title: Bottom-up implementation of disease-management programmes: results of a multisite comparison.
abstract: OBJECTIVE
  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.
authors.affiliation: Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands. lemmens@bmg.eur.nl
authors.forename: K M M
authors.initials: KM
authors.lastname: Lemmens
authors.forename: A P
authors.initials: AP
authors.lastname: Nieboer
authors.forename: M P M H
authors.initials: MP
authors.lastname: Rutten-Van Mölken
authors.forename: C P
authors.initials: CP
authors.lastname: van Schayck
authors.forename: C
authors.initials: C
authors.lastname: Spreeuwenberg
authors.forename: J D
authors.initials: JD
authors.lastname: Asin
authors.forename: R
authors.initials: R
authors.lastname: Huijsman
mesh_terms: D019468:Disease Management; D004417:Dyspnea; D017598:Efficiency, Organizational; D006284:Health Plan Implementation; D006801:Humans; D009426:Netherlands; D018802:Patient-Centered Care; D015397:Program Evaluation; D029424:Pulmonary Disease, Chronic Obstructive / Q000503:physiopathology / Q000628:therapy*; D011788:Quality of Life; D012044:Regression Analysis; D015203:Reproducibility of Results