Eksempler på kostnadseffektiv pasientopplæring i Norge

Transkript

1 Eksempler på kostnadseffektiv pasientopplæring i Norge Frode Gallefoss Forskningssjef Sørlandet Sykehus Professor II, K2, UiB Spesialist i indremedisin og lungesykdommer

2 Agenda Litt om effekter av pasientopplæring ved astma og KOLS Litt om effekter av individuell røykeavvenning

3 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

4 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:

5 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 Followed by GP for one year Intervention group After intervention followed by GP for one year

6 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

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8 Consultations at GP during the one-year follow-up Mean (SD) 4 No 3 of GP consultations 2 2,6 3,4 Control Intervention 1 0,7 0,5 0 (3,6) (2,0) (5,5) (0,9) Asthma n=39/32 COPD n=27/26 p<0,001* p<0,0001* * Mann Whitney U test

9 Proportion of patients making one or more GP visits during the one-year follow-up Percentage Control Intervention 0 Asthma n=39/32 COPD n=27/26 p=0,001* p<0,001* * Mann Whitney U test

10 Days off work during the one-year follow-up Mean (SD) 30 Absenteeism from work, days , (70) 8 (32) (86) (7) Control Intervention 0 Asthma n=24/25 1 COPD n=14/13 p<0,05* p<0,64* * Mann Whitney U test

11 Changes in FEV1 during the one-year follow up Mean (SD) 10 p <0,05* p =0,61* Percent change in FEV1 5 3,4 2,9 5,6 Control (13) (18) (21) Intervention 0 (12) -2,7-5 Asthma COPD n=39/32 n=27/26 * T-test

12 Inhalation steroid compliance during the one-year follow-up 75 p <0.04 p =0.56 Percentage with compliance (> 75%) Control Intervention 25 0 Asthma n=38/30 COPD n=24/24 Compliance= (collected DDD/PDD) x 100

13 Dispensed DDD among those who collected Dispensed short-acting 2- agonists during a one-year follow-up [---p= ] [---p= ] (Mann Whitney U) Percentiles 90th 75th Median 25th th n= Asthma COPD 100 Control group Intervention group

14 Four questions on Health Related Quality of Life ASTHMA Percentage at the one-year follow-up Control Intervention 25 0 A better year Symptoms <2 times a week Does not wake up No impact on daily life p=0.002* p<0.001* p=0.001* p=0.017* * Chi-square test

15 Number Needed to Educate to make one person experience ASTHMA 4 95% confidence intervals to to to 20 3,85 NNE 3 2 2,63 2,22 2, A better year Symptom free days Symptom free nights No impact on daily life

16 Health Related Quality of Life St. George s Respiratory Questionnaire Mean (SD) SGRQ Total 50 36,5 43,1 40 Score at the one-year follow-up 25 20,2 Control Intervention 0 (18) (15) Asthma n=39/32 (21) (16) COPD n=27/26 p<0,001* p<0,54* * ANOVA

17 DIRECT, INDIRECT AND TOTAL COSTS NOK, mean (SD) 12 month follow-up Control Intervention n= 39 n= 32 Education (50) Medication (3 100) (3 400) Doctor visits 700 (900) 200 (500) Hospital admissions (2 700) Travel costs 63 (89) 100 (64) Direct costs (3 800) (4 800) Production loss (33 100) (16 700) Time costs 300 (700) (600) Indirect costs (33 500) (17 300) Total costs (35 400) (20 500)

18 INCREMENTAL COST-EFFECTIVENESS RATIOES SGRQ * total scores at the one year follow-up FEV1 change in % Adjusted incremental costeffectiveness ratio per 10 unit improvement per 5% improvement Adjusted incremental costeffectiveness ratio of making one person have A better year Symptom free days Symptom free nights No impact in daily life * SGRQ = St. George s Respiratory Questionnaire

19 Conclusion patient education Asthma COPD GP visits Days off work - Steroid compl agonists - HRQoL - FEV1 - Total costs

20 Astmaskole i Kristiansand Konklusjon Astmaskole er viktig for brukeren reduserer legekonsultasjoner med 75% reduserer sykmeldingsdager med 70% bedrer lungefunksjon (6% på 12 mndr) Betydelig bedret livskvalitet (16 E i SGRQ) bedrer compliance (inhalasjonssteroider) er kostnadseffektiv astmatikeren blir bedre og det koster mindre enn om han/hun ikke får opplæring

21 DIRECT, INDIRECT AND TOTAL COSTS COPD, NOK, mean (SD) 12 month follo Control Intervention n= 27 n= 26 Education (50) Medication (4 400) (3 400) Doctor visits (1 000) 100 (200) Hospital admissions (21 000) (6 900) Travel costs 89 (200) 100 (30) Direct costs (23 300) (8 500) Production loss (20 200) 300 (1 300) Time costs 500 (1 400) 700 (700) Indirect costs (21 400) ( 1700) Total costs (38 800) (8 400)

22 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 ( ) = NOK 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.

