Disease management for COPD: Avoiding hospitalizations and controlling cost?

Keywords: :

• COPD
• disease management
• self-management
• hospitalizations
• economic

COPD is recognized worldwide as a major public health problem. The disease is known for its progressive course with “flare ups” called COPD exacerbations, which necessitate a change in regular medication (1) with more severe exacerbations requiring hospital admission (2). The increased prevalence of COPD, which is expected to continue over the next several decades, will lead to further stress on healthcare systems worldwide (3,4). There is an urgent need to introduce substantial changes in delivery of care for patients with chronic diseases such as COPD.

Disease management (DM) has been proposed to enhance management of patients with chronic medical problems. DM programs are coordinated health care interventions for chronic medical conditions such as COPD, in which patient self-management plays a major role. The goals are to teach the skills needed to carry out medical regimens specific to a long term disease and to guide behavior change to help patients control their own condition and improve their well being (4,5). To enable a shift towards increased self-management, patients have to be provided with the necessary tools (e.g. action plans, access to a case manager) and gain confidence, “self-efficacy”, to apply the acquired skills on a daily basis.

In addition to improving health outcomes, a major objective of DM is to improve health care quality and control costs, for example by avoiding hospitalizations. A systematic review (6) has confirmed that self-management education, as part of multiple components of the chronic care model (delivery system, decision support, and clinical information system), is an effective strategy to reduce health care use in COPD, while interventions that apply self-management alone are unlikely to show benefits on outcomes such as emergency department visits and hospital admissions. Trials that have included self-management embedded in an integrated health care system, coordinated by a case manager who provided a continuum of care, have shown benefits on patient outcomes and reduced health service use such as emergency department visits and hospital admissions (7–10).

One of the many challenges that remain is determination of the economic benefits of DM programs. In this issue of COPD, Dewan et al. (11) assessed the cost of implementing a DM program and its impact on healthcare resource utilization costs compared to usual care in COPD patients. This study, a pragmatic trial, used the “gold standard” RCT design to evaluate its DM program (10). This method is the most scientifically rigorous as it uses randomization and a comparison group. This is a very important study, providing an economic analysis and the relative cost of a COPD DM program to help position this intervention in a system of care where we are competing for allocation of health resources. Previous RCT, often resource intensive studies with small samples, have shown economic benefits of DM programs in COPD patients. Tougaard et al. (12) showed a saving, Gallefoss and Bakke (13) showed a cost benefit from a reduction in use of care, and Bourbeau et al. (14) showed potential for cost saving not having a direct measure of the real cost but an extrapolation based on plausible costs. The study by Dewan et al. adds to the body of evidence in support of COPD DM programs being potentially cost saving. Furthermore, their results are more generalizable since the trial corresponds to a real life situation. Investment in DM programs, used as an integral component of care for patients with severe disease, is clinically and economically justified.

These new data should answer questions from government agencies, employers and others about the evidence of DM in COPD. The evidence of program effectiveness and the potential for cost saving justify the adoption of COPD DM programs. We will always need to optimize the delivery of existing interventions, explore the challenges of generalizing new research findings and contextualize in the real world. It is time to act on what we know!