Summary of findings 1. Integrated disease management interventions compared to usual care for patients with chronic obstructive pulmonary disease.
| Integrated disease management interventions compared to usual care for patients with chronic obstructive pulmonary disease | ||||||
| Patient or population: patients with chronic obstructive pulmonary disease Setting: 15 studies in primary care, 22 studies in secondary care, 5 studies in tertiary care, 10 studies combination of primary and secondary care. 4 studies performed in North America, 9 studies in Northwestern Europe, 5 studies in Southern Europe, 3 studies in Oceania, 4 studies in East Asia, 3 studies in West Asia Intervention: integrated disease management interventions Comparison: usual care | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | №. of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Risk with usual care | Risk with integrated disease management interventions | |||||
| Health‐related quality of life assessed with SGRQ (total) Scale from 0 to 100 (lower scores indicate better quality of life) Follow‐up: range 9 to 14 months; median 12 months | Mean change in SGRQ in control groups ranged from ‐6.77 to 6.24 points | MD 3.89 points lower (6.16 lower to 1.63 lower) | ‐ | 4321 (18 RCTs) | ⊕⊕⊕⊝ MODERATEa,b | MCID for SGRQ is ‐4 points. Effect is not observed longer than 12 months |
| Functional exercise capacity assessed with 6MWD Follow‐up: range 9 to 14 months; median 12 months | Mean change in 6MWD in control groups ranged from ‐45.0 to 37.4 metres | MD 44.69 metres more (24.01 more to 65.37 more) | ‐ | 2071 (13 RCTs) | ⊕⊕⊕⊝ MODERATEa,c | MCID is 35 metres. The observed effect is consistent over time and is noticeable longer than 12 months |
| Respiratory‐related hospital admissions Follow‐up: range 3 to 36 months; median 12 months | Study population | OR 0.64 (0.50 to 0.81) | 4207 (15 RCTs) | ⊕⊕⊕⊕ HIGH | ||
| 324 per 1000 | 235 per 1000 (193 to 280) | |||||
| Hospital admissions, all causes Follow‐up: range 6 to 48 months; median 12 months | Study population | OR 0.75 (0.57 to 0.98) | 9030 (10 RCTs) | ⊕⊕⊕⊝ MODERATEd | ||
| 517 per 1000 | 445 per 1000 (379 to 512) | |||||
| Hospital days per patient, all causes Follow‐up: range 3 to 24 months; median 12 months | Mean hospital days per patient ranged from 1.6 to 25.5 days | MD 2.27 days fewer (3.98 fewer to 0.56 fewer) | ‐ | 3563 (14 RCTs) | ⊕⊕⊕⊝ MODERATEa | Mean change in hospital days ranged between an increase of 3.3 days and a reduction of 10.8 days |
| ED visits Follow‐up: range 3 to 48 months; median 12 months | Study population | OR 0.69 (0.50 to 0.93) | 8791 (9 RCTs) | ⊕⊕⊕⊝ MODERATEa | ||
| 412 per 1000 | 326 per 1000 (259 to 394) | |||||
| *The basis for the assumed risk is provided in the footnotes. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the usual care group and the relative effect of the intervention (and its 95% CI). 6MWD: six‐minute walking distance; CI: confidence interval; ED: emergency department; IDM: integrated disease management; MCID: minimum clinically important difference; MD: mean difference; OR: odds ratio;RCT: randomised controlled trial;SGRQ: St. George's Respiratory Questionnaire. | ||||||
| GRADE Working Group grades of evidence. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | ||||||
aDowngraded one level because pooling showed substantial heterogeneity between studies, which could not or could only partially be explained by differences in the quality of studies.
bSubgroup analysis on the dominant component and region suggested intervention‐ and context‐specific effects.
cPooling of high‐quality studies showed a smaller non‐statistically significant difference of 6.51 metres (95% CI ‐7.53 to 20.55).
dDowngraded one level because pooling showed considerable heterogeneity and inconsistency in direction of effect between studies with statistical significantly fewer hospitalisations, with more hospitalisations, or with no differences between groups.