Making collaborative self-management successful in COPD patients with high disease burden

Open ArchivePublished:April 01, 2013DOI:https://doi.org/10.1016/j.rmed.2013.03.003

      Summary

      Background

      Exacerbations in severe COPD patients lead to challenges in terms of self-management. This study is a “real-life” situation aiming to assess whether or not it is possible for COPD patients with high burden of disease to self-manage acute exacerbations and to reduce hospital use.

      Methods

      100 randomly selected charts of patients followed in a specialised COPD clinic in 2006 and 2009 (patients with higher burden of disease) were reviewed. Data on patients' characteristics, COPD severity and exacerbation management were extracted.

      Results

      Compared to the 2006 cohort, patients from the 2009 cohort had lower (0.85 L), but not statistically significant different FEV1 (L) than the 2006 cohort (0.98 L) and more exacerbations (2.6 exacerbations/pt vs 3. 6 exacerbations/pt, p = 0.03). Despite having a higher burden of disease, patients in the 2009 cohort as compared to 2006 had more appropriate self-management behaviours in the event of an exacerbation (60% vs 42%, p = 0.05) and fewer emergency room visits and/or hospital admissions (39% vs 57%, p = 0.02). There were more phone calls to the case managers (590 vs 382, p < 0.001) and fewer physician office visits (167 vs 179, p = 0.024).

      Conclusions

      This study of a real life situation adds to the current body of literature that a more severe COPD patient population can be taught self-management skills in the event of exacerbations, leading to fewer health care visits and hospital admissions.

      Keywords

      Background

      Chronic obstructive pulmonary disease (COPD) exacerbations are significant for both patients and the health care system. They contribute to a faster decline in FEV1 and worsening of the quality of life
      • Donaldson G.C.
      • Seemungal T.A.
      • Bhowmik A.
      • et al.
      Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease.
      • Makris D.
      • Moschandreas J.
      • Damianaki A.
      • et al.
      Exacerbations and lung function decline in COPD: new insights in current and ex-smokers.
      for patients. They also represent significant costs to the health care system, COPD being the number one cause of readmission in Canada.
      • Wen E.
      • Sandoval C.
      • Zelmer J.
      • et al.
      Understanding and using the hospital standardized mortality ratio in Canada: challenges and opportunities.
      The recovery from an exacerbation is also of concern. It has been shown that up to 14% of exacerbations take more than 35 days for resolution of symptoms and that more than 4% do not have complete recovery after 91 days.
      • Seemungal T.A.
      • Donaldson G.C.
      • Bhowmik A.
      • et al.
      Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease.
      It has been shown that there are ways to minimize the negative impacts of COPD exacerbations. Adherence to an action plan with a case manager involved can lead to decreased symptoms recovery time.
      • Bischoff E.W.
      • Hamd D.H.
      • Sedeno M.
      • et al.
      Effects of written action plan adherence on COPD exacerbation recovery.
      It has also been demonstrated that hospital admissions can be reduced by up to 39%, emergency room visits by up to 41% and unscheduled physician visits by more than 58% when patients are trained in an intensive comprehensive self-management program.
      • Effing T.
      • Monninkhof E.M.
      • van der Valk P.D.
      • et al.
      Self-management education for patients with chronic obstructive pulmonary disease.
      • Rice K.L.
      • Dewan N.
      • Bloomfield H.E.
      • et al.
      Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.
      • Bourbeau J.
      • Julien M.
      • Maltais F.
      • et al.
      Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention.
      However, when a multicenter Veteran Affairs (VA) cooperative trial attempted to study a similar comprehensive case management program vs. standardized care in patients hospitalized with advanced COPD in the prior year, the study was prematurely discontinued due to excessive mortality in the comprehensive care management group.
      • Fan V.S.
      • Gaziano J.M.
      • Lew R.
      • et al.
      A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial.
      As reported by the investigators, patients in the comprehensive care management program were not successful. They waited almost a week before taking medication. This was not any sooner than the usual care group. Reason for excessive mortality is not clear; however close contact with patients who have a high disease burden may be crucial in maximizing self-management success.
      While these studies were going on, our clinic's COPD case managers noted an increased workload and felt that patients referred had increased disease burden. In this context, concerns around the efficacy of the self-management were raised. As the caseload seemed heavier, it was thus assumed by the team that patients had more severe COPD. Furthermore, there was fear that self-management represented more work for case managers and that despite it, health care utilisation secondary to exacerbations could potentially be rising.
      In the present study of a real life situation of patients monitored in a COPD clinic, we primarily aimed at assessing whether or not it was possible for patients with high and increased disease burden to have the ability to properly self-manage acute exacerbations. This entails patient adherence to their action plan that triggers prompt recognition of worsening symptoms and timely treatment and reducing emergency hospital visits and/or admissions. As secondary objectives, we assessed the need for ongoing regular contact with a knowledgeable supervising case manager and for physician visits.

