Disease Management For Chronic Obstructive Pulmonary Disease

Disease Management for

Chronic Obstructive Pulmonary Disease

DISCLAIMER: The information contained in this annotated bibliography was obtained from the publications listed. The National Pharmaceutical Council (NPC) has worked to ensure that the annotations accurately reflect the information contained in the publications, but cannot guarantee the accuracy of the annotations or the publications. There are articles available on the treatment of chronic obstructive pulmonary disease that are not included in this bibliography, which may include relevant information not covered herein. The inclusion of any publication in this bibliography does not constitute an endorsement of that publication by NPC or an endorsement of the services, programs, treatments, or other information contained in such publication. This bibliography is designed for informational purposes only, and should not be construed as professional advice on any specific set of facts and circumstances. This bibliography is not intended to be a comprehensive source of disease management services or programs in the treatment of chronic obstructive pulmonary disease, or a substitute for informed medical advice. If medical advice or other expert assistance is required, readers are urged to consult a qualified health care provider or other professional. NPC is not responsible for any claims or losses that may arise from any errors or omissions in the information contained in this bibliography or in the listed publications, whether caused by NPC or originating in any of the listed publications, or any reliance thereon, whether in a clinical or other setting. © September 2003 National Pharmaceutical Council, Inc.

Disease Management for Chronic Obstructive Pulmonary Disease Introduction The Centers for Medicare and Medicaid Services and the Disease Management Association of America define disease management as a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are substantial.1,2 Disease management supports the clinician-patient relationship and plan of care, and emphasizes prevention of disease-related exacerbations and complications using evidence-based guidelines and patient empowerment tools.1,2 Disease management also evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.1-3 The specific goals of disease management include:3 • Improving patient self-care through patient education, monitoring, and communication with members of the health care team. • Improving physician performance through feedback and/or reports on patient progress in compliance with protocols. • Improving communication and coordination of services among patient, physician, disease management organization, and other providers. • Improving access to services, including prevention services and prescription drugs as needed. The following functions are the main components of disease management:2,3

• Availability of treatment guidelines with consensus about what constitutes appropriate and effective care. • Presence of generally recognized problems in therapy that are well documented in the medical literature. • Large practice variation and a range of drug treatment modalities. • Large number of patients with the disease whose therapy could be improved. • Preventable acute events that often are associated with the chronic disease (e.g., emergency department or urgent care visits). • Outcomes that can be defined and measured in standardized and objective ways and that can be modified by application of appropriate therapy (e.g., decreased number of emergency department visits or hospitalizations). • The potential for costs savings within a short period (e.g., less than three years). Three major not-for-profit organizations whose mission is to promote quality health care have recognized the contribution of disease management activities to quality health care by establishing disease management certification or accreditation programs. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an independent, not-for-profit organization and the nation’s predominant standards-setting and accrediting body in health care, offers disease-specific care program certification. Program certification is based on an assessment of compliance with consensus-based national standards, effective use of established clinical practice guidelines to manage and optimize care, and activities for performance measurement and improvement.4 The National Committee for Quality Assurance (NCQA) recently began accrediting disease management programs on the basis of standards that are patient oriented, practitioner oriented, or both. It also offers organizations certification for program design (e.g., content development), systems (e.g., clinical information and other support systems), or patient contact (i.e., for nurse call centers and other organizations without comprehensive activities).5 Many

Disease Management for Chronic Obstructive Pulmonary Disease

• Identification of patient populations. • Use of evidence-based practice guidelines. • Support of adherence to evidence-based medical practice guidelines by providing practice guidelines to physicians and other providers, reporting on the patient’s progress in compliance with protocols, and providing support services to assist the physician in monitoring the patient. • Provision of services designed to enhance patient selfmanagement and adherence to the patient’s treatment plan. • Routine reporting and feedback to the health care providers and to the patient. • Communication and collaboration among providers and between the patient and the patient’s providers. • Collection and analysis of process and outcome measures along with a system to make necessary changes based on the findings of those measures.

Disease management programs are used widely for many chronic diseases, but the most common diseases include asthma, congestive heart failure, and diabetes mellitus. Considerations in selecting a disease for disease management often include:2,3

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disease management organizations were so eager to undergo the accreditation or certification process that they volunteered to do so before the standards were finalized.6 The Utilization Review Accreditation Commission (URAC), also known as the American Accreditation HealthCare Commission, establishes standards for the health care and insurance industries. Through establishment of standards, education and communication programs, and a process of accreditation, URAC motivates purchasers, providers, and patients to achieve excellence, thus promoting continuous improvement in the quality and efficiency of health care delivery. URAC has accreditation programs for disease management as well as case management, claims processing, core accreditation, credential verification, health call centers, health networks, health plans, health provider credentialing, health utilization management, health Web sites, Health Insurance Portability and Accountability Act (HIPAA) privacy and security, independent review organizations, vendor certification, and workers’ compensation utilization management. URAC has goals for disease management accreditation and case management.7

Disease Management for Chronic Obstructive Pulmonary Disease

Why Focus on Chronic Obstructive Pulmonary Disease?

