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
Patiënten perspectief
• 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 2006
2 Adams et al Prim Care Resp J 2006
3 Osman et al Eur Respir Rev 2006
Evidence voor zelfmanagement
•Cochrane Review; Effing (2009): selfmanagement 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
Evidence 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
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
Internet-support
• 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.
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)
Difference of health care utilization costs
Costs
%
Study
(euros) (95% CI)
Weight
Steuten e.a. 2006
-47 (-281, 188)
19.79
Hoogendoorn e.a. 2010
2229 (-1133, 5865)
3.08
Ninot e.a. 2011
652 (-728, 2056)
10.77
Chuang e.a. 2011
-2019 (-2406, -1633)
19.00
Gallefoss & Bakke 2006
-1048 (-1189, -907)
20.11
Bourbeau e.a. 2006
-2630 (-4282, -978)
9.04
Dewan e.a. 2011
-1042 (-1629, -455)
17.54
Poole e.a. 2003
-2004 (-10030, 6022)
0.67
Overall (I-squared = 93.0%, p = 0.000)
-898 (-1566, -231)
100.00
NOTE: Weights are from random effects analysis
-5000
Favours DM
0
5000
Favours control
Meta-analysis (2)
Difference in hospitalization costs
Costs
%
Study
(euros) (95% CI)
Weight
Hoogendoorn e.a. 2010
-424 (-2084, 1417)
15.81
Ninot e.a. 2011
1150 (-1636, 3977)
8.82
Gallefoss & Bakke 2006
-708 (-2287, 871)
17.45
Bourbeau e.a. 2006
-2448 (-3153, -1742)
27.37
Dewan e.a. 2011
-936 (-1471, -402)
29.13
Poole e.a. 2003
-2004 (-10030, 6022)
1.42
Overall (I-squared = 69.5%, p = 0.006)
-1060 (-2040, -80)
100.00
NOTE: Weights are from random effects analysis
-5000
Favours DM
0
5000
Favours control
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