. BMJ Open 2018; 8:e019425. [PMID: 29572394 PMCID: PMC5875646 DOI: 10.1136/bmjopen-2017-019425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 02/06/2018] [Accepted: 02/08/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The chronic obstructive pulmonary disease (COPD) integrated care pathway (ICP) programme was designed and implemented to ensure that the care for patients with COPD is comprehensive and integrated across different care settings from primary care to acute hospital and home. We evaluated the effectiveness of the ICP programme for patients with COPD. DESIGN, SETTING AND PARTICIPANTS A retrospective propensity score matched cohort study was conducted comparing differences between programme enrolees and propensity-matched non-enrolees in a Regional Health System in Singapore. Data on patients diagnosed with COPD who enrolled in the programme (n=95) and patients who did not enrol (n=6330) were extracted from the COPD registry and hospital administrative databases. Enrolees and non-enrolees were propensity score matched. OUTCOME MEASURES The risk of COPD hospitalisations and COPD hospital bed days savings were compared between the groups using a difference-in-difference strategy and generalised estimating equation approach. Adherence with recommended care elements for the COPD-ICP group was measured quarterly at baseline and during a 2-year follow-up period. RESULTS Compared with non-enrolees, COPD hospitalisation risk for ICP programme enrolees was significantly lower in year 2 (incidence rate ratio (IRR): 0.73; 95% CI 0.54 to 1.00). Similarly, COPD hospital bed days was significantly lower for enrolees in year 2 (IRR: 0.78; 95% CI 0.64 to 0.95). ICP programme patients had sustained improvements in compliance with all recommended care elements for patients with COPD. The overall all-or-none care bundle compliance rate had improved from 28% to 54%. CONCLUSION The study concluded that the COPD-ICP programme was associated with reductions in COPD hospitalisation risk and COPD health utilisation in a 2-year follow-up period.
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Affiliation(s)
- Christine Xia Wu
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Chi Hong Hwang
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Woan Shin Tan
- Health Services and Outcomes Research, National Healthcare Group, Singapore
- NTU Institute for Health Technologies, Interdisciplinary Graduate School, Nanyang Technological University, Singapore
| | - Kai Pik Tai
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Lynette Siang Lim Kwek
- Clinical Operations, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Thong Gan Chee
- Clinical Operations, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Yee Mun Choo
- Nursing Clinical Services, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Francis Wei Loong Phng
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
| | - Gerald Seng Wee Chua
- Medicine Division, Ng Teng Fong General Hospital and Jurong Community Hospital, Members of the NUHS, Singapore
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Valentijn PP, Pereira FA, Ruospo M, Palmer SC, Hegbrant J, Sterner CW, Vrijhoef HJM, Ruwaard D, Strippoli GFM. Person-Centered Integrated Care for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin J Am Soc Nephrol 2018; 13:375-386. [PMID: 29438975 PMCID: PMC5967678 DOI: 10.2215/cjn.09960917] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/15/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The effectiveness of person-centered integrated care strategies for CKD is uncertain. We conducted a systematic review and meta-analysis of randomized, controlled trials to assess the effect of person-centered integrated care for CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to April of 2016), and selected randomized, controlled trials of person-centered integrated care interventions with a minimum follow-up of 3 months. Random-effects meta-analysis was used to assess the effect of person-centered integrated care. RESULTS We included 14 eligible studies covering 4693 participants with a mean follow-up of 12 months. In moderate quality evidence, person-centered integrated care probably had no effect on all-cause mortality (relative risk [RR], 0.86; 95% confidence interval [95% CI], 0.68 to 1.08) or health-related quality of life (standardized mean difference, 0.02; 95% CI, -0.05 to 0.10). The effects on renal replacement therapy (RRT) (RR, 1.00; 95% CI, 0.65 to 1.55), serum creatinine levels (mean difference, 0.59 mg/dl; 95% CI, -0.38 to 0.36), and eGFR (mean difference, 1.51 ml/min per 1.73 m2; 95% CI, -3.25 to 6.27) were very uncertain. Quantitative analysis suggested that person-centered integrated care interventions may reduce all-cause hospitalization (RR, 0.38; 95% CI, 0.15 to 0.95) and improve BP control (RR, 1.20; 95% CI, 1.00 to 1.44), although the certainty of the evidence was very low. CONCLUSIONS Person-centered integrated care may have little effect on mortality or quality of life. The effects on serum creatinine, eGFR, and RRT are uncertain, although person-centered integrated care may lead to fewer hospitalizations and improved BP control.
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Affiliation(s)
- Pim P Valentijn
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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65
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Sandelowsky H, Natalishvili N, Krakau I, Modin S, Ställberg B, Nager A. COPD management by Swedish general practitioners - baseline results of the PRIMAIR study. Scand J Prim Health Care 2018; 36:5-13. [PMID: 29334861 PMCID: PMC5901441 DOI: 10.1080/02813432.2018.1426148] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/10/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common cause of suffering and death. Evidence-based management of COPD by general practitioners (GPs) is crucial for decreasing the impact of the disease. Efficient strategies include early diagnosis, smoking cessation and multimodal treatment. AIM To describe knowledge about and skills for managing COPD in GPs in Sweden. METHODS Prior to COPD education (the PRIMAIR Study), GPs at primary health care centers (PHCCs) in Stockholm replied to 13 written, patient-case based, multiple choice and free-text questions about COPD. Their knowledge and practical management skills were assessed by assigned points that were analyzed with non-parametric tests. RESULTS Overall, 250 GPs at 34 PHCCs replied (89% response rate). Total mean score was 9.9 (maximum 26). Scores were highest on 'management of smoking cessation', 'follow-up after exacerbation' and 'diagnostic procedures'. Spirometry was used frequently, although interpretation skills were suboptimal. 'Management of maintenance therapy', 'management of multimorbidity' and 'interprofessional cooperation' had mediocre scores. Scores were unrelated to whether there was a nurse-led asthma/COPD clinic at the PHCC. CONCLUSIONS Swedish GPs' knowledge of COPD and adherence to current guidelines seem insufficient. A nurse-led asthma/COPD clinic at the PHCC does not correlate with sufficient COPD skills in the GPs. The relevance of this study to participants' actual clinical practice and usefulness of easy-to-access clinical guides are interesting topics for future investigation. To identify problem areas, we suggest using questionnaires prior to educational interventions. Key Points General practitioners (GPs) play a crucial role in providing evidence-based care for patients with chronic obstructive pulmonary disease (COPD) who are treated in primary care. Swedish GPs' knowledge about COPD and adherence to current guidelines seem insufficient. Areas in greatest need of improvement are spirometry interpretation, management of maintenance therapy, management of multimorbidity in patients with COPD and interprofessional cooperation.
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Affiliation(s)
- Hanna Sandelowsky
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden
| | | | - Ingvar Krakau
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Sonja Modin
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Science, Family Medicine and Preventive medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
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Solanes I, Bolíbar I, Llauger MA, Peiro M, Valverde P, Fraga M, Medrano C, Bigorra T, Freixas M, Ligüerre I, Pou MA, Domínguez L, Valero C, Solà J, Giner J, Plaza V. [Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received]. Aten Primaria 2018; 50:184-196. [PMID: 28735722 PMCID: PMC6837048 DOI: 10.1016/j.aprim.2017.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 01/02/2017] [Accepted: 01/24/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of two management programs on patients with chronic obstructive pulmonary disease (COPD). DESIGN A study with a quasi-experimental design was used to evaluate the effectiveness of two interventions (I1, I2) for the care of patients with COPD after a mean follow-up of 31.2months. SETTING Primary Care Centres in two Barcelona Health Areas and their referral hospitals. PARTICIPANTS Patients with COPD selected by simple random sampling using any disease code corresponding to COPD. INTERVENTIONS I1: Integrated management program that was optimised and coordinated the resources. Training was given, as well as quality control of spirometry. I2: Isolated interventions like a call-centre. Care circuits and computerised clinical notes were shared. MAIN MEASUREMENTS Variables were recorded as regards lung function, severity, use of inhalers, lifestyles, quality of life, and exacerbations. RESULTS Of the 393 patients evaluated at the beginning, 120 and 104 (I1 and I2, respectively) received the final evaluation. With I1, there was a reduction in patients who smoked (P=.034). Lung function and quality of life did not change significantly in either group, but shortness of breath was slightly worse. There was an increase in the correct use of inhalers, although it only reached 48% and 61% with interventions I1 and I2, respectively. The percentage of patients with exacerbations decreased with I1 compared to that of I2 (P<.001), and there were less hospital admissions due to exacerbations with I2 compared to I1 (P<.003]). CONCLUSIONS Both interventions achieved significant improvements, and no overall worsening of a chronic and progressive disease as is COPD.
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Affiliation(s)
- Ingrid Solanes
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut de recerca biomèdica (IIB Sant Pau), Universidad Autónoma de Barcelona, Barcelona, España.
