Coordinated Regionwide Care Management Intervention for Patient with Chronic Obstructive Pulmonary Disease at Risk of Acute Exacerbation Reduces Hospital Days


Richard Mularski, MD, MSHS, MCR; Sanja Uskokovic, MS, PMP;
David M Mosen, PhD; Bryan L Skalberg, MS;
Achikam Haim, PhD; Marianne C Turley, PhD;
Nancy L Lee, RPh; Wui-Leong Koh, MD

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Northwest

Background: Chronic obstructive pulmonary disease (COPD) affects 12 million to 29 million individuals resulting in 800,000 yearly hospitalizations in the US. Implementation deficits for COPD care results in excess acute exacerbations (AEs), lowered quality of life, reduced functional status, and compromised survival. We developed and tested a targeted intervention across the Northwest Region to identify patients at high risk, provide guideline-recommended proactive care, and evaluate process and outcome metrics for this population.
Methods: We identified an at-risk COPD population in 2 phases for implementation defined by (phase 1) age older than 65 years by International Classification of Diseases-10 visits and 2 or more AEs in the prior year with systemic steroid dispensing or (phase 2) age older than 40 years with any COPD AE hospitalizations in the previous year. Multiple coordinated care management teams completed an action plan (standardized symptoms linked to actions such as start medications) with patients, facilitated influenza/pneumococcus vaccines, and provided rescue medications. Process measures assessed care delivery components; outcome metrics (included AEs, utilization, and death) were compared with historical controls and completers (received all planned interventions/medications) were compared with noncompleters.
Results: We identified 149 patients in phase 1 and 264 in phase 2; respective historical cohorts had 118 and 149 patients. Action plans were delivered in 55% of outreached patients; vaccine rates improved from < 50% to 65% (p < 0.01); and rescue medication orders improved from < 1% to 20% (p < 0.0001). Nonsignificant trends were seen in hospital admissions (26% postimplementation vs 31% preimplementation) and 30-day readmission (18% vs 35%). Hospital days were reduced in completers (0.94 ± 2.51 days) vs those who did not receive all components (1.90 ± 5.58 days, p < 0.05). Similar trends were seen in other measures of utilization. Additionally, in the completer group, mortality trended down from 6.0% to 1.3% (not significant), as did overall AEs from 25.0% to 20.5% (not significant) compared with noncompleters.
Discussion: Our analysis showed that a proactive program coordinating care management for at-risk COPD patients had a favorable impact on care delivery and utilization. We completed a second year of the intervention (evaluation pending summer 2019) and are preparing for regionwide spread of these improvements in care delivery with all primary care providers to further attempt to reduce AEs and hospitalizations for patients with COPD. Using a population-based strategy supported by our Region’s learning health system work, we identify individuals for preventative services. Multiple coordinated care management teams are trained; using electronic medical record-based strategies clinicians contact patients, compete an action plan, facilitate vaccine completion, and provide rescue medications to be used at early signs of AE.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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