Intervensjoner i pasientens hjem (4)
Hermiz O, Comino E, Marks G, Daffurn K, Wilson S, Harris M. Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease. BMJ 2002;325(7370):938.
ABSTRACT:
OBJECTIVES: To evaluate usefulness of limited community based care for patients with chronic obstructive pulmo-nary disease after discharge from hospital.
DESIGN: Randomised controlled trial
SETTING: Liverpool Health Service and Macarthur Health Service in outer metropolitan Sydney between Septem-ber 1999 and July 2000
PARTICIPANTS: 177 patients randomised into an intervention group (84 patients) and a control group (93 patients) which received current usual care
INTERVENTIONS: Home visits by community nurse at one and four weeks after discharge and preventive general practitioner care
MAIN OUTCOME MEASURES: Frequency of patients' presentation and admission to hospital; changes in patients' disease-specific quality of life, measured with St George's respiratory questionnaire, over three months after dis-charge; patients' knowledge of illness, self management, and satisfaction with care at discharge and three months later; frequency of general practitioner and nurse visits and their satisfaction with care
RESULTS: Intervention and control groups showed no differences in presentation or admission to hospital or in overall functional status. However, the intervention group improved their activity scores and the control group wors-ened their symptom scores. While intervention group patients received more visits from community nurses and were more satisfied with their care, involvement of general practitioners was much less (with only 31% (22) remembering receiving a care plan). Patients in the intervention group had higher knowledge scores and were more satisfied.
There were no differences in general practitioner visits or management
CONCLUSIONS: This brief intervention after acute care improved patients' knowledge and some aspects of quality of life. However, it failed to prevent presentation and readmission to hospital
Jeppesen E, Brurberg KG, Vist GE, Wedzicha JA, Wright JJ, Greenstone M, et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane database of systematic reviews (Online) 2012;5(pp CD003573):2012.
ABSTRACT:
Hospital at home schemes are a recently adopted method of service delivery for the management of acute exac-erbations of chronic obstructive pulmonary disease (COPD) aimed at reducing demand for acute hospital inpatient beds and promoting a patient-centred approach through admission avoidance. However, evidence in support of such a service is contradictory. To evaluate the efficacy of hospital at home compared to hospital inpatient care in acute exacerbations of COPD. Trials were identified from searches of electronic databases, including CENTRAL, MEDLINE, EMBASE, and the Cochrane Airways Group Register (CAGR). The review authors checked the refer-ence lists of included trials. The CAGR was searched up to February 2012. The additional databases were searched up to October 2010. We considered randomised controlled trials where patients presented to the emer-gency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (e.g. patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions). Two review authors independently selected articles for inclusion, assessed the risk of bias and extract-ed data for each of the includextract-ed trials. Eight trials with 870 patients were includextract-ed in the review and showextract-ed a signif-icant reduction in readmission rates for hospital at home compared with hospital inpatient care of acute exacerba-tions of COPD (risk ratio (RR)0.76; 95% confidence interval (CI) from 0.59 to 0.99; P=0.04). Moreover, we observed
a trend towards lower mortality in the hospital at home group, but the pooled effect estimate did not reach statistical significance (RR 0.65, 95% CI 0.40 to 1.04, P = 0.07). For health-related quality of life, lung function (FEV1) and direct costs, the quality of the available evidence is in general too weak to make firm
CONCLUSIONS. Selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. We found evidence of moderate quality that hospital at home may be advantageous with respect to readmission rates in these patients.
Treatment of acute exacerbation of COPD in hospital at home also show a trend towards reduced mortality rate when compared with conventional inpatient treatment, but these results did not reach statistical significance (mod-erate quality evidence). For other outcomes than readmission and mortality rate, we assessed the evidence to be of low or very low quality
Ram FS, Wedzicha JA, Wright J, Greenstone M. Hospital at home for acute exacerbations of chronic ob-structive pulmonary disease. Cochrane database of systematic reviews (Online) (4) (pp CD003573), 2003 Date of Publication: 2003 2003;(Online):2003.
ABSTRACT:
BACKGROUND: Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease aimed at reducing demand for acute hospital in-patient beds and promoting a in-patient centered approach through admission avoidance. However, evidence in sup-port of such a service is contradictory. OBJECTIVES: To evaluate the efficacy of "hospital at home" compared to hospital inpatient care in acute exacerbations of chronic obstructive pulmonary disease.
SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials; electronically available databases e.g.
MEDLINE (1966-current), EMBASE (1980-current), PubMed, ClincalTrials, Science Citation Index and on-line indi-vidual respiratory journals; bibliographies of included trials were all searched and contact with authors was made to obtain studies. The most recent searches were carried out in August 2003. SELECTION CRITERIA: Only random-ised controlled trials were considered where patients presented to the emergency department with an exacerbation of their chronic obstructive pulmonary disease. Studies must not have recruited patients that are usually deemed obligatory admissions.
DATA COLLECTION AND ANALYSIS: Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted data.
