Integrated Disease Management Improves Clinical Outcomes, QOL in Patients With COPD in Primary Care

With the majority of patients with chronic obstructive pulmonary disease (COPD) being treated in primary care, the healthcare setting represents an ample opportunity for improving care and quality of life (QOL) for these patients. According to a new study, implementing integrated disease management (IDM) among high-risk patients with the disease in primary care results in favorable outcomes.

The study of 146 patients across Ontario, Canada found that IDM can help fill the knowledge-to-care implementation gap that exists in primary care by using a team model that focuses on supporting both physicians and patients to improve best practices.

Primary care providers are faced with the increasingly complex task of managing patients with high-risk COPD and other comorbidities. According to the researchers, primary care providers experience barriers related to spirometry access and utilization and have a low level of knowledge of COPD clinical practice guidelines. Additionally, these patients also require multiple medications often provided in different inhalers.

“In practical terms, these evidence-based objectives are difficult to achieve by individual practitioners within the context of a regular clinical encounter,” wrote the researchers. “Thus, in practice, a minority of patients have an objectively confirmed diagnosis, or action plan, receive smoking cessation counseling, and for many medications, are under-prescribed relative to disease severity.”

Screened between November 2011 and January 2014, patients in the study were randomized 1:1 to IDM with a certified respiratory educator and physician or to usual physician care. Patients receiving IDM were provided case management, self-management education, and skills training.

Compared with patients receiving usual care, patients receiving IDM were significantly less likely to have a severe exacerbation (—48.9%), require an urgent primary care visit for COPD (–30.2%), or have an emergency department visit (–23.6%).

“Upstream interventions that may have contributed to exacerbation in our study include prescribing inhalers appropriate to disease severity, improved adherence, and/or better inhaler technique,” wrote the researchers.

Results from the COPD assessment test (CAT), scored on a scale of 0-40, revealed that patients receiving IDM had improved QOL, with their CAT score improving from 22.6 at baseline to 14.8 at the end of the study period. Meanwhile, patients receiving usual care showed diminished QOL at 12 months, with their CAT score going from 19.3 to 22.0.

The authors noted that IDM is a complex intervention and, therefore, it was not possible to identify the specific intervention that improved QOL. But, there are several possibilities, including case management with regular clinical review and a self-management action plan effectively being implemented during the study, and the fact that reducing exacerbations is tied to improved QOL.

Knowledge of the disease also increased in the IDM group, with these patients improving their knowledge more than the usual care group by 29.6%. Similarly, IDM patients had a mean increase in pre-bronchodilator forced expiratory volume in 1 second (FEV1) of 100 mL while the usual care group showed no significant change.

Reference:

Ferrone M, Masciantonio M, Malus N, et al. The impact of integrated disease management in high-risk COPD patients in primary care [published online March 28, 2019]. NPJ Prim Care Respir Med. doi: 10.1038/s41533-019-0119-9.