CF : Lung TX Part 3

[Guest guest]

Our results suggest that a general practice-based intervention such as

coordinated care may be the wrong approach for people with chronic

respiratory disease. Many patients with advanced respiratory disease may

be so ill that coordinated care can have little effect on the course of

the illness, the patient's well being, or healthcare service utilisation.

It is difficult for large community studies such as the coordinated care

trials to target specific subgroups of the population with chronic

respiratory disease owing to the large participant numbers that such

studies require. It may be better in future to focus on locally targeted

programs, such as pulmonary rehabilitation. Pulmonary rehabilitation has

demonstrated benefits in chronic obstructive pulmonary disease,22 and a

home-based program could be incorporated with home-based management to

improve future coordinated care interventions for respiratory disease.

A Cochrane review of a large, well-designed outreach nursing care study

for patients with chronic obstructive pulmonary disease2 also showed only

modest improvements in quality of life, accompanied by a substantial

increase in healthcare system costs.23 Congruent findings have been

demonstrated in a locally conducted outreach respiratory nurse program,

and by a systematic review of 15 studies of preventive home care visits

in elderly patients.24 The value of modest increases in quality of life

in people with complex and chronic conditions, for substantial increase

in healthcare costs, needs to be considered at a societal level. Given

the many difficulties reported with coordinated care in this study and

the lack of cost benefits, the future of wide-ranging coordinated care

interventions looks limited. Since the introduction in 2001 of the

Enhanced Primary Care items to the MBS (for health assessments, care

plans and case conferences), it is unclear whether the revised costs of

coordinated care will still outweigh any demonstrated benefits, but the

problems encountered in this study are likely to hinder future attempts

to show an overall benefit.

1: Flow diagram of participation in the study by the intervention and

comparison groups

2: Percentage of patients who showed improvement or deterioration in

functionality and quality of life*

Control © (usual care)

Intervention (I) (coordinated care)

P †

DeterioratedSameImprovedDeterioratedSameImproved

SF-36 physical (n = 150; C, 67; I, 83)15%73%12%13%72%15%0.627

SF-36 mental (n = 150; C, 67; I, 83)24%66%10%16%59%25%0.023

MBI (n = 147; C, 59; I, 88)7%80%13%23%68%9%0.080

OARS (n = 150; C, 61; I, 89)25%52%23%28%42%30%0.226

COOP

Physical condition (n = 159; C, 65; I, 94)29%48%23%21%63%16%0.528

Daily activities (n = 160; C, 65; I, 95)28%46%26%31%46%23%0.785

Social activities (n = 159; C, 65; I, 94)37%43%20%32%46%22%0.162

Emotional (n = 160; C, 65; I, 95)46%31%23%24%51%25%0.008

Breathlessness (n = 158; C, 65; I, 93)29%52%19%25%54%22%0.162

Pain (n = 160; C, 65; I, 95)43%29%28%21%54%25%0.031

Overall condition (n = 160; C, 65; I, 95)37%35%28%19%51%31%0.072

Quality of life (n = 160; C, 65; I, 95)31%49%20%21%49%29%0.030

Social support (n = 160; C, 65; I, 95)22%60%18%11%68%21%0.076

* Improvement or deterioration means a change in SF-36 score of 12 or

more, and a change of one unit on the five-item COOP and MBI scales and

on the 15-item OARS scale. † Except for the SF-36 comparisons, P values

are adjusted for MBS expenditure in the previous 12 months, age, sex,

smoking and hospitalisation in the previous 12 months.

3: Recalibrated costs per patient-year for coordinated care and usual

care

Usual careCoordinated careDifferenceRecalibration factor

Becki

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