MAIN RESULTS: Seven studies with 754 patients were included in the review. Studies provided data on hospital readmission and mortality both of which were not significantly different when the two study groups were compared (RR 0.89; 95%CI 0.72 to 1.12 & RR 0.61; 95%CI 0.36 to 1.05, respectively). Both the patients and the carers pre-ferred hospital at home schemes to inpatient care (RR 1.53; 95%CI 1.23 to 1.90). Other reported outcomes included few studies.
REVIEWER'S CONCLUSIONS: This review has shown that one in four carefully selected patients presenting to hospital emergency departments with acute exacerbations of chronic obstructive pulmonary disease can be safely and successfully treated at home with support from respiratory nurses. This review found no evidence of significant differences between "hospital at home" patients and hospital inpatients for readmission rates and mortality at two to three months after the initial exacerbation. Both the patients and carers preferred "hospital at home" schemes to inpatient care
Reishtein JL. Review: hospital at home is as effective as inpatient care for mortality and hospital readmis-sions in patients with acute exacerbations of chronic obstructive pulmonary disease. Evidence Based Nurs-ing 2005;8(1):23.
ABSTRACT:
Is hospital at home (HaH) as effective as inpatient care for reducing mortality and readmission to hospital in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD)?
METHODSData sources: Medlin, EMBASE/Excerpta Medica, Science Citation Index, Cochrane Controlled Trials register, UK National Research Register, Web of Science, individual respiratory journal websites, and proceedings of the European Respiratory Society, American Thoracic Society, British Thoracic Society, and Thoracic Society of Australia and New Zealand (up to and including May 2003)
STUDY SELECTION AND ASSESSMENT: randomised controlled trials (RCTs) in any language that compared HaH with inpatient care for patients who were randomised within 72 hours of presenting to the emergency depart-ment (ED) with an acute exacerbation and were initially assessed by the hospital medical team. Exclusion criteria included patients with impaired consciousness, acute confusion, acute changes on radiography or electrocardiog-raphy, arterial pH<7.35, concomitant medical conditions, or who attended the ED for social reasons. 2 independent reviewers assessed the metodological quality of studies using the Cochrane approach to assessment of allocation concealment (adequate, uncertain, or clearly inadequate)Outcomes: readmission to hospital, mortality, number of patients with acute COPD exacerbations, and costs
MAIN RESULTS Of the 7 RCTs (n = 754) that met the selection criteria, 6 had adequate allocation concealment,
and 1 had uncertain allocation concealment. HaH comprised care by a specialist nurse according to initial assess-ment in the ED (guided by the hospital medical team), and visits by a respiratory nurse until discharge from care.
Inpatient care comprised usual treatment at the discretion of the hospital medical team Meta-analysis was done using a fixed effects model. The HaH and inpatient groups did not differ for the number of patients readmitted to hospital or for mortality (table). 4 trials reported cost analyses: 2 found that HaH was less expensive than inpatient care (average savings per patient pounds 536, 95% CI pounds 532 to pounds 540), 1 found that the mean health service cost for HaH was approximately half of inpatient care ( pounds 867 v pounds 1405, p = 0.003), and 1 trial reported a savings of 201 bed days/year with HaH care
CONCLUSION: In patients with acute exacerbation of chronic obstructive pulmonary disease, hospital at home does not differ from inpatient care for hospital readmissions or mortality
Intervensjoner på sykehuset (3)
Leonard B. Review: existing evidence does not support nurse led interventions in chronic obstructive pul-monary disease. Evidence Based Nursing 2006;9(2):56.
ABSTRACT:
In patients with chronic obstructive pulmonary disease (COPD), are nurse led chronic disease management innova-tions more effective than usual care?
METHODS Data sources: 16 English language and 8 Dutch language citation databases (1980 to January 2005), conference proceedings of 7 respiratory associations, and researchers and practitioners in the field
STUDY SELECTION AND ASSESMENT: randomised controlled trials (RCTs) that evaluated clinical service inter-ventions or care packages aimed at improving the management of community dwelling patients with COED and were led, coordinated, or delivered by nurses. Trials that evaluated drugs, hospital at home or early discharge for acute exacerbations, or educational interventions for healthcare providers, or trials with a minority of patients with COP) were excluded. Methodological quality of individual studies was assessed using the Delphi list and the 5 point Jadad scale
OUTCOMES: mortality, use of healthcare resources, activities of daily living (ADL), patients' health related quality of life (HRQOL), and corers' quaky of life
MAIN RESULTS: 9 RCTs (n= 1428, mean age 63-71 y) and 1 systematic review that included 4 of the individual RCTs met the selection criteria. Methodological quality of the trials was generally low. 2 RCTs involved brief inter-ventions (about 1 mo in duration) after a hospital admission; 7 RCTs involved intensive or long term interinter-ventions (about 1 y in duration). 5 RCTs included home visits by a nurse, 1 RCT was exclusively clinic based, and 3 did not provide a clear description. The interventions used a case management approach and promoted self care, including education about medication and advice on smoking cessation, fitness, and identifying acute exacerbations. Meta-analysis of 7 long term or intensive intervention trials showed no difference in mortality (table). The 2 RCTs on brief interventions showed no difference in hospital readmissions. Among the long term trials, 2 showed a reduction in readmissions favouring nurse led interventions, and 3 showed no difference. Meta-analysis of 3 RCTs measuring HRQOL with the St George's respiratory questionnaire at 3-6 months of follow up showed no difference between groups (Cohen's d standardised difference 0.06, 95% CI -0.14 to 0.26). The evidence was insufficient or too weak to show an effect on patients' ADL or carers' quality of life
CONCLUSION: Little or no evidence exists that nurse led chronic disease management innovations are more effec-tive than usual care in patients with chronic obstruceffec-tive pulmonary disease
Lodewijckx C, Sermeus W, Panella M, Deneckere S, Leigheb F, Decramer M, et al. Impact of care pathways for in-hospital management of COPD exacerbation: A systematic review. Int J Nurs Stud 2011;48(11):1445-56.
