Melbourne School of Population and Global Health - Theses
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ItemWhat is the most suitable disease management model for COPD?: Identifying effective and cost-effective programs for treating COPD( 2013)Pulmonary Rehabilitation (PR) has been developed to target the physical function recovery, and Cognitive-Behavioural Therapy (CBT) has become a potentially useful treatment for managing depression and anxiety disorders induced by COPD. However, it has been difficult for health providers to select appropriate program models because there has been insufficient knowledge of the effectiveness and the cost-effectiveness of these two programs. This thesis therefore aims to investigate in two important questions: 1. What is the optimal model of a PR program that can provide sustained effects with cost-effectiveness? 2. How can more information be provided about the effectiveness and cost-effectiveness of CBT programs by conducting more trials with more robust study designs? This thesis has two parts to its current study of the effectiveness and the cost-effectiveness of PR and CBT and Part B is built on the results from Part A: PART A of the thesis focuses on the effectiveness of PR and the potential cost-saving through reduction of hospital readmission. In previous studies there has been no empirical study measuring the long-term effects of PR up to one year. More importantly, previous meta-analysis studies do not consider the difference of the study designs in their analysis and so create the problem of "comparing apples with oranges." This study is the first study to apply systematic review, meta-analysis and meta-regression analysis to summarize those PR components that are the most critical in producing a lasting improvement for COPD patients. Statistical program, R, is applied for the meta-analysis and meta-regression analysis. Random-effect model is applied for the meta-analysis, and mixed-effect model is applied for the meta-regression analysis. The meta-analysis in this study is the first empirical research to demonstrate that PR components produce both short-term and long-term effects up to one year. The summarized effects indicate that PR components can improve HRQoL of COPD patients by an SGRQ score of -4.33, 95% CI(-5.8, -2.87) in the short-term and -3.7, 95% CI (-6.34,-1.06) in the long-term. The meta-regression analysis further identifies the critical components of PR, which produce the effects lasting up to one year, as the scheduled exercise and the home-based training. PART B: PART B gives the protocol of an economic evaluation alongside with a telephone-based CBT trial and is the first economic evaluation of telephone-based CBT for COPD patients. Cost-utility analysis and cost-effectiveness analysis are applied. A telephone-based program is believed to improve the accessibility of patients to the service. This economic evaluation uses the societal perspective with a life-long time-frame. Patients aged over 45 with stable COPD and mild to moderate depression or anxiety have been recruited. 70 patients are in each arms of the study. The study is a randomized-controlled trial. The time-frame of this trial is 16 weeks, including 8 weeks of treatment program and 8 weeks to observe the prolonged effects. The measurement of outcomes includes the effectiveness measurements of depression measurement - PHQ-9, anxiety measurement – BAI, and the disease-specific measurement of the COPD Assessment Test (CAT). For the utility measurement, AQOL-4D is applied. In order to capture the costs for COPD patients, new cost diaries and questionnaires are developed based on the characteristics of COPD patients. A Markov model will be established to extrapolate the effects beyond the clinical trial. Sensitivity analysis is also applied in order to explore the uncertainties of this study. The economic evaluation from this study will be a unique, current and important assessment for the management of COPD. Overall, this thesis highlights the home-based training of PR is an important component to produce lasting effects. This study does not show that PR components other than scheduled exercise training and home-based training produce significant impacts lasing for 1 year. It is recommended more robust study designs with appropriate time-frame is needed to investigate the effects of these PR components on HRQoL and reduction of hospital readmission. The economic evaluation protocol of this thesis further provides an opportunity to explore not only the effects of CBT for COPD patients, but also the cost-effectiveness of providing this service.