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Disease management programs are common for the management of asthma, congestive heart failure, and diabetes mellitus. However, attention has now focused on chronic obstructive pulmonary disease (COPD) as the next disease management opportunity. There are significant opportunities to improve care for the COPD population based on evidence-based standards of care. In 2003, The National Heart, Lung, and Blood Institute in collaboration with the World Health Organization released an updated authoritative guideline for managing COPD— the Global Initiative for Chronic Obstructive Lung Disease, or GOLD (Table 1). Up-to-date information on treatment guidelines from various sources is also available online from the National Guideline Clearinghouse (http://www.guideline.gov/body_home_nf.asp?view=home). COPD is a target for disease management programs because it is the fourth leading cause of chronic morbidity and mortality in the United States and has significant economic impact.8 In 1990, the worldwide prevalence of COPD was estimated at more than nine of every 1,000 men and seven of every 1,000 women.8 In the year 2000, the U.S. prevalence was estimated at 6.8%, or 10 million American

Table 1. Authoritative Guidelines for Managing Chronic Obstructive Pulmonary Diseasea 1.

The National Heart, Lung, and Blood Institute and the World Health Organization Global Initiative for Chronic Obstructive Lung Disease. Available in print (Respir Care. 2001;46:798-825) and online at http://www.goldcopd.com/.

2.

American Thoracic Society Standards for the diagnosis and care of patients with COPD. Available in print (Am J Respir Crit Care Med. 1995;152[5 pt 2]:S77-121).

3.

British Thoracic Society Guidelines for the management of COPD. Available in print (Thorax. 1997;52[suppl 5]:S1-28).

4.

Canadian Thoracic Society Guidelines for the assessment and management of COPD. Available in print (CMAJ. 1992;147:420-8).

5.

Institute for Clinical Systems Improvement Health Care Guidelines: Chronic Obstructive Pulmonary Disease. Available online at http://www.icsi.org/knowledge/detail.asp?catID=29+item ID=157.

a Clinical practice is subject to constant change, and the guidelines in this list may become outdated or be superseded by newer ones. The reader is encouraged to consult the National Guideline Clearinghouse (http://www.guideline.gov/asp/d2.asp?cp=t&ck=t&nx=&fr=f), a public resource for evidence-based clinical practice guidelines sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans, for the most current guidelines.

adults living with a diagnosis of COPD and another 14 million undiagnosed.9 COPD prevalence and morbidity data are thought to greatly underestimate the disease burden because COPD is usually not diagnosed until it is fairly advanced.9 COPD is commonly perceived as a disease of the elderly and of limited impact to the working age population. However, CDC data reports 70% of the COPD patients were under the age of 65.9 The morbidity from COPD increases with age and is greater in men than in women.8 The mortality rate from

to confirm the diagnosis. Dyspnea is a major cause of disability. Awareness among clinicians of the causes, prevalence, and burden of COPD often is inadequate.8,13 Although cigarette smoking is a well-known risk factor, exposure to occupational dusts and chemicals (e.g., vapors, irritants, fumes) and outdoor and indoor air pollution also are risk factors for COPD. A rare hereditary deficiency of alpha-1 antitrypsin is associated with the disease. Primary care physicians’ access to the spirometric equipment needed to diagnose COPD and their ability to interpret spirometric data are limited. Physicians may not be up-to-date on the latest research in the pathogenesis of COPD, which still is not completely understood, and they may be reluctant to use new therapies.13 Physicians (and patients) often view COPD as an illness that is not responsive to treatment.13 National Institutes of Health research funding for COPD is relatively low compared with other chronic diseases, suggesting that society does not recognize the impact of

Table 2. Organizations with Information About COPD for Patients American Association for Respiratory Care 11030 Ables Lane Dallas, TX 75229 972-243-2272 http://www.aarc.org/

The American Lung Association 61 Broadway, 6th floor New York, NY 10006 212-315-8700 http://www.lungusa.org/

Global Initiative for Chronic Obstructive Lung Disease http://www.goldcopd.com/

National Heart, Lung, and Blood Institute Health Information Center P.O. Box 30105 Bethesda, MD 20824-0105 301-592-8573 http://www.nhlbi.nih.gov/health/public/lung/index.htm

Disease Management for Chronic Obstructive Pulmonary Disease

COPD in the United States increased markedly between 1980 and 2000 in women and to a lesser extent in men.9 In 2000, the number of women dying from COPD exceeded the number of men dying from the disease for the first time.9 Further increases in prevalence of and mortality from COPD are predicted in the next two decades. According to NIH data, the annual cost of COPD in 2002 was estimated at $32.1 billion dollars. It includes the direct costs of $18.0 billion associated with medical and pharmacy resource utilization, and indirect costs of $14.1 billion associated with lost productivity.10 Health care resource use is substantial for patients with COPD, and compared with other chronic medical conditions such as asthma, COPD is more costly. In the year 2000, eight million physician office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths were attributed to COPD.9 COPD is in the top ten illnesses as the principal discharge diagnosis for hospitalizations in the U.S.11 In addition, COPD patients under the age of 65 account for 52% of all outpatient visits, 63% of all ER visits and 33% of all hospitalizations for COPD.10 Nationally, COPD was the seventh most common reason for hospitalizations and fourth leading comorbid condition associated with hospitalization within the 45 to 64 age group.10 Thus, the impact of COPD on the working age population is substantial. COPD impairs the ability to carry out the activities of daily living and adversely affects quality of life.12 In 1990, COPD was the twelfth leading cause of disability-adjusted life years (a measure of the years lost because of premature mortality, and years of life lived with disability adjusted for the severity of disability) worldwide, after major depression, ischemic heart disease, cerebrovascular disease, traffic accidents, and other causes. However, COPD is expected to rank in fifth place after these four causes of disability-adjusted life years by the year 2020.8 COPD is characterized by airflow limitation that is partially reversible; the airflow limitation usually is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases (especially tobacco smoke).8 The disease usually is not diagnosed until it is clinically apparent and relatively advanced; symptoms include cough, sputum production, and dyspnea (difficulty breathing). Chronic cough usually is the first symptom of COPD to develop, but patients typically do not seek medical attention until dyspnea interferes with their quality of life. Measurement of pulmonary function using spirometry is used

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COPD.13 The public recognizes the link between smoking and cancer without appreciating the relationship between smoking and COPD.13 Patients often attribute COPD symptoms to smoking rather than a disease. Obtaining a diagnosis of COPD and a greater understanding of the disease could reduce delays in treatment and forestall declines in lung function and quality of life.13 The high morbidity and mortality, the high cost, and the lack of awareness of the burden of the disease serve as incentives to apply disease management strategies to the treatment of COPD. Education and training of health care providers and the public could improve detection and treatment of COPD. The management of COPD is described in Appendix A. Table 2 lists organizations with information about COPD for patients.

