1. No category

Kan pasientopplæring
være like kostnadseffektiv
som ”vanlig” behandling?
Frode Gallefoss
Forskningssjef Sørlandet Sykehus
Professor II, K2, UiB
Spesialist i indremedisin og lungesykdommer
Agenda



Litt om effekter av pasientopplæring ved
astma og KOLS
Litt om effekter av individuell røykeavvenning
Litt om livsstilsintervensjon ved overvekt
Told, but not heard
Heard, but not understood
Understood, but not accepted
Accepted, but not put into practice
Put into practice, but for how long?
Konrad Lorenz
Patient education in asthma and COPD
INCLUSION CRITERIAS
Asthma:
FEV1 > 80% of predicted
+
20% reversibility, variability or positive metacholine test
COPD:
FEV1 < 80% of predicted with or without reversibility or variability
Exclusion:
Serious medical disease:
Study design:
140 patients with mild to moderate
asthma (n= 78) and COPD (n= 62)
at our out-patient clinic after having received
ordinary consultation care
RANDOMISATION
One-year follow-up
Intervention:
•2 x 2 hour group sessions
•individual sessions
One-year follow-up
Control group
Intervention group
Followed by GP
for one year
After intervention followed
by GP for one year
INTERVENTION PROGRAM
PEF and symptom registration
Written booklet on asthma
2 x 2 hour group sessions (5-8 patients)
1-2 x 40 minutes individual sessions by
nurse
physiotherapist
treatment plan
Consultations at GP
during the one-year follow-up
Mean (SD)
4
3,4
No
3
of GP
consultations
2,6
Control
Intervention
2
1
0,7
(3,6)
(2,0)
0,5
(5,5)
(0,9)
0
Asthma n=39/32
p<0,001*
COPD n=27/26
p<0,0001*
* Mann Whitney U test
Proportion of patients making one
or more GP visits
during the one-year follow-up
100
85
Percentage
75
67
Control
Intervention
50
28
27
25
0
Asthma n=39/32
p=0,001*
COPD n=27/26
p<0,001*
* Mann Whitney U test
Days off work
during the one-year follow-up
Mean (SD)
30
Absenteeism
from work,
days
25
26
20
18,5
Control
Intervention
15
10
8
5
(70)
(32)
(86)
(7)
1
0
Asthma n=24/25
p<0,05*
COPD n=14/13
p<0,64*
* Mann Whitney U test
Changes in FEV1
during the one-year follow up
Mean (SD)
10
p <0,05*
Percent
change in
5
FEV1
p =0,61*
5,6
3,4
(13)
2,9
(18)
(21)
Control
Intervention
0
(12)
-2,7
-5
Asthma
COPD
n=39/32
n=27/26
* T-test
Inhalation steroid compliance
during the one-year follow-up
p <0.04
p =0.56
75
Percentage
with
compliance 50
(> 75%)
57
58
50
Control
Intervention
32
25
0
Asthma n=38/30
Compliance=
(collected DDD/PDD) x 100
COPD n=24/24
Dispensed short-acting 2agonists during a one-year follow-up
[---p=0.15---]
[---p=0.03---]
(Mann Whitney U)
1000
Percentiles
90th
among those who collected
Dispensed DDD
800
75th
Median
600
550
25th
10th
400
375
290
200
162
344
200
Control group
150
75
50
125
50
Intervention
group
0
n= 24
21
Asthma
100
23
24
COPD
Four questions on
Health Related Quality of Life
ASTHMA94
100
81
Percentage 75
at the one-year
50
follow-up
60
43
88
81
62
Control
Intervention
36
25
0
A better Symptoms Does not No impact
year
<2 times a wake up
on daily
week
life
p=0.002* p<0.001*
p=0.001*
p=0.017*
* Chi-square test
Number Needed to Educate to make one
person experience
ASTHMA
1.7 - 5.9
95% confidence intervals
1.5 to 4.2
1.9 to 6.3
3,85
4
3
NNE
2.1 to 20
2,94
2,63
2,22
2
1
0
A better
year
Symptom
free days
Symptom
free
nights
No impact
on daily
life
Health Related Quality of Life
St. George’s Respiratory Questionnaire
Mean (SD)
50
SGRQ
Total
43,1
36,5
40
Score
at the
one-year 25
follow-up
Control
Intervention
20,2
(18)
(15)
(21)
(16)
0
Asthma n=39/32
p<0,001*
COPD n=27/26
p<0,54*
* ANOVA
DIRECT, INDIRECT AND TOTAL COSTS
NOK, mean (SD)
 Education
 Medication
 Doctor visits
12 month follow-up
Control
n= 39
0
3 300
700
 Hospital admissions
 Travel costs
Direct costs
 Production loss
 Time costs
(3 100)
(900)
0
63
4 000
300
(3 800)
(33 100)
(700)
Indirect costs
11 900
Total costs
16 000
3 700
(33 500)
(35 400)
(3 400)
200
700
(89)
11 600
Intervention
n= 32
1 100 (50)
(500)
(2 700)
100
5 900
3 400
(64)
(4 800)
(16 700)
1 300
4 600
(600)
(17 300)
10 500 (20 500)
INCREMENTAL COST-EFFECTIVENESS RATIOES
SGRQ * total scores at
the one year follow-up
FEV1 change in %
A better year
Adjusted incremental costeffectiveness ratio
-3 400 per 10 unit improvement
-4 500 per 5% improvement
Adjusted incremental costeffectiveness ratio of making one
person have
-14 400
Symptom free days
-12 200
Symptom free nights
-16 100
No impact in daily life
-21 100
* SGRQ = St. George’s Respiratory Questionnaire
Conclusion
patient education
Asthma
GP visits
Days off work
Steroid compl.
2- agonists
HRQoL
FEV1
Total costs






