Presentatie over: "Niels Chavannes MD PhD Associate Professor"— Transcript van de presentatie:
1Integrated disease management COPD: rol van zelfmanagement, training en eHealth Niels Chavannes MD PhDAssociate ProfessorDepartment of Public Health and Primary CareLeiden University Medical CenterThe Netherlands
4Patiënten perspectief Patients with COPD want active involvement in decisionmaking; are more compliant when involved1Fear of hospitalisation and passive behaviour hampers detection exacerbations2Recognition personal coping style leads to more effective treatment31 Booker Eur Respir Rev 20062 Adams et al Prim Care Resp J 20063 Osman et al Eur Respir Rev 2006
5Evidence 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
6Evidence voor zelfmanagement 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
7Minder ziekenhuisopnames bij ernstig COPD Bourbeau (Arch Int Med 2003): self-management in severe COPD leads to 40% reduction in hospital admissionsRice (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
8Recente 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 utilisationTrappenburg (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
9Nut van eHealth?Trappenburg (Telemed J E Health 2008): Telemonitoring in severe COPD decreases hospitalisations ( / vs. control /- 1.0, p = 0.02) and exacerbations ( /- 1.4 vs. control /- 1.2, p = 0.004)No effect on HRQoL, but baseline differences flawed studyBartoli (Telemed J E Health 2009): rethinking of organization structure mandatory to maximize technological benefitsPinnock (PCRJ 2011): patients perceive telemonitoring as improving access to professional care, but clinicians concerned about over-treatment and how best to organise
10Internet-supportIn 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.
18Exacerbatie uitkomsten Aantal exacerbaties: geen statistisch sign verschil
19Exacerbatie uitkomsten Aantal ziekenhuisopnames, long gerelateerd:
20Number needed to treat = 15 Long gerelateerde opnames
21Exacerbatie uitkomsten Aantal dagen in ziekenhuis: gemiddeld 4 dagen korter
22Subgroep analysesGéén verschil in effectiviteit tussen eerste of tweede lijnProgramma’s met trainingselement lieten grotere verbeteringen zien dan zelfmanagementprogramma’sIndien controlegroep ook één onderdeel van zorg bevatte (ipv usual care) was het effect minder groot
24Meta-analysis (1)I will no go on with the results of the meta-analysis of our review.The meta-analysis showed an overall health care utilzations savings of almost 900 euros. The pooled results lay in the left side of the 0 line, indicating a significant cost saving of the DM group.
25Meta-analysis (2)These savings are largely due to the hospitalization costs, which were about 1060 euros.
32Op maat gesneden interventie, ondersteund door eHealth Koff (ERJ 2009): A proactive integrated care program in (very) severe COPD improves SGRQ by units [-17.4, -3.1] vs units [-6.5, 5.3] p=0.018) in usual careHealth buddy system identifying all exacerbations correctlyChavannes (PCRJ 2009): Integrated disease management in mild to moderate COPD with MRC Dyspnoea score >2 improved SGRQ by units ([-20.8, -6.1] p=0.002) vs units [-5.5, 4.9] p=0.9) in usual careTailored intervention: personal goals, capabilities & needs, aimed at improving and sustaining health status
34Sustained effects of Integrated Disease Management on Health Status in primary care COPD-patients (Kruis IJCOPD 2010)*Intervention groupCCQ difference** / 95% CIp-valueControl groupAt 12 months-0.4[-0.6, -0.2]0.001+0.01[-0.2, 0.2]0.9At 24 months[-0.7, -0.1]0.004+.02[-0.4, 0.5]*paired samples T-test; p is considered significant at values<0.05;**MCID CCQ = -0.4CCQ, Clinical COPD Questionnaire
35Longterm effects of Integrated Disease Management in Bocholtz Study on Health Status in primary care COPD-patients with baseline CCQ>1*Intervention groupCCQ difference** / 95% CIp-valueControl groupAt 12 months-0.8[-1.1, -0.4]0.001-0.1[-0.3, 0.08]0.2At 24 months-0.9[-1.2, -0.5]-0.03[-0.5, 0.5]0.9*paired samples T-test; p is considered significant at values<0.05;**MCID CCQ = -0.4CCQ, Clinical COPD Questionnaire
36Longterm effects of Integrated Disease Management in Bocholtz Study on Health Status in primary care COPD-patients with baseline MRC>2*Intervention groupCCQ difference** / 95% CIp-valueControl groupAt 12 months-0.9[-1.4, -0.4]0.002+0.01[-0.3, 0.3]1At 24 months-1.2[-1.8, -0.5]0.004-0.02[-0.8, 0.8]*paired samples T-test; p is considered significant at values<0.05;**MCID CCQ = -0.4CCQ, Clinical COPD Questionnaire
37RECODE trial @ LUMC & EMC Netherlands Large RCT in primary care COPD patients (1100+) with two-year follow-upAssessing effectiveness of integrated disease management on health status (CCQ, SGRQ) and cost-effectivenessPowered to assess differential effects in subgroup (MRC>2)Supported by patient portal aimed at case managementFirst results expected beginning of 2014
39Concluderend:-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