BACKGROUND: People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations.
OBJECTIVES: To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes.
SEARCH METHODS: We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020.
SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region.
MAIN RESULTS: Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution.
AUTHORS' CONCLUSIONS: This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.
OBJETIVO: En Australia, muchos investigadores de la salud y responsables políticos están abogando por las etiquetas de advertencia por mandato sobre las bebidas alcohólicas. Daños relacionados con el alcohol son motivo de especial preocupación entre los adolescentes. El objetivo de este artículo es revisar la bibliografía disponible y evaluar el impacto de las advertencias sobre el consumo de alcohol adolescente, el conocimiento y el comportamiento.
ENFOQUE: Se realizó una revisión sistemática de la literatura. Se realizaron búsquedas en bases de datos académicas para los artículos de investigación relevantes. Criterios amplios de inclusión se aplicaron debido a la relativa escasez de literatura.
CONCLUSIÓN: La introducción de las etiquetas de advertencia de alcohol ha demostrado estar asociada con una mayor conciencia inicial de alcohol ley advertencia en la etiqueta, la exposición a las etiquetas, y un mayor reconocimiento de los mensajes de la etiqueta de advertencia. Por el contrario, se observó poco cambio en cuanto a las creencias sobre los riesgos del consumo de alcohol o la participación en las conductas de riesgo relacionadas con el alcohol. Estos hallazgos son similares a los reportados entre muestras de adultos. Sin embargo, la gran mayoría de la literatura se originó a partir del mismo grupo de autores, con muestras extraídas de una misma región geográfica. Esto puede limitar en gran medida la generalisablity de estos hallazgos.
CONSECUENCIAS: La introducción de las etiquetas de advertencia de alcohol en Australia pueden aumentar la sensibilización sobre los riesgos del consumo de alcohol entre los adolescentes, sin embargo, parece poco probable que cambien los comportamientos potable adolescentes o creencias sobre los riesgos relacionados con el alcohol estas etiquetas. Se necesita más investigación en múltiples contextos culturales para confirmar estos hallazgos. Etiquetas de advertencia de alcohol deben considerarse como sólo un aspecto de una serie de otras estrategias comprobadas para modificar sus conocimientos, actitudes y comportamientos.
Antecedentes: el manejo de enfermedades programas pueden mejorar la calidad de la atención prestada a los pacientes con enfermedades crónicas, como enfermedad pulmonar obstructiva crónica (EPOC). El objetivo de esta revisión sistemática fue evaluar la efectividad de manejo de la enfermedad EPOC-programas.
MÉTODOS: Se realizó una búsqueda computarizada en MEDLINE, EMBASE, CINAHL, PsychINFO, y la Cochrane Library (CENTRAL) para las intervenciones de los estudios que evalúan cumplen nuestra definición operativa de la gestión de la enfermedad: la educación del paciente, 2 o más componentes de intervención diferentes, dos o más atención de la salud profesionales involucrados en la atención de los pacientes y la intervención dura 12 meses o más. Programas realizados en el único hospital y los pacientes que reciben cuidados paliativos dirigidos fueron excluidos. Dos revisores evaluaron 12.749 títulos y una revisión exhaustiva 139 artículos, entre éstos, los datos de 13 estudios fueron incluidos y se extrae. Los resultados clínicos considerados fueron muerte por cualquier causa, la función pulmonar, la capacidad de ejercicio (a pie), la salud relacionados con la calidad de vida, los síntomas, exacerbaciones de la EPOC y el uso de servicios de salud. Un meta-análisis de la capacidad de ejercicio y la mortalidad por cualquier causa se ha realizado mediante modelos de efectos aleatorios.
