VA Perfecting Disease Management System for COPD

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MINNEAPOLIS, MN—The difficulty with treating COPD—as with any chronic disease—is that much of the care must be placed in the hands of the patient. The patient needs to be properly educated about their illness, not just about the pathophysiology, but about the importance of proper disease management and how to manage their own symptoms. They must be empowered to make care decisions when their symptoms flare up.

This process could take many hours and require numerous monthly check-ups to ensure the patient is doing well. However, physician-researchers at the Minneapolis VAHCS have found that a little training combined with a healthy dose of patient autonomy can go a long way.

A Simple Solution

In 2004 Robert Petzel, MD, VA’s Under Secretary for Health who was then head of VISN 23, which includes the Minneapolis VAHCS, directed the facilities under his supervision to implement chronic disease management plans for several diseases, including COPD. VA staff were charged with testing and implementing a plan that was feasible, given VA resources, and effective. “There were models that were expensive and resource-intensive that required as many as eight home visits,” explained Kathryn Rice, MD, Minneapolis VAHCS’s medical director of respiratory therapy. “Those methods were probably not feasible in the VA system. We wanted to keep it more streamlined and simple.”

Rice, along with her colleague, Dennis Niewoehner, MD, developed a pilot project across five facilities within the VISN. At each site, they had a trained respiratory therapist who was given a one-day training session on the principles of COPD. Once trained, the therapists led one-time educational group visits for patients with COPD. The patients were instructed on the key principles of the disease: prevention through vaccination for pneumonia and influenza, smoking cessation, checking oxygen levels, exercise, good hand hygiene, and optimizing their maintenance drugs.

Patients were trained how to manage an exacerbation of their own disease with disease management program medications. They were taught how and under what circumstances to self-administer steroids and antibiotics, and they were given prescriptions for those medications.

The entire management plan consisted of a one-hour training session about optimizing their care and a monthly phone call. Patients were asked to call VA if they had a need to use their action plan medications, or if any other problems arose, but did not have to call to get those medications, or to get permission to use them.

“Dr Petzel and the other VISN leadership supported us in what was an amazingly helpful approach and allowed us to do a randomized clinical trial—very vigorous research—on this method,” Rice said.

Over the course of a year, Rice and her colleagues followed 743 patients with severe, chronic COPD. For those who had the disease management program added on top of their usual care, there was a 30% reduction in hospitalization for COPD and half the number of emergency room visits.

“It cut admissions to the hospital for heart disease by about half as well,” Rice said. “When you have pulmonary exacerbation, it makes underlying heart disease worse, and vice versa we think.”

There was also a trend for lower mortality in the disease management group and, perhaps most importantly, the patients in the intervention group reported feeling better as they went about their day-to-day lives.

Rolling Out the Program

The Minneapolis pilot project was deemed a success, and the COPD management program was rolled out to all of VISN 23. “When the VISN translated the disease management programs out of research and into actual practice, it also created a disease registry. Each site could link in and find their patients,” Rice said. “As you’re charting a patient in the electronic medical record, you can just click on boxes that [indicate] ‘yes, I did this aspect of care and that aspect.’ It allows sites to immediately show who’s done what with whom.”

There were some obstacles—some of which still exist—in rolling out the program VISN-wide. “Not all sites in VISN 23 have ready access to spirometry, which is needed to confirm a diagnosis of COPD,” Rice said. “But we’re about to get all that in place so everyone will be able to use it. The numbers from the spirometry tests will be [transmitted] right to our central site for our doctors to read.”

“Now our big challenge is integrating this model with the medical home model,” Rice said. “We’ll be bringing teams together from across the VISN, and working with patient aligned care teams on how to integrate what we do with what they do.”

As for expanding the program VA-wide, Rice and her colleagues presented their research at the annual VA Health Services Research and Development meeting last year and are currently developing manuals to help other VISNS incorporate this method.

Current Research and the Gaps

Currently, Rice is involved in several follow-up research projects on COPD management. She and her team are looking at the feasibility of incorporating telehealth technology into the process—giving a patient a telehealth device that they would log into every day, answer questions about their health, and flag VA physicians if they were concerned. “We would like to see if it enhances the simple disease model that we know already works,” Rice said.

Another study, which was recently completed, looked outside of the high-risk COPD group, which the disease management program was designed for, and at those COPD patients at low or medium risk for complications. “We want to see if we can do something preventative for them to try and head off future hospitalizations that would put them into that high-risk group,” Rice said. “We just completed a randomized trial of 4,000 patients at three different sites using an education intervention with some efficacy components. We’re analyzing data now to see if there was an impact.”

There are still a number of research gaps in the field of COPD—basic science needs which heavily impact disease treatment. “We need to identify new agents that act on different pathophysiologic sites. We need to develop new drugs,” Rice said. “We also don’t know a lot about long-term oxygen treatment. We don’t know how much benefit a patient gets from having ambulatory oxygen. It’s a burden to patients, and it hasn’t really been fully studied.”

There is also the link between CV disease and pulmonary diseases. There is the possibility that anti-inflammatory drugs—ones currently on the market, or ones that have yet to be developed—could help with both diseases. “We need to look at interventions that might target those simultaneously,” Rice said. ‘That is something that’s a very open area.”

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