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Integrated disease management COPD: rol van zelfmanagement , training en eHealth

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.

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Integrated disease management COPD: rol van zelfmanagement , training en eHealth

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  1. Integrated disease management COPD:rol van zelfmanagement, training en eHealth Niels Chavannes MD PhD AssociateProfessor Department of Public Health and Primary Care LeidenUniversityMedical Center The Netherlands

  2. ERS/ATS Standards for COPD ERJ 2004

  3. 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 EurRespir Rev 2006 2 Adams et al Prim Care Resp J 2006 3 Osman et al EurRespir Rev 2006

  4. 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

  5. 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

  6. 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

  7. Recente ontwikkelingen • Bisschoff (Thorax 2011): In severe COPD, adherence to writtenexacerbationaction plan (40%) is associatedwithreduction in recovery time (-5.8 days, p=0.0001) • No effect onunscheduledhealthcareutilisation • Trappenburg (Thorax 2011): Individualisedaction plan in moderate-severe COPD decreases impact of exacerbationsonhealth status (HR 1.58 [0.96, 2.6]) and tends to acceleraterecovery (-3.7 days [-7.3, -0.04]) • Action plan plus ongoing support by case manager

  8. 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

  9. 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.

  10. Methode Participants: • COPD (GOLD criteria) patiënten Interventie: • IntegratedDisease Management Controle: • Usual care Outcome: • Primair: Kwaliteit van leven, inspanningstolerantie, exacerbatie gerelateerde uitkomsten

  11. Interventie Integrateddisease management? • Multidisciplinair (≥ 2 zorgverleners) • Multi treatment (≥ 2 componenten) • Duur ≥ 3 maanden

  12. Multi treatment (≥ 2 componenten) • Educatie/zelf-management • Trainen • Psychosociaal • Stoppen met roken • Medicatie • Dietetiek • Follow-up en/of communicatie • Multidisciplinair team (i.e. meetings) • Financieleinterventies (fees for providing) EPOC 2008

  13. Geincludeerde studies (N=26)

  14. Kwaliteit van leven

  15. Inspanningstolerantie MCID = 35 meter

  16. Exacerbatie uitkomsten Aantal exacerbaties: geen statistisch sign verschil

  17. Exacerbatie uitkomsten Aantal ziekenhuisopnames, long gerelateerd:

  18. Number needed to treat = 15 Long gerelateerdeopnames

  19. Exacerbatie uitkomsten Aantal dagen in ziekenhuis: gemiddeld 4 dagen korter

  20. Meta-analysis (1)

  21. Meta-analysis (2)

  22. Web-based dossier

  23. Empowerment van participerende patiënten

  24. Op maat gesneden interventie, ondersteund door eHealth • Koff (ERJ 2009): A proactiveintegrated 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 exacerbationscorrectly • 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

  25. Concluderend: -Zelfmanagement vermindert ziekenhuisopnames bij ernstig COPD -Actieplannen bevorderen herkenning en herstel van exacerbaties -Integrateddisease management verbetert KvL en inspanningstolerantie; training >>zelfmanagement -Integrateddisease management vermindert aantal en duur van ziekenhuisopnames=> minder ziektekosten! -Behandeling op maat is de toekomst -eHealth is een middel, niet het doel

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