抽象的
A chronic care model in primary care is feasible and effective for the COPD population even at an early stagehttp://ow.ly/yZzR30gE26r
慢性病需要用于整体和彻底管理的“慢性”干预措施,这绝对在所谓的慢性护理模型(CCM)中接受[CCM)[1]。In chronic obstructive pulmonary disease (COPD), an increasing body of evidence stresses the need for this patient-focused approach to care [2]。Since its first application, the chronic care method has needed to identify the ideal subset of patients that would largely benefit from its practice in real life and the most impactful areas of intervention. Recovery from hospitalisation following admission due to acute exacerbations is often recognised as the ideal time during which to educate the patient on how to react to health deterioration. Indeed, the transition from hospital back to the community represents a critical process, failure of which is associated with higher rates of rehospitalisation [3]。
Although this is undoubtedly true, choosing a specific subset of COPD patients might act as a selection bias limiting the potential benefits to a specific phase along the course of the disease. Fromer[4] thus suggested a proactive strategy to reduce the burden of COPD in the early stages, requiring a collaborative strategy in the primary care setting. COPD self-management programmes have thus far been demonstrated to improve patients' quality of life and healthcare use in secondary care settings [5], which do not preclude its applicability even to general practice. Self-management programmes must be focused on the needs of each particular patient and ought to be tailored to a comprehensive dimension that only the primary care setting can actually manage. Moreover, routine monitoring of clinical outcomes and health status should become a shared responsibility between healthcare professionals and well trained patients [6]。
在方法论方面,最近的证据表明,自我管理教育如何不仅限于简单的信息活动,并应作为一种旨在赋予患者修改其行为的教练方法来构造[7]。
The CCM is based on the assumption that effective behavioural changes can only be achieved through the empowerment of patients' self-efficacy. Patients who develop enough confidence in their capacity to positively react to specific events are more prone to change and to maintain this attitude. Adequate self-management of health outcomes is defined as increased self-efficacy, individual mastery and effective integration of self-management skills on a day-to-day basis [2]。These changes in resilience should ultimately result in improved clinical outcomes and reduced healthcare costs [5]。
年代的研究teurer-Steyet al.[8扩大了知识与其他出版费用riences of strategies to improve self-management interventions and change behaviours in a primary care setting [4,7]。特别是,通过比较两种不同的COPD,这是一个与COPD计划一起生活的瑞士[9]应用于慢性阻塞性肺部疾病加剧风险指数同类研究的国际合作努力[10] population as the control, the authors draw the conclusion that a coaching intervention based on self-management leading to empowerment and self-efficacy is feasible among COPD patients in a general practice setting, and provides a 64% rate reduction of acute exacerbation risk over time. In addition, health-related quality of life improved by a ≥0.54-point reduction (on a seven-point scale) in each Chronic Respiratory Questionnaire domain score.
Therefore, it seems that the general practice in primary care settings represents a critical field of application for the CCM in order to reduce the impact on chronic respiratory patients in terms of both clinical burden and healthcare utilisation [11],即使在疾病的早期阶段。因此,在这种情况下的一个主要问题是未经诊断的COPD患者代表的,他们不会从CCM给出的机会中受益。因此,有针对性的案件发现似乎是在提供健康教练和自我管理支持等策略之前的重要步骤[12]。
From the methodological point of view, a strength of the present study [8]是使用的全面方法,包括向患者提供有关疾病的信息,应对技巧和能力以及自信心和主动动机的自我实现。确实,每个患者接受了小组和个人一对一的教练课程,以评估和讨论可能影响其对疾病的韧性的所有身体和心理方面。研究中描述和详细介绍的所有干预措施都具有实际方法,并着重于产生患者对疾病的行为态度的切实变化。此外,同一位作者通过遵循2年内加重率的影响提供了连贯的成本效果。
尽管结果令人鼓舞,但在同一队列中缺乏对照组的随机设计仍然使任何普遍性不可能。为了减轻该方法学限制对整个分析的影响,作者使用了逻辑回归模型,即倾向评分,以计算每个人在治疗组中的概率。他们通过运行敏感性分析完成了统计校正,并以控制可能提供自我管理干预的人的控制。然而,由于不可预测的混杂变量,倾向得分的使用和灵敏度分析无法完全平衡丢失的随机化。
Notwithstanding, the findings of Steurer-Steyet al.[8], and the cost-saving impact in particular, warrant future studies to confirm. In the COPD population at large, the prevention of healthcare utilisation through a self-management approach to symptoms and care would heavily impact on the global disease burden.
就此而言,CCM需要赋予不同方面的能力以提高效率:1)基于初级保健的患者自我效能改善的不断随访;2)以每个患者的身份量身定制护理过程;3)实现综合自我管理能力;4)由多学科专业人士组成的共同干预;5)在以患者为导向的设备的开发与任何技术基础设施之间进行适当的整合;6)在自我管理和自我效能过程中实施新技术。特别是对最后两个点的引用D,DeTOLEDOet al.[13] have reported that a telehealth care model, applied to 157 COPD patients, resulted in a reduction rate of re-admission as compared with controls (51% and 33%, respectively), with high acceptance amongst professionals, and low installation and exploitation costs. In a very recent report [14], detailed insights into the features of a patient-support mobile app integrated into a CCM delivered to COPD patients were presented. These include specific programmes for breathing techniques, stress and dyspnoea management, diet and nutrition and tools for personalised feedback, reminders, and social networking activities [15]. It could be argued that the integration of new technologies would represent the smarter and potentially greater improvement for the chronic care method, shifting the traditional approach towards a digital health for the CCM purposes.
Footnotes
利益冲突:没有声明
- ReceivedOctober 10, 2017.
- AcceptedOctober 13, 2017.
- Copyright ©ERS 2018