ABSTRACT:
BACKGROUND: In-hospital management of COPD exacerbation is suboptimal, and outcomes are poor. Care pathways are a possible strategy for optimizing care processes and outcomes. Objectives: The aim of the literature review was to explore characteristics of existing care pathways for in-hospital management of COPD exacerbations and to address their impact on performance of care processes, clinical outcomes, and team functioning.
METHODS: A literature search was conducted for articles published between 1990 and 2010 in the electronic data-bases of Medline, CINAHL, EMBASE, and Cochrane Library. Main inclusion criteria were (I) patients hospitalized for a COPD exacerbation; (II) implementation and evaluation of a care pathway; (III) report of original research, includ-ing experimental and quasi experimental designs, variance analysis, and interviews of professionals and patients
about their perception on pathway effectiveness.
RESULTS: Four studies with a quasi experimental design were included. Three studies used a preGÇôpost test design; the fourth study was a non randomized controlled trial comparing an experimental group where patients were treated according to a care pathway with a control group where usual care was provided. The four studied care pathways were multidisciplinary structured care plans, outlining time-specific clinical interventions and respon-sibilities by discipline. Statistic analyses were rarely performed, and the trials used very divergent indicators to eval-uate the impact of the care pathways. The studies described positive effects on blood sampling, daily weight meas-urement, arterial blood gas measmeas-urement, referral to rehabilitation, feelings of anxiety, length of stay, readmission, and in-hospital mortality.
CONCLUSIONS: Research on COPD care pathways is very limited. The studies described few positive effects of the care pathways on diagnostic processes and on clinical outcomes. Though due to limited statistical analysis and weak design of the studies, the internal validity of resykts is limited. Therefore, based on these studies the impact of care pathways on COPD exacerbation is inconclusive. These findings indicate the need for properly designed research like a cluster randomized controlled trial to evaluate the impact of COPD care pathways on performance of care processes, clinical outcomes, and teamwork
Taylor SJ, Candy B, Bryar RM, Ramsay J, Vrijhoef HJ, Esmond G, et al. Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systemat-ic review of evidence. [Review] [37 refs]. BMJ 2005;331(7515):485.
ABSTRACT:
OBJECTIVE: To determine the effectiveness of innovations in management of chronic disease involving nurses for patients with chronic obstructive pulmonary disease (COPD)
DESIGN: Systematic review of randomised controlled trials
DATA SOURCES: 24 electronic databases searched for English or Dutch language studies published between January 1980 and January 2005
REVIEW METHODS: Included studies described inpatient, outpatient, and community based interventions for chronic disease management that were led, coordinated, or delivered by nurses. Hospital at home and early dis-charge schemes for acute exacerbations of COPD were excluded
RESULTS: We identified nine relevant randomised controlled trials, most of which had some potential methodologi-cal flaws. All the interventions seemed to be variations on a case management model. The interventions described could be divided into brief (one month) and longer term (around a year) or more intensive interventions. Only two studies examined the effect of brief interventions, these found little evidence of any benefit. Meta-analysis of the long term interventions failed to detect any influence on mortality at 9-12 months' follow-up (Peto odds ratio 0.85, 95% confidence interval 0.58 to 1.26). There was evidence that the long term interventions had not improved pa-tients' health related quality of life, psychological wellbeing, disability, or pulmonary function. The evidence on whether long term interventions reduced readmissions to hospital was equivocal, but the only study exclusively directed at patients on long term oxygen therapy reported a reduction in readmission. We identified several out-comes where little or no evidence was available; these included patients' satisfaction, self management skills, ad-herence with treatment recommendations, the likelihood of smoking cessation, and the effect of the interventions on carers
CONCLUSION: There is little evidence to date to support the widespread implementation of nurse led management interventions for COPD, but the data are too sparse to exclude any clinically relevant benefit or harm arising from such interventions. [References: 37]