Cost-Effectiveness of Integrated COPD Management in Primary Care
Cost-Effectiveness of Integrated COPD Management in Primary Care
Chronic obstructive pulmonary disease (COPD) is a smoking-related pulmonary disorder, characterized by largely irreversible airflow obstruction, multisystemic manifestations and frequent co-morbidities. According to current guidelines, stable COPD is managed with a combination of different treatment components (e.g. smoking cessation, physiotherapeutic reactivation, self-management, optimization of medication adherence), involving different healthcare providers. Currently, treatment is mostly guided by the severity of airflow limitation. However, COPD is a complex disease, with great variation in symptoms, functional limitations and co-morbidities as well as in progression towards more severe stages. Therefore, the existence of several clinically relevant phenotypes calls for a more personalized approach. Ideally, optimal care of COPD patients requires an individualized, patient-centered approach that recognizes and treats all aspects of the disease, addresses the systemic effects and co-morbidities, and integrates medical care among healthcare professionals and across healthcare sectors. Since professional treatment, hospital admissions and loss of work contribute to the economic burden of disease worldwide, there is much interest in systematically improving the quality of care, while reducing total costs for patients with COPD and other chronic illness. Integrated Disease Management (IDM) programs have proliferated as a means of improving the quality and efficiency of care.
The most frequently applied IDM programs in COPD patients are pulmonary rehabilitation (PR) programs. According to a Cochrane systematic review, the effectiveness of PR on exercise tolerance and quality of life is well established. In international reports and guidelines, it is acknowledged that PR is indicated for all individuals with COPD who have decreased exercise tolerance, exertional dyspnea or fatigue, and/or impairment of activities of daily living. However, widespread access is restricted, due to limited availability of resources and high costs. Furthermore, PR programs usually include only the more severe patients and last only for a limited period of time, while initial benefits seem to decline over time. After returning home, patients are frequently insufficiently motivated to continue a more physically active and healthy lifestyle. Unfortunately, general practitioners (GPs) are rarely involved in PR programs and, as a consequence, are often unable to support program methods after a rehabilitation phase has formally been concluded.
We previously argued that when components of PR are integrated into a primary care IDM program, patients can be treated in their home environment. Primary care providers can then be (more) involved as direct coaches of this process. To establish such a program of combined interventions, the set-up of a multidisciplinary team is vital, in which different healthcare professionals participate and provide their share in the spectrum of the required care (Figure 1). Ideally, patients and healthcare providers are close partners in IDM, in order to better control daily symptoms and promote self-management. Furthermore, strong cooperation between several disciplines in primary care and mutually agreeable collaboration with secondary and tertiary care are prerequisites for integrated chronic care.
(Enlarge Image)
Figure 1.
Components of an Integrated Disease Management program for COPD patients in primary care.
Systematic reviews of disease management for COPD patients emphasise the need for well-designed, practical multicenter trials, including broad representative patient samples, with a wide range of physicians and settings to improve external validity. Furthermore, authors of systematic reviews advocate studies designed to evaluate the long-term effectiveness of IDM, and advise more health economic studies across different care settings. When considering the large number of eligible patients for IDM in the community, the potential impact is high. However, no trials have been published that are specifically targeted to measure the cost-effectiveness of IDM in patients recruited in primary care.
Therefore, the aim of the current RECODE (acronym for Randomized Clinical Trial on Effectiveness of integrated COPD management in primary care) cluster randomized clinical trial (NTR 2268) is to assess the cost-effectiveness of an IDM program for COPD patients in primary care in the Netherlands. Based on an earlier controlled clinical trial evaluating the effect of an IDM program in mild to moderate COPD, we found the greatest improvements on quality of life in patients with an MRC dyspnea score >2. As a result, we based our sample size estimates on the a priori planned subgroup of patients with MRC dyspnea score >2. This article describes the design, rationale and baseline results of this trial.
Background
Chronic obstructive pulmonary disease (COPD) is a smoking-related pulmonary disorder, characterized by largely irreversible airflow obstruction, multisystemic manifestations and frequent co-morbidities. According to current guidelines, stable COPD is managed with a combination of different treatment components (e.g. smoking cessation, physiotherapeutic reactivation, self-management, optimization of medication adherence), involving different healthcare providers. Currently, treatment is mostly guided by the severity of airflow limitation. However, COPD is a complex disease, with great variation in symptoms, functional limitations and co-morbidities as well as in progression towards more severe stages. Therefore, the existence of several clinically relevant phenotypes calls for a more personalized approach. Ideally, optimal care of COPD patients requires an individualized, patient-centered approach that recognizes and treats all aspects of the disease, addresses the systemic effects and co-morbidities, and integrates medical care among healthcare professionals and across healthcare sectors. Since professional treatment, hospital admissions and loss of work contribute to the economic burden of disease worldwide, there is much interest in systematically improving the quality of care, while reducing total costs for patients with COPD and other chronic illness. Integrated Disease Management (IDM) programs have proliferated as a means of improving the quality and efficiency of care.
The most frequently applied IDM programs in COPD patients are pulmonary rehabilitation (PR) programs. According to a Cochrane systematic review, the effectiveness of PR on exercise tolerance and quality of life is well established. In international reports and guidelines, it is acknowledged that PR is indicated for all individuals with COPD who have decreased exercise tolerance, exertional dyspnea or fatigue, and/or impairment of activities of daily living. However, widespread access is restricted, due to limited availability of resources and high costs. Furthermore, PR programs usually include only the more severe patients and last only for a limited period of time, while initial benefits seem to decline over time. After returning home, patients are frequently insufficiently motivated to continue a more physically active and healthy lifestyle. Unfortunately, general practitioners (GPs) are rarely involved in PR programs and, as a consequence, are often unable to support program methods after a rehabilitation phase has formally been concluded.
We previously argued that when components of PR are integrated into a primary care IDM program, patients can be treated in their home environment. Primary care providers can then be (more) involved as direct coaches of this process. To establish such a program of combined interventions, the set-up of a multidisciplinary team is vital, in which different healthcare professionals participate and provide their share in the spectrum of the required care (Figure 1). Ideally, patients and healthcare providers are close partners in IDM, in order to better control daily symptoms and promote self-management. Furthermore, strong cooperation between several disciplines in primary care and mutually agreeable collaboration with secondary and tertiary care are prerequisites for integrated chronic care.
(Enlarge Image)
Figure 1.
Components of an Integrated Disease Management program for COPD patients in primary care.
Systematic reviews of disease management for COPD patients emphasise the need for well-designed, practical multicenter trials, including broad representative patient samples, with a wide range of physicians and settings to improve external validity. Furthermore, authors of systematic reviews advocate studies designed to evaluate the long-term effectiveness of IDM, and advise more health economic studies across different care settings. When considering the large number of eligible patients for IDM in the community, the potential impact is high. However, no trials have been published that are specifically targeted to measure the cost-effectiveness of IDM in patients recruited in primary care.
Therefore, the aim of the current RECODE (acronym for Randomized Clinical Trial on Effectiveness of integrated COPD management in primary care) cluster randomized clinical trial (NTR 2268) is to assess the cost-effectiveness of an IDM program for COPD patients in primary care in the Netherlands. Based on an earlier controlled clinical trial evaluating the effect of an IDM program in mild to moderate COPD, we found the greatest improvements on quality of life in patients with an MRC dyspnea score >2. As a result, we based our sample size estimates on the a priori planned subgroup of patients with MRC dyspnea score >2. This article describes the design, rationale and baseline results of this trial.