COPD



Astmaskole i Kristiansand
Konklusjon

Astmaskole

er viktig for brukeren






reduserer legekonsultasjoner med 75%
reduserer sykmeldingsdager med 70%
bedrer lungefunksjon (6% på 12 mndr)
bedrer livskvalitet (16 enheter i SGRQ total score)
bedrer compliance (inhalasjonssteroider)
er kostnadseffektiv

astmatikeren blir bedre og det koster mindre enn om
han/hun ikke får opplæring
DIRECT, INDIRECT AND TOTAL COSTS
COPD, NOK, mean (SD)
12 month follo
 Education
Control
n= 27
0
Intervention
n= 26
1 100 (50)
 Medication
6 700 (4 400)
5 700 (3 400)
 Doctor visits
1 000 (1 000)
100 (200)
 Hospital admissions
6 300 (21 000)
2 400 (6 900)
 Travel costs
89 (200)
100 (30)
Direct costs
14 000 (23 300)
9 600 (8 500)
5 500 (20 200)
300 (1 300)
500 (1 400)
700 (700)
5 900 (21 400)
1 100 ( 1700)
 Production loss
 Time costs
Indirect costs
Total costs
19 900
(38 800)
10 600 (8 400)
Cost-benefit

A cost-benefit ratio after patient education was calculated as
follows:
– (Educational costs + patient time cost for educational programme)/
(total costs – (Educational costs + patient time cost for educational
programme)).

The mean difference in total costs were NOK 9 300, while the
benefit in monetary terms when adapted for the calculation of a
cost-benefit ratio was (9 300-1600) = NOK 7 700. The cost
benefit ratio for patient education thus became 1 600: 7 700,
meaning that
– for
every NOK put into patient
education, there was a saving of 4.8.
Conclusion COPD
A one year follow-up indicates that patient education
with emphasis on self-management in patients with
COPD
•reduced the need for GP visits
•reduced the proportion of patients in need of GP visits
•improved patient satisfaction with GP
•reduced the need for rescue medication
•was cost-beneficial
•was cost-effective
•
•
en brukerundersøkelse ved 18 norske
poliklinikker
90% av norske poliklinikker bruker NPAS
Kostnadseffektivitet av
individuell røykeavvening
Russel, MAH: Effect of general
practitioner advice against smoking
BMJ, 1979, 231-235
all p’s < 0.001
6
5,1
Questionnaire
5
%
4
3,3
3
2
1,6
1
0
12-month follow-up
equals 25 long-term quitters / GP / year
Questionnaire +
advice
Questionnaire +
advice + leaflet +
warning of followup
n=2000
Estimated abstinence rates for various
intensity levels of person-to-person contact
Meta-analysis, 43 studier,
Clinical Practice Guidelines, 2000, US Dep HHS
25
22
20
Estimated
15
abstinence
rates
%
10
16
13
11
5
0
No contact
Low intensity (3-10min)
Minimal counseling (<3min)
Higher intensity (>10min)
Effekt av røykestopp etter hjerteinfarkt
Det er viljen som det gjelder
Viljen frigjør eller feller
Henrik Ibsen
90
80
Kumulativ
mortalitet (%)
70
82 %
Sluttet å røyke
Fortsatte å røyke
60
50
40
37 %
30
20
10
0
6
13
Antall år etter AMI/UAP
Daly, BMJ, 1983. 498 pas.
Intervention (n=100)
Control (n=118)
70 %
60 %
57,0 %
50 %
37,3 %
40 %
30 %
20 %
10 %
0%
p=0.004
NNT: 5.1
BMJ 2003
Intention to treat analyse:
50% mot 37% (p 0.045)
Comparison of the cost effectiveness of the smoking cessation program after coronary
revascularisation (low risk model) with other treatment modalities in patients with
coronary heart disease. Estimates are in the life time perspective.
Cost in Euro per life year gained
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
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As
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)
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95
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Sm
Hvordan spør du om røykevaner?
Minimal intervensjon