      Methods

       Study design and selection of patients

      This study was a retrospective chart review of two distinct cohorts of randomly selected patients who were followed in a COPD clinic with self-management program and communication with a nurse case manager. Each cohort was separated from 3 years apart based on the assumption that patients most recently referred to the COPD clinic had a higher disease burden. We planned to choose fifty patients from the nurse caseload in each of the 2005–2006 and 2008–2009 patient list. All COPD patients had to be newly referred and been followed at least once in the COPD clinic of the Montreal Chest Institute during the subsequent year. The project received the approval of the Institutional Research Ethic Board.

       Case manager qualifications and tasks

      In both 2006 and 2009, the same three case managers were working at the COPD clinic, thus both cohorts had nurses that had equivalent skills and knowledge. The case managers were all nurses who were specialised in chronic respiratory disease and had at least 5 years experience in managing complexly ill COPD patients. They were also competent in motivational interviewing and on knowledge translation pertaining to the “Living well with COPD” self-management program. The nurses had access to a respirologist who has chronic respiratory diseases as main interest, in particular COPD. Each patient was assigned to a case manager and each case manager had a caseload of 70–100 patients. Patients were usually seen in the COPD clinic 2–4 times per year. Case managers were available by phone or in person in the clinic between 9:00 and 18:00 on weekdays. After these hours, patients had access to a 24 h hot line and a community nurse that specialises in COPD. As part of the action plan strategy, patients were instructed to call the case manager if new respiratory symptoms developed or if the prescribed treatment for a COPD exacerbation was initiated. During visits and/or telephone contacts, the case manager and/or physician reviewed with the patient the specific symptoms they experienced when having an exacerbation, the action plan that should be implemented and patients' adherence when an exacerbation had already been experienced.

       Action plan and COPD exacerbations

      Many formats of action plans have been described and used clinically, but in this study, the term “action plan” refers to a written document handed to each patient with personalised explanations. The written action plan is central to the program “Living Well with COPD”. It is available on www.livingwellwithcopd.com (password: COPD) and it highlights how to take regular medications, to promptly recognize the worsening of symptoms and to initiate treatment including the self-administration of antibiotics and oral corticosteroids. Patients are asked to refer to the written plan regularly until they are familiar with all inhalers and other drugs. Both patient cohorts received training based on the self-management program “Living well with COPD”.
      Exacerbations are often difficult to identify.
      • Bischoff E.W.
      • Hamd D.H.
      • Sedeno M.
      • et al.
      Effects of written action plan adherence on COPD exacerbation recovery.
      • Aaron S.D.
      • Donaldson G.C.
      • Whitmore G.A.
      • et al.
      Time course and pattern of COPD exacerbations onset.
      As per the written action plan, an exacerbation is defined as a change in any of the 3 cardinal respiratory symptoms for more than 48 h. Symptoms were either an increase or a change in colour of the sputum or an increase in shortness of breath. Patients were instructed to take the prescribed antibiotics and/or the oral corticosteroids if there was a persistent change in sputum and/or increased shortness of breath and not to wait more than 48 h. Patients were also encouraged to call the case manager as soon as possible to inform, to allow patients’empowerment over their exacerbation and to insure follow up.