| | - Ignasi Bolíbar
- Servicio de Epidemiologia Clínica y Salud Pública, Hospital de la Santa Creu i Sant Pau, Institut de recerca biomèdica (IIB Sant Pau), Universidad Autónoma de Barcelona, Ciber de Epidemiología y Salud Pública (CIBERESP), Barcelona, España
| | | | - Meritxell Peiro
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut de recerca biomèdica (IIB Sant Pau), Universidad Autónoma de Barcelona, Barcelona, España
| | - Pepi Valverde
- EAP Gaudí, Consorci Sanitari Integral, Barcelona, España
| | - Mar Fraga
- EAP Xafarinas, Institut Català de la Salut, Barcelona, España
| | | | - Teresa Bigorra
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut de recerca biomèdica (IIB Sant Pau), Universidad Autónoma de Barcelona, Barcelona, España
| | | | - Iskra Ligüerre
- Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, España
| | | | | | - Carles Valero
- Unitat d'Avaluació de Sistemes d'Informació i Qualitat, Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, España
| | - Judit Solà
- Departamento de Epidemiologia Clínica y Salud Pública. Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Jordi Giner
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut de recerca biomèdica (IIB Sant Pau), Universidad Autónoma de Barcelona, Barcelona, España
| | - Vicente Plaza
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut de recerca biomèdica (IIB Sant Pau), Universidad Autónoma de Barcelona, Barcelona, España
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67
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Steurer-Stey C, Dalla Lana K, Braun J, Ter Riet G, Puhan MA. Effects of the "Living well with COPD" intervention in primary care: a comparative study. Eur Respir J 2018; 51:51/1/1701375. [PMID: 29301921 DOI: 10.1183/13993003.01375-2017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 09/28/2017] [Indexed: 12/23/2022]
Abstract
The pivotal objective of chronic obstructive pulmonary disease (COPD) self-management programmes is behaviour change to avoid moderate and severe exacerbations and improve health related quality of life.In a prospectively planned, controlled study, COPD patients who participated in the "Living well with COPD" (LWWCOPD) self-management intervention were compared with usual care patients from the primary care COPD Cohort ICE COLD ERIC, who did not receive self-management intervention (NCT00706602) The primary outcome was behaviour change and disease-specific health related quality of life after 1 year. Secondary end-points included exacerbation rates. We calculated mixed linear, zero-inflated negative binomial and logistic regression models and used propensity scores to counteract confounding.467 patients, 71 from the LWWCOPD and 396 from the usual care cohort, were included. The differences between intervention and control were 0.54 (95% CI 0.13-0.94) on the Chronic Respiratory Questionnaire domain "mastery", 0.55 (95% CI 0.11-0.99) on "fatigue", 0.54 (0.14-0.93) on "emotional function" and 0.64 (95% CI 0.14-1.14) on "dyspnoea". The intervention considerably reduced the risk of moderate and severe exacerbations (incidence rate ratio 0.36, 95% CI 0.25-0.52).Self-management coaching in primary care improves health-related quality of life and lowers exacerbation rates and health care use.
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Affiliation(s)
- Claudia Steurer-Stey
- Institute of Primary Care, University of Zurich, Zurich, Switzerland .,Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.,mediX Group Practice, Zurich, Switzerland
| | - Kaba Dalla Lana
- Institute of Primary Care, University of Zurich, Zurich, Switzerland.,Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.,mediX Group Practice, Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Gerben Ter Riet
- Dept of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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68
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Hashem F, Merritt R. Supporting patients self-managing respiratory health: a qualitative study on the impact of the Breathe Easy voluntary group network. ERJ Open Res 2018; 4:00076-2017. [PMID: 29450201 PMCID: PMC5809141 DOI: 10.1183/23120541.00076-2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/14/2017] [Indexed: 11/09/2022] Open
Abstract
Self-management strategies are designed to improve lung and respiratory health through structured self-management plans with regular practitioner reviews. Strategies have not, however, focused upon how patient support groups and advocacy networks can help with the management of these conditions; therefore, it is unknown what impact they may have on patient self-management. A qualitative study was designed to help understand what impact the British Lung Foundation's Breathe Easy (BE) groups have on patients managing their lung and respiratory conditions. A semistructured telephone interview schedule was developed to study the network. Topics covered included: perceptions about the BE groups; current referrals systems and integration pathways; benefits of attending the BE groups; and integration of the BE groups into the respiratory pathway. Key themes explored included: shared patient experience and peer support; patient self-management and self-education; attendance of healthcare professionals; and the impact of integrating BE groups into the respiratory pathway. BE networks were shown to support self-care initiatives for people attending the groups, and members expressed a social and educational benefit. BE networks were working with the local National Health Service to become an integral part of the respiratory pathway, yet there was evidence of resistance from the health service in incorporating the networks.
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69
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Parekh TM, Bhatt SP, Westfall AO, Wells JM, Kirkpatrick D, Iyer AS, Mugavero M, Willig JH, Dransfield MT. Implications of DRG Classification in a Bundled Payment Initiative for COPD. AMERICAN JOURNAL OF ACCOUNTABLE CARE 2017; 5:12-18. [PMID: 29623307 PMCID: PMC5881946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative. STUDY DESIGN Retrospective observational study. METHODS We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation. RESULTS Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001). CONCLUSIONS The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative.
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Affiliation(s)
- Trisha M Parekh
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Surya P Bhatt
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Andrew O Westfall
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - James M Wells
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Denay Kirkpatrick
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Anand S Iyer
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Michael Mugavero
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - James H Willig
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Mark T Dransfield
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
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Doshi R, Aseltine RH, Sabina AB, Graham GN. Interventions to Improve Management of Chronic Conditions Among Racial and Ethnic Minorities. J Racial Ethn Health Disparities 2017; 4:1033-1041. [PMID: 29067651 DOI: 10.1007/s40615-017-0431-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/05/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.
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Affiliation(s)
- Riddhi Doshi
- Department of Community Medicine and Healthcare, University of Connecticut Health Center, Farmington, CT, USA
| | - Robert H Aseltine
- Division of Behavioral Science and Community Health, University of Connecticut Health Center, 263 Farmington avenue MC 6030, Farmington, CT, 06030, USA.
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Flanagan S, Damery S, Combes G. The effectiveness of integrated care interventions in improving patient quality of life (QoL) for patients with chronic conditions. An overview of the systematic review evidence. Health Qual Life Outcomes 2017; 15:188. [PMID: 28962570 PMCID: PMC5622519 DOI: 10.1186/s12955-017-0765-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/24/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine the effectiveness of integrated care interventions in improving the Quality of Life (QoL) for patients with chronic conditions. DESIGN A review of the systematic reviews evidence (umbrella review). DATA SOURCES Medline, Embase, ASSIA, PsychINFO, HMIC, CINAHL, Cochrane Library (including HTA database), DARE, and Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP and Health Economics Evaluations databases. Reference lists of included reviews were searched for additional references not returned by electronic searches. REVIEW METHODS English language systematic reviews or meta-analyses published since 2000 that assessed the effectiveness of interventions in improving the QoL of patients with chronic conditions. Two reviewers independently assessed reviews for eligibility, extracted data, and assessed the quality of included studies. RESULTS A total of 41 reviews assessed QoL. Twenty one reviews presented quantitative data, 17 reviews were narrative and three were reviews of reviews. The intervention categories included case management, Chronic care model (CCM), discharge management, multidisciplinary teams (MDT), complex interventions, primary vs. secondary care follow-up, and self-management. CONCLUSIONS Taken together, the 41 reviews that assessed QoL provided a mixed picture of the effectiveness of integrated care interventions. Case management interventions showed some positive findings as did CCM interventions, although these interventions were more likely to be effective when they included a greater number of components. Discharge management interventions appeared to be particularly successful for patients with heart failure. MDT and self-management interventions showed a mixed picture. In general terms, interventions were typically more effective in improving condition-specific QoL rather than global QoL. This review provided the first overview of international evidence for the effectiveness of integrated care interventions for improving the QoL for patients with chronic conditions.
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Affiliation(s)
- Sarah Flanagan
- Research Fellow, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, West Midlands B15 2TT UK
| | - Sarah Damery
- Research Fellow, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, West Midlands B15 2TT UK
| | - Gill Combes
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands Research Lead for Chronic Conditions Theme, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, West Midlands B15 2TT UK
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Liang J, Abramson MJ, Zwar N, Russell G, Holland AE, Bonevski B, Mahal A, van Hecke B, Phillips K, Eustace P, Paul E, Petrie K, Wilson S, George J. Interdisciplinary model of care (RADICALS) for early detection and management of chronic obstructive pulmonary disease (COPD) in Australian primary care: study protocol for a cluster randomised controlled trial. BMJ Open 2017; 7:e016985. [PMID: 28928190 PMCID: PMC5623556 DOI: 10.1136/bmjopen-2017-016985] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/30/2017] [Accepted: 07/05/2017] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Up to half of all smokers develop clinically significant chronic obstructive pulmonary disease (COPD). Gaps exist in the implementation and uptake of evidence-based guidelines for managing COPD in primary care. We describe the methodology of a cluster randomised controlled trial (cRCT) evaluating the efficacy and cost-effectiveness of an interdisciplinary model of care aimed at reducing the burden of smoking and COPD in Australian primary care settings. METHODS AND ANALYSIS A cRCT is being undertaken to evaluate an interdisciplinary model of care (RADICALS - Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers). General practice clinics across Melbourne, Australia, are identified and randomised to the intervention group (RADICALS) or usual care. Patients who are current or ex-smokers, of at least 10 pack years, including those with an existing diagnosis of COPD, are being recruited to identify 280 participants with a spirometry-confirmed diagnosis of COPD. Handheld lung function devices are being used to facilitate case-finding. RADICALS includes individualised smoking cessation support, home-based pulmonary rehabilitation and home medicines review. Patients at control group sites receive usual care and Quitline referral, as appropriate. Follow-ups occur at 6 and 12 months from baseline to assess changes in quality of life, abstinence rates, health resource utilisation, symptom severity and lung function. The primary outcome is change in St George's Respiratory Questionnaire score of patients with COPD at 6 months from baseline. ETHICS AND DISSEMINATION This project has been approved by the Monash University Human Research Ethics Committee and La Trobe University Human Ethics Committee (CF14/1018 - 2014000433). Results of the study will be disseminated in peer-reviewed journals and research conferences. If the intervention is successful, the RADICALS programme could potentially be integrated into general practices across Australia and sustained over time. TRIAL REGISTRATION NUMBER ACTRN12614001155684; Pre-results.
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Affiliation(s)
- Jenifer Liang
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Michael J Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicholas Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine, University of Wollongong, Keiraville, New South Wales, Australia
| | - Grant Russell
- Southern Academic Primary Care Research Unit, Department of General Practice, Monash University, Notting Hill, Victoria, Australia
| | - Anne E Holland
- Discipline of Physiotherapy, La Trobe University, Bundoora, Victoria, Australia
- Department of Physiotherapy, Alfred Health, Prahran, Victoria, Australia
- Institute for Breathing and Sleep, Austin Hospital, Heidelberg, Victoria, Australia
| | - Billie Bonevski
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Ajay Mahal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Nossal Institute for Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Benjamin van Hecke
- Boehringer Ingelheim (BI) Pty Ltd, North Ryde, New South Wales, Australia
| | | | - Paula Eustace
- Eastern Melbourne PHN (EMPHN), Box Hill, Victoria, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Haematology Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Kate Petrie
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Sally Wilson
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
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Lalmolda C, Coll-Fernández R, Martínez N, Baré M, Teixidó Colet M, Epelde F, Monsó E. Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns. Int J Chron Obstruct Pulmon Dis 2017; 12:2531-2538. [PMID: 28883720 PMCID: PMC5574698 DOI: 10.2147/copd.s138451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established. Aims The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year. Materials and methods COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care. Results Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0–1] vs 1 [0–2.5]; P=0.022) and in days of admission (0 [0–7] vs 7 [0–12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (β coefficient −0.785, P=0.014, and R2=0.219). Conclusion A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention.
