Proactive Integrated Care for COPD

R. William Vandivier, MD University of Colorado Anschutz Medical Campus

Optimize Delivery of Care



Decrease Symptoms



Improve Quality of Life



Decrease Exacerbations



Improve Survival

COPD is Undertreated in the US



Overall

 58.0%  58.0%

McGlynn EA NEJM 348;2635, 2003 Mularski RA Chest 130;1844, 2006



Routine Care

 46.1%

Mularski RA Chest 130;1844, 2006



Exacerbation Care

 60.4%

Mularski RA Chest 130;1844, 2006

Integrated Care



A management program that integrates:

 1) disease-specific education  2) self-management strategies  3) enhanced communication

COPD Patient

Integrated Care

Healthcare Provider

Education Action Plan & Enhanced Communication

Care Coordinator

COPD Patient

Integrated Care

Healthcare Provider

COPD Exacerbation

Education Action Plan & Enhanced Communication

Care Coordinator

Integrated Care for COPD Rice et al. AJRCCM 182;890 2010

•

Design:

743 patients randomized to: • Integrated Care • Usual Care •

Primary Outcome:

COPD-related hospital/ER visits •

Results

– Decreased COPD-related hospital/ER visits (P<0.001) – Improved quality of life (P<0.001) – Trend toward decreased mortality (P=0.09)

Integrated Care for COPD Fan et al. Ann Intern Med 156;673 2012

•

Design:

960 patients randomized to: • Integrated Care • Usual Care •

Primary Outcome:

Time to first COPD hospitalization •

Results

– Stopped at 44% enrollment – Increased deaths in integrated care (n=28) vs. usual care (n=10); P=0.0003

“Patients were advised to call their case manager when they started treatment for an exacerbation and if symptoms did not improve.”

Did Patients Contact Coordinators When Advised?

 600 total exacerbations  27 weekday calls (4.5%)  No documentation for after-hours calls Why?

•Denial?

•Overconfidence?

Vandivier RW, Ann Intern Med 157;530, 2012

Proactive Integrated Care Integrated Care + Telemonitoring



A management program that integrates:

 1) daily disease-specific education  2) self-management strategies  3) enhanced communication  4) daily (M-F) remote disease monitoring

Proactive Integrated Care Monitoring Package At Home

COPD Patient

Education Monitoring & Enhanced Communication

Care Coordinator Healthcare Provider

COPD Patient Healthcare Provider

COPD Exacerbation

Education Monitoring & Enhanced Communication

Care Coordinator

Proactive Self Management

COPD Patient

Proactive Treatment

Healthcare Provider

COPD Exacerbation

Education Monitoring & Enhanced Communication Early Warning & Education

Care Coordinator

Proactive Integrated Care

  Trial 1 – Randomized, controlled trial at University of Colorado (N=40)

Koff PB, Eur Respir J 33;1031, 2009

  Trial 2 – Multicenter, quasi-randomized, controlled trial in urban Colorado (N=400) unpublished   Trial 3 – Longitudinal trial in high mortality areas of rural Colorado (N=100)

Linderman DJ, Arch Intern Med 171;2059, 2011

40 Subjects

Trial 1 Pilot Study SGRQ SGRQ

Results:

1.

SGRQ improved by 10 units (P=0.018) 0 3 Months

Koff PB, Eur Resp J 33;1031, 2009

Trial 2 Urban Study



Quasi-randomized, controlled study

 Rotating randomization scheme  3 Days Treatment Group  1 Day Control Group 

Primary Outcome

 Decreased healthcare utilization 

Secondary Outcomes

 Improved QOL  Decreased symptoms  Increased exercise capacity  Decreased healthcare costs

Methods Inclusion Criteria

 Advanced COPD  GOLD 3-4 COPD  COPD exacerbation < 1y  Standard telephone

Exclusion Criteria

 Asthma  Co-existing lung disorder  End-stage kidney or liver disease  Terminal illness  Active drug abuse

1 yr

Healthcare Utilization Questionnaire Lung Function 6MWT SGRQ SGRQ SGRQ Questionnaire Lung Function 6MWT SGRQ

0 m 3 m

HCU

6 m

HCU

9 m

HCU

Enrollment by Site

Improved Quality of Life

Control Treatment

Decreased Healthcare Utilization

ICU Hosp Vent Hosp Urgent Visits Control Treatment Control Treatment Control Treatment

Improved Clinical Measurements

Improved Clinical Measurements

Mortality

Trial 3 Rural Study

Trial 3 Rural Study Questionnaire Lung Function 6MWT SGRQ Questionnaire Lung Function 6MWT SGRQ

100 Subjects 0 Months 3

Linderman DJ, Arch Intern Med 171;2059, 2011

Trial 3 Rural Study

Linderman DJ, Arch Intern Med171;2059, 2011

Trial 3 Rural Study

Linderman DJ, Arch Intern Med171;2059, 2011

Proactive Integrated Care Summary

 Increases guideline-based therapy  Decreases symptoms  Improves quality of life  Decreases healthcare utilization  May improve survival

Opinion

 Hospitals need a financial incentive to keep patients out of the emergency room  Integrated care + telemonitoring will likely play an important role in management  High quality research is needed to identify the right approaches, systems and patients

Acknowledgements

 University of CO Hospital          Patty Koff, RRT, MEd Debbie Diaz Tammie Freitag, RN Shannon James, RN Linda Gunnison, RRT Laura Kunde, RRT Nancy Osborn, RN Joyce Cashman, RN Suzanne Sullivan, RN  Kaiser Permanente Denver      Arne Beck, PhD Debra Ritzwoller, PhD Tom Stelzner, MD Christine Kveton, RRT Stephanie Carwin, RRT  Denver VA Medical Center  Robert Keith, MD  University of Colorado   Derek Linderman, MD Max Min PhD

Funded by the Colorado Cancer, Cardiovascular Disease and Pulmonary Disease Grants Program and The University of Colorado Hospital