Integrated disease management of COPD in long-term care. A Bruyère Rapid Review
This rapid review examined the evidence of the effectiveness of integrated disease management of COPD in people with chronic obstructive pulmonary disease (COPD) in long-term care. We found one systematic review and five guidelines of moderate to high quality that met our inclusion criteria.
COPD is a chronic, progressive disease associated with airflow limitation due to an enhanced chronic inflammatory response to noxious particles or gases in the airways and lungs. It can be accompanied by periods of acute exacerbations usually triggered by infection or air pollution that may require hospitalization.
Cigarette smoke is the most common risk factor for COPD. Other risk factors are occupational irritants (dust and chemicals), and air pollution. A diagnosis of COPD is based on a combination of symptom screening, dyspnea severity, and post-bronchodilator spirometry. There are four levels of classification of COPD, based on the symptoms and disability (mild, moderate, and severe), and four levels of classification of airflow obstruction based on spirometry results (mild, moderate, severe, and very severe). Exacerbations and comorbidities contribute to the overall severity in individual patients.
Smoking cessation is a key step in the prevention and control of COPD. The management of COPD includes both: pharmacological interventions (inhaled therapy, oral therapy, and combined oral and inhaled therapy); and non-pharmacological interventions such as pulmonary rehabilitation, patient education/self-management programs, nutrition, and vaccination. Adjunct therapies include supplemental oxygen, treatment of comorbidities according to usual treatment guidelines, palliative care, and surgery, as appropriate.
Prevention or early diagnosis and treatment of an acute exacerbation are imperative, as hospitalization for acute exacerbations greatly contributes to the high economic burden of COPD. Preventive measures include smoking cessation, pneumococcal and influenza vaccinations, education and case management, as well as pharmacotherapy.
There is limited evidence to support specific COPD interventions in the long-term care population. Most guideline recommendations for this context and population are based on expert opinion.
The full report is available for download.
Table of Contents
- Cigarette smoke is the most common risk factor for COPD. Other risk factors are occupational irritants (dust and chemicals), and air pollution.
- Common comorbidities include cardiovascular diseases, osteoporosis, anxiety and depression, lung cancer, infections, and metabolic syndrome and diabetes.
- Most individuals with COPD are not diagnosed until the disease is well advanced. This can be improved through targeted testing of symptomatic individuals and those with risk factors for the development of COPD.
- Diagnosis of COPD is based on a combination of symptom screening, dyspnea severity, and spirometry. Post-bronchodilator spirometry is required to make a confident diagnosis of COPD, based on the severity of the airflow limitation detected.
- The management approach is based on an individualized care plan – matching the patient’s therapy more closely to his or her needs. Smoking cessation is a key step in the prevention and control of COPD.
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in Canada(1, 2) and among chronic diseases it is the only cause of death that is increasing (2). Almost 80% of deaths from COPD are due to smoking(3). Inpatient hospitalization is the most significant contributor to the economic burden of the disease(4-6) and hospitalization costs increase with severity of the disease(7). The economic burden associated with moderate and severe COPD exacerbations in Canada was estimated at $646 million to $736 million annually(6, 8).
COPD is usually underdiagnosed because of a lack of symptom recognition in patients(2, 6, 7, 9) and the lack of the use of an objective diagnostic test, such as spirometry(4, 7). With the growing clinical, economic and social burden of COPD due to aging and the long-term effects/continued exposure to risk factors, early diagnosis and the development of optimal COPD management programs in the long-term care setting and the community are necessary.
Saint-Vincent Hospital (SVH) is a 336-bed Complex Continuing Care (CCC) hospital in Ottawa, affiliated with Bruyère Continuing Care. It is the sole provider of complex continuing care in the Ottawa region and SVH patients usually transition to the community or long-term care facilities.
The prevalence of respiratory disease including COPD among inpatients at SVH is estimated to be 32%, based on hospital pharmacy data, though the number of patients coded as having COPD in the Resident Assessment Instrument Minimum Data Set (RAI-MDS) are significantly lower. Two analyses of inhaled medication use at SVH, however, have strongly suggested that the number of patients prescribed inhaled medications indicative of COPD far exceeds the number of patients coded as having the disease. An analysis of Ontario provincial health administrative data also found that 35% of residents in long-term care facilities have COPD(10). There is a need for transitional care of COPD patients as they move to long-term care facilities. Also, early diagnosis and optimal management of COPD in long-term care will reduce hospitalizations and resource use as well as the economic burden of the disease(5).
