Health technology assessment of asthma disease management programs

Chronic disease management programmes for adults with asthma

BACKGROUND

The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education.

OBJECTIVES

To evaluate the effectiveness of chronic disease management programmes for adults with asthma.

SEARCH METHODS

Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months.

DATA COLLECTION AND ANALYSIS

After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs).

MAIN RESULTS

A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes.

AUTHORS' CONCLUSIONS

There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

Indicators for childhood asthma in Spain, using the Rand method

OBJECTIVE

To develop quality indicators to measure asthma care in primary health care.

METHOD

A modified RAND was used, which included the systematic review of the literature in Embase, Cochrane and Pubmed Quality Agencies and Database. The work group identified the indicators, translated them into Spanish and resolved any duplicates. Each indicator is composed of several dimensions (access to care, clinical effectiveness, patient-centred quality and patient safety). A multidisciplinary panel of 98 professionals from all over Spain were invited to score each indicator using a Likert scale. After calculating the average and median of each indicator, this information was sent to those who responded (n=38) for a second round and further scoring. The agreement percentage for the group was obtained for each indicator.

RESULTS

Of the 105 asthma indicators reviewed, we selected 46 that were presented to the panel of experts. In both Delphi phases, 37.1% of the members of the initial panel of experts responded. Of these, 26 were primary care paediatricians, six were pulmonologists, three were nurses, two were pharmacists and one was an allergist. For 32 indicators, agreement exceeded 70% and seven of those scored highest for the various care aspects for asthmatic children.

CONCLUSION

Quality indicators are presented for the follow-up of asthma and their implementation in primary care, which have undergone a strict selection and agreement process by a multidisciplinary work group.

Strategies used by respiratory nurses to stimulate self-management in patients with COPD

AIMS AND OBJECTIVES

To gain an insight into strategies, adopted by Dutch respiratory nurses during clinic sessions, to improve self-management of patients with chronic obstructive pulmonary disease.

BACKGROUND

Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is therefore an important consideration. By applying specific strategies, respiratory nurses can play a major role in the promotion of self-management. Research has shown that respiratory nurses, who run clinics, have insufficient knowledge of evidence-based strategies that can be adopted to promote self-management among chronic obstructive pulmonary disease patients. It appears that respiratory nurses adopt their own strategies during clinic sessions.

DESIGN

A qualitative research study was carried out using Grounded Theory method.

METHODS

Data were collected during open interviews conducted by an external researcher with a nursing background. The interviews were analysed through coding after which categories were developed.

RESULTS

Fourteen respiratory nurses were interviewed. The results show that respiratory nurses emphasise quitting smoking during the consult. Attention is also paid to inhalation medication and techniques. Other self-management strategies that respiratory nurses use are: application of specific interviewing techniques, referring to other healthcare professionals and providing tools for coping with the illness in everyday life.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

The main emphasis during the clinic session is directed at quitting smoking. Other self-management strategies such as providing information regarding nutrition and exercise, instilling confidence and becoming an equal discussion partner, gain less attention. During the clinic session, respiratory nurses should also focus on these self-management strategies in addition to quitting smoking. Further research should be directed at self-management strategies used by respiratory nurses in relation to different characteristics of patients. In this way, a more patient-oriented form of consultation could be developed for chronic obstructive pulmonary disease patients.

Economic evaluation of pay-for-performance in health care: a systematic review

BACKGROUND

Pay-for-performance (P4P) intents to stimulate both more effective and more efficient health care delivery. To date, evidence on whether P4P itself is an efficient method has not been systematically analyzed.

OBJECTIVE

To identify and analyze the existing literature regarding economic evaluation of P4P.

DATA SOURCES

English, German, Spanish, and Turkish language literature were searched in the following databases: Business Source Complete, the Cochrane Library, Econlit, ISI web of knowledge, Medline (via PubMed), and PsycInfo (January 2000-April 2010).

STUDY SELECTION

Articles published in peer-reviewed journals and describing economic evaluations of P4P initiatives. Full economic evaluations, considering costs and consequences of the P4P intervention simultaneously, were the prime focus. Additionally, comparative partial evaluations were included if costs were described and the study allows for an assessment of consequences. Both experimental and observational studies were considered.

RESULTS

In total, nine studies could be identified. Three studies could be regarded as full economic evaluations, and six studies were classified as partial economic evaluations. Based on the full economic evaluations, P4P efficiency could not be demonstrated. Partial economic evaluations showed mixed results, but several flaws limit their significance. Ranges of costs and consequences were typically narrow, and programs differed considerably in design. Methodological quality assessment showed scores between 32% and 65%.

CONCLUSION

The results show that evidence on the efficiency of P4P is scarce and inconclusive. P4P efficiency could not be demonstrated. The small number and variability of included studies limit the strength of our conclusions. More research addressing P4P efficiency is needed.

The effectiveness and efficiency of disease management programs for patients with chronic diseases

Objective:

Disease management (DM) approach is increasingly advocated as a means of improving effectiveness and efficiency of healthcare for chronic diseases. To evaluate the evidence on effectiveness and efficiency of DM, evidence synthesis was carried out.

Methods:

To locate eligible meta-analyses and systematic reviews, we searched Medline, EMBASE, the Cochrane Library, SCI-EXPANDED, SSCI, A&HCI, DARE, HTA and NHS EED from 1995 to 2010. Two reviewers independently extracted data and assessed a study quality.

Results:

Twenty-eight meta-analyses and systematic reviews were included for synthesizing evidence. The proportion of articles which observed improvement with a reasonable amount of evidence was the highest at process (69%), followed by health services (63%), QOL (57%), health outcomes (51%), satisfaction (50%), costs (38%) and so on. As to mortality, statistically significant results were observed only in coronary heart disease. Important components in DM, such as a multidisciplinary approach, were identified.

Conclusion:

The evidence synthesized shows considerable evidence in the effectiveness and efficiency of DM programs in process, health services, QOL and so on. The question is no longer whether DM programs work, but rather which type or component of DM programs works best and efficiently in the context of each healthcare system or country.