Integrated disease management COPD: rol van zelfmanagement, training en eHealth Niels Chavannes MD PhD Associate Professor Department of Public Health and Primary Care Leiden University Medical Center The Netherlands
May 24, 2015
Integrated disease management COPD:rol van zelfmanagement, training en eHealth
Niels Chavannes MD PhD
Associate Professor
Department of Public Health and Primary Care
Leiden University Medical Center
The Netherlands
ERS/ATS Standards for COPD ERJ 2004
• Patients with COPD want active involvement in decisionmaking; are more compliant when involved1
• Fear of hospitalisation and passive behaviour hampers detection exacerbations2
• Recognition personal coping style leads to more effective treatment3
1 Booker Eur Respir Rev 20062 Adams et al Prim Care Resp J 20063 Osman et al Eur Respir Rev 2006
Patiënten perspectief
Evidence voor zelfmanagement
• Cochrane Review; Effing (2009): self-management education leads to reduction in hospital admissions (OR 0.64, NNT 10-24)
• significant improvements on SGRQ (-2.58 [-5.1, -0.02]) and small effect BORG-scale (-0.53 [-0.96, -0.1])
• Inconclusive effects on exacerbations, ED visits, lung function and medication
• Cochrane Review; Walters (2010): exacerbation action plans with limited patient education lead to better recognition (MD 2.5 [1.04, 3.96]) and self initiating action in severe exacerbations (MD 1.5 [ 0.62, 2.38])
• No evidence for reduced healthcare utilisation or improved HRQoL; => should be part of multi-faceted self-management program or ongoing case management
Evidence voor zelfmanagement
Minder ziekenhuisopnames bij ernstig COPD
• Bourbeau (Arch Int Med 2003): self-management in severe
COPD leads to 40% reduction in hospital admissions
• Rice (AJRCCM 2010): relatively simple DM program for
severe COPD reduces hospitalizations and ED visits after one
year by 41% (MD 0.34 [0.15, 0.52], p<0.001)
• 1-1.5hr education, exacerbation action plan, case manager
Recente ontwikkelingen
• Bisschoff (Thorax 2011): In severe COPD, adherence to
written exacerbation action plan (40%) is associated with
reduction in recovery time (-5.8 days, p=0.0001)
• No effect on unscheduled healthcare utilisation
• Trappenburg (Thorax 2011): Individualised action plan in
moderate-severe COPD decreases impact of exacerbations
on health status (HR 1.58 [0.96, 2.6]) and tends to accelerate
recovery (-3.7 days [-7.3, -0.04])
• Action plan plus ongoing support by case manager
Nut van eHealth?
• Trappenburg (Telemed J E Health 2008): Telemonitoring in
severe COPD decreases hospitalisations (-0.11 +/- 1.16 vs.
control +0.27 +/- 1.0, p = 0.02) and exacerbations (-0.35 +/-
1.4 vs. control +0.32 +/- 1.2, p = 0.004)
• No effect on HRQoL, but baseline differences flawed study
• Bartoli (Telemed J E Health 2009): rethinking of organization
structure mandatory to maximize technological benefits
• Pinnock (PCRJ 2011): patients perceive telemonitoring as
improving access to professional care, but clinicians
concerned about over-treatment and how best to organise
• In participants with a history of admission for exacerbations of
COPD, telemonitoring was not effective in postponing
admissions and did not improve quality of life.
• The positive effect of telemonitoring seen in previous trials
could be due to enhancement of the underpinning clinical
service rather than the telemonitoring communication.
Internet-support
Methode
Participants:
• COPD (GOLD criteria) patiënten
Interventie:
• Integrated Disease Management
Controle:
• Usual care
Outcome:
• Primair: Kwaliteit van leven, inspanningstolerantie,
exacerbatie gerelateerde uitkomsten
Interventie
Integrated disease management?