The optimal management of COPD is complex and involves multiple components. An integrated disease management approach that aims to reduce symptoms and avoid the fragmentation of care while containing costs has been suggested for the management of COPD(5, 11). This approach includes both pharmacologic and non-pharmacologic interventions, provided in a coordinated manner, generally by an inter-professional care team. The choice of therapy is guided by the assessment of the disease severity, its impact on the patient’s health status and the risk of future events such as exacerbations(7).
Existing guidelines for the management of COPD are designed for any clinical setting(6, 7) but it is unclear if these recommendations could be easily adapted to the long-term care setting with multi-morbid elderly patients. Current guidelines for the assessment of COPD include assessing the patient’s symptoms, severity of their spirometric abnormality, exacerbation risk and presence of comorbidities(7).
The aim of this rapid review is to identify evidence about the effectiveness of integrated disease management of COPD in long-term care.
We used the PICO (population, intervention, comparison, and outcome) framework to develop the eligibility criteria.
Population: people with COPD in long term care
Intervention: integrated disease management of COPD involving at least two interventions listed below for a minimum duration of three months; and active involvement of at least two different categories of healthcare providers.
- Education/self-management: i.e. education, self-management, personal goals and/or action plan, exacerbation management
- Exercise: i.e. (home) exercise training and/or strength and/or endurance training
- Psychosocial: cognitive behavioral therapy, stress management, other psychological assessment and/or treatment
- Smoking cessation
- Medication: optimal medication/prescription of medication adherence
- Nutrition: dietary intervention
- Follow-up and/or communication: structural follow-up and/or communication, case management by healthcare providers, ensuring optimal diagnosis
- Multidisciplinary team: active participation and formation of teams of professional caregivers from different disciplines, revision of professional roles, integration of services, local team meetings
- Financial intervention: fees/payment/grants for providing IDM.
Comparison: usual care
Outcomes: health-related quality of life, functional capacity (e.g. walking distance), number of exacerbations, acute-care episodes (hospital admissions) and resource use.
We updated the search of the Cochrane review on integrated disease management interventions for patients with chronic obstructive pulmonary disease(5) from 2008 to May 25 2015 using the Cochrane Airways Group Register of trials, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and CINAHL (See Appendix 1). We identified 1622 articles after deduplication.
We also ran a search in the Trip Database and found 861 records including 54 systematic reviews and 499 guidelines.
Relevance Assessment (Selection of Articles)
We reviewed the search results in duplicate for relevance. We found only one guideline specific to the management of COPD in long-term care(12) and four others that were not specific to any setting – the 2015 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines(7), the 2010 UK National Institute for Health and Care Excellence (NICE) guidelines(4), the 2007 Canadian Thoracic Society (CTS) guidelines(9) for the management of COPD, as well as the 2014 American College of Chest Physicians’ and CTS guidelines for the management of COPD acute exacerbations(6). We found no new studies or systematic reviews on integrated disease management interventions for patients with COPD in long-term care besides the existing Cochrane review(5) which examined COPD patients in the primary, secondary and tertiary care settings but not the long-term care setting.
We assessed the quality of the guidelines and the Cochrane systematic review using AGREE II(13) and AMSTAR(14) respectively. The systematic review was high quality scoring 10/11 on AMSTAR. The quality of the guidelines ranged from 99 to 122/168. See Appendix 2 for details.
We graded the quality of the evidence as platinum, gold, silver or bronze level as described in Appendix 3(15). The quality of the evidence ranged from bronze to gold.
The overarching goals of COPD management are to reduce patients’ symptoms and to reduce future risks(7). IDM interventions are aimed at reducing symptoms and avoiding fragmentation of care, while containing costs(5, 11, 16). At least two interventions for a minimum duration of three months, and active involvement of at least two different categories of healthcare providers must be considered for the optimal management of COPD(5, 16-19).