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Affiliation(s)
- C Lalmolda
- Respiratory Diseases Department, Hospital Universitari Parc Tauli.,Ciber de Enfermedades Respiratorias - Ciberes.,Universitat Autònoma de Barcelona - UAB
| | | | - N Martínez
- Respiratory Diseases Department, Hospital Universitari Parc Tauli
| | - M Baré
- Primary Care Unit Vallés Occidental, Institut Català de la Salut
| | - M Teixidó Colet
- Primary Care Unit Vallés Occidental, Institut Català de la Salut
| | - F Epelde
- Short Stay Unit, Emergency Service, Hospital Universitari Parc Taulí, Barcelona, Spain
| | - E Monsó
- Respiratory Diseases Department, Hospital Universitari Parc Tauli.,Ciber de Enfermedades Respiratorias - Ciberes.,Universitat Autònoma de Barcelona - UAB
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Talboom-Kamp EP, Verdijk NA, Kasteleyn MJ, Harmans LM, Talboom IJ, Looijmans-van den Akker I, van Geloven N, Numans ME, Chavannes NH. The Effect of Integration of Self-Management Web Platforms on Health Status in Chronic Obstructive Pulmonary Disease Management in Primary Care (e-Vita Study): Interrupted Time Series Design. J Med Internet Res 2017; 19:e291. [PMID: 28814380 PMCID: PMC5577456 DOI: 10.2196/jmir.8262] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/24/2017] [Accepted: 07/27/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Worldwide nearly 3 million people die from chronic obstructive pulmonary disease (COPD) every year. Integrated disease management (IDM) improves quality of life for COPD patients and can reduce hospitalization. Self-management of COPD through eHealth is an effective method to improve IDM and clinical outcomes. OBJECTIVES The objective of this implementation study was to investigate the effect of 3 chronic obstructive pulmonary disease eHealth programs applied in primary care on health status. The e-Vita COPD study compares different levels of integration of Web-based self-management platforms in IDM in 3 primary care settings. Patient health status is examined using the Clinical COPD Questionnaire (CCQ). METHODS The parallel cohort design includes 3 levels of integration in IDM (groups 1, 2, 3) and randomization of 2 levels of personal assistance for patients (group A, high assistance, group B, low assistance). Interrupted time series (ITS) design was used to collect CCQ data at multiple time points before and after intervention, and multilevel linear regression modeling was used to analyze CCQ data. RESULTS Of the 702 invited patients, 215 (30.6%) registered to a platform. Of these, 82 participated in group 1 (high integration IDM), 36 in group 1A (high assistance), and 46 in group 1B (low assistance); 96 participated in group 2 (medium integration IDM), 44 in group 2A (high assistance) and 52 in group 2B (low assistance); also, 37 participated in group 3 (no integration IDM). In the total group, no significant difference was found in change in CCQ trend (P=.334) before (-0.47% per month) and after the intervention (-0.084% per month). Also, no significant difference was found in CCQ changes before versus after the intervention between the groups with high versus low personal assistance. In all subgroups, there was no significant change in the CCQ trend before and after the intervention (group 1A, P=.237; 1B, P=.991; 2A, P=.120; 2B, P=.166; 3, P=.945). CONCLUSIONS The e-Vita eHealth-supported COPD programs had no beneficial impact on the health status of COPD patients. Also, no differences were found between the patient groups receiving different levels of personal assistance. TRIAL REGISTRATION Netherlands Trial Registry NTR4098; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4098 (Archived by WebCite at http://www.webcitation.org/6sbM5PayG).
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Affiliation(s)
- Esther Pwa Talboom-Kamp
- Leiden University Medical Center, Public Health and Primary Care Department, Leiden, Netherlands
- Saltro Diagnostic Center, Utrecht, Netherlands
| | - Noortje A Verdijk
- Leiden University Medical Center, Public Health and Primary Care Department, Leiden, Netherlands
- Saltro Diagnostic Center, Utrecht, Netherlands
| | - Marise J Kasteleyn
- Leiden University Medical Center, Public Health and Primary Care Department, Leiden, Netherlands
| | | | | | | | - Nan van Geloven
- Leiden University Medical Center, Department of Medical Statistics and Bioinformatics, Leiden, Netherlands
| | - Mattijs E Numans
- Leiden University Medical Center, Public Health and Primary Care Department, Leiden, Netherlands
| | - Niels H Chavannes
- Leiden University Medical Center, Public Health and Primary Care Department, Leiden, Netherlands
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Rinne ST, Castaneda J, Lindenauer PK, Cleary PD, Paz HL, Gomez JL. Chronic Obstructive Pulmonary Disease Readmissions and Other Measures of Hospital Quality. Am J Respir Crit Care Med 2017; 196:47-55. [PMID: 28145726 DOI: 10.1164/rccm.201609-1944oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The Centers for Medicare and Medicaid Services recently implemented financial penalties to reduce hospital readmissions for select conditions, including chronic obstructive pulmonary disease (COPD). Despite growing pressure to reduce COPD readmissions, it is unclear how COPD readmission rates are related to other measures of quality, which could inform efforts on common organizational factors that affect high-quality care. OBJECTIVES To examine the association between COPD readmissions and other quality measures. METHODS We analyzed data from the 2015 Centers for Medicare and Medicaid Services annual files, downloaded from the Hospital Compare website. We included 3,705 hospitals nationwide that had publically reported data on COPD readmissions. We compared COPD readmission rates to other risk-adjusted measures of quality, including readmission and mortality rates for other conditions, and patient reports about care experiences. MEASUREMENTS AND MAIN RESULTS There were modest correlations between COPD readmission rates and readmission rates for other medical conditions, including heart failure (r = 0.39; P < 0.01), acute myocardial infarction (r = 0.30; P < 0.01), pneumonia (r = 0.38; P < 0.01), and stroke (r = 0.29; P < 0.01). In contrast, we found low correlations between COPD readmission rates and readmission rates for surgical conditions, as well as mortality rates for all measured conditions. There were significant correlations between COPD readmission rates and all patient experience measures. CONCLUSIONS These findings suggest there may be common organizational factors that influence multiple disease-specific outcomes. As pay-for-performance programs focus attention on individual disease outcomes, hospitals may benefit from in-depth assessments of organizational factors that affect multiple aspects of hospital quality.
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Affiliation(s)
- Seppo T Rinne
- 1 Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Department of Veterans Affairs, Bedford, Massachusetts.,2 Department of Medicine, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Jose Castaneda
- 3 Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Peter K Lindenauer
- 4 Center for Quality of Care Research, Division of Hospital Medicine, Baystate Medical Center, Springfield, Massachusetts.,5 Section of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Medford, Massachusetts
| | - Paul D Cleary
- 6 Yale School of Public Health, New Haven, Connecticut
| | - Harold L Paz
- 7 Aetna, Inc., Hartford, Connecticut; and.,8 Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University, New Haven, Connecticut
| | - Jose L Gomez
- 8 Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University, New Haven, Connecticut
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Lanning E, Roberts C, Green B, Brown T, Storrar W, Jones T, Fogg C, Dewey A, Longstaff J, Bassett P, Chauhan AJ. Modern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD): A Comparison of Clinical Outcomes Before and After the MISSION Clinic. JMIR Res Protoc 2017; 6:e104. [PMID: 28583907 PMCID: PMC5476866 DOI: 10.2196/resprot.6850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/30/2017] [Accepted: 04/04/2017] [Indexed: 11/13/2022] Open
Abstract
Background Chronic obstructive pulmonary disorder (COPD) affects over 1 million people in the United Kingdom, and 1 person dies from COPD every 20 minutes. The cost to people with COPD and the National Health Service is huge – more than 24 million working days lost a year and the annual expenditure on COPD is £810 million and £930 million a year. Objective We aim to identify patients with COPD who are at risk of exacerbations and hospital admissions as well as those who have not been formally diagnosed, yet remain at risk. Methods This mixed-methods study will use both data and interviews from patients and health care professionals. The project Modern Innovative SolutionS in Improving Outcomes iN COPD (MISSION COPD) will hold multidisciplinary carousel style clinics to rapidly assess the patients’ COPD and related comorbidities, and enhance patient knowledge and skills for self-management. Results This study is ongoing. Conclusions This research will capture quantitative and qualitative outcomes to accompany a program of quality improvement through delivery of novel care models.