• Multidisciplinair (≥ 2 zorgverleners)
• Multi treatment (≥ 2 componenten)
• Duur ≥ 3 maanden
Multi treatment (≥ 2 componenten)
1. Educatie/zelf-management
2. Trainen
3. Psychosociaal
4. Stoppen met roken
5. Medicatie
6. Dietetiek
7. Follow-up en/of communicatie
8. Multidisciplinair team (i.e. meetings)
9. Financiele interventies (fees for providing)
EPOC 2008
Geincludeerde studies (N=26)
Kwaliteit van leven
Inspanningstolerantie
MCID = 35 meter
Exacerbatie uitkomsten
Aantal exacerbaties: geen statistisch sign verschil
Exacerbatie uitkomsten
Aantal ziekenhuisopnames, long gerelateerd:
Number needed to treat = 15
Long gerelateerde opnames
Exacerbatie uitkomsten
Aantal dagen in ziekenhuis: gemiddeld 4 dagen korter
Meta-analysis (1)
NOTE: Weights are from random effects analysis
Overall (I-squared = 93.0%, p = 0.000)
Dewan e.a. 2011
Bourbeau e.a. 2006
Gallefoss & Bakke 2006
Hoogendoorn e.a. 2010
Study
Chuang e.a. 2011
Ninot e.a. 2011
Steuten e.a. 2006
Poole e.a. 2003
-898 (-1566, -231)
Costs
-1042 (-1629, -455)
-2630 (-4282, -978)
-1048 (-1189, -907)
2229 (-1133, 5865)
(euros) (95% CI)
-2019 (-2406, -1633)
652 (-728, 2056)
-47 (-281, 188)
-2004 (-10030, 6022)
100.00
%
17.54
9.04
20.11
3.08
Weight
19.00
10.77
19.79
0.67
-898 (-1566, -231)
Costs
-1042 (-1629, -455)
-2630 (-4282, -978)
-1048 (-1189, -907)
2229 (-1133, 5865)
(euros) (95% CI)
-2019 (-2406, -1633)
652 (-728, 2056)
-47 (-281, 188)
-2004 (-10030, 6022)
100.00
%
17.54
9.04
20.11
3.08
Weight
19.00
10.77
19.79
0.67
Favours DM Favours control 0-5000 5000
Difference of health care utilization costs
Meta-analysis (2)
NOTE: Weights are from random effects analysis
Overall (I-squared = 69.5%, p = 0.006)
Bourbeau e.a. 2006
Poole e.a. 2003
Dewan e.a. 2011
Study
Gallefoss & Bakke 2006
Hoogendoorn e.a. 2010
Ninot e.a. 2011
-1060 (-2040, -80)
-2448 (-3153, -1742)
-2004 (-10030, 6022)
-936 (-1471, -402)
(euros) (95% CI)
-708 (-2287, 871)
-424 (-2084, 1417)
1150 (-1636, 3977)
Costs
100.00
27.37
1.42
29.13
Weight
17.45
15.81
8.82
%
-1060 (-2040, -80)
-2448 (-3153, -1742)
-2004 (-10030, 6022)
-936 (-1471, -402)
(euros) (95% CI)
-708 (-2287, 871)
-424 (-2084, 1417)
1150 (-1636, 3977)
Costs
100.00
27.37
1.42
29.13
Weight
17.45
15.81
8.82
%
Favours DM Favours control 0-5000 5000
Difference in hospitalization costs
Web-based dossier
Empowerment van participerende patiënten
Op maat gesneden interventie, ondersteund door eHealth
• Koff (ERJ 2009): A proactive integrated care program in (very)
severe COPD improves SGRQ by -10.3 units [-17.4, -3.1] vs.
-0.6 units [-6.5, 5.3] p=0.018) in usual care
• Health buddy system identifying all exacerbations correctly
• Chavannes (PCRJ 2009): Integrated disease management in
mild to moderate COPD with MRC Dyspnoea score >2
improved SGRQ by -13.4 units ([-20.8, -6.1] p=0.002) vs. -0.3
units [-5.5, 4.9] p=0.9) in usual care
• Tailored intervention: personal goals, capabilities & needs, aimed
at improving and sustaining health status
Concluderend:
-Zelfmanagement vermindert ziekenhuisopnames bij
ernstig COPD
-Actieplannen bevorderen herkenning en herstel van
exacerbaties
-Integrated disease management verbetert KvL en
inspanningstolerantie; training >>zelfmanagement
-Integrated disease management vermindert aantal en
duur van ziekenhuisopnames=> minder ziektekosten!
-Behandeling op maat is de toekomst
-eHealth is een middel, niet het doel