Elsevier

The Lancet Neurology

Volume 12, Issue 10, October 2013, Pages 947-956
The Lancet Neurology

Articles
Integrated multidisciplinary care in Parkinson's disease: a non-randomised, controlled trial (IMPACT)

https://doi.org/10.1016/S1474-4422(13)70196-0Get rights and content

Summary

Background

A multidisciplinary approach is thought to be the best way to manage the motor and non-motor symptoms of Parkinson's disease, but how such care should be delivered is unknown. To address this gap in knowledge, we assessed the effectiveness of an integrated multidisciplinary approach compared with usual care.

Methods

We recruited patients for our non-randomised controlled trial from six community hospitals in the Netherlands (two in regions where the integrated care intervention was available and four in control regions that administered usual care). Eligible patients were those with Parkinson's disease, aged 20–80 years, and without severe cognitive impairment or comorbidity. Patients in the intervention group were offered an individually tailored comprehensive assessment in an expert tertiary referral centre and subsequent referrals to a regional network of allied health professionals specialised in Parkinson's disease. Primary outcomes were activities of daily living (Academic Medical Center linear disability score [ALDS]) and quality of life (Parkinson's disease quality of life questionnaire [PDQL]) measured at 4, 6, and 8 months. Secondary outcomes included motor functioning (unified Parkinson's disease rating scale, part III [UPDRS III], at 4 months), caregiver burden (belastungsfragebogen Parkinson angehörigen–kurzversion [BELA-A-k] at 4 and 8 months), and costs (during whole study period). Primary analysis was by intention to treat and included scores over 4, 6, and 8 months, with correction for baseline score. The trial is registered at Clinicaltrials.gov, number NCT00518791.

Findings

We recruited 301 patients (150 patients in the intervention group and 151 in the control group) between August, 2007, and December, 2009, of whom 285 completed follow-up (last follow-up was July, 2010). 101 (67%) patients in the intervention group visited the expert centre; 49 (33%) opted not to visit the expert centre. The average ALDS score from months 4, 6, and 8, with correction for baseline score, was greater in the intervention group than in the control group (difference 1·3 points, 95% CI −2·1 to 2·8; corresponding raw logit score difference 0·1, 95% CI 0·003 to 0·2) as was the average PDQL score (difference 3·0 points, 0·4 to 5·6). Secondary analysis with correction for baseline disease severity showed no differences between groups for ALDS (difference 0·9 points, 95% CI −0·6 to 2·4; corresponding raw logit score difference 0·1, −0·02 to 0·3) or PDQL (difference 1·7 points, −1·2 to 4·6). Secondary outcomes did not differ between groups (UPDRS III score difference 0·6 points, 95% CI −1·4 to 2·6; BELA-A-k score difference 0·8 points, −0·2 to 1·8; cost difference €742, −€489 to €1950).

Interpretation

This integrated care approach offered only small benefits to patients with Parkinson's disease, and these disappeared after correction for baseline disease severity. These results suggest that different approaches are needed to achieve more substantial health benefits.

Funding

NutsOhra Foundation, Stichting Parkinson Nederland, National Parkinson Foundation.

Introduction

Parkinson's disease is increasingly recognised as a multidimensional disorder. In addition to classic motor symptoms, patients have a wide variety of non-motor symptoms that substantially affect quality of life but often remain unrecognised and untreated.1 Moreover, most non-motor features do not respond satisfactorily to dopaminergic drugs, and some might even get worse, such as orthostatic hypotension and cognitive function.1 Therefore, the possible benefits of non-pharmacological interventions are generating interest. A multidisciplinary approach combining pharmacological treatment with non-pharmacological interventions to manage a complex disorder such as Parkinson's disease might be beneficial.2 Despite the shortage of evidence for effectiveness,3 guidelines recommend regular access to a broad range of medical and allied health-care professionals.4, 5 Indeed, many centres deliver integrated and multidisciplinary care for patients with Parkinson's disease.2, 6 However, a standard template for multidisciplinary care in Parkinson's disease does not exist, and guidelines do not clarify how a team approach should be organised and structured.

We developed an integrated model to organise care for patients with Parkinson's disease, with two complementary elements: an individually tailored assessment by a multidisciplinary team that defines a comprehensive treatment plan (including advice on drug treatment and recommendations for non-pharmacological interventions); and subsequent implementation of this plan within a network of specifically trained allied health professionals, supervised by the referring neurologist.7 To assess the effectiveness of this model, we designed Integrated Multidisciplinary care for Parkinson's disease: a Controlled Trial (IMPACT) to compare outcomes in patients with Parkinson's disease who had access to this model of care with those in patients receiving standard care.

Section snippets

Study design and participants

We recruited patients for this non-randomised, controlled trial from neurological outpatient clinics in six community hospitals in the Netherlands—two in a region where the intervention was available (intervention region), and four in regions where it was not (control regions; appendix). The control regions were geographically separated from the intervention region.

Inclusion criteria were having Parkinson's disease (diagnosed by a neurologist according to UK Brain Bank criteria),8 being aged

Results

We recruited 301 patients (150 patients in the intervention group and 151 in the control group) between August, 2007, and December, 2009, of whom 285 completed follow-up (5% dropout rate; figure 2). The final follow-up measurement took place in July, 2010. Of the 150 participants in the intervention group, 101 (67%) received a multidisciplinary assessment. 49 (33%) patients opted not to visit the expert centre. Reasons to decline included lack of perceived benefit or an anticipated burden of

Discussion

Parkinson's disease is increasingly acknowledged as a multidimensional disorder, with disabling symptoms in physical, emotional, and cognitive domains.1, 4, 23 Because of this complexity, many specialised Parkinson's disease clinics worldwide use a multidisciplinary team approach, because this approach is felt to offer the best management of Parkinson's disease.2, 6, 24, 25 However, this assumption is supported by only a small amount of inconclusive scientific evidence.3, 26 Here, we assessed

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