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Affiliation(s)
| | | | - Ben Green
- Portsmouth Hopitals NHS Trust, Cosham, United Kingdom
| | - Thomas Brown
- Portsmouth Hopitals NHS Trust, Cosham, United Kingdom
| | - Will Storrar
- Portsmouth Hopitals NHS Trust, Cosham, United Kingdom
| | - Thomas Jones
- Portsmouth Hopitals NHS Trust, Cosham, United Kingdom
| | - Carole Fogg
- Portsmouth Hopitals NHS Trust, Cosham, United Kingdom
| | - Ann Dewey
- University of Portsmouth, Portsmouth, United Kingdom
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Talboom-Kamp EP, Verdijk NA, Kasteleyn MJ, Harmans LM, Talboom IJ, Numans ME, Chavannes NH. High Level of Integration in Integrated Disease Management Leads to Higher Usage in the e-Vita Study: Self-Management of Chronic Obstructive Pulmonary Disease With Web-Based Platforms in a Parallel Cohort Design. J Med Internet Res 2017; 19:e185. [PMID: 28566268 PMCID: PMC5471344 DOI: 10.2196/jmir.7037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/28/2017] [Accepted: 04/24/2017] [Indexed: 12/17/2022] Open
Abstract
Background Worldwide, nearly 3 million people die of chronic obstructive pulmonary disease (COPD) every year. Integrated disease management (IDM) improves disease-specific quality of life and exercise capacity for people with COPD, but can also reduce hospital admissions and hospital days. Self-management of COPD through eHealth interventions has shown to be an effective method to improve the quality and efficiency of IDM in several settings, but it remains unknown which factors influence usage of eHealth and change in behavior of patients. Objective Our study, e-Vita COPD, compares different levels of integration of Web-based self-management platforms in IDM in three primary care settings. The main aim of this study is to analyze the factors that successfully promote the use of a self-management platform for COPD patients. Methods The e-Vita COPD study compares three different approaches to incorporating eHealth via Web-based self-management platforms into IDM of COPD using a parallel cohort design. Three groups integrated the platforms to different levels. In groups 1 (high integration) and 2 (medium integration), randomization was performed to two levels of personal assistance for patients (high and low assistance); in group 3 there was no integration into disease management (none integration). Every visit to the e-Vita and Zorgdraad COPD Web platforms was tracked objectively by collecting log data (sessions and services). At the first log-in, patients completed a baseline questionnaire. Baseline characteristics were automatically extracted from the log files including age, gender, education level, scores on the Clinical COPD Questionnaire (CCQ), dyspnea scale (MRC), and quality of life questionnaire (EQ5D). To predict the use of the platforms, multiple linear regression analyses for the different independent variables were performed: integration in IDM (high, medium, none), personal assistance for the participants (high vs low), educational level, and self-efficacy level (General Self-Efficacy Scale [GSES]). All analyses were adjusted for age and gender. Results Of the 702 invited COPD patients, 215 (30.6%) registered to a platform. Of the 82 patients in group 1 (high integration IDM), 36 were in group 1A (personal assistance) and 46 in group 1B (low assistance). Of the 96 patients in group 2 (medium integration IDM), 44 were in group 2A (telephone assistance) and 52 in group 2B (low assistance). A total of 37 patients participated in group 3 (no integration IDM). In all, 107 users (49.8%) visited the platform at least once in the 15-month period. The mean number of sessions differed between the three groups (group 1: mean 10.5, SD 1.3; group 2: mean 8.8, SD 1.4; group 3: mean 3.7, SD 1.8; P=.01). The mean number of sessions differed between the high-assistance and low-assistance groups in groups 1 and 2 (high: mean 11.8, SD 1.3; low: mean 6.7, SD 1.4; F1,80=6.55, P=.01). High-assistance participants used more services (mean 45.4, SD 6.2) than low-assistance participants (mean 21.2, SD 6.8; F1,80=6.82, P=.01). No association was found between educational level and usage and between GSES and usage. Conclusions Use of a self-management platform is higher when participants receive adequate personal assistance about how to use the platform. Blended care, where digital health and usual care are integrated, will likely lead to increased use of the online program. Future research should provide additional insights into the preferences of different patient groups. Trial Registration Nederlands Trial Register NTR4098; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4098 (Archived by WebCite at http://www.webcitation.org/6qO1hqiJ1)
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Affiliation(s)
- Esther Pwa Talboom-Kamp
- Public Health and Primary Care Department, Leiden University Medical Centre (LUMC), Leiden, Netherlands.,Saltro Diagnostic Centre, Utrecht, Netherlands
| | - Noortje A Verdijk
- Public Health and Primary Care Department, Leiden University Medical Centre (LUMC), Leiden, Netherlands.,Saltro Diagnostic Centre, Utrecht, Netherlands
| | - Marise J Kasteleyn
- Public Health and Primary Care Department, Leiden University Medical Centre (LUMC), Leiden, Netherlands
| | | | | | - Mattijs E Numans
- Public Health and Primary Care Department, Leiden University Medical Centre (LUMC), Leiden, Netherlands
| | - Niels H Chavannes
- Public Health and Primary Care Department, Leiden University Medical Centre (LUMC), Leiden, Netherlands
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COPD: Health Care Utilisation Patterns with Different Disease Management Interventions. Lung 2017; 195:455-461. [PMID: 28474109 DOI: 10.1007/s00408-017-0010-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The management of COPD is a significant and costly issue worldwide, with acute healthcare utilisation consisting of admissions and outpatient attendances being a major contributor to the cost. Pulmonary rehabilitation (PR) and integrated disease management (IDM) are often offered. Whilst there is strong evidence of physical and quality of life outcomes following IDM and PR, few studies have looked into healthcare utilisation. The aims of this study were to confirm whether IDM and PR reduce acute healthcare utilisation and to identify factors which contribute to acute health care utilisation or increased mortality. METHODS This was a retrospective cohort study of patients with COPD who were referred to IDM over a 10-year period. Patients were also offered an 8-week PR program. Data collected were matched with the hospital dataset to obtain information on inpatient, ED and outpatient attendances. RESULTS 517 patients were enrolled to IDM. 315 (61%) also commenced PR and 220 (43%) completed PR. Patients who were referred to PR were younger and had less comorbidities (p < 0.001). Both groups (IDM only and IDM + PR referred) had reductions in healthcare utilisation but the IDM-only group had greater reductions. A survival benefit (HR 0.68, 95% CI 0.50-0.92) was seen in those who were PR completers compared to patients who received IDM only. CONCLUSIONS Patients with COPD who successfully complete PR in addition to participating in IDM have improved survival. IDM alone was effective in the reduction of healthcare utilisation; however, the addition of PR did not reduce healthcare usage further.
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Murphy LA, Harrington P, Taylor SJ, Teljeur C, Smith SM, Pinnock H, Ryan M. Clinical-effectiveness of self-management interventions in chronic obstructive pulmonary disease: An overview of reviews. Chron Respir Dis 2017; 14:276-288. [PMID: 28774200 PMCID: PMC5720233 DOI: 10.1177/1479972316687208] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Self-management (SM) is defined as the provision of interventions to increase patients’ skills and confidence, empowering the individual to take an active part in their disease management. There is uncertainty regarding the optimal format and the short- and long-term benefits of chronic obstructive pulmonary disease (COPD) SM interventions in adults. Therefore, a high-quality overview of reviews was updated to examine their clinical effectiveness. Sixteen reviews were identified, interventions were broadly classified as education or action plans, complex interventions with an SM focus, pulmonary rehabilitation (PR), telehealth and outreach nursing. Systematic review and meta-analysis quality and the risk of bias of underlying primary studies were assessed. Strong evidence was found that PR is associated with significant improvements in health-related quality of life (HRQoL). Limited to moderate evidence for complex interventions (SM focus) with limited evidence for education, action plans, telehealth interventions and outreach nursing for HRQoL was found. There was strong evidence that education is associated with a significant reduction in COPD-related hospital admissions, moderate to strong evidence that telehealth interventions and moderate evidence that complex interventions (SM focus) are associated with reduced health care utilization. These findings from a large body of evidence suggesting that SM, through education or as a component of PR, confers significant health gains in people with COPD in terms of HRQoL. SM supported by telehealth confers significant reductions in healthcare utilization, including hospitalization and emergency department visits.
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Affiliation(s)
- Linda A Murphy
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Patricia Harrington
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Stephanie Jc Taylor
- 2 Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Conor Teljeur
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Susan M Smith
- 3 RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Hilary Pinnock
- 4 Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Scotland, Edinburgh, UK
| | - Máirín Ryan
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
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80
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Yeung CHT, Santesso N, Pai M, Kessler C, Key NS, Makris M, Navarro-Ruan T, Soucie JM, Schünemann HJ, Iorio A. Care models in the management of haemophilia: a systematic review. Haemophilia 2017; 22 Suppl 3:31-40. [PMID: 27348399 DOI: 10.1111/hae.13000] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Haemophilia care is commonly provided via multidisciplinary specialized management. To date, there has been no systematic assessment of the impact of haemophilia care delivery models on patient-important outcomes. OBJECTIVE To conduct a systematic review of published studies assessing the effects of the integrated care model for persons with haemophilia (PWH). SEARCH METHODS We searched MEDLINE, EMBASE and CINAHL up to April 22, 2015, contacted experts in the field, and reviewed reference lists. SELECTION CRITERIA Randomized and non-randomized studies of PWH or carriers, focusing mainly on the assessment of care models on delivery. DATA COLLECTION AND ANALYSIS Two investigators independently screened title, abstract, and full text of retrieved articles for inclusion. Risk of bias and overall quality of evidence was assessed using Cochrane's ACROBAT-NRSI tool and GRADE respectively. Relative risks, mean differences, proportions, and means and their variability were calculated as appropriate. RESULTS 27 non-randomized studies were included: eight comparative and 19 non-comparative studies. We found low- to very low-quality evidence that in comparison to other models of care, integrated care may reduce mortality, hospitalizations and emergency room visits, may lead to fewer missed days of school and work, and may increase knowledge seeking. CONCLUSION Our comprehensive review found low- to very low-quality evidence from a limited number of non-randomized studies assessing the impact of haemophilia care models on some patient-important outcomes. While the available evidence suggests that adoption of the integrated care model may provide benefit to PWH, further high-quality research in the field is needed.