Disease Management for Chronic Obstructive Pulmonary Disease

Current Status of Disease Management Programs for COPD

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Although disease management strategies have great potential to improve therapeutic outcomes for patients with COPD, implementation of those strategies is more common for the treatment of asthma, congestive heart failure, and diabetes mellitus. These are chronic diseases that are commonly seen in the primary care setting, where physicians are well trained to recognize and treat them. Many disease management firms recently have begun to apply the systems developed for use with other diseases to COPD.16 The experiences to date with COPD disease management programs are described here. Appendixes B and C describe reports about the impact of disease management interventions (e.g., education of patients or health care staff) on COPD treatment.

COPD Management Programs AirLogix Program (Dallas, Texas) AirLogix, formerly known as AccuLab Diagnostic, is one of the first disease management firms to provide disease management for patients with COPD. AirLogix attained full three-year NCQA disease management accreditation effective November 1, 2002. The company has provided comprehensive respiratory disease management services to more than 300,000 patients since 1994.17 The AirLogix COPD Management Program is based on the GOLD guidelines. It reinforces the treatment plan and encourages

patient self-care and adherence to the plan. A combination of educational materials, telephone contact, and in-home evaluation and education is used. The company has a nationwide staff of respiratory care practitioners. Patient-reported data from 10 health plan clients with nearly 7,000 commercial and Medicare patients who had moderate or severe COPD suggest dramatic decreases in emergency department visits, hospital admissions, hospital days, and missed work days with the AirLogix COPD Management Program.18 A 9.8% cost savings and a 2.8 to 1 return on investment were calculated. The AirLogix COPD Management Program yielded a net cost savings of $3.5 million in the first year for PacifiCare Health Systems Inc., a health and consumer services company located in Cypress, California.19 The cost savings were derived from reductions in service utilization. There was a 27% reduction in the number of bed days per patient per month, a 23% reduction in dollars paid per patient per month for the enrolled population, and a 14% reduction in costs for the entire COPD population compared with the 12-month period before program implementation. Reductions in emergency department visits, hospital admissions, hospital days, and missed work days by 30%, 47%, 54%, and 88%, respectively, were reported for members who were enrolled in and receiving disease management intervention services. Complaints of chest tightness, cough, nocturnal awakening, and wheezing decreased by 47%, 22%, 38%, and 38%, respectively. Patient satisfaction with the program was high. Based on the PacifiCare clinical and financial results in California and Texas, the AirLogix program was expanded in late 2002 to provide COPD disease management to Medicare+Choice health plan members in Washington, Oregon, Arizona, and Colorado over a three-year period.19 PacifiCare uses a “best-of-breed” approach to contracting with disease management firms. The company contracts with several different disease management firms for various diseases based on the firms’ specialties rather than contracting with a single firm for all diseases. AirLogix also provides COPD disease management services to CHA Health, a company based in Lexington, Kentucky (for more information, contact Tim Costich at 859232-8565).

Boehringer Ingelheim Pharmaceuticals, Inc. (Ridgefield, Connecticut) Since 2001, Boehringer Ingelheim’s breatheWise™ portfolio of COPD disease management resources have assisted health care organizations to develop and implement

of COPD, a model to predict the impact of COPD disease management interventions, and programs to provide physician feedback based on national guideline recommendations and to assist in the implementation of a COPD quality improvement initiative. For additional information, contact Gail Goss at 877-933-4310 ext. 9364 or John Spoon at ext. 9765.

American Healthways (Nashville, Tennessee) American Healthways is a disease management firm with nearly 20 years of experience. The company has used algorithms to identify patients with early-stage COPD for behavior-change strategies to slow the progression of the disease. American Healthways received validation for its COPD disease management program from the Johns Hopkins Outcomes Verification Program, launched in 2001 to independently evaluate the clinical and financial effectiveness of disease management programs (see Disease Management News, October 10, 2002, pages 3, 7, & 8). American Healthways received full NCQA disease management accreditation effective June 6, 2002. For additional information about the company, go to http://www.americanhealthways.com/.

CareMark, Inc. (Birmingham, Alabama) CareMark is a large pharmaceutical services company with a COPD disease management program that stresses patient education, self-care, and adherence to the treatment plan. Trained nurses communicate by telephone with patients. For additional information, go to http://www.caremark.com/.

