BACKGROUND
Self-management interventions improve various outcomes for many chronic diseases. The definite place of self-management in the care of chronic obstructive pulmonary disease (COPD) has not been established. We evaluated the effect of a continuum of self-management, specific to COPD, on the use of hospital services and health status among patients with moderate to severe disease.


METHODS
A multicenter, randomized clinical trial was carried out in 7 hospitals from February 1998 to July 1999. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and patient health status.


RESULTS
Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group (P =.01), and admissions for other health problems were reduced by 57.1% (P =.01). Emergency department visits were reduced by 41.0% (P =.02) and unscheduled physician visits by 58.9% (P =.003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months.


CONCLUSIONS
A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice.

Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention

The telemonitoring of vital signs from the home is an essential element of telehealth services for the management of patients with chronic conditions, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, or poorly controlled hypertension. Telehealth is now being deployed widely in both rural and urban settings, and in this paper, we discuss the contribution made by biomedical instrumentation, user interfaces, and automated risk stratification algorithms in developing a clinical diagnostic quality longitudinal health record at home. We identify technical challenges in the acquisition of high-quality biometric signals from unsupervised patients at home, identify new technical solutions and user interfaces, and propose new measurement modalities and signal processing techniques for increasing the quality and value of vital signs monitoring at home. We also discuss use of vital signs data for the automated risk stratification of patients, so that clinical resources can be targeted to those most at risk of unscheduled admission to hospital. New research is also proposed to integrate primary care, hospital, personal genomic, and telehealth electronic health records, and apply predictive analytics and data mining for enhancing clinical decision support.

Home Telemonitoring of Vital Signs—Technical Challenges and Future Directions

TO THE EDITOR: Screening is more effective when the incidence of the target disease is high (that is, more deaths will be prevented while fewer positive screening test results will be false-positive). The idea of optimizing screening effectiveness in women aged 40 to 49 years by targeting those with greater risk for breast cancer is appealing. The review of breast cancer risk factors by Nelson and colleagues (1) may guide physicians on how to provide personalized counseling to premenopausal women about the likely benefits and side effects of mammography screening. The review found that breast radiologic density, family history, reproductive history, use of oral contraceptives, and prior benign breast biopsy were factors associated with higher breast cancer incidence in women aged 40 to 49 years. However, because the primary goal of screening is to decrease the risk for death from breast cancer, it would be more effective for women at higher risk for death and not just at higher risk for diagnosis. The caveat that risk factors for breast cancer occurrence would have a similar influence on the risk for death is not correct. Few studies have been done on risk factors associated with death from breast cancer, but they show that reproductive factors have little influence. (2). High breast density is associated with more aggressive cancer and, thus, is relevant to both incidence and mortality rates (3). Adiposity is associated with reduced breast cancer risk in premenopausal women and therefore was not included in the review. However, the risk for death from breast cancer in premenopausal women increases with adiposity (4), and obese women would probably benefit more from screening than lean women. Women giving birth in their 40s have become increasingly common, and breast cancer occurring in the first 2 years after childbirth is known to be more lethal (5). These women should probably be offered screening shortly after discontinuation of breastfeeding. The risk for death from breast cancer associated with use of oral contraceptives and prior benign breast biopsy is not known. In conclusion, compared with risk factors for breast cancer occurrence, personalized counseling based on risk factors for death from breast cancer may be more effective in identifying women likely to benefit from screening.

A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations

Background
Telehealth services based on at-home monitoring of vital signs and the administration of clinical questionnaires are being increasingly used to manage chronic disease in the community, but few statistically robust studies are available in Australia to evaluate a wide range of health and socio-economic outcomes. The objectives of this study are to use robust statistical methods to research the impact of at home telemonitoring on health care outcomes, acceptability of telemonitoring to patients, carers and clinicians and to identify workplace cultural factors and capacity for organisational change management that will impact on large scale national deployment of telehealth services. Additionally, to develop advanced modelling and data analytics tools to risk stratify patients on a daily basis to automatically identify exacerbations of their chronic conditions.

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Design of a multi-site multi-state clinical trial of home monitoring of chronic disease in the community in Australia

Knowing which factors influence breast cancer risk for women aged 40 to 49 years could help target screening. This systematic review of 65 studies found that the following factors increased breast ...

Risk Factors for Breast Cancer for Women Aged 40 to 49 Years

Proactive Integrated Care Reduces Critical Care & Improves Quality-of-Life in COPD.

Background. Up to 50% of COPD patients do not receive recommended care for COPD. To address this important issue, we developed Proactive Integrated Care (Proactive iCare), a healthcare delivery model that couples integrated care with remote monitoring. Methods. We conducted a prospective, quasi-randomized clinical trial in 511 patients with advanced COPD, or a recent COPD exacerbation, to test whether Proactive iCare impacts patient- centered outcomes and healthcare utilization. Patients were allocated to Proactive iCare (n =352) or Usual Care (n = 159), and were examined for changes in quality of life using the St. Georges Respiratory Questionnaire (SGRQ), symptoms, guideline-based care, and healthcare utilization. Findings. Proactive iCare improved the total SGRQ by 7-9 units (p<0.0001), symptom SGRQ by 9 units (p<0.0001), activity SGRQ by 6-7 units (p<0.001) and impact SGRQ by 7-11 units (p<0.0001) at 3, 6 and 9 months, compared with Usual Care. Proactive iCare increased the 6-minute walk distance by 40 m (p<0.001), reduced COPD-related urgent office visits by 76 visits per 100 subjects (p<0.0001), identified unreported exacerbations, and decreased smoking (p = 0.01). Proactive iCare also improved cough, sputum, shortness of breath, the BODE index and oxygen titration (p<0.05). Mortality in the Proactive iCare group (1.1%) was not significantly different than mortality in the Usual Care group (3.8%; p = 0.08). Interpretation. Results suggest that linking integrated care with remote monitoring improves the lives of people with advanced COPD.

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T. J. Stelzner

Papers

Proactive Integrated Care Reduces Critical Care & Improves Quality-of-Life in COPD.

Impact of Proactive Integrated Care on Chronic Obstructive Pulmonary Disease