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Affiliation(s)
- C H T Yeung
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - N Santesso
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - C Kessler
- Georgetown University, Washington, DC, USA
| | - N S Key
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - M Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - T Navarro-Ruan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - J M Soucie
- Centers for Disease Control and Prevention, Division of Blood Disorders, National Center for Birth Defects and Developmental Disabilities, Atlanta, GA, USA
| | - H J Schünemann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - A Iorio
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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81
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Titova E, Salvesen Ø, Bentsen SB, Sunde S, Steinshamn S, Henriksen AH. Does an Integrated Care Intervention for COPD Patients Have Long-Term Effects on Quality of Life and Patient Activation? A Prospective, Open, Controlled Single-Center Intervention Study. PLoS One 2017; 12:e0167887. [PMID: 28060921 PMCID: PMC5218408 DOI: 10.1371/journal.pone.0167887] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 11/18/2016] [Indexed: 12/13/2022] Open
Abstract
Background Implementation of the COPD-Home integrated disease management (IDM) intervention at discharge after hospitalizations for acute exacerbations of COPD (AECOPD) led to reduced hospital utilization during the following 24 months compared to the year prior to study start. Aims To analyze the impact of the COPD-Home IDM intervention on health related quality of life, symptoms of anxiety and depression, and the degree of patient activation during 24 months of follow-up and to assess the association between these outcomes. Methods A single center, prospective, open, controlled clinical study. Changes in The St. George Respiratory Questionnaire (SGRQ), the Hospital anxiety (HADS-A) and depression (HADS-D) and the patient activation measure (PAM) scores were compared between the patients in the integrated care group (ICG) and the usual care group (UCG) 6, 12 and 24 months after enrolment. Results The questionnaire response rate was 80–96%. There were no statistically significant differences in the change of the SGRQ scores between the groups during follow up. After 12 months of follow-up there was a trend towards a reduction in the mean HADS–A score in the ICG compared to the UCG. The HADS-D scores remained stable in the ICG compared with an increasing trend in the UCG. Clinically significant difference in the PAM score was achieved only in the ICG, 6.7 (CI95% 0.7 to 7.5) compared to 3.6 (CI95% -1.4 to 8.6) in the UCG. In a logistic regression model a higher HADS-D score and current smoking significantly increased the odds for a low PAM score. Conclusion The COPD–Home IDM intervention did not result in any statistically significant changes in mean SGRQ, HADS-A, HADS- D or PAM scores during the 24 months of follow-up. Trial registration The ID number for the study in the Clinical.Trials.gov registration system is 17417. ClinicalTrials.gov Identifier: NCT 00702078
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Affiliation(s)
- Elena Titova
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Thoracic and Occupational Medicine, Trondheim University Hospital, Trondheim, Norway
- * E-mail:
| | - Øyvind Salvesen
- The Faculty of medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Synnøve Sunde
- Department of Thoracic and Occupational Medicine, Trondheim University Hospital, Trondheim, Norway
| | - Sigurd Steinshamn
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Thoracic and Occupational Medicine, Trondheim University Hospital, Trondheim, Norway
| | - Anne Hildur Henriksen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Thoracic and Occupational Medicine, Trondheim University Hospital, Trondheim, Norway
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82
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Chung LP, Lake F, Hyde E, McCamley C, Phuangmalai N, Lim M, Waterer G, Summers Q, Moodley Y. Integrated multidisciplinary community service for chronic obstructive pulmonary disease reduces hospitalisations. Intern Med J 2017; 46:427-34. [PMID: 26691743 DOI: 10.1111/imj.12984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/02/2015] [Accepted: 12/13/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospitalisations for chronic obstructive pulmonary disease (COPD) exacerbation affect patient outcomes and healthcare costs. The long-term impact of an integrated COPD disease-management approach on hospitalisation remains controversial. AIM The aim of this study was to evaluate whether a multidisciplinary community service reduces respiratory hospitalisations for COPD patients. METHODS A total of 346 patients was followed for a mean duration of 27.3 months. The number of admissions, total bed days for respiratory (COPD exacerbation or pneumonia) or general medical causes and length of stay (LOS) per respiratory admission was compared before and after referral with the service. A secondary multivariate analysis examined which clinical parameters best predict benefit from such service. RESULTS The total respiratory admission and hospital bed days after referral were reduced by 31% (288 vs 417, P < 0.001) and 40.4% (1637 vs 2746, P < 0.0001) respectively, compared with the equivalent duration prior. The average LOS for each respiratory admission was also significantly reduced after referral (6.61 vs 5.70, P = 0.02). Overall, 55% patients experienced a reduction in admission frequency and hospital days. The impact on admission frequency and hospital days was the greatest in those with an at least moderate disease (GOLD ≥2, odds ratio (OR): 3.2, 95% confidence interval (CI): 1.2, 8.9; P = 0.019) and those who completed pulmonary rehabilitation (PR) (OR: 1.7, 95% CI: 1.1, 2.8; P = 0.04). In contrast, general medical admissions increased, one-third attributable to a cardiovascular cause both before and after referral. CONCLUSIONS The implementation of COPD multidisciplinary community service was associated with reduced respiratory hospitalisations in the long term. Patients with moderate or severe disease and who are able to complete PR are much more likely to benefit.
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Affiliation(s)
- L P Chung
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - F Lake
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, Sir Charles Gairdner Hospital, The University of Western Australia, Perth, Western Australia, Australia
| | - E Hyde
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - C McCamley
- Department of Physiotherapy, Royal Perth Hospital, Perth, Western Australia, Australia
| | - N Phuangmalai
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - M Lim
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - G Waterer
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia
| | - Q Summers
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Y Moodley
- Department of Respiratory and Sleep Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia
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83
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Zakrisson AB. Symptom-reducing actions: a concept analysis in the context of chronic obstructive pulmonary disease. Int J Qual Stud Health Well-being 2017; 12:1387452. [PMID: 29034812 PMCID: PMC5654016 DOI: 10.1080/17482631.2017.1387452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 11/24/2022] Open
Abstract
Patients with Chronic Obstructive Pulmonary Disease (COPD) have multiple symptoms. Nursing care is based on six core competencies and one of them is person-centred care that includes the aspect of professional symptom relief. The aim was to clarify a meaning of the concept of Symptom-reducing actions in the context of COPD. Databases MEDLINE and CINAHL were searched between 1982 and February 2016 and 26 publications were found. Two dictionaries and three books were investigated. The method of Walker & Avant was followed. The use of the concept of Symptom-reducing actions may be categorized by the sub-concepts of supervision, information, and patient education. Exploration of defining attributes was symptom management, instructions, support, motivation, explanation, advice, teaching, and learning. Antecedent occurrences were related to factors that affect the patient's level of function such as physical performance and cognitive function. Symptom-reducing actions offer a way to support patients with COPD in self-management. Symptom-reducing actions can mediate facts in a purposeful process performed by the nurse to enable the patient to take control over and manage unpleasant symptoms by a person-centred, planned process. The nurse can achieve this via supervision, information, and patient education with an integrated emotional component. Evaluating the outcomes is needed.
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Affiliation(s)
- Ann-Britt Zakrisson
- University Healthcare Research Centre, Faculty of Health and Medicine, Örebro University, Örebro, Sweden
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84
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Howcroft M, Walters EH, Wood‐Baker R, Walters JAE. Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016; 12:CD005074. [PMID: 27990628 PMCID: PMC6463844 DOI: 10.1002/14651858.cd005074.pub4] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Exacerbations of chronic obstructive pulmonary disease (COPD) are a major driver of decline in health status and impose high costs on healthcare systems. Action plans offer a form of self-management that can be delivered in the outpatient setting to help individuals recognise and initiate early treatment for exacerbations, thereby reducing their impact. OBJECTIVES To compare effects of an action plan for COPD exacerbations provided with a single short patient education component and without a comprehensive self-management programme versus usual care. Primary outcomes were healthcare utilisation, mortality and medication use. Secondary outcomes were health-related quality of life, psychological morbidity, lung function and cost-effectiveness. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register along with CENTRAL, MEDLINE, Embase and clinical trials registers. Searches are current to November 2015. We handsearched bibliographic lists and contacted study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCT) and quasi-RCTs comparing use of an action plan versus usual care for patients with a clinical diagnosis of COPD. We permitted inclusion of a single short education component that would allow individualisation of action plans according to management needs and symptoms of people with COPD, as well as ongoing support directed at use of the action plan. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. For meta-analyses, we subgrouped studies via phone call follow-up directed at facilitating use of the action plan. MAIN RESULTS This updated review includes two additional studies (and 976 additional participants), for a total of seven parallel-group RCTs and 1550 participants, 66% of whom were male. Participants' mean age was 68 years and was similar among studies. Airflow obstruction was moderately severe in three studies and severe in four studies; mean post bronchodilator forced expiratory volume in one second (FEV1) was 54% predicted, and 27% of participants were current smokers. Four studies prepared individualised action plans, one study an oral plan and two studies standard written action plans. All studies provided short educational input on COPD, and two studies supplied ongoing support for action plan use. Follow-up was 12 months in four studies and six months in three studies.When compared with usual care, an action plan with phone call follow-up significantly reduced the combined rate of hospitalisations and emergency department (ED) visits for COPD over 12 months in one study with 743 participants (rate ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.79; high-quality evidence), but the rate of hospitalisations alone in this study failed to achieve statistical significance (RR 0.69, 95% CI 0.47 to 1.01; moderate-quality evidence). Over 12 months, action plans significantly decreased the likelihood of hospital admission (odds ratio (OR) 0.69, 95% CI 0.49 to 0.97; n = 897; two RCTs; moderate-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) 19 (11 to 201)) and the likelihood of an ED visit (OR 0.55, 95% CI 0.38 to 0.78; n = 897; two RCTs; moderate-quality evidence; NNTB over 12 months 12 (9 to 26)) compared with usual care.Results showed no significant difference in all-cause mortality during 12 months (OR 0.88, 95% CI 0.59 to 1.31; n = 1134; four RCTs; moderate-quality evidence due to wide confidence interval). Over 12 months, use of oral corticosteroids was increased with action plans compared with usual care (mean difference (MD) 0.74 courses, 95% CI 0.12 to 1.35; n = 200; two RCTs; moderate-quality evidence), and the cumulative prednisolone dose was significantly higher (MD 779.0 mg, 95% CI 533.2 to 10248; n = 743; one RCT; high-quality evidence). Use of antibiotics was greater in the intervention group than in the usual care group (subgrouped by phone call follow-up) over 12 months (MD 2.3 courses, 95% CI 1.8 to 2.7; n = 943; three RCTs; moderate-quality evidence).Subgroup analysis by ongoing support for action plan use was limited; review authors noted no subgroup differences in the likelihood of hospital admission or ED visits or all-cause mortality over 12 months. Antibiotic use over 12 months showed a significant difference between subgroups in studies without and with ongoing support.Overall quality of life score on St George's Respiratory Questionnaire (SGRQ) showed a small improvement with action plans compared with usual care over 12 months (MD -2.8, 95% CI -0.8 to -4.8; n = 1009; three RCTs; moderate-quality evidence). Low-quality evidence showed no benefit for psychological morbidity as measured with the Hospital Anxiety and Depression Scale (HADS). AUTHORS' CONCLUSIONS Use of COPD exacerbation action plans with a single short educational component along with ongoing support directed at use of the action plan, but without a comprehensive self-management programme, reduces in-hospital healthcare utilisation and increases treatment of COPD exacerbations with corticosteroids and antibiotics. Use of COPD action plans in this context is unlikely to increase or decrease mortality. Whether additional benefit is derived from periodic ongoing support directed at use of an action plan cannot be determined from the results of this review.
