Kan pasientopplæring være like effektivt som behandling?

Kan pasientopplæring være like effektivt som 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: 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:

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 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

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

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 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

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

Dispensed short-acting β2- agonists during a one-year follow-up 1000 800 [---p=0.15---] [---p=0.03---] (Mann Whitney U) Percentiles 90th 75th Dispensed DDD among those who collected 600 400 200 0 375 162 50 200 75 50 550 290 150 344 125 100 Median 25th 10th Control group Intervention group n= 24 21 23 24 Asthma COPD

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 Score at the one-year follow-up 50 25 36,5 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

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

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 6 5 all p s < 0.001 5,1 Questionnaire % 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.

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)

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. 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 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)

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 n = 84 89 Baseline 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

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

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 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

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