RESULTADOS: Los estudios incluidos fueron 9 ensayos controlados aleatorios, un ensayo controlado, y 3 controlados antes-después del proceso. Los resultados indican que los programas de manejo de la enfermedad estudiada mejoró significativamente la capacidad de ejercicio (32,2 m, 95% intervalo de confianza [IC], 4,1 hasta 60,3), la disminución del riesgo de hospitalización, y moderada mejora de la salud relacionados con la calidad de vida. Todas las causas de la mortalidad no difirió entre los grupos (odds-ratio 0,84, IC del 95%, 0,54-1,40).
Conclusión: el manejo de enfermedades EPOC programas modesta mejora de la capacidad de ejercicio, la salud relacionados con la calidad de vida, y los ingresos hospitalarios, pero no todas las causas de mortalidad. Los estudios futuros deberían explorar los elementos o características específicas de estos programas que llevan el mayor beneficio.
OBJETIVO: Desarrollar un meta-análisis para determinar la efectividad de la rehabilitación en pacientes con enfermedad pulmonar obstructiva crónica (EPOC).
FUENTES DE DATOS: Medline, CINHAL y búsquedas Cochrane Library para los ensayos de rehabilitación para pacientes con EPOC. Los resúmenes presentados en las reuniones nacionales y las listas de referencias de artículos pertinentes fueron revisadas.
SELECCIÓN DE ESTUDIOS: Se incluyeron los estudios: ensayos fueron aleatorios, los pacientes fueron sintomáticos con el volumen espiratorio forzado en un segundo (FEV1) <70% o FEV1 dividido por la capacidad vital forzada (VEF1/CVF) <70% predicho, el grupo de rehabilitación recibido por lo menos 4 semanas de rehabilitación, el grupo control no recibió rehabilitación, y medidas de resultado incluyen la capacidad de ejercicio o falta de aliento. Se identificaron 69 ensayos, de los cuales 20 ensayos se incluyeron en el análisis final.
EXTRACCIÓN DE DATOS: Efecto de la rehabilitación se calcula como el tamaño del efecto estandarizado (ES) utilizando técnicas de estimación de efectos aleatorios.
RESULTADOS: Los grupos de rehabilitación de 20 ensayos (979 pacientes) fue significativamente mejor que los grupos de control en la prueba de caminata (ES = 0,71, IC del 95% intervalo de confianza [IC 95%], 0,43 a 0,99). Los grupos de rehabilitación de 12 ensayos (723 pacientes) que utilizaron el Chronic Respiratory Disease Questionnaire tuvieron menos dificultad para respirar que los que los grupos de control (ES = 0,62, IC 95%, 0,35 a 0,89). Los ensayos que utilizaron entrenamiento muscular respiratorio sólo no mostró diferencias significativas entre la rehabilitación y el grupo control, mientras que los ensayos que usaron al menos las extremidades inferiores de entrenamiento mostraron que los grupos de rehabilitación fue significativamente mejor que los grupos de control en el andar de prueba y dificultad para respirar. Los ensayos que incluyeron pacientes con EPOC grave demostró que los grupos de rehabilitación fue significativamente mejor que los grupos de control sólo cuando los programas de rehabilitación de entre 6 meses o más. Los ensayos que incluyeron pacientes con EPOC leve / moderado mostró que los grupos de rehabilitación fue significativamente mejor que con grupos de control tanto a corto como los programas de rehabilitación a largo plazo.
Conclusión: los pacientes con EPOC que reciben la rehabilitación tiene una capacidad para el ejercicio mejor y sufren menos la falta de aire que los pacientes que no reciben la rehabilitación. Los pacientes con EPOC pueden beneficiarse de los programas de rehabilitación que incluyan al menos las extremidades inferiores de formación. Los pacientes con insuficiencia hepática leve / moderada EPOC se benefician de la rehabilitación a corto y largo plazo, mientras que los pacientes con EPOC grave pueden beneficiarse de los programas de rehabilitación de al menos 6 meses.
People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations.
OBJECTIVES:
To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes.
SEARCH METHODS:
We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020.
SELECTION CRITERIA:
Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration.
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region.
MAIN RESULTS:
Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution.
AUTHORS' CONCLUSIONS:
This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.