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Affiliation(s)
| | - E Haydn Walters
- School of Medicine, University of TasmaniaNHMRC Centre of Research Excellence for Chronic Respiratory DiseaseHobartTasmaniaAustralia
| | | | - Julia AE Walters
- School of Medicine, University of TasmaniaMSP, 17 Liverpool StreetPO Box 23HobartTasmaniaAustralia7001
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85
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Gillett K, Lippiett K, Astles C, Longstaff J, Orlando R, Lin SX, Powell A, Roberts C, Chauhan AJ, Thomas M, Wilkinson TM. Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service. BMJ Open Respir Res 2016; 3:e000145. [PMID: 28074134 PMCID: PMC5174798 DOI: 10.1136/bmjresp-2016-000145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/14/2016] [Accepted: 09/23/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating. Methods To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review. Results 82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting β2-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86. Conclusions Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.
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Affiliation(s)
- K Gillett
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme , Southampton , UK
| | - K Lippiett
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme , Southampton , UK
| | - C Astles
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme , Southampton , UK
| | - J Longstaff
- Wessex Academic Health Sciences Network (AHSN) , Portsmouth , UK
| | - R Orlando
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Methodological Hub , Southampton , UK
| | - S X Lin
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Methodological Hub , Southampton , UK
| | - A Powell
- West Hampshire Clinical Commissioning Group (CCG) , Eastleigh , UK
| | - C Roberts
- Wessex Academic Health Sciences Network (AHSN) , Portsmouth , UK
| | - A J Chauhan
- Wessex Academic Health Sciences Network (AHSN) , Portsmouth , UK
| | - M Thomas
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme, Southampton, UK; Department of Primary Care and Populations Sciences, University of Southampton, Southampton, UK
| | - T M Wilkinson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme, Southampton, UK; Department of Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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86
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Arne M, Emtner M, Lisspers K, Wadell K, Ställberg B. Availability of pulmonary rehabilitation in primary care for patients with COPD: a cross-sectional study in Sweden. Eur Clin Respir J 2016; 3:31601. [PMID: 27900930 PMCID: PMC5129097 DOI: 10.3402/ecrj.v3.31601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 10/16/2016] [Indexed: 02/03/2023] Open
Abstract
Background Pulmonary rehabilitation (PR) is an important, evidence-based component for the management of individuals with chronic obstructive pulmonary disease (COPD). In daily practice, the majority of COPD patients are treated in primary care. However, information about the availability of PR in primary care in Sweden is lacking. The aim was to investigate the availability of rehabilitation resources in primary care settings for patients with COPD in Sweden. Methods A cross-sectional descriptive design was applied, using web-based questionnaires sent to all primary care centres in four regions, comprising more than half of the 9.6 million inhabitants of Sweden. The main questionnaire included questions about the content and availability of rehabilitation resources for COPD patients. PR was defined as exercise training and one or more of the following activities: education, nutritional intervention, energy conservation techniques or psychosocial support. Results A total of 381 (55.9%) of the 682 primary care centres answered the main questionnaire. In addition to physicians and nurses, availability of healthcare professionals for rehabilitation in primary care settings was physiotherapists 92.0%, occupational therapists 91.9%, dieticians 83.9% and social workers or psychologists 98.4%. At 23.7% of all centres, PR was not available to COPD patients – neither in primary care nor at hospitals. Conclusion Despite high availability of professionals for rehabilitation in primary care settings, about one-quarter of managers at primary care centres stated that their COPD patients had no access to PR. This indicates a need to structure resources for rehabilitation and to present and communicate the available resources within the healthcare system.
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Affiliation(s)
- Mats Arne
- Primary Care Research Unit, Karlstad, Sweden.,Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden;
| | - Margareta Emtner
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Wadell
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open 2016; 6:e011952. [PMID: 27872113 PMCID: PMC5129137 DOI: 10.1136/bmjopen-2016-011952] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 08/08/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity. DESIGN Umbrella review of systematic reviews and meta-analyses. SETTING Interventions must have delivered care crossing the boundary between at least two health and/or social care settings. PARTICIPANTS Adult patients with one or more chronic diseases. DATA SOURCES MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references. OUTCOME MEASURES Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs. RESULTS 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15-50%); 11/24 showed significant reductions in all-cause (10-30%) or condition-specific (15-50%) readmissions; 9/16 reported LoS reductions of 1-7 days and 4/9 showed significantly lower A&E use (30-40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with postdischarge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients' homes. CONCLUSIONS Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity. TRIAL REGISTRATION NUMBER CRD42015016458.
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Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Sarah Flanagan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Gill Combes
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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88
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Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. Chest 2016; 150:916-926. [PMID: 27167208 PMCID: PMC5812767 DOI: 10.1016/j.chest.2016.05.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/19/2016] [Accepted: 05/01/2016] [Indexed: 11/17/2022] Open
Abstract
Of those patients hospitalized for an exacerbation of COPD, one in five will require rehospitalization within 30 days. Many developed countries are now implementing policies to increase care quality while controlling costs for COPD, known as value-based health care. In the United States, COPD is part of Medicare's Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for excess 30-day, all-cause readmissions after a hospitalization for an acute exacerbation of COPD, despite minimal evidence to guide hospitals on how to reduce readmissions. This review outlines challenges for improving overall COPD care quality and specifically for the HRRP. These challenges include heterogeneity in the literature for how COPD and readmissions are defined, difficulty finding the target population during hospitalizations, and a lack of literature to guide evidence-based programs for COPD readmissions as defined by the HRRP in the hospital setting. It then identifies risk factors for early readmissions after acute exacerbation of COPD and discusses tested and emerging strategies to reduce these readmissions. Finally, we evaluate the current HRRP and future policy changes and their effect on the goal to deliver value-based COPD care. COPD remains a chronic disease with a high prevalence that has finally garnered the attention of health systems and policy makers, but we still have a long way to go to truly deliver value-based care to patients.
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Affiliation(s)
- Tina Shah
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago, Chicago, IL
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
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89
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90
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Librero J, Ibañez-Beroiz B, Peiró S, Ridao-López M, Rodríguez-Bernal CL, Gómez-Romero FJ, Bernal-Delgado E. Trends and area variations in Potentially Preventable Admissions for COPD in Spain (2002-2013): a significant decline and convergence between areas. BMC Health Serv Res 2016; 16:367. [PMID: 27507560 PMCID: PMC4979149 DOI: 10.1186/s12913-016-1624-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 08/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Potentially Preventable Hospitalizations (PPH) are hospital admissions for conditions which are preventable with timely and appropriate outpatient care being Chronic Obstructive Pulmonary Disease (COPD) admissions one of the most relevant PPH. We estimate the population age-sex standardized relative risk of admission for COPD-PPH by year and area of residence in the Spanish National Health System (sNHS) during the period 2002-2013. METHODS The study was conducted in the 203 Hospital Service Areas of the sNHS, using the 2002 to 2013 hospital admissions for a COPD-PPH condition of patients aged 20 and over. We use conventional small area variation statistics and a Bayesian hierarchical approach to model the different risk structures of dependence in both space and time. RESULTS COPD-PPH admissions declined from 24.5 to 15.5 per 10,000 persons-year (Men: from 40.6 to 25.1; Women: from 9.1 to 6.4). The relative risk declined from 1.19 (19 % above 2002-2013 average) in 2002 to 0.77 (30 % below average) in 2013. Both the starting point and the slope were different for the different regions. Variation among admission rates between extreme areas dropped from 6.7 times higher in 2002 to 4.6 times higher in 2013. CONCLUSIONS COPD-PPH conditions in Spain have undergone a strong decline and a reduction in geographical variation in the last 12 years, suggesting a general improvement in health policies and health care over time. Variability among areas still remains, with a substantial room for improvement.
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Affiliation(s)
- Julián Librero
- Centro Superior de Investigación en Salud Pública (CSISP-FISABIO), Catalunya Av. 21, 46020, Valencia, Spain.
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain.
| | - Berta Ibañez-Beroiz
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- NavarraBiomed - Fundación Miguel Servet, Pamplona, Spain
| | - Salvador Peiró
- Centro Superior de Investigación en Salud Pública (CSISP-FISABIO), Catalunya Av. 21, 46020, Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - M Ridao-López
- Centro Superior de Investigación en Salud Pública (CSISP-FISABIO), Catalunya Av. 21, 46020, Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- Instituto Aragonés de Ciencias de la Salud. IIS Aragón, Zaragoza, Spain
| | - Clara L Rodríguez-Bernal
- Centro Superior de Investigación en Salud Pública (CSISP-FISABIO), Catalunya Av. 21, 46020, Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Francisco J Gómez-Romero
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- Instituto Aragonés de Ciencias de la Salud. IIS Aragón, Zaragoza, Spain
| | - Enrique Bernal-Delgado
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- Instituto Aragonés de Ciencias de la Salud. IIS Aragón, Zaragoza, Spain
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91
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Morris RL, Ashcroft D, Phipps D, Bower P, O'Donoghue D, Roderick P, Harding S, Lewington A, Blakeman T. Preventing Acute Kidney Injury: a qualitative study exploring 'sick day rules' implementation in primary care. BMC FAMILY PRACTICE 2016; 17:91. [PMID: 27449672 PMCID: PMC4957384 DOI: 10.1186/s12875-016-0480-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/13/2016] [Indexed: 03/12/2023]
Abstract
Background In response to growing demand for urgent care services there is a need to implement more effective strategies in primary care to support patients with complex care needs. Improving primary care management of kidney health through the implementation of ‘sick day rules’ (i.e. temporary cessation of medicines) to prevent Acute Kidney Injury (AKI) has the potential to address a major patient safety issue and reduce unplanned hospital admissions. The aim of this study is to examine processes that may enable or constrain the implementation of ‘sick day rules’ for AKI prevention into routine care delivery in primary care. Methods Forty semi-structured interviews were conducted with patients with stage 3 chronic kidney disease and purposefully sampled, general practitioners, practice nurses and community pharmacists who either had, or had not, implemented a ‘sick day rule’. Normalisation Process Theory was used as a framework for data collection and analysis. Results Participants tended to express initial enthusiasm for sick day rules to prevent AKI, which fitted with the delivery of comprehensive care. However, interest tended to diminish with consideration of factors influencing their implementation. These included engagement within and across services; consistency of clinical message; and resources available for implementation. Participants identified that supporting patients with multiple conditions, particularly with chronic heart failure, made tailoring initiatives complex. Conclusions Implementation of AKI initiatives into routine practice requires appropriate resourcing as well as training support for both patients and clinicians tailored at a local level to support system redesign. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0480-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca L Morris
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, 5th Floor Williamson Building, Oxford Road, M13 9PL, Manchester, UK. .,NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK.