CorSolutions, Inc. (Buffalo Grove, Illinois) CorSolutions is a health intelligence and solutions company with full NCQA disease management accreditation effective September 6, 2003. The company provides proactive chronic care management services for patients with COPD, coronary artery disease, congestive heart failure, diabetes mellitus, and asthma. The goals of the company’s disease management programs are to stabilize and improve patients’ health and quality of life, promote patient satisfaction, and reduce unnecessary health care costs. Telephone consultation with experienced registered nurses, interactive voice response, home visits, and an interactive patient/member Web site (http://www.ecorsolutions.com) are used. Patients have 24-hour telephone access to the nurses. The Respiratory Solutions disease management program for

Disease Management for Chronic Obstructive Pulmonary Disease

the main components of a COPD disease management program. The breatheWise portfolio is based on the evidence-based recommendations of GOLD and the American Thoracic Society, and it aims to increase knowledge of COPD management, facilitate appropriate diagnosis and treatment of COPD, and identify and target areas for intervention. As part of the portfolio, the monograph titled The Significance of COPD in Managed Care examines incidence and utilization data to determine burden-of-illness and treatment patterns in a representative national sample of 23,000 managed care patients with COPD. The breatheWise portfolio includes the following organizational research tools and modular intervention materials and programs: • COPD Predict is a software forecasting tool to support a managed care organization’s planning efforts for COPD disease management programs by (1) estimating COPD prevalence and total and COPDrelated health care utilization and costs and (2) identifying opportunities and targets for potential quality improvement initiatives. • COPD InterACT provides detailed analytic specifications to enable an organization to extract planlevel information specific to COPD cost and burden and also to identify and stratify members for a COPD intervention program. • Drug Utilization Evaluation is a program that supports the assessment of plan-specific COPD pharmacological treatment patterns and the intervention tools to improve appropriate evidencebased COPD management. • Just Quit™ Smoking Cessation Program, developed by the National Jewish Medical and Research Center, is a comprehensive turnkey program that provides program implementation materials and patient educational tools. • Physician-directed interventions include tools to improve COPD management (e.g., speaker continuing medical education programs, guideline pocket guides, educational brochures on selected COPD-related topics). • Patient intervention materials are focused on improving self-management and are provided in a variety of different formats (e.g., BreatheWell Magazine, patient brochures on COPD-related topics, Web-based information [http://www.thebreathingspace.com]). Other COPD disease management tools in development include screening questionnaires to facilitate early diagnosis

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patients with COPD is based on American Thoracic Society guidelines. For additional information, see Disease Management News, January 25, 2000, or go to http://www.corsolutions.com/.

company added COPD to its disease management program offerings in early 2003. The program is based on the GOLD guidelines. It is designed to encourage patients to assume an active role in health care, empower patients to improve their quality of life, and reinforce patient adherence to the

Health Dialog (Boston, Massachusetts) Health Dialog is a disease management company that received full NCQA disease management accreditation effective May 6, 2003. The company’s collaborative care program provides continuous (24/7) support for patients with COPD and other chronic diseases. Functions include identifying individuals with “coachable high needs” (using proprietary predictive risk models that include both clinical factors and treatment pattern variation factors), using an extensive library of direct mail materials and telephone outreach protocols for individuals with coachable high needs, providing tailored nurse Health Coach telephone support (which includes the dissemination of evidence-based video, Web-based, and printed material), and measuring and reporting outcomes. For additional information, go to http://www.healthdialog.com/.

treatment plan. Patients have 24-hour telephone access to nurses, some of whom are bilingual. The program focuses on smoking cessation, the use of home oxygen therapy, and optimizing prescription drug therapies. A predictive model is used to identify patients who are likely to experience an adverse event or complication in the coming year. Telephone calls are made by nurses on a regular basis to promote patient self-management in those patients with “highintensity needs.” Other “standard intensity” patients receive educational mailings instead of telephone calls. Nurses also use computerized algorithms to ensure that practice guidelines and the plan of care are followed for all patients. Barriers to patient adherence are identified and resolved to the extent possible. A 2:1 return on investment is anticipated with the program. Medication adherence, physical activity levels, smoking cessation, use of oxygen therapy, quality of

Disease Management for Chronic Obstructive Pulmonary Disease

Health Hero Network, Inc. (Mountain View, California)

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Health Hero Network is a provider of technology for remote health monitoring and management. Health Hero Network customers use Health Hero solutions for disease management programs in COPD, heart failure, cardiovascular disease, diabetes, asthma, and many other chronic conditions. The company is collaborating with the Department of Veterans Affairs to develop a disease management program for COPD. The program uses Internetbased, two-way communication to monitor patients’ clinical condition and deliver individualized interventions. A 74% reduction in inpatient and outpatient costs was demonstrated over six months in a Florida Veterans Integrated Service Network representing more than 600 patients with emphysema, congestive heart failure, and other chronic diseases. For additional information, see Disease Management News, February 10, 2001 (page 4), and June 25, 2001 (page 2), or go to http://www.healthhero.com/index.html.

life, and health resource utilization will be monitored. For additional information, go to http://www.choosehmc.com/; see Disease Management Advisor, April 2003;9(4):49-54, or Disease Management News, February 10, 2003 (page 8); or contact Marcia Rowan at 800-523-9279.

LifeMasters Supported SelfCare (Irvine, California) LifeMasters Supported SelfCare received full NCQA disease management accreditation effective November 13, 2002. LifeMasters uses tools such as health education, training in self-monitoring, and personalized coaching. Timely, clinically validated information is provided to physicians to prevent serious medical episodes that can result in unnecessary emergency department visits and hospitalizations. LifeMasters recently entered the direct-to-employer market with an Oklahoma-based health care system (Integris Health). It will provide disease management services to more than 10,000 employees and their dependents with COPD,

Health Management Corp (Richmond, Virginia)

asthma, diabetes, coronary artery disease, or congestive

Health Management Corp is a disease management firm offering services for patients with complex and costly diseases, including diabetes mellitus, respiratory disease, cardiovascular disease, and high-risk pregnancy. The

Management News, February 25, 2002 (pages 2 & 6), or

heart failure. For additional information, see Disease contact Christobel Selecky of LifeMasters at 949-380-0800 or Chris Havens of Integris at 888-951-2277.