Røyker du?
Hva tenker du om det at du røyker?
Jeg vil anbefale deg å slutte
Tre innstillinger til røykestopp?

Kunde


Den ambivalente klager


klar og grei bestilling
vil nok, men tror ikke du kan hjelpe eller har selv
unnskyldninger
Besøkende

usikre på om de har en bestilling
Vanlige “klager”-utsagn?








Jeg skal kanskje slutte, men ikke nå
Jeg begynner hvis jeg legger på meg
Det er vanskelig å slutte, jeg har prøvd før
Jeg trener mye, det oppveier for røykingen
Alle vennene mine røyker
Jeg vil ikke slutte, men kanskje redusere
Jeg får se hva som skjer
Jeg er ikke så tung i pusten ennå
Et godt samtaleklima


Respektfull holdning overfor valg
Ikke forstå for fort -> still ”åpne, dumme
spørsmål”


forsøk å etablere en felles målsetting


kanskje bestillingen blir klarere?
hva kan jeg hjelpe deg med?
OBS “ekspert-følelsen”
Gi råd

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





hva gikk galt sist?
forklar abstinenssymptomer
OBS Kaffe
identifisér utløser  endre rutiner
informasjonsmateriell?
nedtrapping?
Nikotinbehandling/Zyban/Champix?
røykestoppdag!
Gi råd









hva gikk galt sist?
forklar abstinenssymptomer
OBS Kaffe
identifisér utløser  endre rutiner
informasjonsmateriell?
nedtrapping?
Nikotinbehandling/Zyban/Champix?
røykestoppdag!
kontroll/oppfølging
Lifestyle change when at risk for DMII
Background


Lifestyle change is probably the most
important single action to prevent type 2
diabetes mellitus
The purpose of this study was to assess the
effects of a low-intensity individual
lifestyle intervention by a physician and
compare this to the same physician
intervention combined with an
interdisciplinary, group-based approach in a
real-life setting
Article 1
Proportion with unhealthy diet
p<0,001
p<0,001
70
61
60
60
50
%
40
p= 0.21
30
17
20
10
10
0
n = 104
109
n = 84
Baseline
IG
89
Follow-up
IIG
34% increased exercise capacity > 1 MET
Main findings article 1



It is possible to achieve important lifestyle
changes in persons at risk for type 2 diabetes
with modest clinical efforts
Group intervention yields no additional effects
The design of the study, with high inclusion
and low dropout rates, should make the
results applicable to ordinary clinical settings
Article 2
Purpose: To assess health-related quality of life (HRQOL) of subjects at risk for type
2 diabetes undergoing lifestyle intervention, and predictors for improved HRQOL
Change in HRQOL for subjects achieving versus
not achieving clinically significant lifestyle change
Weight loss at least 5% and fitness improvement 10%
p<0,001
Score
p=0,34
Main findings article 2


Conclusions: Subjects at risk for type 2
diabetes report a clinically important
reduction in HRQOL compared with general
Norwegians
The best predictor of improved HRQOL was
a small weight loss combined with a small
improvement in aerobic capacity
Oppsummering
Pasientopplæring og livsstilsintervensjon
 gir meget store kliniske effekter som ofte
overgår effekten av enkeltmedisiner
 er meget kostnadseffektivt
 Er godt evaluert i studier med høy
inklusjonsrate og lav drop out  stor
overføringsverdi
Et par momenter



Rehabilitering er truet
Telemedisinsk oppfølging etter utskrivelse for
KOLS-forverring
E-læring KOLS
Telemedisinske moduler
Psykiatri
Alarmer
EWS/KØH
Norsk
Helsenett
GSM 4G
Fastlege/SSHF
E-læringspakke i KOLS
Et tverrfaglig samarbeidsprosjekt mellom Sørlandet sykehus i
Kristiansand, Kristiansand kommune og brukere.
Egen nettside: sshf.no/kols
RCT ‘Ideal’ conditions
‘Real world’ conditions