D: Develop a plan of care

IN THE EARLY STAGES OF DISEASE, patients with COPD will often ignore mild symptoms, and this contributes to delay in diagnosis. As the disease progresses, impairment and disability increase. As a health state, severe COPD has the third-highest perceived “severity” rating, on a par with paraplegia and first-stage AIDS (Mathers 1999). Depression, anxiety, panic disorder, and social isolation add to the burden of disease as complications and comorbidities accu­mulate. Patients with severe COPD often have neuropsychological deficits suggestive of cerebral dysfunction. The deficits are with verbal (Incalzi 1997) and visual short-term memory (Crews 2001), simple motor skills (Roehrs 1995), visuomotor speed and abstract thought processing (Grant 1982). Severe COPD is also associated with lower cognitive performance over time (Hung 2009) [evidence level III-2]. One of the most effective means of improving the patient’s functional and psychological state is pulmonary rehabilitation.

People with chronic conditions are often cared for by partners or family members. There is evidence that family carers of people with COPD experience significant psychological and physical burdens (Strang 2018).

Health systems around the world are reorienting health care delivery in ways that continue to provide services for people with acute and episodic care needs while at the same time meeting the proactive and anticipatory care needs of people with chronic diseases and multiple morbidities. Wagner and colleagues have articulated domains for system reform in their Chronic Care Model (Wagner 1996). These include Delivery System Design (e.g. multi-professional teams, clear division of labour, acute versus planned care); Self Management Support (e.g. systematic support for patients / families to acquire skills and confidence to manage their condition); Decision Support (e.g. evidence-based guidelines, continuing professional development programs) and Clinical Information Systems (e.g. recall reminder systems and registries for planning care) (Adams 2007). Many of these domains are addressed in the following sections.

A retrospective cohort study of 2,451 health administrative records demonstrated the significant and positive impact that integrated disease management program for COPD can have on reducing health system utilisation (Licskai 2024) [evidence level III-2]. The integrated disease management program evaluated in this study (“Best Care COPD”) is an electronic point of service system that was integrated in primary care across the province of Ontario, Canada. This technology solution prompted guideline-based care, including spirometry, immunisations, medication review, and referrals.

Interrupted time series analysis compared monthly COPD-related hospitalisations and emergency department event rates in the 3 years after (intervention) and the 3 years preceding (control) program implementation. Early improvements were sustained throughout the 36-month observation period for both COPD-related hospital admissions (12-month rate reduction: -9.1, 95% CI −12.72 to −5.44; 36-month rate reduction: -18.1, 95% CI, -24.39 to -1.78) and emergency department visits (12-month rate reduction: -19.0, 95% CI -25.50 to -12.46; 36-month rate reduction: -44.6, 95% CI -55.86 to -33.29). All-cause health system utilisation also demonstrated significant rate reductions at 12, 24 and 36 months.

The immediate and sustained reductions in health system utilisation observed in this study highlight the potential benefits that integrated disease management programs using digital tools may have in improving guidelines-based care (and therefore patient outcomes) when implemented at scale in Australia.