Improving Chronic Care: Developing and testing disease-management interventions applied in COPD care

Disease management has emerged as a new strategy to enhance quality of care for patients suffering from chronic conditions, and to control health care costs. So far, however, the effects of this strategy remain unclear. The purpose of this thesis was to determine the core elements of disease management and to understand how they operate and interact in order to effectively evaluate disease-management programmes, particularly for patients with chronic obstructive pulmonary disease. An evaluation model â?" based on social learning theories â?" was developed that relates programme components with the underlying mechanisms (e.g. knowledge and behaviour) by which they influence outcomes, and proposes direct and indirect relationships among them. Systematic literature reviews were performed to determine the current knowledge on the effectiveness of disease-management programmes. These found promising improvements in quality of life and reductions in hospitalisati! ons, especially for triple intervention disease-management programmes in COPD care. (Parts of) this evaluation model was/ were tested by evaluating three Dutch regional COPD disease-management programmes. The application of a theoretical model enhanced the design and evaluation of such programmes. Furthermore, it was concluded that bottom-up implementation of COPD disease-management programmes is a feasible approach, which leads to significant improvements in various quality of life dimensions, dyspnoea, and patient experiences with practice nurses in multiple settings. Disease-management programmes should preferably include the triptych of patient-related, professional-directed and organisational interventions. Achieving change in the behaviour of patients as well as professionals is essential in disease-management programmes. Organisational structures to this end should also be modified by case management, follow-up systems and/ or multidisciplinary care provision.