Matria Healthcare (Marietta, Georgia) Matria Healthcare is a disease management company with full NCQA disease management accreditation effective January 13, 2003. The company combines population-based disease management programs, telemedicine services, and supplies and medications fulfillment for patients, physicians, health plans, and corporate America. Its COPD disease management program is based on the GOLD guidelines and provides education programs to both patients and health care professionals. Patients have access by telephone to respiratoryspecialty registered nurses. For additional information, go to http://www.matria.com/, or contact Chris Coloian at 770-7678371 or George Dunaway at 770-767-4500.

National Jewish Medical and Research Center (Denver, Colorado)

Disease management has been shown to improve patient outcomes and quality of life while potentially reducing overall costs. It is an important approach to integrated care. Applying the key components of disease management to the treatment of COPD can help ensure successful treatment. Disease management has continued to gain widespread acceptance over the past 10 years, and health plans that provide multiple services to patients that need coordinated services are seeing the most success with their chronic disease patients. Disease management programs have varied widely in quality. The Johns Hopkins Outcomes Verification Program was launched in 2001 to provide an impartial, independent evaluation of the clinical and financial effectiveness of disease management programs. Disease management firms have expanded their program offerings to include COPD in increasing numbers in recent years. As the COPD disease management marketplace becomes more crowded, these evaluations will carry greater weight in selecting among the available programs. Analysis of large administrative databases can provide documentation of the health outcomes and cost savings from COPD disease management programs.20

Conclusion Disease management can improve patient outcomes and quality of life while potentially reducing overall health care costs and the social and economic burdens of disease. It is key to integrating care and, as more health care payers incorporate disease management principles into the delivery of care, we will begin to see many more COPD disease management programs.

Disease Management for Chronic Obstructive Pulmonary Disease

The National Jewish Medical and Research Center was founded in 1899 as a nonsectarian, nonprofit hospital for patients with tuberculosis and is now a medical and research center devoted to respiratory, allergic, and immune system diseases. The disease management program at the National Jewish Medical and Research Center provides education, support, and reinforcement of self-management practices for patients with COPD or asthma. Physicians create symptombased action plans that are implemented with the support of nurses who are available by telephone 24 hours a day. An Internet-based smoking cessation program has been launched. Substantial reductions in hospitalizations, emergency department visits, and adult days missed from work were demonstrated six months after the program was implemented compared with the six-month period before implementation. For additional information, see Disease Management News, May 10, 2001 (pages 1, 4, & 5), contact Abby Schwartz of National Jewish Medical and Research Center at 303-398-1859, or go to http://www.nationaljewish.org/.

The Future of COPD Disease Management

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Appendix A. Management of Chronic Obstructive Pulmonary Disease Reduction of risk factors for chronic obstructive pulmonary disease (COPD), especially exposure to tobacco smoke, is recommended to prevent the onset and reduce the progression of the disease.8 Smoking cessation is the single most effective (and cost-effective) intervention to reduce the risk of developing COPD and progression of the disease.8 Guidelines for smoking cessation are available from authoritative sources.14,15 Various effective drug therapies (e.g., nicotine replacement therapy, the antidepressant bupropion) are available to facilitate smoking cessation. Steps should be taken to reduce exposure to occupational dusts and chemicals and indoor and outdoor air pollution. Annual influenza vaccination is recommended for patients with COPD because it reduces the risk of serious illness and death by about 50%.8

A stepwise approach is used to manage COPD, taking into consideration the severity of the disease.8 Drug therapy is used to prevent and control COPD symptoms, reduce the frequency and severity of exacerbations, and improve exercise tolerance and health status; but it does not modify the long-term decline in lung function associated with COPD.8 Bronchodilators (e.g., beta2adrenergic agonists, anticholinergic agents, theophylline) play a vital role in treating COPD. Short-acting bronchodilators are used as needed for patients with mild COPD and long-lasting bronchodilators on a regular basis in patients with moderate or severe COPD to prevent or reduce symptoms.8 Corticosteroids may be used by inhalation in selected patients with severe COPD who respond to such therapy, but long-term treatment with oral corticosteroids is not recommended.8 The use of antibiotics is not recommended except for treatment of infectious complications.8 Patients with moderate or severe COPD stand to benefit from pulmonary rehabilitation, exercise training, nutrition counseling, and education.8 Oxygen therapy may increase survival in patients with severe COPD and respiratory failure.8

Disease Management for Chronic Obstructive Pulmonary Disease

The information in this appendix is adapted from sources in Table 1, found on page 2 of this document.

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Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Chronic Obstructive Pulmonary Disease Reduction of hospital utilization in patients with chronic obstructive pulmonary disease. Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupré A, Bégin R, Renzi P, Nault D, Borycki E, Schwartzman K, Singh R, Collet J. Archives of Internal Medicine. 2003;163:585-91. Patients hospitalized at least once in the preceding year for acute exacerbation of chronic obstructive pulmonary disease (COPD) in one of seven Quebec hospitals were randomized to a self-management program or usual care. The selfmanagement program comprised a comprehensive patient education program involving approximately one hour per week of teaching by a trained health professional (nurse, respiratory therapist, or physiotherapist) in the home setting for seven or eight weeks followed by monthly telephone calls. There were no significant differences between the intervention group and the usual care group in number of acute exacerbations of COPD during the 1-year study. However, there were significantly fewer hospital admissions for acute exacerbations in the intervention group (71 admissions among 96 patients) than in the usual care group (118 admissions among 95 patients), representing a 40% reduction with the self-management program. Admissions for other health problems were reduced by 57% by the self-management program (compared with usual care). The number of emergency department visits for acute exacerbations and number of unscheduled visits to the family physician also were significantly lower (by 41% and 59%, respectively) in the intervention group than in the usual care group.

