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Proactive Integrated Care for COPD

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

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Proactive Integrated Care for COPD

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  1. Proactive Integrated Care for COPD R. William Vandivier, MD University of Colorado Anschutz Medical Campus

  2. Optimize Delivery of Care Decrease Symptoms Improve Quality of Life Decrease Exacerbations Improve Survival

  3. COPD is Undertreated in the US • Overall • 58.0% McGlynn EA NEJM 348;2635, 2003 • 58.0% 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

  4. Integrated Care • A management program that integrates: • 1) disease-specific education • 2) self-management strategies • 3) enhanced communication

  5. COPD Patient Healthcare Provider Care Coordinator Integrated Care Education Action Plan & Enhanced Communication

  6. COPD Patient Healthcare Provider Care Coordinator Integrated Care COPD Exacerbation Education Action Plan & Enhanced Communication

  7. Integrated Care for COPDRice 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)

  8. Integrated Care for COPDFan 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.”

  9. Did Patients Contact Coordinators When Advised? • Why? • Denial? • Overconfidence? 600 total exacerbations 27 weekday calls (4.5%) No documentation for after-hours calls Vandivier RW, Ann Intern Med 157;530, 2012

  10. Proactive Integrated CareIntegrated 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

  11. Proactive Integrated Care Monitoring Package At Home

  12. COPD Patient Healthcare Provider Care Coordinator Education Monitoring & Enhanced Communication

  13. COPD Patient Healthcare Provider Care Coordinator COPD Exacerbation Education Monitoring & Enhanced Communication

  14. Proactive Self Management Proactive Treatment COPD Patient Healthcare Provider Care Coordinator COPD Exacerbation Education Monitoring & Enhanced Communication Early Warning & Education

  15. 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

  16. Trial 1Pilot Study SGRQ SGRQ Treatment Results: SGRQ improved by 10 units (P=0.018) n=20 40 Subjects n=20 Usual Care 0 3 Months Koff PB, Eur Resp J 33;1031, 2009

  17. 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 Trial 2Urban Study

  18. Advanced COPD GOLD 3-4 COPD COPD exacerbation < 1y Standard telephone Asthma Co-existing lung disorder End-stage kidney or liver disease Terminal illness Active drug abuse Methods Inclusion Criteria Exclusion Criteria

  19. Questionnaire Lung Function 6MWT SGRQ Questionnaire Lung Function 6MWT SGRQ SGRQ SGRQ Healthcare Utilization 0 m 3 m 6 m 9 m HCU HCU HCU Treatment 1 yr n=270 n=130 Control

  20. Enrollment by Site

  21. Improved Quality of Life Control Treatment

  22. ICU Hosp Vent Hosp Urgent Visits Decreased Healthcare Utilization Control Treatment Control Treatment Control Treatment

  23. Improved Clinical Measurements

  24. Improved Clinical Measurements

  25. Mortality

  26. Trial 3Rural Study

  27. Trial 3Rural Study Questionnaire Lung Function 6MWT SGRQ Questionnaire Lung Function 6MWT SGRQ 100 Subjects 0 3 Months Linderman DJ, Arch Intern Med 171;2059, 2011

  28. Trial 3Rural Study Linderman DJ, Arch Intern Med171;2059, 2011

  29. Trial 3Rural Study Linderman DJ, Arch Intern Med171;2059, 2011

  30. Proactive Integrated Care Summary • Increases guideline-based therapy • Decreases symptoms • Improves quality of life • Decreases healthcare utilization • May improve survival

  31. 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

  32. 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 University of Colorado Derek Linderman, MD Max Min PhD 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 Acknowledgements Funded by the Colorado Cancer, Cardiovascular Disease and Pulmonary Disease Grants Program and The University of Colorado Hospital

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