| | - Darren Ashcroft
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK.,Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK
| | - Denham Phipps
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK.,Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK
| | - Donal O'Donoghue
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Paul Roderick
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Andrew Lewington
- Department of Renal Medicine, Lincoln Wing, St James's University Hospital, Beckett Street, Leeds, UK
| | - Thomas Blakeman
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, 5th Floor Williamson Building, Oxford Road, M13 9PL, Manchester, UK.,NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester, Manchester, UK
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92
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Slok AHM, Kotz D, van Breukelen G, Chavannes NH, Rutten-van Mölken MPMH, Kerstjens HAM, van der Molen T, Asijee GM, Dekhuijzen PNR, Holverda S, Salomé PL, Goossens LMA, Twellaar M, In 't Veen JCCM, van Schayck OCP. Effectiveness of the Assessment of Burden of COPD (ABC) tool on health-related quality of life in patients with COPD: a cluster randomised controlled trial in primary and hospital care. BMJ Open 2016; 6:e011519. [PMID: 27401361 PMCID: PMC4947734 DOI: 10.1136/bmjopen-2016-011519] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Assessing the effectiveness of the Assessment of Burden of COPD (ABC) tool on disease-specific quality of life in patients with chronic obstructive pulmonary disease (COPD) measured with the St. George's Respiratory Questionnaire (SGRQ), compared with usual care. METHODS A pragmatic cluster randomised controlled trial, in 39 Dutch primary care practices and 17 hospitals, with 357 patients with COPD (postbronchodilator FEV1/FVC ratio <0.7) aged ≥40 years, who could understand and read the Dutch language. Healthcare providers were randomly assigned to the intervention or control group. The intervention group applied the ABC tool, which consists of a short validated questionnaire assessing the experienced burden of COPD, objective COPD parameter (eg, lung function) and a treatment algorithm including a visual display and treatment advice. The control group provided usual care. Researchers were blinded to group allocation during analyses. Primary outcome was the number of patients with a clinically relevant improvement in SGRQ score between baseline and 18-month follow-up. Secondary outcomes were the COPD Assessment Test (CAT) and the Patient Assessment of Chronic Illness Care (PACIC; a measurement of perceived quality of care). RESULTS At 18-month follow-up, 34% of the 146 patients from 27 healthcare providers in the intervention group showed a clinically relevant improvement in the SGRQ, compared with 22% of the 148 patients from 29 healthcare providers in the control group (OR 1.85, 95% CI 1.08 to 3.16). No difference was found on the CAT (-0.26 points (scores ranging from 0 to 40); 95% CI -1.52 to 0.99). The PACIC showed a higher improvement in the intervention group (0.32 points (scores ranging from 1 to 5); 95% CI 0.14 to 0.50). CONCLUSIONS This study showed that use of the ABC tool may increase quality of life and perceived quality of care. TRIAL REGISTRATION NUMBER NTR3788; Results.
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Affiliation(s)
- Annerika H M Slok
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Daniel Kotz
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Gerard van Breukelen
- Department of Methodology & Statistics, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Maureen P M H Rutten-van Mölken
- Institute for Health Policy and Management/Institute for Medical Technology Assessment, Erasmus University Rotterdam, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Thys van der Molen
- Department of General Practice, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Guus M Asijee
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Foundation PICASSO for COPD, Alkmaar, The Netherlands
| | - P N Richard Dekhuijzen
- Department of Pulmonary Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | | | - Lucas M A Goossens
- Institute for Health Policy and Management/Institute for Medical Technology Assessment, Erasmus University Rotterdam, The Netherlands
| | - Mascha Twellaar
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Johannes C C M In 't Veen
- Department of Pulmonology and SZT Centre of Excellence for Asthma & COPD, Sint Franciscus Vlietland Gasthuis, Rotterdam, The Netherlands
| | - Onno C P van Schayck
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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93
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Breland JY, Hundt NE, Barrera TL, Mignogna J, Petersen NJ, Stanley MA, Cully JA. Identification of Anxiety Symptom Clusters in Patients with COPD: Implications for Assessment and Treatment. Int J Behav Med 2016; 22:590-6. [PMID: 25622813 DOI: 10.1007/s12529-014-9450-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Treatment of chronic obstructive pulmonary disease (COPD) is palliative, and quality of life is important. Increased understanding of correlates of quality of life and its domains could help clinicians and researchers better tailor COPD treatments and better support patients engaging in those treatments or other important self-management behaviors. PURPOSE Anxiety is common in those with COPD; however, overlap of physical and emotional symptoms complicates its assessment. The current study aimed to identify anxiety symptom clusters and to assess the association of these symptom clusters with COPD-related quality of life. METHODS Participants (N = 162) with COPD completed the Beck Anxiety Inventory (BAI), Chronic Respiratory Disease Questionnaire, Patient Health Questionnaire-9, and Medical Research Council dyspnea scale. Anxiety clusters were identified, using principal component analysis (PCA) on the BAI's 21 items. Anxiety clusters, along with factors previously associated with quality of life, were entered into a multiple regression designed to predict COPD-related quality of life. RESULTS PCA identified four symptom clusters related to (1) general somatic distress, (2) fear, (3) nervousness, and (4) respiration-related distress. Multiple regression analyses indicated that greater fear was associated with less perceived mastery over COPD (β = -0.19, t(149) = -2.69, p < 0.01). CONCLUSION Anxiety symptoms associated with fear appear to be an important indicator of anxiety in patients with COPD. In particular, fear was associated with perceptions of mastery, an important psychological construct linked to disease self-management. Assessing the BAI symptom cluster associated with fear (five items) may be a valuable rapid assessment tool to improve COPD treatment and physical health outcomes.
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Affiliation(s)
- Jessica Y Breland
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, Stanford, CA, 94304, USA
| | - Natalie E Hundt
- Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd, Houston, TX, 77030, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM 350, Houston, TX, 77030, USA.,Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA
| | - Terri L Barrera
- Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd, Houston, TX, 77030, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM 350, Houston, TX, 77030, USA.,Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA
| | - Joseph Mignogna
- Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd, Houston, TX, 77030, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM 350, Houston, TX, 77030, USA.,Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA
| | - Nancy J Petersen
- Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd, Houston, TX, 77030, USA.,Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Melinda A Stanley
- Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd, Houston, TX, 77030, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM 350, Houston, TX, 77030, USA.,Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA
| | - Jeffery A Cully
- Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd, Houston, TX, 77030, USA. .,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM 350, Houston, TX, 77030, USA. .,Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA.
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94
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Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. Int J Integr Care 2016; 16:9. [PMID: 27616953 PMCID: PMC5015529 DOI: 10.5334/ijic.2454] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Teamwork between healthcare providers is conditional
for the delivery of integrated care. This study aimed to assess the usefulness
of the conceptual framework Integrated Team Effectiveness Model for developing
and testing of the Integrated Team Effectiveness Instrument. Theory and methods: Focus groups with healthcare providers in an
integrated care setting for people with chronic obstructive pulmonary disease
(COPD) were conducted to examine the recognisability of the conceptual framework
and to explore critical success factors for collaborative COPD practice out of
this framework. The resulting items were transposed into a pilot instrument.
This was reviewed by expert opinion and completed 153 times by healthcare
providers. The underlying structure and internal consistency of the instrument
were verified by factor analysis and Cronbach’s alpha. Results: The conceptual framework turned out to be comprehensible
for discussing teamwork effectiveness. The pilot instrument measures 25 relevant
aspects of teamwork in integrated COPD care. Factor analysis suggested three
reliable components: teamwork effectiveness, team processes and team
psychosocial traits (Cronbach’s alpha between 0.76 and 0.81). Conclusions and discussion: The conceptual framework Integrated Team
Effectiveness Model is relevant in developing a practical full-spectrum
instrument to facilitate discussing teamwork effectiveness. The Integrated Team
Effectiveness Instrument provides a well-founded basis to self-evaluate teamwork
effectiveness in integrated COPD care by healthcare providers. Recommendations
are provided for the improvement of the instrument.
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95
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Ko FW, Chan KP, Hui DS, Goddard JR, Shaw JG, Reid DW, Yang IA. Acute exacerbation of COPD. Respirology 2016; 21:1152-65. [PMID: 27028990 PMCID: PMC7169165 DOI: 10.1111/resp.12780] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/18/2015] [Accepted: 01/20/2016] [Indexed: 01/14/2023]
Abstract
The literature of acute exacerbation of chronic obstructive pulmonary disease (COPD) is fast expanding. This review focuses on several aspects of acute exacerbation of COPD (AECOPD) including epidemiology, diagnosis and management. COPD poses a major health and economic burden in the Asia-Pacific region, as it does worldwide. Triggering factors of AECOPD include infectious (bacteria and viruses) and environmental (air pollution and meteorological effect) factors. Disruption in the dynamic balance between the 'pathogens' (viral and bacterial) and the normal bacterial communities that constitute the lung microbiome likely contributes to the risk of exacerbations. The diagnostic approach to AECOPD varies based on the clinical setting and severity of the exacerbation. After history and examination, a number of investigations may be useful, including oximetry, sputum culture, chest X-ray and blood tests for inflammatory markers. Arterial blood gases should be considered in severe exacerbations, to characterize respiratory failure. Depending on the severity, the acute management of AECOPD involves use of bronchodilators, steroids, antibiotics, oxygen and noninvasive ventilation. Hospitalization may be required, for severe exacerbations. Nonpharmacological interventions including disease-specific self-management, pulmonary rehabilitation, early medical follow-up, home visits by respiratory health workers, integrated programmes and telehealth-assisted hospital at home have been studied during hospitalization and shortly after discharge in patients who have had a recent AECOPD. Pharmacological approaches to reducing risk of future exacerbations include long-acting bronchodilators, inhaled steroids, mucolytics, vaccinations and long-term macrolides. Further studies are needed to assess the cost-effectiveness of these interventions in preventing COPD exacerbations.
