Primary care management of chronic obstructive pulmonary disease: an integrated goal-directed approach.

Division of Pulmonary and Critical Care Medicine, The Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA.
Current opinion in pulmonary medicine (Impact Factor: 3.12). 12/2009; 16(2):83-8. DOI: 10.1097/MCP.0b013e3283354981
Source: PubMed

ABSTRACT This review discusses the role of the primary care physician in the care of the patient with chronic obstructive pulmonary disease and considers how an integrated chronic care model can be applied.
Evidence suggests that a multidisciplinary approach can be successfully applied to a chronic obstructive pulmonary disease patient. These interventions can lead to improvement in quality of life and reduced healthcare utilization.
An integrated care program for chronic obstructive pulmonary disease to assist the primary care provider should include the elements of the chronic care model. The support of a community-based outreach nurse, allied health staff, rehabilitation services and a case manager can assure best practices and identify gaps in quality care.

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    ABSTRACT: In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.AFTER AN INITIAL REVIEW OF HEALTH TECHNOLOGY ASSESSMENTS AND SYSTEMATIC REVIEWS OF COPD LITERATURE, AND CONSULTATION WITH EXPERTS, MAS IDENTIFIED THE FOLLOWING TOPICS FOR ANALYSIS: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: Obstructive Pulmonary Disease (COPD) Evidentiary FrameworkInfluenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisSmoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCommunity-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisPulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisLong-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHome Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy ModelEXPERIENCES OF LIVING AND DYING WITH COPD: A Systematic Review and Synthesis of the Qualitative Empirical LiteratureFOR MORE INFORMATION ON THE QUALITATIVE REVIEW, PLEASE CONTACT MITA GIACOMINI AT: MORE INFORMATION ON THE ECONOMIC ANALYSIS, PLEASE VISIT THE PATH WEBSITE: Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: OBJECTIVE: The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED). CLINICAL NEED: CONDITION AND TARGET POPULATION ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations. Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year. Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter. TECHNOLOGY: Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients' treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling. There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home. In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only. Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home. The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population. ONTARIO CONTEXT: No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals. RESEARCH QUESTION: What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD? RESEARCH METHODS: LITERATURE SEARCH: SEARCH STRATEGY: A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search. INCLUSION CRITERIA: English language full-text reports;health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs);studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately;studies performed in patients with acute exacerbations of COPD who present to the ED;studies published between January 1, 1990, and August 5, 2010;studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD;studies that include at least 1 of the outcomes of interest (listed below).Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment. (ABSTRACT TRUNCATED)
    Ontario Health Technology Assessment Series 01/2012; 12(10):1-65.