The effects of patient education on self-reported health resource utilization (physician visits) and work absenteeism were assessed in a 12-month, randomized, controlled study of 62 patients with COPD. Patients in the intervention (education) group were provided with a booklet with information about medications, compliance, and self-care, and a self-management plan was developed. The importance of smoking cessation was emphasized. Instructions for recording peak expiratory flow and symptoms in a diary were provided. Patients attended a two-hour group educational session conducted by a physician that emphasized self-care and prevention of exacerbations, a two-hour group session on drug pharmacology conducted by a pharmacist, one or two individual sessions with a nurse on maintaining a symptom diary, and one or two individual sessions with a physiotherapist on respiration, rest positions, and relaxation exercise.

Cost-benefit and cost-effectiveness analysis of selfmanagement in patients with COPD—a 1-year follow-up randomized, controlled trial. Gallefoss F, Bakke PS. Respiratory Medicine. June 2002;96(6):424-31. The costs for patients with COPD who participated in a patient education and self-management program (the education group) were compared with the costs for a control group over a one-year period. The patient education and self-management program is described in Respiratory Medicine, March 2000;94(3):279-87. Patient satisfaction after one year was significantly higher in the education group than in the control group. The costs for physician visits, hospitalizations, and absenteeism from work were significantly lower in the education group. For every dollar invested in the education group, there was a cost savings of $4.80.

Part 2. Clinical and economic outcomes in the hypertension and COPD arms of a multicenter outcomes study. Solomon SK, Portner TS, Bass GE, Gourley DR, Gourley GA, Holt JM, Wicke WR, Braden RL, Eberle TN, Self TH, Lawrence BL. Journal of the American Pharmaceutical Association. 1998;38:57485. The impact of providing pharmaceutical care to 98 patients with COPD over a six-month period was assessed at 10 Department of Veterans Affairs and one university medical center. Patients were randomly assigned to a treatment group (pharmaceutical care) or a control group (traditional pharmacy care ranging from nonstandardized interventions to distribution of medication only). Pharmaceutical care services included drug therapy management, use of a patient-specific, stepped-care approach, patient education, patient assessment at clinic visits, and telephone followup. The number of hospitalizations and the number of health care provider visits were higher in the treatment group than in the control group. Patient satisfaction was greater in the treatment group than in the control group.

{Continued on next page}

Disease Management for Chronic Obstructive Pulmonary Disease

Impact of patient education and self-management on morbidity in asthmatics and patients with chronic obstructive pulmonary disease. Gallefoss F, Bakke PS. Respiratory Medicine. March 2000;94(3):279-87.

Twelve months after the intervention, approximately three times as many patients in the control group as in the intervention group had visited their physicians, a difference that is significant. The mean reduction in physician visits in the intervention group compared with the control group was 85%. Absenteeism from work was reported by 21% of the control group patients and 16% of the intervention group patients, a difference that is not significant. The mean reduction in lost work days for the intervention group compared with the control group was 95%, which is significant.

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Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Chronic Obstructive Pulmonary Disease (continued) A care pathway for COPD. Marley AM. Professional Nurse. October 2000;16(1):821-3. The impact of a project to optimize the care of patients with COPD at an inner-city hospital in Belfast, Ireland, on length of hospital stay and quality of care was assessed. The objectives of the project were to develop and implement a multiprofessional care pathway for acute exacerbation of COPD, conduct a training program for the multidisciplinary team consistent with British Thoracic Society guidelines for treating COPD, and provide nurse specialist assessment of patients admitted to the hospital with COPD. The care pathway outlined essential steps in the care of patients with specific clinical problems. A 12-week pilot study was conducted to assess the feasibility of the care pathway, and the pathway was well received by patients and the health care team. Deficits in nursing knowledge and awareness of the guidelines, and a lack of staff confidence in providing patient education were identified, and training was provided on an individual and small-group basis. Nurse specialists measured the impact of COPD on lung function using spirometry, ability to perform the activities of daily living, and quality of life. The average length of stay was 9.4 days per admission over the three year period before implementation of the project. It was reduced to 5.4 days as a result of implementation of the care pathway. Multidisciplinary communication and patient and staff satisfaction improved, and care exceeded quality standards.

Disease Management for Chronic Obstructive Pulmonary Disease

Dramatic improvement in COPD patient care in nurse-led clinic. Stothard A, Brewer K. Nursing Times. June 14-20, 2001;97(24):36-7.

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Retrospective audits were performed before and during the oneyear period after patients with COPD participated in a nurse-led clinic to assess the impact of the clinic on patient care. Forty-five of 120 patients diagnosed with COPD at a medical center attended the clinic. Documentation of the diagnosis and smoking status, rates of vaccination for influenza and pneumococcus, medication use, and numbers of physician visits and hospitalizations were evaluated in the audits. A 100% target rate was established for documentation of diagnosis and smoking status. These data were documented in nearly all (97.8%) of the patients after clinic attendance. Patients attending the clinic were managed with fewer medications (compared with baseline), and there was a 29% reduction in steroid use. The rates of vaccination for influenza and pneumococcus before clinic attendance were 75% and 50%, respectively, and 84% and 80%, respectively, after clinic attendance. Physician visits and hospitalizations were reduced by 55% and 42%, respectively, after clinic participation. Thus, the nurse-led clinic was effective in managing COPD, and it reduced the burden on physicians and hospitals.

Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Weinberger M, Oddone EZ, Henderson WG. New England Journal of Medicine. 1996;334:1441-7. In a multicenter, randomized, controlled trial conducted at nine Veterans Affairs Medical Centers, 1396 veterans hospitalized with diabetes (n = 751), chronic obstructive pulmonary disease (n = 583), or congestive heart failure (n = 504) were randomized to a customary postdischarge care group or an intensive, primary-care intervention group. Baseline assessment showed that the patients were severely ill; two thirds were considered at medium or high risk for readmission. Baseline quality-of-life scores were poor. Before discharge, patients in the intervention group were assessed by a primary care nurse and were given educational materials and a card with team member names and beeper numbers. A primary care physician also visited patients to review the hospital course, discharge plans, and medication regimens. The nurse scheduled a follow-up clinic appointment within one week after discharge and telephoned patients within two days after discharge to assess potential problems and remind patients about their appointments. Additional reminders and protocols for missed appointments were implemented as necessary. Patients in the control group received customary postdischarge care, without primary care nurse access, supplemental education, or needs assessment. Patients were followed for 180 days after hospital discharge. Patients in the intervention group had a significantly higher monthly readmission rate (0.19 vs. 0.14) and more days of rehospitalization (10.2 vs. 8.8) than patients in the control group. Patients in the intervention group were more likely to be readmitted than patients in the control group (49% vs. 44%, respectively), and the readmission tended to occur sooner. However, intervention patients were significantly more satisfied with their care than were control patients, although quality-of-life scores did not differ between the two groups. The study lacked adequate power to permit subgroup analysis, but no significant differences in outcomes were noted among the three disease strata.

Measuring outcomes of a chronic obstructive pulmonary disease management program. Zajac B. Disease Management. 2002;5:9-23. The AirLogix disease management program for chronic obstructive pulmonary disease (COPD) involves patient education, self-management tools and support, case management, and follow-up based on American Thoracic Society and National Heart, Lung, and Blood Institute guidelines. The program was used for at least 90 days by {Continued on next page}

Appendix B. Reports of the Impact of Disease Management Interventions on Treatment of Chronic Obstructive Pulmonary Disease (continued) 6428 members of contracted managed care organizations with COPD. The percentage of patients who reported that their breathing interfered with normal activities more than slightly decreased significantly from 62% to 48% as a result of program participation. The percentage of patients reporting nighttime

awakening because of shortness of breath more than occasionally decreased significantly from 25% to 14%, and the percentage of patients who experienced wheezing more than occasionally decreased significantly from 24% to 13%. A net savings of 17% was found in a claims analysis of a mixed Medicare and commercial population.

Disease Management for Chronic Obstructive Pulmonary Disease [11]

Disease Management for Chronic Obstructive Pulmonary Disease

Appendix C.

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Author(s) Bourbeau et al, 2003

Size of Population 191 patients with COPD

Gallefoss and Bakke, 2000

62 patients with COPD

Gallefoss and Bakke, 2002

Solomon et al, 1998

Method of Identifying Population for Whom Data Are Evaluated Patients hospitalized at least once in the preceding year for acute exacerbation

Intervention Strategy Comprehensive weekly patient education at home for 7-8 wk followed by monthly phone calls

Guideline Based? Not stated

Audience for Intervention Patients

Primary Manager of Intervention Multidisciplinary (nurse, respiratory therapist, or physiotherapist)

Recruited from hospital outpatient clinic

Education about medications, compliance, and self-care

Not stated

Patients

Multidisciplinary (physician, pharmacist, nurse, physiotherapist)

62 patients with COPD

Recruited from hospital outpatient clinic

Education about medications, compliance, and self-care

Not stated

Patients

Multidisciplinary (physician, pharmacist, nurse, physiotherapist)

98 patients with COPD

Recruited from Pharmaceutical Not specified investigators’ care (drug therapy practice population management, use of patient-specific stepped-care approach, patient education, patient assessment at clinic visits, and telephone follow-up)

Patients

Pharmacists

CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; RCT = randomized controlled trial. NHLBI = National Heart, Lung and Blood Institute

Time Period Studied 12 months

Study/Evaluation Design RCT

Economic Effects Assessed None

Physician visits and work absenteeism

12 months

RCT

None

Physician visits and work absenteeism

12 months

Hospitalizations and health care provider visits

6 months

Setting Patient homes

Key Results The intervention reduced hospital admissions for acute exacerbations, emergency visits, and unscheduled physician visits by 40%, 41%, and 59%, respectively.

Hospital outpatient clinic

Physician visits and absenteeism from work were significantly greater in the control group than in the intervention group. The mean reductions in physician visits and lost work days in the intervention group were 85% and 95%, respectively, compared with the control group.

RCT

Total direct and Hospital indirect costs, costs outpatient clinic for physician visits, hospitalizations, and absenteeism from work

The costs for physician visits, hospitalizations, and absenteeism from work were significantly lower in the education group. For every dollar invested in the education group, there was a cost savings of $4.80.

RCT

None

The number of hospitalizations and the number of health care provider visits were higher in the treatment group (pharmaceutical care) than in the control group.

