185 6 Cochrane review on integrated disease management for COPD involvement, follow-up window, number of participants, and outcome reporting. Nonetheless, we were able to pool data on all primary outcomes for short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Results of the previous review support IDM for management of COPD. Results of this update reinforce these ndings, providing evidence of higher certainty and including evidence on long-term e ects (up to 48 months). First, this review showed that IDM probably improves health-related quality of life (HRQoL) as indicated by a change in St. George’s Respiratory Questionnaire (SGRQ) overall score by 3.89 points after 12 months without reaching the minimum clinically important di erence (MCID) of -4 points. This improvement was more pronounced among high- quality studies only, indicating the robustness of our conclusions. This e ect was not observed after 15 months (mean di erence (MD) -0.69). IDM probably leads to improvement after 12 months in the symptoms domain (MD -3.88) and in the impact domain (MD- 3.34) but not in the activity domain of the SGRQ. Across all outcomes, we observed considerable heterogeneity, which could be explained in part by di erences in the quality of studies. Subgroup analysis suggested context-speci c e ects with no di erences among studies performed in Northwestern Europe and Oceania. Pooling of data from the Chronic Respiratory Questionnaire (CRQ), another measurement for HRQoL, showed statistically signi cant long-term e ects in favour of IDM in fatigue (MD 0.46), emotion (MD 0.53), and mastery (MD 0.83) domains. No signi cant e ects were found for short- and medium-term follow-up, nor for generic quality of life. Second, IDM probably results in a large improvement in maximum and functional exercise capacity as measured by the six-minute walking distance test (6MWD), which exceeds the MCID of 35 metres. At short-term follow-up, pooling showed improvement of 48 metres. This e ect was sustained over time, as shown by pooled data after 12 months (MD 44.69) and after 15 months’ follow-up (MD 60.41). Subgroup analysis indicated a considerable intervention-speci c e ect, with a larger e ect in studies with exercise, structural follow-up, or telemonitoring as the dominant intervention component. Third, the total number of patients with at least one respiratory-related hospital admission receiving an IDM programme, after median follow-up of 12 months, was on average 235 per 1000 patients compared to 324 per 1000 receiving usual care. Likewise the number of all-cause hospital admissions decreased from 517 per 1000 for usual care to 445 per 1000 for IDM. Within the group of patients admitted to the hospital, IDM likely reduces the length of stay by 2.3 days after median follow-up of 12 months. However, length of stay di ered considerably between studies, ranging from a reduction of 10.8 days to an increase of 3.5 days in the IDM group compared to the usual care group. In terms of the number of emergency department (ED) visits, IDM probably reduces the number of visits by 86 per 1000 ED visits. E ects on the aforementioned primary outcomes and details on level of certainty are summarised in Summary of ndings Table 1. In addition to e ects on our primary outcomes, we found a statistically signi cant improvement in lung function parameters
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