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.
Las revisiones sistemáticas anteriores han confirmado los beneficios tanto de la práctica de ejercicio y las intervenciones psicológicas en las personas con enfermedad pulmonar obstructiva crónica (EPOC). El objetivo de esta revisión sistemática fue examinar el efecto de las intervenciones que combinan la práctica de ejercicio y las intervenciones psicológicas para una gama de resultados de salud en personas con EPOC. Búsquedas de bases de datos identificados ensayos controlados aleatorios de las personas con EPOC que participan en las intervenciones que combinan la práctica de ejercicio con una estrategia psicológica en comparación con el control (atención habitual, la lista de espera) o comparadores activos (educación, el ejercicio, las intervenciones psicológicas solos). Los resultados de salud incluyen disnea, ansiedad, depresión, calidad de vida o la capacidad de ejercicio funcional. Se calcularon las diferencias de medias estandarizadas (DME) para cada comparación intervención brazo / control. A través de los 12 estudios incluidos (738 participantes), en comparación con las condiciones de control, SMD favoreció sistemáticamente intervenciones que incluían tanto el ejercicio + componentes psicológicos (rango SMD disnea -1,63 a -0,25; ansiedad -0,50 a -0,20; depresión -0,46 a -0,18; calidad de vida 0,09-1,16; la capacidad de ejercicio funcional 0,22-1,23). Cuando se compara con comparadores activos, SMD favoreció sistemáticamente intervenciones que incluían ejercicios de entrenamiento + componente psicológico de la disnea (SMD rango -0,35 a -0,97), la ansiedad (SMD rango -0,13 a -1,00) y la capacidad de ejercicio (SMD rango 0,64 a 0,71), pero eran incompatibles para la depresión (-0,11 a 1,27) y la calidad de vida (0,02 a -2,00). La magnitud del efecto para la mayoría de las intervenciones fue mayor que el mínimo requerido para la significación clínica (es decir,> 0,32) en la medicina conductual. Si bien las intervenciones, los resultados y los tamaños de los efectos difieren sustancialmente entre los estudios, que combina el entrenamiento con ejercicios con una intervención psicológica puede proporcionar un medio de optimizar la rehabilitación en personas con EPOC.
PROPÓSITO: El programa de rehabilitación pulmonar se ha convertido en una piedra angular en el manejo de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Los programas basados en instalaciones hospitalarias y el tratamiento, sin embargo, son un inconveniente y poco utilizada. Un programa basado en el hogar es una alternativa prometedora, pero los estudios de su eficacia han producido resultados inconsistentes. El propósito de este estudio es evaluar el impacto de los programas de rehabilitación respiratoria domiciliaria en la calidad relacionada con la salud de la vida (CVRS) y otros resultados de salud en los pacientes con EPOC. MÉTODOS: Los ensayos controlados aleatorios (ECA) de los programas de rehabilitación respiratoria domiciliaria publicados entre febrero de 1991 y febrero de 2012, fueron recuperados de bases de datos electrónicas (PubMed, Cochrane Library, Science Direct, China National Infrastructure Conocimiento [CNKI], y la base de datos Wanfang). Dos revisores de forma independiente evaluaron la pertinencia temática y calidad de los ensayos, extrajeron los datos para el metanálisis con el programa informático Review Manager v5.1, y se contactó con los autores de los estudios originales para obtener información adicional. RESULTADOS: Dieciocho ensayos, que incluyen 733 pacientes asignados al azar se incluyeron en el meta-análisis. Pacientes con EPOC experimentan un alivio significativo en el estado de disnea, medida por la escala de Borg (modelo de efectos fijo, DMP -0,92, IC del 95%: -1.61 ~ -0.23, p = 0,009) y el índice de disnea basal (BDI) (modelo de efectos fijo , DMP -1,77, IC del 95%: -2.65 ~ -0.89, p <0,0001) después de 12 semanas de intervención basado en el hogar. Intervención domiciliaria también mejoró las puntuaciones de CVRS de los pacientes, medida por el Chronic Respiratory Questionnaire (CRQ) y el Cuestionario Respiratorio de St. George (SGRQ) (modelo de efectos fijos, DMP = -11,33, IC del 95%: -16,37 ~ -6.29, p <0.0001, puntuación total del SGRQ después de 12 semanas de intervención), la capacidad de ejercicio (medido por el ensayo de la distancia recorrida en 6 minutos (6MWD) (modelo de efectos fijos, DMP = 35,88, IC del 95%: 9,38 ~ 62,38, p = 0,008 , después de 12 semanas de intervención), y las funciones pulmonares (en volumen espiratorio forzado en la capacidad vital one-second/forced (FEV1 / FVC) [modelo de efectos aleatorios, DMP = -10,72, IC del 95%: -15,86 ~ -5.58, p <0,0001, después de 12 semanas de la intervención), en comparación con el grupo control de no intervención, sin embargo, no hay cambios estadísticamente significativos se observaron en la carga de trabajo máxima, ingreso en el hospital, coste de la asistencia, o la mortalidad entre los dos grupos. Conclusiones y relevancia clínica: Los programas de rehabilitación respiratoria a domicilio representan métodos eficaces de intervención terapéutica para aliviar los síntomas respiratorios asociados con la EPOC y la mejora de la CVRS y la capacidad de ejercicio. Rigurosamente diseñados, con ECA a gran escala siguen siendo necesarios para identificar un programa de rehabilitación respiratoria domiciliaria estándar óptimo.
INTRODUCCIÓN: La gestión de la enfermedad crónica en los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) puede mejorar la calidad, los resultados y el acceso a la atención.
OBJETIVO: Investigar la eficacia de los programas de manejo de enfermedades crónicas en la calidad de vida de las personas con EPOC.
MÉTODOS: Medline y Embase (1995-2005) en busca de artículos pertinentes, y listas de referencias y resúmenes en busca de ensayos controlados de programas de enfermedades crónicas, manejo de los pacientes con EPOC. Calidad de vida se evaluó como un parámetro de resultado. Dos revisores examinaron de forma independiente cada uno de papel para la calidad metodológica y extrajeron los datos.
RESULTADOS: Se encontraron 10 ensayos controlados aleatorios que compararon el tratamiento de enfermedades crónicas con la atención habitual. Las poblaciones de pacientes, los profesionales de la salud, la intensidad y contenido de la intervención fueron heterogéneos. Se emplearon diversos instrumentos para evaluar la calidad de vida. Cinco de cada 10 estudios mostraron resultados positivos estadísticamente significativos en uno o más dominios de la calidad de los instrumentos de la vida. Tres estudios, ubicados en parte en la atención primaria, mostraron resultados positivos.
Conclusiones: Todos los proyectos de gestión de enfermedades crónicas para las personas con EPOC relacionados con la calidad de atención primaria de vida. En la mayoría de los estudios, los aspectos de la gestión de la enfermedad crónica se aplicaron a un grado limitado. La calidad de los ensayos controlados aleatorios no era óptima. Se necesita más investigación sobre la gestión de enfermedades crónicas en los pacientes con EPOC en atención primaria y secundaria.
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.
