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A2161 - Management of COPD Via a Clinical Guidance System: 16th Year of a Continuous Improvement Model
Author Block: B. L. Tiep1, M. Barnett1, R. R. Carter2, R. Murray1; 1Pulmonary, Respiratory Disease Management Inst, Monrovia, CA, United States, 2Lamar University, Beaumont, TX, United States.
Rationale: COPD is a partly reversible and treatable illness that is often progressive with recurring acute exacerbations commonly requiring hospitalizations. COPD Exacerbations are time sensitive and destructive suggesting a benefit to rapid detection quick response. We previously presented a lifetime continuous improvement model based on tools of pulmonary rehabilitation termed a “Clinical Guidance System”, that is now in its 16th year. It incorporates collaborative self-management - administered in a Doctor Therapeutic Office Visit (DTOV) setting. This is an update of this ongoing care model. Methods: Patients are trained in self-management skills perfected via practice and reinforcement during their ongoing monthly DTOV. Skills include: inhaler techniques, exercise, oxygen, pursed lips breathing, airway clearance, exacerbation prevention, early exacerbation recognition and rapid response via a telephonically guided rapid action plan (RAP). Outcome measures that include exacerbation hospitalizations are tracked and recorded. Results: 195 patients (initial Age = 70 +/- 8 yrs. FEV1 = .79 +/- .2 L; FVC = 2.4 +/- .7 L) were referred over the past 15 years. 131 patients participated. There was a total of 3609 DTOV visits. 83 patients experienced 1408 exacerbations resulting in 56 hospitalizations (4.0%) with 51 of these 83 patients having an exacerbation hospitalization prior to our program. There were 17 respiratory related ER visits. 72 deaths were recorded: 35 died at home, 15 in the hospital, 10 in SNF and 18 are unknown. 6 patients required end-of-life mechanical ventilation. Most adhered to the RAP - although some had implementation delays. 2 patients were dropped from the study due to compliance issues. We compare our 4.0% exacerbation hospitalization rate with two referent COPD Cohorts studied for different purposes. The exacerbation hospitalization rate for both of these studies was 27% thus, representing a 575% reduction from the published data. Conclusions: A feasible strategy for management of COPD may consist of simple, inexpensive, ongoing, low tech methodology in the DTOV setting. Hospitalizations for exacerbations are reduced and may be avoidable all together. Self-management skills and habits may improve rather than deteriorate over time through practice and reinforcement promoting better disease control with improved morbidity and prognosis. Additional prospective studies are necessary to confirm these findings in various settings and patient populations. Clinical Implications: Thoughtful outpatient management of COPD may be improved via a clinical guidance system that includes a telephonically guided RAP.