       Outcome measures

      To assess the changes in COPD disease burden from each cohort, demographics along with FEV1, smoking status, number of respiratory medications and exacerbations and comorbidities were collected by reviewing medical charts. As part of regular practice, nurse and physician visits and telephone contacts were also systematically recorded in the medical chart of COPD patients via a standardized form implemented in 2005. To assess the change in workload between 2006 (refers to 2005–2006) and 2009 (refers to 2008–2009), each visit or contact, in person or by telephone, was recorded based on the notes in the chart.
      Appropriate self-management behaviours refers to the ability of the patients to recognise changes in their symptoms and act on them, either by calling their case managers and/or by adjusting their treatment (to initiate antibiotics and/or oral corticosteroids) for a COPD exacerbation. Exacerbations were systematically recorded in the medical chart from telephone contact with the case manager. When patients did not call, the information with respect to an exacerbation was recorded at their regular visit with the respirologist. All emergency room visits and hospitalisations for respiratory reasons within 4 weeks of starting the action plan were also recorded to evaluate the potential benefit, i.e., hospital use outcomes post action plan.

       Statistical analysis

      Analyses were performed with SAS (version 9.1, SAS Institute; Cary, NC). For the primary and secondary outcomes, comparisons of the two cohorts were done using unpaired student t-test (continuous data) and chi-square test (binominal data). We considered p values <0.05 as statistically significant.

      Results

      After random selection, 50 chart numbers were identified in each cohort. Retrieval of charts based on chart number lead to the exclusion of 2 from the 2006 cohort and 4 from the 2009. These charts were excluded because they could not be retrieved from the archives at the time of the chart review. They had been requested elsewhere and no tracking system existed at that time. From the 2006 and 2009 cohorts 48 and 46 distinct charts were kept for the study.
      Characteristics of the COPD patients are presented in Table 1. Patients from the 2 cohorts were comparable with respect to sex, age, co-morbid conditions. Patients in the 2009 cohort as compared to those in the 2006 cohort showed a non statistically significant trend for more severe airflow obstruction and a statistically significant increase in the frequency of exacerbations, i.e., a higher burden of disease, while being more often prescribed a combination of long acting anticholinergic, long acting beta-agonist and inhaled corticosteroids.
      Table 1Characteristics of the COPD patients in each cohort.
      2006 refers to 2005–2006 and 2009 refers to 2008–2009.
      Cohort 2006 (N = 48)Cohort 2009 (N = 46)p-Values
      Age, years ± SD70.26 ± 9.8769.74 ± 9.500.70
      Sex, male27 (56%)25 (54%)0.80
      Smoking history
      • Smokers
      9 (19%)6 (13%)0.50
      • Ex-smokers
      39 (81%)40 (87%)0.50
      FEV1, liters ± SD0.98 ± 0 0.410.85 ± 0.370.14
      FEV1, % predicted ± SD40% ± 18%34% ± 15%0.17
      FEV1/FVC0.45 ± 0.150.43 ± 0.15
      Number of exacerbations126 (2.6 exacerbations/pt)167 (3.6 exacerbations/pt)0.03
      Therapy with combination (LAAC + LABA/ICS)26 (54%)37 (80%)0.07
      Pulmonary rehabilitation38 (79%)38 (83%)0.41
      Referral in the community44 (92%)44 (96%)0.92
      SD: Standard deviation; FEV1: Forced expiratory volume in 1 s; FVC: Forced vital capacity; LAAC: Long-acting anticholenergic; LABA: Long-acting beta-agonist; ICS: Inhaled cortico-steroids.
      a 2006 refers to 2005–2006 and 2009 refers to 2008–2009.
      Table 2 shows that patients in the 2009 cohort as compared to those in the 2006 cohort have better self-management behaviours in the event of an exacerbation, i.e., a call by the patient to the case manager if new respiratory symptoms develop or if the patient initiated the prescribed treatment for a COPD exacerbation, and decreased emergency department visits and hospital admissions.
      Table 2Self-management behaviours according to the action plan in the event of an exacerbation and hospital use.
      2006 refers to 2005–2006 and 2009 refers to 2008–2009.
      Cohort 2006Cohort 2009p-Value
      Number of exacerbations1261670.03
      Appropriate self-management behaviours
      Appropriate self-management behaviours are defined as a call by the patient to the case manager if new respiratory symptoms develop or if the prescribed treatment for a COPD exacerbation was initiated.
      54 (42%)101 (60%)0.05
      Hospital use
      Hospital use is defined as a visit to the emergency room or an admission to the hospital within 4 weeks of initiating an action plan.
      72 (57%)66 (39%)0.024
      a 2006 refers to 2005–2006 and 2009 refers to 2008–2009.
      b Appropriate self-management behaviours are defined as a call by the patient to the case manager if new respiratory symptoms develop or if the prescribed treatment for a COPD exacerbation was initiated.
      c Hospital use is defined as a visit to the emergency room or an admission to the hospital within 4 weeks of initiating an action plan.
      Table 3 shows the number of visits and telephone calls with case managers and physicians in the cohorts from 2006 to 2009. There was an increase in telephone calls with case managers while for the same period, there was a decrease in visits to case managers and physicians.
      Table 3Visits and telephone calls with the case manager and the physician.
      2006 refers to 2005–2006 and 2009 refers to 2008–2009.
      Cohort 2006Cohort 2009p-Value
      Phones calls to the case manager382590< 0.001
      Clinical visits to the case manager184113< 0.001
      Clinical visits to the physician1791670.02
      a 2006 refers to 2005–2006 and 2009 refers to 2008–2009.

