Kan pasientopplæring være like kostnadseffektiv som vanlig behandling?

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 Followed by GP for one year Intervention group 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 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

Proportion of patients making one or more GP visits during the one-year follow-up Percentage 100 75 67 85 50 25 28 27 Control Intervention 0 Asthma n=39/32 COPD n=27/26 p=0,001* p<0,001* * Mann Whitney U test

Days off work during the one-year follow-up Mean (SD) 30 Absenteeism from work, days 25 20 26 18,5 15 10 5 (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

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

Inhalation steroid compliance during the one-year follow-up 75 p <0.04 p =0.56 Percentage with compliance (> 75%) 50 32 57 58 50 Control Intervention 25 0 Asthma n=38/30 COPD n=24/24 Compliance= (collected DDD/PDD) x 100

Dispensed DDD among those who collected Dispensed short-acting 2- agonists during a one-year follow-up 1000 800 [---p=0.15---] [---p=0.03---] (Mann Whitney U) Percentiles 90th 75th 600 550 Median 25th 400 375 290 344 10th 200 0 200 162 150 125 75 50 50 n= 24 21 23 24 Asthma COPD 100 Control group Intervention group

Four questions on Health Related Quality of Life 100 81 81 ASTHMA 94 88 Percentage at the one-year follow-up 75 50 43 36 60 62 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

Number Needed to Educate to make one person experience ASTHMA 4 95% confidence intervals 1.7-5.9 1.5 to 4.2 1.9 to 6.3 2.1 to 20 3,85 NNE 3 2 2,63 2,22 2,94 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) 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

DIRECT, INDIRECT AND TOTAL COSTS NOK, mean (SD) 12 month follow-up Control Intervention n= 39 n= 32 Education 0 1 100 (50) Medication 3 300 (3 100) 3 700 (3 400) Doctor visits 700 (900) 200 (500) Hospital admissions 0 700 (2 700) Travel costs 63 (89) 100 (64) Direct costs 4 000 (3 800) 5 900 (4 800) Production loss 11 600 (33 100) 3 400 (16 700) Time costs 300 (700) 1 300 (600) Indirect costs 11 900 (33 500) 4 600 (17 300) Total costs 16 000 (35 400) 10 500 (20 500)

INCREMENTAL COST-EFFECTIVENESS RATIOES SGRQ * total scores at the one year follow-up FEV1 change in % Adjusted incremental costeffectiveness ratio -3 400 per 10 unit improvement -4 500 per 5% improvement Adjusted incremental costeffectiveness ratio of making one person have A better year -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 COPD GP visits Days off work - Steroid compl. - 2- agonists - HRQoL - FEV1 - Total costs

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 Control Intervention n= 27 n= 26 Education 0 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) Production loss 5 500 (20 200) 300 (1 300) Time costs 500 (1 400) 700 (700) Indirect costs 5 900 (21 400) 1 100 ( 1700) 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 Questionnaire 5,1 5 % 4 3 3,3 Questionnaire + advice 2 1 0 1,6 12-month follow-up Questionnaire + advice + leaflet + warning of followup n=2000 equals 25 long-term quitters / GP / year

Estimated abstinence rates for various intensity levels of person-to-person contact Meta-analysis, 43 studier, Clinical Practice Guidelines, 2000, US Dep HHS 25 20 22 Estimated 15 abstinence rates 10 % 5 11 13 16 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

Kumulativ mortalitet (%) 90 80 70 60 50 40 30 20 10 0 Sluttet å røyke Fortsatte å røyke 6 Antall år etter AMI/UAP 82 % 37 % 13 Daly, BMJ, 1983. 498 pas.

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)

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 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)*

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 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

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 kanskje bestillingen blir klarere? forsøk å etablere en felles målsetting hva kan jeg hjelpe deg med? OBS ekspert-følelsen

Gi råd 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 70 60 61 60 50 p<0,001 % 40 30 20 10 p= 0.21 17 10 0 n = 104 109 Baseline n = 84 89 Follow-up IG 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