Chronic obstructive pulmonary disease is one of the most common lung conditions and there are several Cochrane reviews of possible treatments. One of these, dealing with integrated disease management, was updated in September 2021 and we asked lead author Charlotte Poot from the Leiden University Medical Center in the Netherlands to tell us about the latest findings.
John: Hello, I'm John Hilton, senior editor at Cochrane. Chronic obstructive pulmonary disease is one of the most common lung conditions and there are several Cochrane reviews of possible treatments. One of these, dealing with integrated disease management, was updated in September 2021 and we asked lead author Charlotte Poot from the Leiden University Medical Center in the Netherlands to tell us about the latest findings.
Charlotte: Chronic obstructive pulmonary disease, or COPD for short, makes people feel short of breath, gives a persistent cough and can lead to more sputum than normal. As such, it has an enormous impact on people's lives. Their breathlessness limits their daily activities, they have to go for regular check-ups and they may need to depend on oxygen in the more severe stages of the disease. If their symptoms suddenly worsen, they are at risk for hospitalisation, worse quality of life and when not properly cared for, even, death.
COPD cannot be cured and progresses over time, so it is really important that care is focused on slowing down progression from all possible angles. These include directing the patient's care towards maintaining a healthy lifestyle, remaining physically active and quitting smoking. As such, many people are involved in the care of people with COPD, including respiratory physicians, physiotherapists, dieticians and specialised nurses. COPD care also needs to be individualised to the patient, meaning that care providers should look closely at what each individual needs.
However, in practice, this does not often happen. Usually only one or two health professionals are involved, care is focused either on a single component, such as proper medication use or physical activity and it is not always clear who takes care of which component. To address these issues, integrated disease management programs were developed, in which multiple healthcare professionals are involved and multiple disease components are addressed and taken care of.
The previous Cochrane review of this topic, in 2013, found that these programs, called IDM programs in short, can benefit people with COPD compared to usual care. However, the follow-up in those studies was generally not more than one year, so the reviewers could not conclude anything about the benefits beyond that time.
In updating the review, we have included all studies that evaluated an IDM program with a minimum duration of 3 months, with at least two different health professionals involved and addressing at least two different components of COPD care. We looked at a range of outcomes, in the short term, medium term, which we defined as approximately one year, and long-term, which was sometimes up to four years. We also assessed whether there were differences in outcomes for primary and secondary care and for different types of programs, such as those focusing more on physical activity versus those mainly focused on self-management.
We were able to include 52 studies, involving more than 21,000 people with COPD from 18 different countries. This is twice as many studies as the previous review, with several of the new studies using remote monitoring technology in their programs.
Our evidence continues to show that an IDM program probably results in a clinically meaningful better quality of life for patients. We also found that people's ability to exercise is probably improved, with people being able to walk an average of 45 meters further in four minutes when they received an IDM program. When looking at whether there was a difference in the number of people who need to be hospitalised because of their COPD, we saw fewer hospital admissions for lung diseases and fewer visits to the emergency department. However, we did not see a difference in the number of patients who died during the study, nor the number of times that the person's COPD worsened rapidly. Also, because few of the studies had follow-up beyond 15 months, we cannot be sure whether the benefits continue for longer and we also weren't able to determine which components were the best ones to use in an IDM program or the optimal length of such a program.
In conclusion, we now have sufficient evidence that IDM programs are beneficial for people with COPD in terms of quality of life, ability to exercise and hospitalisation in the short and medium term. There are still uncertainties about how long the effect of an IDM program lasts, and the ideal duration and components of an IDM program. So, although we have shown that IDM programs are of benefit to people with COPD, there is not a clear cut 'one size fits all' solution. Therefore, we encourage health decision makers to always start by assessing local needs and the already available interventions, and then to use our review to develop and implement an IDM program in a way that suits their context and their patients.
John: If you would like to use the review in this way, or find out more about the evidence within it, go online to Cochrane Library dot com and search 'integrated management for COPD' to find the full version.