Implementing integrated care guidelines in asthma and COPD:It ain’t easy!

Objective: To evaluate the implementation of a guideline-based, integrated, standardised, personal approach in patients with Chronic ObstructivePulmonary Disease (COPD) or Asthma in a real-life situation.Methods: Patients at the outpatient clinic of the department of pulmonary disease were included in a controlled cohort study, comparing the use ofdiagnostic items and ‘Personalised care plans’ (PCPs) in patients with obstructive lung disease before (2013) and after (2015) implementation of apersonalised diagnostic pathway. Results were compared with reference data (2016) from two control hospitals that used the same guidelines butdid not implement this pathway.Results: 100 patients were selected for all three cohorts. After implementing the diagnostic pathway in 2015, 35 % of patients visited attended allpre-planned appointments, whereas 65 % of patients did not: they were diagnosed using usual care. Factors contributing to patients not attendingthe diagnostic care pathway were: the logistical complexity and intensity of the 2-day pathway, patients willingness to participate in a personalisedpathway, and low social economic status or low literacy. After the implementation of the pathway, a significant improvement was seen in thenumber of PCPs (P < 0.001) and the number of diagnostic items registered recorded in the patients’ electronic medical records (P < 0.001).Conclusion: Implementing a standardised diagnostic pathway in a real-life population significantly improved the number of personalised care plans,demonstrating that the implementation of holistic care planning is feasible in this population. Nevertheless, the pathway needs further improvements to maximize the number of patients benefitting from it, including logistical streamlining, removing unnecessary diagnostic tools, andincreasing the focus on low literacy. Additionally, we found that implementing existing guidelines in a real life context is complex. Therefore, it isrequired to prioritize the translation of current guidelines into every-day practice, before expanding existing guidelines and protocol

Effectiveness and cost-effectiveness of early assisted discharge for Chronic Obstructive Pulmonary Disease exacerbations: the design of a randomised controlled trial

Background: Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) are the main cause for hospitalisation. These hospitalisations result in a high pressure on hospital beds and high health care costs. Because of the increasing prevalence of COPD this will only become worse. Hospital at home is one of the alternatives that has been proved to be a safe alternative for hospitalisation in COPD. Most schemes are early assisted discharge schemes with specialised respiratory nurses providing care at home. Whether this type of service is cost-effective depends on the setting in which it is delivered and the way in which it is organised. Methods/Design: GO AHEAD (Assessment Of Going Home under Early Assisted Discharge) is a 3-months, randomised controlled, multi-centre clinical trial. Patients admitted to hospital for a COPD exacerbation are either discharged on the fourth day of admission and further treated at home, or receive usual inpatient hospital care. Home treatment is supervised by general nurses. Primary outcome is the effectiveness and cost effectiveness of an early assisted discharge intervention in comparison with usual inpatient hospital care for patients hospitalised with a COPD exacerbation. Secondary outcomes include effects on quality of life, primary informal caregiver burden and patient and primary caregiver satisfaction. Additionally, a discrete choice experiment is performed to provide insight in patient and informal caregiver preferences for different treatment characteristics. Measurements are performed on the first day of admission and 3 days, 7 days, 1 month and 3 months thereafter. Ethical approval has been obtained and the study has been registered. Discussion: This article describes the study protocol of the GO AHEAD study. Early assisted discharge could be an effective and cost-effective method to reduce length of hospital stay in the Netherlands which is beneficial for patients and society. If effectiveness and cost-effectiveness can be proven, implementation in the Dutch health care system should be considered. Trial registration: Netherlands Trial Register NTR1129

Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Background: In the absence of clear differences in effectiveness and cost-effectiveness between hospital-at-home schemes and usual hospital care, patient preference plays an important role. This study investigates patient preference for treatment place, associated factors and patient satisfaction with a community-based hospital-at-home scheme for COPD exacerbations. Methods: The study is part of a larger randomised controlled trial. Patients were randomised to usual hospital care or early assisted discharge which incorporated discharge at day 4 and visits by a home care nurse until day 7 of treatment (T + 4 days). The hospital care group received care as usual and was discharged from hospital at day 7. Patients were followed for 90 days (T+90 days). Patient preference for treatment place and patient satisfaction (overall and per item) were assessed quantitatively and qualitatively using questionnaires at T + 4 days and T + 90 days. Factors associated with patient preference were analysed in the early assisted discharge group. Results: 139 patients were randomised. No difference was found in overall satisfaction. At T + 4 days, patients in the early assisted discharge group were less satisfied with care at night and were less able to resume normal daily activities. At T + 90 days there were no differences for the separate items. Patient preference for home treatment at T + 4 days was 42% in the hospital care group and 86% in the early assisted discharge group and 35% and 59% at T+90 days. Patients' mental state was associated with preference. Conclusion: Results support the wider implementation of early assisted discharge for COPD exacerbations and this treatment option should be offered to selected patients that prefer home treatment

Cost-Effectiveness of Early Assisted Discharge for COPD Exacerbations in The Netherlands

AbstractObjectivesHospital admissions for exacerbations of chronic obstructive pulmonary disease are the main cost drivers of the disease. An alternative is to treat suitable patients at home instead of in the hospital. This article reports on the cost-effectiveness and cost-utility of early assisted discharge in The Netherlands.MethodsIn the multicenter randomized controlled Assessment of GOing Home under Early Assisted Discharge trial (n = 139), one group received 7 days of inpatient hospital treatment (HOSP) and one group was discharged after 3 days and treated at home by community nurses for 4 days. Health care resource use, productivity losses, and informal care were recorded in cost questionnaires. Microcosting was performed for inpatient day costs.ResultsSeven days after admission, mean change from baseline Clinical Chronic Obstructive Pulmonary Disease Questionnaire score was better for HOSP, but not statistically significantly: 0.29 (95% confidence interval [CI]−0.04 to 0.61). The difference in the probability of having a clinically relevant improvement was significant in favor of HOSP: 19.0%-point (95% CI 0.5%–36.3%). After 3 months of follow-up, differences in effectiveness had almost disappeared. The difference in quality-adjusted life-years was 0.0054 (95% CI−0.021 to 0.0095). From a health care perspective, early assisted discharge was cost saving:−€244 (treatment phase, 95% CI−€315 to−€168) and−€168 (3 months, 95% CI−€1253 to €922). Societal perspective:−€65 (treatment phase, 95% CI−€152 to €25) and €908 (3 months, 95% CI−€553 to €2296). The savings per quality-adjusted life-year lost were €31,111 from a health care perspective. From a societal perspective, HOSP was dominant.ConclusionsNo clear evidence was found to conclude that either treatment was more effective or less costly

A call to action for expanded sleep research in pediatric oncology: A position paper on behalf of the International Psycho-Oncology Society Pediatrics Special Interest Group

Sleep and circadian rhythms are closely related to physical and psychosocial well-being. However, sleep and circadian rhythm disruptions are often overlooked in children with cancer, as they are frequently considered temporary side effects of therapy that resolve when treatment ends. Yet, evidence from adult oncology suggests a bidirectional relationship wherein cancer and its treatment disrupt sleep and circadian rhythms, which are associated with negative health outcomes such as poor immune functioning and lower survival rates. A growing body of research demonstrates that sleep problems are prevalent among children with cancer and can persist into survivorship. However, medical and psychosocial outcomes of poor sleep and circadian rhythmicity have not been explored in this context. It is essential to increase our understanding because sleep and circadian rhythms are vital components of health and quality of life. In children without cancer, sleep and circadian disturbances respond well to intervention, suggesting that they may also be modifiable in children with cancer. We present this paper as a call to (a) incorporate sleep or circadian rhythm assessment into pediatric cancer clinical trials, (b) address gaps in understanding the bidirectional relationship between sleep or circadian rhythms and health throughout the cancer trajectory, and (c) integrate sleep and circadian science into oncologic treatment