Disease Management Program for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial
Rice KL, Dewan N, Bloomfield HE, et al.
Am J Respir Crit Care Med. 2010;182:890-896
Evidence that a disease management (DM) program for COPD can reduce the morbidity associated with this disease has not been convincing to date. Rice and colleagues therefore conducted a 1-year, prospective, randomized, placebo-controlled, single-blind study of a relatively simple disease management program in 743 patients in the Veterans Affairs (VA) system. Patients with relatively severe COPD and a history of significant healthcare utilization in the previous year were recruited and randomly assigned to usual care (UC) or usual care plus a DM intervention. The intervention consisted of a 1- to 1.5-hour educational session with a respiratory therapist, optimization of therapy, smoking cessation, exercise counseling, and prophylactic vaccination. Patients in the DM program also received both prescriptions for prednisone and an antibiotic with an action plan specifying their use and routine follow-up telephone calls from staff. The primary outcome was the combined number of hospitalizations and emergency department (ED) visits for COPD during the following year. Secondary outcomes were all-cause medical care utilization, duration of hospitalizations, medication usage, etc.
The combined frequency of hospitalization and ED visits for COPD was reduced by 41% in the DM arm (48 times per 100 patient-years in the DM arm vs 82.2 times per 100 patient-years in the UC arm); the rate ratio was 0.59 (P < .001). The reduction in ED visits was somewhat more than the reduction in hospitalizations. The effect was consistent among subgroups defined by age, smoking status, disease severity, previous treatments and study sites, and the difference between treatment arms was maintained in frequency throughout the 12 months of observation. Patients in the DM program also filled more outpatient prescriptions. No estimate of cost efficacy of DM could be made. The investigators concluded that "...a relatively simple DM program reduced hospitalizations and ED visits for COPD."
Acute exacerbations are the major medical events associated with COPD. They are also the most costly components of the long-term care of the condition. Measures to reduce these statistics are thus of prime medical and economic importance. As with some other chronic diseases, the major barrier to optimal care is failure on the part of caregivers to ensure that appropriate care is individually tailored, explained, and made available to patients, and failure of patients to follow those recommendations. DM aims to eliminate those barriers, but also to motivate patients and reinforce the recommendations.
DM programs typically include education and motivation of patients, and promote the uniform implementation of evidence-based medicine. They usually have a self-management component, and their use in other chronic disorders such as heart failure and diabetes mellitus has mostly met with success.[53,54]
The present study is the largest and most carefully planned and executed such study to be performed in COPD. The results are quite convincing, indicating that highly significant improvements in the management of this very common condition, particularly reductions in the frequency and duration of acute exacerbations, can be achieved by a relatively simple intervention. It would be interesting to know which components of the multicomponent intervention were the most effective, but that information cannot be obtained from the present study. Cost-efficacy information would also be interesting and could support the widespread acceptance of a DM program for COPD. One limitation, however, is that the study, because it was conducted in VA facilities, was almost entirely confined to men, and COPD is rapidly becoming a disease predominantly of women. The results may therefore not be generalizable, although this seems unlikely.
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