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 informa-
tion 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.
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
• 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 self-
management 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
• 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
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Disease Management for Chronic
Obstructive Pulmonary Disease
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
Why Focus on Chronic Obstructive
Pulmonary Disease?
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
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
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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.
Table 1. Authoritative
Guidelines for
Managing Chronic
Obstructive
Pulmonary
Disease
a
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.
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
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
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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
Table 2. Organizations with
Information About
COPD for Patients
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.
Current Status of Disease
Management Programs for COPD
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 859-
232-8565).
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
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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 COPD-
related 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 plan-
level 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 evidence-
based 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
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
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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/.
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/.
Health Hero Network, Inc. (Mountain
View, California)
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 Internet-
based, 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.
Health Management Corp (Richmond,
Virginia)
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
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
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 “high-
intensity 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
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,
asthma, diabetes, coronary artery disease, or congestive
heart failure. For additional information, see Disease
Management News, February 25, 2002 (pages 2 & 6), or
contact Christobel Selecky of LifeMasters at 949-380-0800
or Chris Havens of Integris at 888-951-2277.
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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 respiratory-
specialty registered nurses. For additional information, go to
http://www.matria.com/, or contact Chris Coloian at 770-767-
8371 or George Dunaway at 770-767-4500.
National Jewish Medical and Research
Center (Denver, Colorado)
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 symptom-
based 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
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.
[7]
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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., beta
2
-
adrenergic 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
Appendix A.
Management of Chronic Obstructive Pulmonary Disease
The information in this appendix is adapted from sources in Table 1, found on page 2 of this document.
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 self-
management 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.
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.
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.
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.
Cost-benefit and cost-effectiveness analysis of self-
management 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;38:574-
85.
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 follow-
up. 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.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Chronic Obstructive Pulmonary Disease
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{Continued on next page}
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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.
Dramatic improvement in COPD patient care in nurse-led
clinic.
Stothard A, Brewer K.
Nursing Times. June 14-20, 2001;97(24):36-7.
Retrospective audits were performed before and during the one-
year 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
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Chronic Obstructive Pulmonary Disease (continued)
{Continued on next page}
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.
Appendix B.
Reports of the Impact of Disease Management Interventions on
Treatment of Chronic Obstructive Pulmonary Disease (continued)
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CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease;
RCT = randomized controlled trial.
NHLBI = National Heart, Lung and Blood Institute
Appendix C.
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention
Bourbeau et al, 2003 191 patients Patients Comprehensive Not stated Patients Multidisciplinary (nurse,
with COPD hospitalized at weekly patient respiratory therapist,
least once in the education at or physiotherapist)
preceding year home for 7-8 wk
for acute followed by
exacerbation monthly phone
calls
Gallefoss and 62 patients Recruited from Education about Not stated Patients Multidisciplinary
Bakke, 2000 with COPD hospital outpatient medications, (physician,
clinic compliance, and pharmacist,
self-care nurse,
physiotherapist)
Gallefoss and 62 patients Recruited from Education about Not stated Patients Multidisciplinary
Bakke, 2002 with COPD hospital outpatient medications, (physician,
clinic compliance, and pharmacist,
self-care nurse,
physiotherapist)
Solomon et al, 1998 98 patients Recruited from Pharmaceutical Not specified Patients Pharmacists
with COPD 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)
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Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results
hospitalizations, 12 months RCT None Patient homes The intervention reduced
emergency visits, hospital admissions for
unscheduled acute exacerbations,
physician visits emergency visits, and
unscheduled physician
visits by 40%, 41%, and
59%, respectively.
Physician visits 12 months RCT None Hospital Physician visits and
and work outpatient clinic absenteeism from work
absenteeism 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.
Physician visits 12 months RCT Total direct and Hospital The costs for physician
and work indirect costs, costs outpatient clinic visits, hospitalizations,
absenteeism for physician visits, and absenteeism from
hospitalizations, and work were significantly
absenteeism from lower in the education
work group. For every dollar
invested in the education
group, there was a cost
savings of $4.80.
Hospitalizations and 6 months RCT None Hospital clinics The number of
health care provider hospitalizations and the
visits number of health care
provider visits were higher
in the treatment group
(pharmaceutical care) than
in the control group.
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Appendix C.
(continued)
Method of
Identifying
Population for
Size of Whom Data Are Intervention Guideline Audience for Primary Manager
Author(s) Population Evaluated Strategy Based? Intervention of Intervention
Marley, 2000 Not specified Patients Care pathway for British Thoracic Patients and Not specified
hospitalized with acute COPD Society guidelines nursing staff
COPD exacerbation, for treating
nursing staff COPD
training program,
and patient
assessment by
nurse specialists
Stothard and 45 patients Not specified Nurse-led clinic, British Thoracic Patients Nurses
Brewer, 2001 attending a with efforts to Society guidelines
nurse-led clinic document COPD for treating COPD
from a diagnosis and
population of smoking status,
>8000 patients promote influenza
with COPD and pneumococcal
vaccination,
improve medication
use, and reduce
health care
utilization
Weinberger et al, 1396 patients Patients Intensive Not specified Patients Primary care teams,
1996 with diabetes hospitalized at one outpatient primary consisting of one
(n = 751), of nine Veterans care by a primary care nurse
COPD Affairs hospitals dedicated and one primary
(n = 583), with CHF, COPD, physician-nurse care physician
or CHF or diabetes team after inpatient
(n = 504) assessment and
provision of patient
educational
materials
Zajac, 2002 6428 patients Referrals and AirLogix patient American Thoracic Patients Multidisciplinary
with COPD claims education, Society and (physicians,
self-management NHLBI guidelines therapists)
tools and support,
case management,
and follow-up
CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease;
RCT = randomized controlled trial.
NHLBI = National Heart, Lung and Blood Institute
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Economic
Outcomes Time Period Study/Evaluation Effects
Measured Studied Design Assessed Setting Key Results
Length of hospital 12 weeks Pilot study None Hospital Average length of stay
stay and quality decreased from 9.4 to
of care 5.4 days per admission,
and care exceeded
quality standards
Documentation of 12 months Retrospective audits None Clinic Documentation was
diagnosis and of period before complete for 97.8% of
smoking status, and after clinic patients. Vaccination for
vaccinations, attendance influenza and
medication use, pneumococcus was
physician visits, performed in 84% and
and hospital 80% of patients,
admissions 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.
Hospital 6 months after Multicenter RCT None Hospitals and Patients in the intervention
readmissions, days intervention clinics at nine group had a higher
of hospitalization, Veterans Affairs monthly readmission rate
quality of life, Medical Centers (0.19 vs. 0.14) and more
satisfaction with days of rehospitalization
care (10.2 vs. 8.8) despite
greater satisfaction than
patients in the control
group
Symptom severity Variable (e.g., Cross-sectional Total costs Patient homes Program participation
30 months population comparison (medical and led to significant
before and before and after pharmacy reductions in symptom
12 months after program participation claims) severity and a 17% net
program savings.
participation)
[16]
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The National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433
Phone: 703-620-6390
Fax: 703-476-0904
www.npcnow.org
www.dmnow.org
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