Effectiveness of COPD disease management programs: a systematic review and metaanalysis

1
Effectiveness of COPD disease management
programs a systematic review and meta-analysis

• 8th Annual Conference on Integrated Care
• 6 March 2008, Goteborg
• I. Peytremann Bridevaux, MD, MPH, DSc
• Healthcare Evaluation Unit, Institute of Social
  and Preventive Medicine, University of Lausanne
  and Centre Hospitalier Universitaire Vaudois

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• Background

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Chronic Obstructive Pulmonary Disease (COPD)
definition

• GOLD (Global Initiative on Chronic Obstructive
  Lung Disease) definition
• COPD is a progressive but preventable chronic
  disease most frequently caused by smoking
• COPD is characterized by
• a progressive airflow limitation, which is not
  fully reversible
• a rapid decline in lung function
• a local and systemic inflammatory process not
  responsive to corticosteroids

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COPD epidemiology

• Prevalence
• men gt women
• increases with age 8 40-60 years, 13 gt60
  years
• Morbidity
• often associated with decreased quality-of-life
• frequent cause of emergency visits and
  hospitalization
• Mortality a chronic disease which mortality
  increases over time

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Mortality and COPD a continuing increase
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COPD treatment

• Treatments depend on the severity of the disease
• Pulmonary rehabilitation programs
• include physical activity, education and diet
  recommendations
• often last lt 4 months
• bring benefits to the patients in terms of
  exercise capacity, quality-of-life (Lacasse
  2006), limited in time, however

This may suggest that more comprehensive and
sustained programs might help maintain benefits
over time.
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Disease Management
 Disease management is a system of coordinated
health care interventions and communications for
populations with conditions in which patient
self-care efforts are significant. 
(www.dmaa.org) Disease Management components
include

• processes of population identification
• use of evidence-based practice guidelines
• multidisciplinarity (collaboration between
  healthcare providers)
• patient self-management education
• evaluation with process and outcomes measurement
• routine reporting/feedback loop

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Objective

• ? To conduct a systematic review of the
  effectiveness of COPD disease management
  programs, using an operational definition of
  disease management defined a priori. When
  appropriate, to perform a meta-analysis.

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• Methods

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Operational definition

• Intervention with gt 2 components (eg action plan
  and phone-call follow-up)
• gt 2 healthcare professionals involved (ex
  physician-nurse, physician-physical therapist)
• Education (including self-management)
• Minimal duration of 12 months
• Exclusions hospital only programs, palliative
  care patients, lt18 years

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Study inclusions

• Population Adult COPD patients
• Intervention All interventions meeting our
  operational definition of DM
• Study design RCT, controlled clinical trials,
  before/after study, interrupted time series
• Outcomes Lung functions, exercise capacity,
  quality-of- life, symptoms, COPD exacerbations,
  healthcare utilization, mortality

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Literature search and data extraction

• Medline (OVID)
• EMBASE
• CINHAL
• PsychINFO
• Cochrane Library
• reference lists
• 3-steps selection procedures (title, abstract,
  full text)
• 2 authors independently extracted data using a
  standardized grid

Dec 2006
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Synthesis of results

• 1. Systematic review part
• lung functions (FEV1)
• exercise capacity (6-minutes walking tests)
• quality-of-life
• symptoms, COPD exacerbations
• healthcare utilization
• 2. Meta-analysis part exercise capacity and
  all-cause mortality
• pooled mean difference and mortality OR (random
  effect)
• assessment of heterogeneity (Cochrans Q test, I2
  statistics)
• publication bias (funnel plot)

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• Results

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Flow-chart
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Studies
Post-Bronchodilator values
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Components of Interventions
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Lung functions

• Forced expiratory volume in 1 second (FEV1 of
  predicted value, or liters)
• 7 studies considered that outcome
• 1 study showed statistically significant
  improvements for the disease management group
  (Rea)

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Quality-of-life (QoL)

• All except 1 study measured quality-of-life
• Instruments used
• St-Georges Respiratory Questionnaire (SGRQ)
• Chest Respiratory Questionnaire (CRQ)
• Significant effect in gt 1 domain 5 studies
• Effect on subjective health (1), or when using 4
  non-validated QoL questions (1)
• No effect on quality-of-life 4 studies

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Symptoms and COPD exacerbations

• 7 out of 12 studies assessed respiratory symptoms
  (dyspnea, cough, sputum)
• Only 2 showed a beneficial effect (Guell, Zajac)
• 1 of the 3 studies reporting COPD exacerbations
  suggested a decrease in the mean number of
  exacerbations per patient (Guell)

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Healthcare utilization

• 9 out of 12 studies reported gt 1 measure of
  healthcare utilization
• 6 studies decreased risk of hospitalization, and
  also number of days in hospital
• 3 studies did not demonstrate a beneficial effect
  on hospitalization and/or ambulatory/emergency
  visits (Engstrom, Guell, Ries)

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12 months walking distances (meters) random
effects mean difference
















32m (4-60)

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12 months all-cause mortalityrandom effects
odds ratios (OR)











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• Discussion and conclusion

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Discussion

• COPD disease management programs are effective
• modestly but significantly improve exercise
  capacity
• reduce the risk of hospitalization
• improve quality-of-life
• All those results are particularly interesting
  because COPD worsens irremmediably and only
  partly responds to treatment

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Conclusion

• In the future, studies should try to
• use consistent disease management definitions
• describe the components of the intervention
• have adequate power
• have longer follow-up
• systematically consider and appropriately measure
  key clinical end-points
• measure economic indicators

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Thank you for your attention !

• Peytremann-Bridevaux I, Staeger P, Bridevaux PO,
  Ghali W, Burnand B. Effectiveness of COPD disease
  management programs systematic review and
  meta-analysis. Am J Med 2008 (in press)

Questions?