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

Niels Chavannes MD PhDAssociate Professor

Department of Public Health and Primary CareLeiden 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