Hospital clinics

Disease Management for Chronic Obstructive Pulmonary Disease

Outcomes Measured hospitalizations, emergency visits, unscheduled physician visits

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Appendix C. (continued)

Disease Management for Chronic Obstructive Pulmonary Disease

Author(s) Marley, 2000

[14]

Size of Population Not specified

Method of Identifying Population for Whom Data Are Evaluated Patients hospitalized with COPD

Intervention Strategy Care pathway for acute COPD exacerbation, nursing staff training program, and patient assessment by nurse specialists

Guideline Based? British Thoracic Society guidelines for treating COPD

Audience for Intervention Patients and nursing staff

Primary Manager of Intervention Not specified

Stothard and Brewer, 2001

45 patients attending a nurse-led clinic from a population of >8000 patients with COPD

Not specified

Nurse-led clinic, British Thoracic with efforts to Society guidelines document COPD for treating COPD diagnosis and smoking status, promote influenza and pneumococcal vaccination, improve medication use, and reduce health care utilization

Patients

Nurses

Weinberger et al, 1996

1396 patients with diabetes (n = 751), COPD (n = 583), or CHF (n = 504)

Patients hospitalized at one of nine Veterans Affairs hospitals with CHF, COPD, or diabetes

Intensive Not specified outpatient primary care by a dedicated physician-nurse team after inpatient assessment and provision of patient educational materials

Patients

Primary care teams, consisting of one primary care nurse and one primary care physician

Zajac, 2002

6428 patients with COPD

Referrals and claims

AirLogix patient American Thoracic education, Society and self-management NHLBI guidelines tools and support, case management, and follow-up

Patients

Multidisciplinary (physicians, therapists)

CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; RCT = randomized controlled trial. NHLBI = National Heart, Lung and Blood Institute

Setting Hospital

Key Results Average length of stay decreased from 9.4 to 5.4 days per admission, and care exceeded quality standards

Retrospective audits of period before and after clinic attendance

None

Clinic

Documentation was complete for 97.8% of patients. Vaccination for influenza and pneumococcus was performed in 84% and 80% of patients, respectively. There was a 29% reduction in steroid use. The number of physician visits and number of hospitalizations were reduced by 55% and 42%, respectively.

6 months after intervention

Multicenter RCT

None

Hospitals and clinics at nine Veterans Affairs Medical Centers

Patients in the intervention group had a higher monthly readmission rate (0.19 vs. 0.14) and more days of rehospitalization (10.2 vs. 8.8) despite greater satisfaction than patients in the control group

Variable (e.g., 30 months before and 12 months after program participation)

Cross-sectional population comparison before and after program participation

Total costs (medical and pharmacy claims)

Patient homes

Program participation led to significant reductions in symptom severity and a 17% net savings.

Time Period Studied 12 weeks

Study/Evaluation Design Pilot study

Documentation of diagnosis and smoking status, vaccinations, medication use, physician visits, and hospital admissions

12 months

Hospital readmissions, days of hospitalization, quality of life, satisfaction with care

Symptom severity

Disease Management for Chronic Obstructive Pulmonary Disease

Economic Effects Assessed None

Outcomes Measured Length of hospital stay and quality of care

[15]

References

Disease Management for Chronic Obstructive Pulmonary Disease

1. Centers for Medicare and Medicaid Services. Discussion of disease management. Available at: http://cms.hhs.gov/media/press/release.asp?Counter=418. Accessed October 1, 2002. 2. Disease Management Association of America. Definition of disease management. Available at: http://www.dmaa.org/definition.html. Accessed March 20, 2003. 3. National Pharmaceutical Council. Medicaid disease management & health outcomes: what is disease management? Available at: http://www.dmnow.org/. Accessed March 20, 2003. 4. Joint Commission on Accreditation of Healthcare Organizations. Disease-specific care certification. Available at: http://www.jcaho.org/dscc/index.htm. Accessed October 24, 2002. 5. National Committee for Quality Assurance. NCQA disease management accreditation/certification information. Available at: http://www.ncqa.org/Programs/Accreditation/DM/dmmain.htm. Accessed October 24, 2002. 6. Final NCQA DM accreditation standards hit the street. DM News. December 25, 2001;7(5):1,4,5. 7. American Accreditation HealthCare Commission. URAC accreditation programs. Available at: http://www.urac.org. Accessed May 22, 2003. 8. National Heart, Lung, and Blood Institute. Global Initiative for Chronic Obstructive Lung Disease. Bethesda, MD: National Heart, Lung, and Blood Institute; March 2001 (updated 2003). NIH publication 2701A. Available at: http://www.goldcopd.com/. 9. Mannino DM, Homa DM, Akinbami LG, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. MMWR Surveill Summ. 2002;51:1-16.

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10. National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chartbook on Cardiovascular, Lung, and Blood Diseases. Available at: http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf. 11. Elixhauser A, et al, for the Healthcare Cost and Utilization Project. Hospitalization in the United States, 1997. Rockville, MD: Agency for Healthcare Research and Quality; 2000. AHRQ Pub No. 00-0031/HCUP Fact Book No. 1. 12. Buist AS. Guidelines for the management of chronic obstructive pulmonary disease. Respir Med. 2002;96(suppl C):S11-6. 13. Vermeire P. The burden of chronic obstructive pulmonary disease. Respir Med. 2002;96(suppl C):S3-10. 14. A Clinical Practice Guideline for Treating Tobacco Use and Dependence: A US Public Health Service Report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA. 2000;283:3244-54. 15. Fiore MC, Bailer WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No 18. Rockville, MD: US Department of Health and Human Services, Agency for Health Care Policy and Research; April 1996. AHCPR publication 960692. 16. Disease Management News. May 10, 2001:5. 17. Disease Management News. December 25, 2000:2. 18. Disease Management News. May 25, 2001:2. 19. Disease Management News. November 10, 2002. 20. Mapel D, Pearson M. Obtaining evidence for use by healthcare payers on the success of chronic obstructive pulmonary disease management. Respir Med. 2002;96(suppl C):S11-6.

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