Integrated Disease Management for Chronic Obstructive Pulmonary Disease in Primary Care, from the Controlled Trial to Clinical Program: A Cohort Study

Abstract

Purpose Integrated disease management (IDM) for COPD in primary care has been primarily investigated under clinical trial conditions. We previously published a randomized controlled trial (RCT) where the IDM intervention improved quality of life (QoL) and exacerbation-related outcomes. In this study, we assess the same IDM intervention in a real-world evaluation and identify patient characteristics associated with improved outcomes. Methods This historical cohort study included patients enrolled for 12 (±3 months) in the Best Care COPD IDM program. The main outcome was a ≥3 point improvement in COPD assessment test (CAT). Secondary outcomes were COPD exacerbations requiring antibiotics and/or prednisone, unscheduled physician visits, emergency department visits and hospitalizations. Results Data for 571 patients ( all patients) were included, 158 met the reference RCT eligibility (RCT matched) . Improved QoL was observed in 43% (95% CI:38.9,47.2) of all patients , 47% (95% CI:39.5,55.6) of RCT matched vs 92% (95% CI:79.2,95.1) in the reference RCT intervention arm (n=72). Reductions (12 months IDM vs prior year) were observed in the proportion of patients experiencing exacerbation-related events ( all patients ): antibiotics/prednisone (−9.0%,95% CI:-13.9,-3.9); unscheduled physician (−33.1%,95% CI:-38.2,-27.9); emergency department (−9.6%,95% CI:-13.5,-5); and hospitalizations (−6.8%,95% CI:-10.0,-3.7). For the RCT matched group all reductions were comparable to the reference RCT intervention arm. The strongest predictors of improved QoL were baseline CAT, CAT≥20 vs CAT<10 (OR 15.6,95% CI:7.91,30.83), GOLD group B (OR 6.4,95% CI:3.42,11.85) and D (OR 5.64,95% CI:2.80,11.37) vs GOLD group A. Patients with prior antibiotic/prednisone use, FEV 1 <30% predicted and GOLD group D were less likely to have no urgent health service utilization (OR 0.5,95% CI:0.30,0.68), (OR 0.2,95% CI:0.07,0.78) and (OR 0.3,95% CI:0.14,0.51), respectively. Conclusion Best Care COPD improved QoL and reduced exacerbation-related outcomes in a manner directionally similar to the RCT from which it emanated. Baseline QoL, exacerbation history, and GOLD category were identified as possible predictors of IDM impact and will inform future program development and resource allocation.

Does uptake of specialty care affect HRQoL development in COPD patients beneficially? A difference-in-difference analysis linking claims and survey data

“…Another important aspect for further research could also be the impact on HRQoL of improving cooperation and communication between specialists and GPs. Recent literature shows that multidisciplinary approaches such as integrated disease management can result in a clinically relevant improvement in disease-specific HRQoL [66].…”

Quantifying sustained health system benefits of primary care-based integrated disease management for COPD: a 6-year interrupted time series study

“…17 Further evaluative studies of the Best Care COPD Programme supported real-world effectiveness, reporting that Best Care improved patient and provider experiences, and that it was cost-effective and dominant relative to the usual standard of care. [18][19][20][21][22][23] As with the majority of studies forming a large body of published literature on IDM, the quantitative evaluations were limited to 1 year of locally collected follow-up data. 13 Additionally, even for pulmonary rehabilitation, a gold-standard COPD IDM intervention, the long-term impacts are unproven.…”

“…Figure2An overview of the Best Care integrated disease management programme. Adapted from Table1: Ferrone et al17 and Figure1: Hussey et al20 CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global initiative for Obstructive Lung Disease.…”

Estimating the Health and Economic Impact of Improved Management in Prevalent Chronic Obstructive Pulmonary Disease Populations in England, Germany, Canada, and Japan: A Modelling Study

“…Assessing outcomes over three years, a large study of the German IDM programme found participants had reduced mortality risk (hazard ratio: 0.89, 95% confidence interval [CI]: 0.84-0.94) and higher total costs (€553 per year). 31 IDM can improve quality of life; [28][29][30] a recent costeffectiveness analysis of IDM in Canadian primary care by Scarffe et al, found the programme dominated UC, with cost savings and higher quality-adjusted life years (QALYs) in the short-(1-year; within-trial) and long-term (30-years; model-based analysis). 58 Approximating the effect on severe exacerbation from the same RCT, 29 corresponding analyses from our study (Canada, Policy 2; RR: 0.40) corroborate this finding of improved health outcomes and cost savings and provide additional evidence on the impact at alternative uptake levels.…”

“…They often include pharmacological and non-pharmacological interventions (eg, treatment review, smoking cessation counselling, telemonitoring, etc.). Pulmonary rehabilitation is a well-known form of IDM; the organisation of two primary care programmes from Canada 29 , 30 and Germany 31 is detailed in Table S1 . A recent meta-analysis of 52 studies found improvements in disease-specific quality of life, exercise capacity and respiratory-related hospital admissions for patients with IDM.…”