Designing patient-related interventions in COPD care: empirical test of a theoretical model.

OBJECTIVES: The aim of this exploratory study was to test the applicability of a theoretical model to develop patient-related interventions. In this model knowledge, psychosocial mediators, self-efficacy and behaviour are determinants of patient-related interventions. METHODS: The model was tested on 278 patients with mild or moderate chronic obstructive pulmonary disease (COPD), recruited in a primary care setting. Hierarchical regression analyses were applied using data from self-reported questionnaires and clinical data from an electronic data registry. RESULTS: Knowledge, psychosocial mediators, self-efficacy and behaviour proved to be, to a moderate degree, predictors of outcomes in COPD care. Moreover, physical activity appeared to be a significant predictor for all clinical and functional outcomes. CONCLUSION: Theoretically expected associations of patient-related interventions are existent in patients with mild or moderate COPD. The application of theoretical models in designing patient-directed interventions in COPD care is therefore feasible. PRACTICE IMPLICATIONS: More attention should be paid to the patterns of physical activity in patients with mild to moderate COPD. The results of this study are also useful in the development of patient-related interventions. Future interventions should be designed along the lines of theory on behaviour change, such as social cognitive theory.

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.

Identifying potentially cost effective chronic care programs for people with COPD.

OBJECTIVE: To review published evidence regarding the cost effectiveness of multi-component COPD programs and to illustrate how potentially cost effective programs can be identified. METHODS: Systematic search of Medline and Cochrane databases for evaluations of multi-component disease management or chronic care programs for adults with COPD, describing process, intermediate, and end results of care. Data were independently extracted by two reviewers and descriptively summarized. RESULTS: Twenty articles describing 17 unique COPD programs were included. There is little evidence for significant improvements in process and intermediate outcomes, except for increased provision of patient self-management education and improved disease-specific knowledge. Overall, the COPD programs generate end results equivalent to usual care, but programs containing >or=3 components show lower relative risks for hospitalization. There is limited scope for programs to break-even or save money. CONCLUSION: Identifying cost effective multi-component COPD programs remains a challenge due to scarce methodologically sound studies that demonstrate significant improvements on process, intermediate and end results of care. Estimations of potential cost effectiveness of specific programs illustrated in this paper can, in the absence of 'perfect data', support timely decision-making regarding these programs. Nevertheless, well-designed health economic studies are needed to decrease the current decision uncertainty.

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.