192 6 Chapter 6 indicate clinical signi cance of the e ects of IDM for a large group of patients. Authors’ conclusions Implications for practice This review and meta-analysis provides evidence that integrated disease management (IDM) programmes of at least 12 weeks’ duration are generally e ective for people with chronic obstructive pulmonary disease (COPD) and result in clinically bene cial outcomes. E ects are most pronounced on the short term and in the medium term. For the long term only, e ects on six-minute walking distance (6MWD) persist, although this may be explained in part by the smaller number of studies. Also, the e ect size di ers between studies and interventions. In practice, this means there is no one size ts all solution, and interventions should always be carefully designed and evaluated. We calculated that 89 hospital admissions related to respiratory problems can be prevented for every 1000 patients treated with IDM, leading to a number needed to treat for additional bene cial outcome (NNTB) of 12 patients to prevent one from being admitted over follow-up of 12 months. Although the numbers of patients admitted to hospital for all causes di ered slightly between groups, time spent in the hospital decreased by two days in patients treated with IDM compared to those receiving usual care. This is of utmost importance, as hospitalisations contribute to the highest burden and costs among patients with COPD. In our review, we do not provide the ideal combination of components that represent the optimal IDM programme. Rather, our results indicate that di erent dominant components of IDM have bene cial e ects for speci c outcomes. Our dominant component analysis showed that telemonitoring improves quality of life, whereas exercise tolerance is improved by IDM programmes with a dominant component of exercise, structural follow-up, or telemonitoring, and respiratory-related admissions are improved by self-management. This means that IDM programmes should consist of several di erent components to reach the highest potential. Ideally, components of the IDM programme should be linked to personal goals of the patient. Previously, Kessler 2018 and Marsiglia 2015 showed important di erences in usual care between countries, and our review also found di erences between regions. These di erences might stem from a disparity in local availability of di erent components, from di erences in the healthcare system, or from di erent customs. Furthermore, they are dependent on available resources and costs of interventions. Therefore, we suggest that policy makers and healthcare leaders should assess local needs and available interventions and use this overview to develop and implement an IDM programme in a context-sensitive manner. This review suggests that an IDM programme with a combination of exercise Implications for research Well-designed and appropriately conducted studies are still needed to minimise bias,
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