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A clinical trial verifies the benefits of a case manager on the number of hospitalizations in patients with COPD.

A Canadian randomized controlled trial published by Fan and colleagues in the journal Annals of Internal Medicine in 2012 assessed the efficacy of a therapeutic education program based on a case manager on the number of hospitalizations of patients with chronic obstructive pulmonary disease (COPD) and self-management of disease symptoms. The results show no decrease in the number of hospitalizations per patient education including a case manager. Moreover, this support was associated with a higher mortality in the intervention group than the group that does not benefit. These unexpected results are different from similar studies.

The Study Rationale

The exacerbation of COPD is the increase of one or more respiratory symptoms (cough, sputum, wheezing, dyspnea, chest tightness, fever) which persist for at least two days. Hospitalization for exacerbation lasts five days. It significantly impairs the quality of life. It aggravates temporarily and sometimes permanently respiratory function. It reduces life expectancy. These hospitalizations accounted for more than half of the medical costs associated with this disease. Find non-pharmacological interventions to reduce the number and duration of hospitalizations have considerable human and economic benefits. The case manager also called on France case manager or course manager, is a possible solution. He is a trained person who individually and remotely using a chronically ill patient to face the difficulties of living with the illness. He or she has a role of organization, planning, reminder, surveillance, advice on care as prevention and welfare. The course manager does not replace professionals in the field, he directs the patient to the right place at the right time of the disease. It is thus directly related to the patient by phone, email or video conferencing. He knows his medical file and therapeutic education plan. It exchanges if necessary with health professionals, prevention and patient welfare. In the case of COPD, the case manager aims to increase adherence to medical recommendations and requirements and prevent the onset of diseases often associated such as depression, diabetes, osteoarthritis and heart failure.

The Question

A tour manager working by phone it reduces the number of hospitalizations of patients with COPD?

The Method

The Canadian randomized controlled Fan and his colleagues tested the effectiveness of a therapeutic education program led by a tour manager on the number of hospitalizations of patients COPD. 426 patients aged over 40 years were included in the study. They have everyone been hospitalized at least once in the 12 months prior to inclusion. The intervention lasted 1 year. Each intervention patient group enjoyed exchanging a case manager by phone on the basis of an individual therapeutic education program. The control patients were receiving usual care. Both groups received an educational manual on how to manage COPD.

The study compared the groups on the time that elapsed between the start of the intervention and the first hospitalization. Secondary outcomes related to all-cause mortality, the number of exacerbations, quality of life related to health, patient satisfaction, knowledge about COPD and self-efficacy.

The Non-Pharmacological Intervention (NPI) assessed

The NPI is a case management action by telephone on the basis of a specific therapeutic education program in COPD and validated. Patients were required to participate in four individual sessions of therapeutic education for a period of one and a half face to face. An educational booklet was used. Professionals assessed the needs of each patient and provided them information and good practices. Systematic contributions of knowledge about drugs, on exacerbations, on self-management of respiratory symptoms and self-administration of an antibiotic for respiratory exacerbation were issued. Individual sessions were reinforced by a monthly group session. Telephone follow-up was conducted by the case manager once a month in the first quarter, and once a quarter. Breathing techniques and reduced anxiety related to coughing, a healthy diet and regular physical activity at home were recommended to patients.

Main Results

The study showed no statistical difference between the two groups in the number of hospitalizations. This number was 27% for the intervention group and 24% for the usual care group. At the end of the operation, 28 patients in the group receiving the intervention and 10 control patients died.

Mortality from all causes, was statistically higher in the group that received case management program. By cons, mortality from COPD is higher in the control group (10 patients) compared to the group benefiting from the innovative program (3 patients).

What it means for Patients

A case manager working telephone does not prove more effective in this study to reduce the number and duration of hospitalizations in a year in patients with COPD. Progress must be made on the training of these professionals and their way of working with patients with COPD.

What it means for Healthcare Professionals

A disease management program based a case manager is not enough to reduce the number of hospitalizations for exacerbations or improve health and depressive symptoms of COPD patients. It is vital that patients feel able to personally manage their COPD symptoms and comorbidity. A case manager may unwittingly create a feeling of omnipotence in patients who may have serious health consequences.

What it means for Researchers

The number of hospitalizations was not different between the two groups at the end of the study. In contrast, mortality was higher for the intervention group. The study data do not explain this unexpected result. Patients in group benefiting from the case manager could use antibiotics differently or delay to seek the advice of professionals. Self-management has been able to provide them with a false sense of security, causing a delay in the care of an exacerbation of COPD and its comorbidities.

The study had to be stopped because the number of deaths in the intervention group. Deaths are not exclusively due to COPD but comorbidities. It appears vital to take account of all new studies on the subject.

It is emphasized ethics authors who made public the results even if they do not go in the direction of their hypothesis. It is to their credit. The scientific approach should lead all researchers involved in a randomized controlled trial to publish their neutral and even negative results, and journal editors to accept this kind of items. This is of major importance in the non-drug intervention research sensitive to methodological bias, conflict of interest and the most dubious interpretations. It also goes to the quality of future meta-analyzes.

What it means for Policymakers

Mortality was higher in the group receiving non-drug intervention, a therapeutic education program based on a case manager. This study shows that interventional study is not without risks. The officials noticed these problems and were able to stop the study early.

The Reference

Fan V, Gaziano J, Lew R, Bourbeau J, Adams S, Leatherman S, Thwin SS, Huang GD, Robbins R, S. Sriram PS, Sharafkhaneh A, Mador JM, Sarosi G, Panos RJ, Rastogi P, Wagner TH, Mazzuca SA, Shannon C, Colling C, Liang MH, Stoller JK, Fiore L, Niewoehner DE (2012). A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations. Annals of Internal Medicine, 156, 673-683.

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To reference this Blog en Sante © article.

Ninot G (2015). A case manager to reduce hospitalizations. Blog en Sante, A45.

© Copyright 2015 Gregory Ninot. All rights reserved.