23 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

24 en brukerundersøkelse ved 18 norske poliklinikker 90% av norske poliklinikker bruker NPAS

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27 Kostnadseffektivitet av individuell røykeavvening

28 Russel, MAH: Effect of general practitioner advice against smoking BMJ, 1979, all p s < Questionnaire 5,1 5 % 4 3 3,3 Questionnaire + advice ,6 12-month follow-up Questionnaire + advice + leaflet + warning of followup n=2000 equals 25 long-term quitters / GP / year

29 Estimated abstinence rates for various intensity levels of person-to-person contact Meta-analysis, 43 studier, Clinical Practice Guidelines, 2000, US Dep HHS Estimated 15 abstinence rates 10 % No contact Low intensity (3-10min) Minimal counseling (<3min) Higher intensity (>10min)

30 Effekt av røykestopp etter hjerteinfarkt

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32 Det er viljen som det gjelder Viljen frigjør eller feller Henrik Ibsen

33 Kumulativ mortalitet (%) Sluttet å røyke Fortsatte å røyke 6 Antall år etter AMI/UAP 82 % 37 % 13 Daly, BMJ, pas.

34 Intervention (n=100) Control (n=118) 70 % 60 % 57,0 % 50 % 40 % 37,3 % 30 % 20 % 10 % 0 % BMJ 2003 p=0.004 NNT: 5.1 Intention to treat analyse: 50% mot 37% (p 0.045)

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36 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 Cardiac rehabilitation post-mi (1995) Smoking cessation program (2000) Beta blockers post-mi (1995) Thrombolytic therapy (1992) CABG/PCI high risk (1993) Statins 4S ACEI post-mi (1995) Aspirin in CAD (2000)*

37 Hvordan spør du om røykevaner?

38 Minimal intervensjon Røyker du? Hva tenker du om det at du røyker? Jeg vil anbefale deg å slutte

39 Tre innstillinger til røykestopp? Kunde klar og grei bestilling Den ambivalente klager vil nok, men tror ikke du kan hjelpe eller har selv unnskyldninger Besøkende usikre på om de har en bestilling

40 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

41 Et godt samtaleklima Respektfull holdning overfor valg Ikke forstå for fort -> still åpne, dumme spørsmål kanskje bestillingen blir klarere? forsøk å etablere en felles målsetting hva kan jeg hjelpe deg med? OBS ekspert-følelsen

42 Gi råd hva gikk galt sist? forklar abstinenssymptomer OBS Kaffe identifisér utløser endre rutiner informasjonsmateriell? nedtrapping? Nikotinbehandling/Zyban/Champix? røykestoppdag!

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44 Gi råd hva gikk galt sist? forklar abstinenssymptomer OBS Kaffe identifisér utløser endre rutiner informasjonsmateriell? nedtrapping? Nikotinbehandling/Zyban/Champix? røykestoppdag! kontroll/oppfølging

45 Et par momenter Rehabilitering er truet Overgang fra prosjekt til drift

46 Meget sårbar fase Fra prosjekt til drift Fra person til institusjon Fra entusiaster til ansatte ledere Fra entusiasme til Kostnadseffektivitet Prioritering Underskudd Nevrose Fra prosjektøkonomi til planøkonomi Fra innovasjonskultur til nullfeilskultur

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49 Telemedisinske moduler Psykiatri Alarmer EWS/KØH

50 Norsk Helsenett GSM 4G Fastlege/SSHF

51 E-læringspakke i KOLS Et tverrfaglig samarbeidsprosjekt mellom Sørlandet sykehus i Kristiansand, Kristiansand kommune og brukere.

52 Egen nettside: sshf.no/kols

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55 RCT Ideal conditions Real world conditions