      Discussion

      This study of a real life situation demonstrated that in severe COPD patients more prone to exacerbations, patients increased their ability to properly self-manage their acute exacerbations and reduced emergency hospital visits and/or admissions.
      It has been shown that exacerbations lead to prolonged symptoms which do not return to pre-exacerbation level.
      • Wedzicha J.A.
      • Donaldson G.C.
      Exacerbations of chronic obstructive pulmonary disease.
      Early treatment is necessary to help recovery and avoid early mortality.
      • Suissa S.
      • Dell'Aniello S.
      • Ernst P.
      Long-term natural history of chronic pulmonary disease: severe exacerbations and mortality.
      Our study is the first to show in a clinical setting that COPD patients with increased disease burden can successfully develop self-management behaviour. These results are conflicting with those of the VA trial.
      • Fan V.S.
      • Gaziano J.M.
      • Lew R.
      • et al.
      A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial.
      As reported by the investigators, patients in the comprehensive care management program did not take medication any sooner than the usual care group. The study care managers who instructed the cohort had varying professional backgrounds that included nurses, respiratory therapists, study coordinators and medical assistants. Their background and skills in managing complex and very ill COPD patients was unclear. A greater number of patients in the interventional arm had fatal COPD related events and less urgent ER visits, suggesting less intense treatment received by the comprehensive care management arm. These data also suggest that in the VA trial, the comprehensive care management plan failed in its intent to provide timely care for patients with worsening symptoms of exacerbations. This shows the importance of measuring the intended behaviour of self-managing COPD.
      It has also been demonstrated that exacerbations and hospital admissions for a COPD exacerbations lead to increased mortality and morbidities,
      • Wedzicha J.A.
      • Donaldson G.C.
      Exacerbations of chronic obstructive pulmonary disease.
      • Bustamante-Fermosel A.
      • De Miguel-Yanes J.M.
      • Duffort-Falco M.
      • et al.
      Mortality-related factors after hospitalization for acute exacerbation of chronic obstructive pulmonary disease: the burden of clinical features.
      • Groenewegen K.H.
      • Schols A.M.
      • Wouters E.F.
      Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD.
      hence avoiding hospitalisation is essential. Our study adds to previous publications by demonstrating that despite increases in exacerbations per patient over time, physician office visits can still be minimized by implementing a case manager run program. However, in order to be effective and harmless to patients and to lead to appropriate self-management behaviours, the program must include essential components such as easy access, timely interaction and increased telephone communications with a highly skilled case manager. In our study, the same training had been given to both groups, so the increase in phone calls does reflect proper integration of self-management skills despite the severity of the disease.
      The increase in phone communications in the context of an exacerbation has some clinical importance. This observation reinforces the previously emphasized need to put action plans in place in the setting of appropriate teaching and coaching.
      • Rice K.L.
      • Dewan N.
      • Bloomfield H.E.
      • et al.
      Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.
      • Walters J.A.
      • Turnock A.C.
      • Walters E.H.
      • et al.
      Action plans with limited patient education only for exacerbations of chronic obstructive pulmonary disease.
      An increase in phone calls could have created new opportunities for patient empowerment. It has been demonstrated that in chronic disease management, patients need to be informed and guided in order to gain empowerement.
      • Li T.
      • Wu H.M.
      • Wang F.
      • et al.
      Education programmes for people with diabetic kidney disease.
      • Inglis S.C.