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Affiliation(s)
- Fanny W Ko
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
| | - Ka Pang Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - David S Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - John R Goddard
- School of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health District, Brisbane, Australia
| | - Janet G Shaw
- School of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health District, Brisbane, Australia
| | - David W Reid
- School of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health District, Brisbane, Australia.,Lung Infection and Inflammation Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Ian A Yang
- School of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health District, Brisbane, Australia
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96
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Richardson M, Garner P, Donegan S. Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice. PLoS One 2016; 11:e0151818. [PMID: 26982697 PMCID: PMC4794236 DOI: 10.1371/journal.pone.0151818] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objective Systematic reviews can include cluster-randomised controlled trials (C-RCTs), which require different analysis compared with standard individual-randomised controlled trials. However, it is not known whether review authors follow the methodological and reporting guidance when including these trials. The aim of this study was to assess the methodological and reporting practice of Cochrane reviews that included C-RCTs against criteria developed from existing guidance. Methods Criteria were developed, based on methodological literature and personal experience supervising review production and quality. Criteria were grouped into four themes: identifying, reporting, assessing risk of bias, and analysing C-RCTs. The Cochrane Database of Systematic Reviews was searched (2nd December 2013), and the 50 most recent reviews that included C-RCTs were retrieved. Each review was then assessed using the criteria. Results The 50 reviews we identified were published by 26 Cochrane Review Groups between June 2013 and November 2013. For identifying C-RCTs, only 56% identified that C-RCTs were eligible for inclusion in the review in the eligibility criteria. For reporting C-RCTs, only eight (24%) of the 33 reviews reported the method of cluster adjustment for their included C-RCTs. For assessing risk of bias, only one review assessed all five C-RCT-specific risk-of-bias criteria. For analysing C-RCTs, of the 27 reviews that presented unadjusted data, only nine (33%) provided a warning that confidence intervals may be artificially narrow. Of the 34 reviews that reported data from unadjusted C-RCTs, only 13 (38%) excluded the unadjusted results from the meta-analyses. Conclusions The methodological and reporting practices in Cochrane reviews incorporating C-RCTs could be greatly improved, particularly with regard to analyses. Criteria developed as part of the current study could be used by review authors or editors to identify errors and improve the quality of published systematic reviews incorporating C-RCTs.
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Affiliation(s)
- Marty Richardson
- Centre for Evidence Synthesis in Global Health, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sarah Donegan
- Department of Biostatistics, Block F Waterhouse Building, University of Liverpool, Liverpool, United Kingdom
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Jolly K, Majothi S, Sitch AJ, Heneghan NR, Riley RD, Moore DJ, Bates EJ, Turner AM, Bayliss SE, Price MJ, Singh SJ, Adab P, Fitzmaurice DA, Jordan RE. Self-management of health care behaviors for COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:305-26. [PMID: 26937183 PMCID: PMC4762587 DOI: 10.2147/copd.s90812] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This systematic review aimed to identify the most effective components of interventions to facilitate self-management of health care behaviors for patients with COPD. PROSPERO registration number CRD42011001588. Methods We used standard review methods with a systematic search to May 2012 for randomized controlled trials of self-management interventions reporting hospital admissions or health-related quality of life (HRQoL). Mean differences (MD), hazard ratios, and 95% confidence intervals (CIs) were calculated and pooled using random-effects meta-analyses. Effects among different subgroups of interventions were explored including single/multiple components and multicomponent interventions with/without exercise. Results One hundred and seventy-three randomized controlled trials were identified. Self-management interventions had a minimal effect on hospital admission rates. Multicomponent interventions improved HRQoL (studies with follow-up >6 months St George’s Respiratory Questionnaire (MD 2.40, 95% CI 0.75–4.04, I2 57.9). Exercise was an effective individual component (St George’s Respiratory Questionnaire at 3 months MD 4.87, 95% CI 3.96–5.79, I2 0%). Conclusion While many self-management interventions increased HRQoL, little effect was seen on hospital admissions. More trials should report admissions and follow-up participants beyond the end of the intervention.
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Affiliation(s)
- Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Saimma Majothi
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Nicola R Heneghan
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Richard D Riley
- Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire
| | - David J Moore
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Elizabeth J Bates
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Alice M Turner
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Susan E Bayliss
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Sally J Singh
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Peymane Adab
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - David A Fitzmaurice
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Rachel E Jordan
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
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98
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Talboom-Kamp EP, Verdijk NA, Harmans LM, Numans ME, Chavannes NH. An eHealth Platform to Manage Chronic Disease in Primary Care: An Innovative Approach. Interact J Med Res 2016; 5:e5. [PMID: 26860333 PMCID: PMC4764788 DOI: 10.2196/ijmr.4217] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 10/16/2015] [Accepted: 11/11/2015] [Indexed: 11/13/2022] Open
Abstract
The number of individuals with chronic illness and multimorbidity is growing due to the rapid ageing of the population and the greater longevity of individuals. This causes an increasing workload in care, which results in a growing need for structural changes of the health care system. In recent years this led to a strong focus on promoting "self-management" in chronically ill patients. Research showed that patients who understand more about their disease, health, and lifestyle have better experiences and health outcomes, and often use less health care resources; the effect is even more when these patients are empowered to and responsible for managing their health and disease. In addition to the skills of patients, health care professionals need to shift to a role of teacher, partner, and professional supervisor of their patients. One way of supervising patients is by the use of electronic health (eHealth), which helps patients manage and control their disease. The application of eHealth solutions can provide chronically ill patients high-quality care, to the satisfaction of both patients and health care professionals, alongside a reduction in health care consumption and costs.
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Affiliation(s)
- Esther Pwa Talboom-Kamp
- Public Health and Primary Care Department, Leiden University Medical Centre (LUMC), Leiden, Netherlands.
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99
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Boland MRS, Kruis AL, Huygens SA, Tsiachristas A, Assendelft WJJ, Gussekloo J, Blom CMG, Chavannes NH, Rutten-van Mölken MPMH. Exploring the variation in implementation of a COPD disease management programme and its impact on health outcomes: a post hoc analysis of the RECODE cluster randomised trial. NPJ Prim Care Respir Med 2015; 25:15071. [PMID: 26677770 PMCID: PMC4682572 DOI: 10.1038/npjpcrm.2015.71] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 05/16/2015] [Accepted: 06/11/2015] [Indexed: 01/18/2023] Open
Abstract
This study aims to (1) examine the variation in implementation of a 2-year chronic obstructive pulmonary disease (COPD) management programme called RECODE, (2) analyse the facilitators and barriers to implementation and (3) investigate the influence of this variation on health outcomes. Implementation variation among the 20 primary-care teams was measured directly using a self-developed scale and indirectly through the level of care integration as measured with the Patient Assessment of Chronic Illness Care (PACIC) and the Assessment of Chronic Illness Care (ACIC). Interviews were held to obtain detailed information regarding the facilitators and barriers to implementation. Multilevel models were used to investigate the association between variation in implementation and change in outcomes. The teams implemented, on average, eight of the 19 interventions, and the specific package of interventions varied widely. Important barriers and facilitators of implementation were (in)sufficient motivation of healthcare provider and patient, the high starting level of COPD care, the small size of the COPD population per team, the mild COPD population, practicalities of the information and communication technology (ICT) system, and hurdles in reimbursement. Level of implementation as measured with our own scale and the ACIC was not associated with health outcomes. A higher level of implementation measured with the PACIC was positively associated with improved self-management capabilities, but this association was not found for other outcomes. There was a wide variety in the implementation of RECODE, associated with barriers at individual, social, organisational and societal level. There was little association between extent of implementation and health outcomes.
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Affiliation(s)
- Melinde R S Boland
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Simone A Huygens
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Apostolos Tsiachristas
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- Health Economics Research Centre, Department of Population Health, University of Oxford, Oxford, UK
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Coert M G Blom
- Zorgdraad Foundation, Wijnand van Arnhemweg 54, Oosterbeek, The Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Maureen P M H Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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100
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Boland MRS, Kruis AL, Tsiachristas A, Assendelft WJJ, Gussekloo J, Blom CMG, Chavannes NH, Rutten-van Mölken MPMH. Cost-effectiveness of integrated COPD care: the RECODE cluster randomised trial. BMJ Open 2015; 5:e007284. [PMID: 26525419 PMCID: PMC4636669 DOI: 10.1136/bmjopen-2014-007284] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 07/06/2015] [Accepted: 08/21/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To investigate the cost-effectiveness of a chronic obstructive pulmonary disease (COPD) disease management (COPD-DM) programme in primary care, called RECODE, compared to usual care. DESIGN A 2-year cluster-randomised controlled trial. SETTING 40 general practices in the western part of the Netherlands. PARTICIPANTS 1086 patients with COPD according to GOLD (Global Initiative for COPD) criteria. Exclusion criteria were terminal illness, cognitive impairment, alcohol or drug misuse and inability to fill in Dutch questionnaires. Practices were included if they were willing to create a multidisciplinary COPD team. INTERVENTIONS A multidisciplinary team of caregivers was trained in motivational interviewing, setting up individual care plans, exacerbation management, implementing clinical guidelines and redesigning the care process. In addition, clinical decision-making was supported by feedback reports provided by an ICT programme. MAIN OUTCOME MEASURES We investigated the impact on health outcomes (quality-adjusted life years (QALYs), Clinical COPD Questionnaire, St. George's Respiratory Questionnaire and exacerbations) and costs (healthcare and societal perspective). RESULTS The intervention costs were €324 per patient. Excluding these costs, the intervention group had €584 (95% CI €86 to €1046) higher healthcare costs than did the usual care group and €645 (95% CI €28 to €1190) higher costs from the societal perspective. Health outcomes were similar in both groups, except for 0.04 (95% CI -0.07 to -0.01) less QALYs in the intervention group. CONCLUSIONS This integrated care programme for patients with COPD that mainly included professionally directed interventions was not cost-effective in primary care. TRIAL REGISTRATION NUMBER Netherlands Trial Register NTR2268.
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Affiliation(s)
- Melinde R S Boland
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Apostolos Tsiachristas
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Coert M G Blom
- Stichting Zorgdraad foundation, Oosterbeek, The Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Maureen P M H Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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