147 6 Cochrane review on integrated disease management for COPD In the previous decade, the concept of IDM was introduced as a means of improving quality and e ciency of care for patients with chronic non-communicable diseases such as COPD, heart failure, and diabetes mellitus. IDM interventions are aimed at reducing symptoms and avoiding fragmentation of care while containing costs. However, although IDM programmes are generally believed to be cost-e ective, evidence shows inconclusive results. Several systematic reviews have shown (partly) bene cial results for people with chronic heart failure (Gonseth 2004; Roccaforte 2005), diabetes (Bongaerts 2017; Knight 2005; Norris 2002; Pimouguet 2010), depression (Badamgarav 2003; Neumeyer-Gromen 2004), and COPD (Cronin 2017). It is important to note that there is no consensus in the literature about the de nition of IDM. Several de nitions have been proposed since the concept of ‘disease management’ was introduced. To facilitate communication between researchers, policy makers, and IDM program leaders, Schrijvers proposed a de nition based on earlier reported de nitions (Faxon 2004): “disease management consists of a group of coherent interventions designed to prevent or manage one or more chronic conditions using a systematic, multidisciplinary approach and potentially employing multiple treatment modalities. The goal of chronic disease management is to identify persons at risk for one or more chronic conditions, to promote self-management by patients, and to address the illness or conditions with maximum clinical outcome, e ectiveness, and e ciency regardless of treatment setting(s) or typical reimbursement patterns” (Schrijvers 2009). Peytremann-Bridevaux and Burnand adapted the de nition as follows: “chronic disease prevention and management consist of a group of coherent interventions, designed to prevent or manage one or more chronic conditions using a community-wide, systematic, and structured multi-disciplinary approach potentially employing multiple treatment modalities. The goal of chronic disease prevention and management is to identify persons with one or more chronic conditions, to promote self-management by patients, and to address the illness or conditions according to disease severity and patient needs and based on the best available evidence, maximising clinical e ectiveness and e ciency regardless of treatment setting(s) or typical reimbursement patterns. Routine process and outcome measurements should allow feedback to all those involved, as well as to adapt the programme” (Peytremann- Bridevaux 2009). Over the years, IDM programmes combining patient-related, professional-directed, and organisational interventions were developed with the goal of improving e ectiveness and economic e ciency of long-term care delivery (Lemmens 2009; Norris 2003; Wagner 2001). Since the previous version of this review of IDM for COPD patients (Kruis 2013), we have seen the advent of technology in IDM programmes, which potentially allows for continuously available and personalised types of patient guidance and monitoring (Kruse 2019). Technology can be integrated into IDM programmes in di erent ways, such as use of SMS services, websites, apps, or home monitoring devices. Consequently, several di erent names are used to describe concepts within this area, such as telehealth, telemonitoring, telerehabilitation, eHealth, and mHealth, which have
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