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
58.0%
 58.0%


Mularski RA Chest 130;1844, 2006
Routine Care


McGlynn EA NEJM 348;2635, 2003
46.1%
Mularski RA Chest 130;1844, 2006
Exacerbation Care

60.4%
Mularski RA Chest 130;1844, 2006
Integrated Care

A management program that integrates:
1) disease-specific education
 2) self-management strategies
 3) enhanced communication

Integrated Care
COPD Patient
Healthcare Provider
Education
Action Plan
&
Enhanced Communication
Care Coordinator
Integrated Care
COPD Patient
Healthcare Provider
COPD Exacerbation
Education
Action Plan
&
Enhanced Communication
Care Coordinator
Integrated Care for COPD
Rice 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)
Integrated Care for COPD
Fan 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.”
Did Patients Contact
Coordinators When Advised?



600 total exacerbations
27 weekday calls (4.5%)
No documentation for after-hours calls
Why?
•Denial?
•Overconfidence?
Vandivier RW, Ann Intern Med 157;530, 2012
Proactive Integrated Care
Integrated 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

Proactive Integrated Care
Monitoring Package
At Home
COPD Patient
Healthcare Provider
Education
Monitoring
&
Enhanced Communication
Care Coordinator
COPD Patient
Healthcare Provider
COPD Exacerbation
Education
Monitoring
&
Enhanced Communication
Care Coordinator
Proactive
Self Management
COPD Patient
Proactive
Treatment
Healthcare Provider
COPD Exacerbation
Education
Monitoring
&
Enhanced Communication
Care Coordinator
Early Warning
&
Education
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
Trial 1
Pilot Study
SGRQ
SGRQ
Results:
1.
40 Subjects
0
SGRQ improved by 10 units
(P=0.018)
3
Months
Koff PB, Eur Resp J 33;1031, 2009
Trial 2
Urban Study

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
Methods
Inclusion Criteria

Advanced COPD



GOLD 3-4 COPD
COPD exacerbation < 1y
Standard telephone
Exclusion Criteria

Asthma

Co-existing lung disorder

End-stage kidney or liver
disease

Terminal illness

Active drug abuse
Questionnaire
Lung Function
6MWT
SGRQ
Questionnaire
Lung Function
6MWT
SGRQ
SGRQ
SGRQ
1 yr
Healthcare
Utilization
0m
3m
6m
9m
HCU
HCU
HCU
Enrollment by Site
Improved Quality of Life
Control
Treatment
Decreased Healthcare Utilization
ICU Hosp
Control
Treatment
Vent Hosp
Control
Treatment
Urgent Visits
Control
Treatment
Improved Clinical Measurements
Improved Clinical Measurements
Mortality
Trial 3
Rural Study
Trial 3
Rural Study
Questionnaire
Lung Function
6MWT
SGRQ
Questionnaire
Lung Function
6MWT
SGRQ
0
3
100 Subjects
Months
Linderman DJ, Arch Intern Med 171;2059, 2011
Trial 3
Rural Study
Linderman DJ, Arch Intern Med171;2059, 2011
Trial 3
Rural Study
Linderman DJ, Arch Intern Med171;2059, 2011
Proactive Integrated Care
Summary

Increases guideline-based therapy

Decreases symptoms

Improves quality of life

Decreases healthcare utilization

May improve survival
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
Acknowledgements

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

Kaiser Permanente
Denver






Denver VA Medical
Center


Arne Beck, PhD
Debra Ritzwoller, PhD
Tom Stelzner, MD
Christine Kveton, RRT
Stephanie Carwin, RRT
Robert Keith, MD
University of Colorado


Derek Linderman, MD
Max Min PhD
Funded by the Colorado Cancer, Cardiovascular Disease and Pulmonary Disease
Grants Program and The University of Colorado Hospital