      • Clark R.A.
      • McAlister F.A.
      • et al.
      Structured telephone support or telemonitoring programmes for patients with chronic heart failure.
      Case managers provide the teaching necessary in COPD to allow empowerment and this study shows that it is a resource that severe COPD patients use to take proper action in the event of an exacerbation and to decrease emergency visits and hospital admissions.
      This study highlights the feasibility of implementing a self-management program in a population of COPD patients with an increased and high burden of disease. Furthermore, the study reports results from a real life situation enhancing the applicability of such practice. The study's main focus was on measuring intermediate outcomes, such as intended behaviour change and the process of self-management, instead of only measuring ultimate outcomes, such as health service use. This is an essential attribute of successful self-management programs. Finally, this study touches on and helps understand why some programs fail while others work.
      Certain limitations to this study should be discussed. The success of this program in an integrated approach of care took place in a specialized COPD clinic. It may not be possible to generalize these results to another practice setting. This was not a randomized clinical trial. However, we did not intend to compare patients with similar disease severity. Our objective was to see if collaborative self-management could be successful and harmless over time when COPD patients had increased disease severity. A clinical trial with data collected prospectively instead of a chart review would have allowed for a more accurate recording of exacerbations and of the self-management behaviours to which they are associated. Another limitation of the study is related to the fact that it often takes more than one exacerbation before patients can manage successfully. Adherence to self-management instructions takes time and in the present study, we don't know how long patients had to be followed to manage their exacerbations properly. Furthermore, adherence may not only depend on patient characteristics, but also on exacerbation-related factors, such as exacerbation severity and time to next exacerbation. None of the patients' charts documented a death occurring during the year that of it's review.
      This study adds to the current body of literature demonstrating that a more severe COPD patient population can implement self-management skills (i.e. they can apply the principles being taught) in the event of exacerbations and decrease health care visits and hospital admissions. In order for a self-management program to be successful and harmless to patients, this study highlights the necessity for detailed, easily accessible, and frequent interactive communication with highly skilled and experienced case-manager. However, this can only happen in an integrate system of care well adapted and responsive to patient needs. Future studies would be necessary to provide complementary information on patients' decision making and the need for certain patients to have decisions taken by the health care professional.

      Acknowledgements

      This study was funded by GSK but the funder was not involved in the study protocol development, implementation, analysis or this paper. The authors would like to thank Pei Zhi Li for the data management and analysis and Louise Auclair for the secretarial support. Jean Bourbeau takes responsibility for (is the guarantor of) the content of the manuscript, including the data and analysis. Jean Bourbeau, Nathalie Saad, Alexandre Joubert, Isabelle Ouellet, Isabelle Drouin, France Paquet, Danielle Beaucage and Michel Lebel contributed to the protocol development, data management and analysis, and interpretation of the results. Alexandre Joubert, Isabelle Ouellet, and Isabelle Drouin reviewed the charts. Jean Bourbeau and Nathalie Saad wrote the manuscript and the other authors reviewed it.

      Source of support

      Unrestricted educational grant from GlaxoSmithKline Canada.

      Conflict of interest statement

      None of the authors have conflict of interest for this article.

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