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Bottom-up implementation of disease-management programmes: results of a multisite comparison
  1. K M M Lemmens1,
  2. A P Nieboer1,
  3. M P M H Rutten-Van Mölken2,
  4. C P van Schayck3,
  5. C Spreeuwenberg3,
  6. J D Asin4,
  7. R Huijsman1
  1. 1Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  2. 2Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
  3. 3Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
  4. 4ACSION: Advance Care Solutions and Insights for Optimization, Amstelveen, The Netherlands
  1. Correspondence to Dr K M M Lemmens, Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands; lemmens{at}


Objectives To evaluate the implementation of three regional disease-management programmes on chronic obstructive pulmonary disease (COPD) based on bottlenecks experienced in professional practice.

Methods The authors performed a multisite comparison of three Dutch regional disease-management programmes combining patient-related, professional-directed and organisational interventions. Process (Assessing Chronic Illness Care survey) and outcome (disease specific quality of life (clinical COPD questionnaire (CCQ); chronic respiratory questionnaire (CRQ)), Medical Research Council dyspnoea and patients' experiences) data were collected for 370 COPD patients and their care providers.

Results Bottlenecks in region A were mostly related to patient involvement, in region B to organisational issues and in region C to both. Selected interventions related to identified bottlenecks were implemented in all programmes, except for patient-related interventions in programme A. Within programmes, significant improvements were found on dyspnoea and patients' experiences with practice nurses. Outcomes on quality of life differed between programmes: programme A did not show any significant improvements; programme B did show any significant improvements on CCQ total (p<0.001), functional (p=0.011) and symptom (p<0.001), CRQ fatigue (p<0.001) and emotional scales (p<0.001); in programme C, CCQ symptom (p<0.001) improved significantly, whereas CCQ mental score (p<0.001) deteriorated significantly. Regression analyses showed that programmes with better implementation of selected interventions resulted in relatively larger improvements in quality of life (CCQ).

Conclusions Bottom-up implementation of COPD disease-management programmes is a feasible approach, which in multiple settings leads to significant improvements in outcomes of care. Programmes with a better fit between implemented interventions and bottlenecks showed more positive changes in outcomes.

  • Chronic disease
  • patient education
  • clinical practice guidelines
  • primary care
  • quality of care

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  • Funding This work was supported by an unrestricted grant from PICASSO for COPD, an initiative of Pfizer BV and Boehringer Ingelheim BV in cooperation with research institute Caphri (Care and Public Health Research Institute) of Maastricht University. One disease-management programme was also supported by Menzis care and income insurer.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.