Kan pasientopplæring være like effektivt som behandling?

Transkript

1 Kan pasientopplæring være like effektivt som behandling? 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 Litt om livsstilsintervensjon ved overvekt

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: nfev1 > 80% of predicted + n20% reversibility, variability or positive metacholine test COPD: nfev1 < 80% of predicted with or without reversibility or variability Exclusion: nserious 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 npef and symptom registration nwritten booklet on asthma n2 x 2 hour group sessions (5-8 patients) n1-2 x 40 minutes individual sessions by nnurse nphysiotherapist ntreatment plan

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8 Consultations at GP during the one-year follow-up Mean (SD) 4 3 No 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 0 (12) 3,4 (13) 2,9 (18) 5,6 (21) Control Intervention -5-2,7 Asthma COPD n=39/32 n=27/26 * T-test

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

13 Dispensed short-acting β2- agonists during a one-year follow-up [---p= ] [---p= ] (Mann Whitney U) Percentiles 90th 75th Dispensed DDD among those who collected Median 25th 10th Control group Intervention group n= Asthma COPD

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 Score at the one-year follow-up ,5 20,2 43,1 40 Control Intervention 0 (18) (15) Asthma n=39/32 (21) (16) COPD n=27/26 p<0,001* p<0,54* * ANOVA

17 Conclusion patienteducation Asthma COPD GP visits Days off work - Steroid compl. - β2- agonists - HRQoL - FEV1 - Total costs

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

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21 Kostnadseffektivitet av individuell røykeavvening

22 Russel, MAH: Effect of general practitioner advice against smoking BMJ, 1979, all p s < ,1 Questionnaire % 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

23 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)

24 Effekt av røykestopp etter hjerteinfarkt

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

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

28 70 % 60 % 50 % 40 % 57,0 % Intervention (n=100) Control (n=118) 37,3 % 30 % 20 % 10 % 0 % BMJ 2003 p=0.004 NNT: 5.1 Intentionto treatanalyse: 50% mot 37% (p 0.045)

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

31 Hvordan spør du om røykevaner?

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

33 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

34 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

35 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

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

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

39 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

40 Article 1

41 Proportion with unhealthy diet p<0, p<0,001 % p= n = n = Baseline Follow-up IG IIG 34% increased exercise capacity > 1 MET

42 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

43 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

44 Changein HRQOL for subjectsachievingversus not achieving clinically significant lifestyle change Weight loss at least 5% and fitness improvement 10% p<0,001 Score p=0,34

45 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

46 Oppsummering Pasientopplæring gir meget store kliniske effekter som ofte overgår effekten av enkeltmedisiner er meget kostnadseffektivt Er godt evaluert i studier med høy inklusjonsrate og lav dropout stor overføringsverdi

47 Et par momenter Rehabilitering er truet Telemedisinsk oppfølging etter utskrivelse for KOLS-forverring E-læring KOLS

48 Telemedisinske moduler Psykiatri Alarmer EWS/KØH

49 Norsk Helsenett GSM 4G Fastlege/SSHF

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

51 Egen nettside: sshf.no/kols

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55 RCT Ideal conditions Real world conditions