Bottom-up implementation of disease-management programmes: results of a multisite comparison.

OBJECTIVES: To evaluate the implementation of three regional disease-management programmes on chronic obstructive pulmonary disease (COPD) based on bottlenecks experienced in professional practice. METHODS: The authors performed a multisite comparison of three Dutch regional disease-management programmes combining patient-related, professional-directed and organisational interventions. Process (Assessing Chronic Illness Care survey) and outcome (disease specific quality of life (clinical COPD questionnaire (CCQ); chronic respiratory questionnaire (CRQ)), Medical Research Council dyspnoea and patients' experiences) data were collected for 370 COPD patients and their care providers. RESULTS: Bottlenecks in region A were mostly related to patient involvement, in region B to organisational issues and in region C to both. Selected interventions related to identified bottlenecks were implemented in all programmes, except for patient-related interventions in programme A. Within programmes, significant improvements were found on dyspnoea and patients' experiences with practice nurses. Outcomes on quality of life differed between programmes: programme A did not show any significant improvements; programme B did show any significant improvements on CCQ total (p<0.001), functional (p=0.011) and symptom (p<0.001), CRQ fatigue (p<0.001) and emotional scales (p<0.001); in programme C, CCQ symptom (p<0.001) improved significantly, whereas CCQ mental score (p<0.001) deteriorated significantly. Regression analyses showed that programmes with better implementation of selected interventions resulted in relatively larger improvements in quality of life (CCQ). CONCLUSIONS: Bottom-up implementation of COPD disease-management programmes is a feasible approach, which in multiple settings leads to significant improvements in outcomes of care. Programmes with a better fit between implemented interventions and bottlenecks showed more positive changes in outcomes.

A model to evaluate quality and effectiveness of disease management.

Disease management has emerged as a new strategy to enhance quality of care for patients suffering from chronic conditions, and to control healthcare costs. So far, however, the effects of this strategy remain unclear. Although current models define the concept of disease management, they do not provide a systematic development or an explanatory theory of how disease management affects the outcomes of care. The objective of this paper is to present a framework for valid evaluation of disease-management initiatives. The evaluation model is built on two pillars of disease management: patient-related and professional-directed interventions. The effectiveness of these interventions is thought to be affected by the organisational design of the healthcare system. Disease management requires a multifaceted approach; hence disease-management programme evaluations should focus on the effects of multiple interventions, namely patient-related, professional-directed and organisational interventions. The framework has been built upon the conceptualisation of these disease-management interventions. Analysis of the underlying mechanisms of these interventions revealed that learning and behavioural theories support the core assumptions of disease management. The evaluation model can be used to identify the components of disease-management programmes and the mechanisms behind them, making valid comparison feasible. In addition, this model links the programme interventions to indicators that can be used to evaluate the disease-management programme. Consistent use of this framework will enable comparisons among disease-management programmes and outcomes in evaluation research.

Routine testing for Chlamydia trachomatis on Curaçao, Netherlands Antilles.

OBJECTIVE: Although genital Chlamydia trachomatis infection is most often asymptomatic, early treatment may prevent serious complications. For screening or routine testing to be cost effective, the prevalence of the infection must not be too low. STUDY DESIGN: On Curaçao, Netherlands Antilles, the prevalence of chlamydial infection in 205 asymptomatic women of reproductive age, who were seen by a general practitioner or gynecologist for a gynecologic examination was measured. RESULTS: The overall prevalence was found to be 5.4% (95% confidence interval 2.7% to 9.4%) with the enzyme-linked immunosorbent assay method. Of all possible predictors of a chlamydial infection, only young age (< 25 years, prevalence 10.3%) seemed to be indicative of such an infection. CONCLUSION: Routine testing for Chlamydia trachomatis in sexually active women on Curaçao and on other Caribbean islands is indicated for women < 25 years old.