Integrated disease management for chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory (lung), disabling disease which affects a lot of people worldwide and causes millions of deaths every year. People with COPD suffer differing levels of impairment, daily complaints/symptoms and number of exacerbations.

Different health care providers, such as doctors, nurses and physiotherapists, typically provide different components of care (for example medication, self management and education, exercise training) to people with COPD. The aim of an integrated disease management (IDM) program is to establish a program of different components of care in which different health care providers are co-operating and collaborating to provide efficient and good quality care.

Review question

We wished to determine the effect of such a program on quality of life, exercise tolerance and the number of exacerbations. We have chosen these outcomes as they are most important for people with COPD.

What we found

We evaluated 26 studies in 2997 people with COPD. Overall the evidence found was of high to moderate quality. The trials were conducted in 11 different countries. The average age of participants was 68 years, 68% of participants were men and the severity of COPD on average was severe (according to lung function measures). Some of the trials took place in GP clinics and some in hospitals. Overall, the studies were of good to moderate methodological quality.

People who participated in an IDM program had better quality of life and improved their exercise tolerance after 12 months. Furthermore, in participants treated with such a program, the number of hospital admissions related to exacerbations decreased and the total number of hospital days was reduced by three days. We found no evidence of an effect on mortality.

The results support an IDM program for people with COPD to optimize quality of life and exercise tolerance.

This plain language summary is up-to-date as of April 2012.

Authors' conclusions: 

In these COPD participants, IDM not only improved disease-specific QoL and exercise capacity, but also reduced hospital admissions and hospital days per person.

Read the full abstract...
Background: 

In people with chronic obstructive pulmonary disease (COPD) there is considerable variation in symptoms, limitations and well-being, which often complicates medical care. To improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations, a multidisciplinary program including different elements of care is needed.

Objectives: 

To evaluate the effects of integrated disease management (IDM) programs or interventions in people with COPD on health-related QoL, exercise tolerance and number of exacerbations.

Search strategy: 

We searched the Cochrane Airways Group Register of trials, CENTRAL, MEDLINE, EMBASE and CINAHL for potentially eligible studies (last searched 12 April 2012).

Selection criteria: 

Randomized controlled trials evaluating IDM programs for COPD compared with controls were included. Included interventions consisted of multidisciplinary (two or more health care providers) and multi-treatment (two or more components) IDM programs with a duration of at least three months.

Data collection and analysis: 

Two review authors independently assessed trial quality and extracted data; if required, we contacted authors for additional data. We performed meta-analyses using random-effects modeling. We carried out sensitivity analysis for allocation concealment, blinding of outcome assessment, study design and intention-to-treat analysis.

Main results: 

A total of 26 trials involving 2997 people were included, with a follow-up ranging from 3 to 24 months. Studies were conducted in 11 different countries. The mean age of the included participants was 68 years, 68% were male and the mean forced expiratory volume in one second (FEV1)% predicted value was 44.3% (range 28% to 66%). Participants were treated in all types of healthcare settings: primary (n = 8), secondary (n = 12), tertiary care (n = 1), and in both primary and secondary care (n = 5). Overall, the studies were of high to moderate methodological quality.

Compared with controls, IDM showed a statistically and clinically significant improvement in disease-specific QoL on all domains of the Chronic Respiratory Questionnaire after 12 months: dyspnea (mean difference (MD) 1.02; 95% confidence interval (CI) 0.67 to 1.36); fatigue (MD 0.82; 95% CI 0.46 to 1.17); emotional (MD 0.61; 95% CI 0.26 to 0.95) and mastery (MD 0.75; 95% CI 0.38 to 1.12). The St. George's Respiratory Questionnaire (SGRQ) for QoL reached the clinically relevant difference of four units only for the impact domain (MD -4.04; 95% CI -5.96 to -2.11, P < 0.0001). IDM showed a significantly improved disease-specific QoL on the activity domain of the SGRQ: MD -2.70 (95% CI -4.84 to -0.55, P = 0.01). There was no significant difference on the symptom domain of the SGRQ: MD -2.39 (95% CI -5.31 to 0.53, P = 0.11). According to the GRADE approach, quality of evidence on the SGRQ was scored as high quality, and on the CRQ as moderate quality evidence. Participants treated with an IDM program had a clinically relevant improvement in six-minute walking distance of 43.86 meters compared with controls after 12 months (95% CI 21.83 to 65.89; P < 0.001, moderate quality). There was a reduction in the number of participants with one or more hospital admissions over three to 12 months from 27 per 100 participants in the control group to 20 (95% CI 15 to 27) per 100 participants in the IDM group (OR 0.68; 95% CI 0.47 to 0.99, P = 0.04; number needed to treat = 15). Hospitalization days were significantly lower in the IDM group compared with controls after 12 months (MD -3.78 days; 95% CI -5.90 to -1.67, P < 0.001). Admissions and hospital days were graded as high quality evidence. No adverse effects were reported in the intervention group. No difference between groups was found on mortality (OR 0.96; 95%CI 0.52 to 1.74). There was insufficient evidence to refute or confirm the long term effectiveness of IDM.

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