Tshepo Rasekaba

Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease.

OBJECTIVEnTo establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD).nnnDESIGNnAnalysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD.nnnSETTINGnOutpatient pulmonary rehabilitation program at 2 teaching hospitals.nnnPARTICIPANTSnSeventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9 y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104 m).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnParticipants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD.nnnRESULTSnThe mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change (P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20-61 m). There was excellent agreement with distribution-based methods (25.5-26.5m, kappa=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85).nnnCONCLUSIONSnThe MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice.

The six-minute walk test: a useful metric for the cardiopulmonary patient

Measurement of exercise capacity is an integral element in assessment of patients with cardiopulmonary disease. The 6‐min walk test (6MWT) provides information regarding functional capacity, response to therapy and prognosis across a range of chronic cardiopulmonary conditions. A distance less than 350u2003m is associated with increased mortality in chronic obstructive pulmonary disease, chronic heart failure and pulmonary arterial hypertension. Desaturation during a 6MWT is an important prognostic indicator for patients with interstitial lung disease. The 6MWT is sensitive to commonly used therapies in chronic obstructive pulmonary disease such as pulmonary rehabilitation, oxygen, long‐term use of inhaled corticosteroids and lung volume reduction surgery. However, it appears less reliable to detect changes in clinical status associated with medical therapies for heart failure. A change in walking distance of more than 50u2003m is clinically significant in most disease states. When interpreting the results of a 6MWT, consideration should be given to choice of predictive values and the methods by which the test was carried out.

Impact of a diabetes disease management program on diabetes control and patient quality of life.

The worldwide burden of diabetes is projected to be 5.4% of the adult population by the year 2025. Diabetes is associated with multiple medical complications that both decrease health-related quality of life (HR-QOL) and contribute to earlier mortality. There is growing evidence for the effectiveness of multidisciplinary disease management programs that incorporate self-management principles in improving patients long-term outcomes. The aim of this project was to evaluate the effectiveness of this approach in improving: (1) glycemic control measured by HbA1c, and (2) HR-QOL measured by the Assessment of Quality of Life (AQOL), at enrollment and at 12-months follow-up. Between 2004 and 2008, a total of 967 patients were enrolled in the program; 545 (56%) of these patients had HbA1c data available at baseline and at 12 months. Mean HbA1c at enrollment was 8.6% (SD 1.9) versus 7.3% (SD 1.2) at 12 months (P<0.001). Overall, 68% of patients experienced improvements in HbA1c. At enrollment, patients reported fair HR-QOL, which was significantly lower than age-adjusted population norms who reported good HR-QOL. At 12 months, 251 (64%) patients had improved HR-QOL, 27 (7%) had no change, and 114 (29%) deteriorated. Mean utility scores improved by 0.11 (P<0.001), which is almost twice the minimum clinically important difference for the AQOL. This study confirms that a multidisciplinary disease management program for patients with poorly controlled type 2 diabetes can improve both glycemic control and HR-QOL.

Can a chronic disease management pulmonary rehabilitation program for COPD reduce acute rural hospital utilization

Chronic obstructive pulmonary disease (COPD) imposes a costly burden on healthcare. Pulmonary rehabilitation (PR) is the best practice to better manage COPD to improve patient outcomes and reduce acute hospital care utilization. To evaluate the impact of a once-weekly, eight-week multidisciplinary PR program as an integral part of the COPD chronic disease management (CDM) Program at Kyabram District Health Services. The study compared two cohorts of COPD patients: CDM-PR Cohort (4–8 weeks) and Opt-out Cohort (0–3 weeks) between February 2006 and March 2007. The CDM-PR Program involved multidisciplinary patient education and group exercise training. Nonparametric statistical tests were used to compare acute hospital care utilization 12 months before and after the introduction of CDM-PR. The number of patients involved in the CDM-PR Cohort was 29 (n = 29), and that in the Opt-out Cohort was 24 (n = 24). The CDM-PR Cohort showed significant reductions in cumulative acute hospital care utilization indicators (95% emergency department presentations, 95% inpatient admissions, 99% length of stay; effect sizes = 0.62–0.66, P < 0.001) 12 months after the introduction of the CDM Program; in contrast, changes in the cumulative indicators were statistically insignificant for the Opt-out Cohort (emergency department presentations decreased by 5%, inpatient admissions decreased by 12%, length of stay increased by 30%; effect size = 0.14–0.40, P > 0.05). Total costs associated with the hospital care utilization decreased from

Telehealth in cystic fibrosis: a systematic review

130,000 to

Telemedicine interventions for gestational diabetes mellitus: A systematic review and meta-analysis

7,500 for the CDM-PR Cohort and increased from

Early mobilisation for elbow fractures in adults

77,700 to

Relationship between health-related quality of life, and acute care re-admissions and survival in older adults with chronic illness.

101,200 for the Opt-out Cohort. Participation in the CDM-PR for COPD patients can significantly reduce acute hospital care utilization and associated costs in a small rural health service.

Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions

We conducted a systematic review of the use of telehealth in people with Cystic Fibrosis (CF). The studies reviewed were of adults and children with CF, and incorporated telehealth for monitoring symptoms, assessing adherence to prescribed therapies or providing a therapeutic intervention. Searches of four electronic databases returned 293 references. Eight studies met the inclusion criteria. Variability in study design and outcome measures precluded meta-analysis. Seven studies assessed telemonitoring feasibility for patient usability and acceptance, or for physiological monitoring. Two studies were randomised controlled trials, although only one showed differences in outcome between the intervention and usual care with improved spirometry stability and significantly increased antibiotic use in the intervention group. In four studies participants were asked to transmit data on spirometry (FEV1) or symptoms. Participant non-compliance with data reporting ranged from 43–63%. Generally, participants reported being able to use the required technology. There is insufficient evidence to reach a firm conclusion about the benefits of telehealth in people with CF, but it remains a promising area for future investigation.

Desaturation During the 3-Minute Step Test Predicts Impaired 12-Month Outcomes in Adult Patients With Cystic Fibrosis

OBJECTIVEnTo evaluate the effect of telemedicine on GDM service and maternal, and foetal outcomes.nnnMETHODSnA systematic review and meta-analysis of randomised controlled trials (RCT) of telemedicine interventions for GDM was conducted. We searched English publications from 01/01/1990 to 31/08/2013, with further new publication tracking to June 2015 on MEDLINE, EMBASE, PUBMED, CINAHL, the Cochrane Central Register of Controlled Trials and the World Health Organization International Clinical Trials Registry electronic databases. Findings are presented as standardised mean difference (SMD) and odds ratios (OR) or narrative and quantitative description of findings where meta-analysis was not possible.nnnRESULTSnOur search yielded 721 abstracts. Four met the inclusion criteria; two publications arose from the same study, resulting in three studies for review. All studies compared telemedicine to usual care. Telemedicine was associated with significantly fewer unscheduled GDM clinic visits, SMD. Quality of life, glycaemic control (HbA1c, pre and postprandial blood glucose level (BGL)), and caesarean section rate were similar between the telemedicine and usual care groups. None of the studies evaluated costs.nnnCONCLUSIONSnTelemedicine has the potential to streamline GDM service utilisation without compromising maternal and foetal outcomes. Its advantage may lie in the convenience of reducing face-to-face and unscheduled consultations. Studies are limited and more trials that include cost evaluation are required.