An integrated pulmonary and primary care COPD disease management program: Impact on clinical outcomes

Introduction: COPD practice guidelines recommend evidence based interventions that improve clinical outcomes. These therapies are commonly omitted by primary care providers who usually manage these patients. We hypothesized that a COPD disease management program integrating subspecialist and primary care expertise facilitated by a computer based system (CareManager) would reduce exacerbations and improve quality of life. Methods: This study is divided into three phases. The first phase included design and testing of workflow protocols developed by pulmonologists. The second phase included developing a CareManager COPD patient management module. This module was designed by two pulmonologists, primary care physicians and the CareManager development team. It includes population tracking, embedded clinical guidelines, patient connectivity tools and point-of-care prompts. Data will be shared between primary care and specialty practices. The module combined with provider education is hypothesized to facilitate implementation of evidence based interventions improving clinical outcomes. Based on a power analysis, 123 patients with COPD with 2 outpatient exacerbations or 1 emergency room (ER) visit or 1 hospitalization in the prior year will be randomized from 4 clinics utilizing CareManager and compared to 123 patients in 7 clinics from the same medical group. Spirometry, 6 minute walk, and SGRQ will be obtained at baseline and after 1 year in intervention clinics. Outpatient exacerbations, ER visits, and hospitalizations will be compared to those occurring in the same patient in the year prior to the program and to those in the control clinics. Results: The first and second phases of the study are complete. The third phase, the primary care study, will enroll patients from November 2010-January 2011. In phase 1, testing the workflow protocol, 47 patients with COPD were prospectively studied in our pulmonary clinic (FEV1 1.09 ± 0.09 l, FEV1% 51 ± 2, 6 minute walk 843 ± 52 feet). They had 87 exacerbations requiring antibiotics or corticosteroids in the 12 months prior to enrollment. COPD exacerbations during the subsequent 1 year program were reduced to 44 (1.83 ± 0.3 exacerbations/year versus 1 ± 0.2; p= 0.002). Conclusion: Phase one data demonstrates our disease specific interventions decreases exacerbation rates in patients with advanced COPD. The primary care study will determine if these specialist developed workflow protocols and education in conjunction with a computer-based population management tool decrease the frequency of exacerbations and improve clinical outcomes in primary care.