Evidence from Systematic Reviews
The 2013 Cochrane systematic review on integrated disease management interventions for patients with chronic obstructive pulmonary included 26 trials and 2997 participants(5). The mean age of the study population was 68 years and 68% were male. The patients were treated in primary, secondary, tertiary or a combination of primary and secondary health care settings. However, no included studies considered patients in the long-term care setting. The mean number of healthcare providers involved in the IDM program was three (range two to seven) and the mean number of components per program was four (range two to eight).
The following six categories of IDM components were identified:
- IDM dominant component exercise
- IDM dominant component self-management with an exacerbation action plan
- IDM structured follow-up with nurses/GP
- IDM exercise and self-management action plan
- IDM self-management action plan and structured follow-up
- IDM program of educational sessions, followed by a phase of individually tailored education according to scores on the Lung Information Needs Questionnaire score.
IDM was found to improve health-related quality of life and exercise capacity of the patients and reduced hospital admissions and hospital days per person. The patients were elderly and the assessed interventions have been recommended for use in long term care(12). Resource use was not assessed. Details are in Table 1 (in PDF).
Evidence from Clinical Practice Guidelines
The optimal management of COPD involves four phases: recognition (or diagnosis), assessment, treatment and monitoring. Four of the five included guidelines(4, 7, 9, 12) dealt with all four phases of the management of COPD and risk factors. The other guideline(6) focused on the prevention of acute exacerbations of COPD.
The most common risk factor for COPD is a history of smoking. Other risk factors include occupational exposures to respiratory irritants (dust and chemicals), air pollution, family history of pulmonary disease (COPD), genetic factors (alpha-1 antitrypsin deficiency), age, gender, lung growth and development, childhood respiratory infections, recurrent or chronic respiratory symptoms, nutrition and socioeconomic status.
Diagnosis and Assessment
The clinical diagnosis of COPD is based on the presence of dyspnoea, chronic cough, chronic sputum production and a history of exposure to risk factors in an individual at least 35 to 45 years old(4, 7, 9, 11). The severity of breathlessness during daily activities can be assessed using the modified Medical Research Council (mMRC) Dyspnoea scale and ranges from grade 0 (breathless with strenuous exercise) to grade 4 (too breathless to leave the house) (see Appendix 4 for details). In the Canadian COPD guidelines the severity of COPD can be classified as mild, moderate or severe based on symptoms and disability(9) as shown in Table 2 (in PDF).
Spirometry is required to confirm the diagnosis and assessment of the severity of COPD using the fixed ratio, post-bronchodilator FEV1/FVC < 0.70 to define airflow limitation (see Table 3 in PDF). The classification of the severity of lung function impairment is based on the results of post-bronchodilator spirometry, and is divided into four grades: Mild, Moderate, Severe, and Very Severe)(4, 7, 9, 12).
In addition, the assessment of comorbidities in patients with COPD better reflects the complexity of the disease as they may contribute to its severity(7, 11).
Recommended interventions and practices related to diagnosis and assessment are summarised in Table 4 (in PDF)
Synthesis of Findings
A variety of residents live in long-term care facilities: those with a primary diagnosis of COPD; those with a secondary diagnosis of COPD; those who have unrecognized COPD or who develop symptoms of COPD while in residence; and those with end-stage COPD.
The only included systematic review showed that integrated disease management of COPD involving at least two interventions for a minimum duration of three months and active involvement of at least two different categories of healthcare providers improves the quality of life and exercise capacity of COPD patients, and reduces hospital admissions and hospital days per person.
According to the guidelines, tobacco smoke is the most common risk factor. Others include occupational exposures to respiratory irritants (dust and chemicals), air pollution, family history of pulmonary disease (COPD), genetic factors (alpha-1 antitrypsin deficiency), age, gender, lung growth and development, childhood respiratory infections, recurrent or chronic respiratory symptoms, nutrition and socioeconomic status.
Most COPD patients are not diagnosed until the disease has progressed and symptoms become fairly severe, because they develop COPD symptoms insidiously. Canadian guidelines recommend against mass screening of asymptomatic individuals, but recommend targeted screening for patients with known risk factors. Specifically, patients who are older than 40 years of age and who are current or ex-smokers should undergo spirometry if they report coughing or coughing up phlegm regularly, shortness of breath with simple chores, wheezing when they exert themselves or at night, or frequent colds that persist longer than those of other people they know(9). All residents in long-term care facilities should be assessed for the presence of known or suspected COPD or risk factors for developing COPD upon admission; targeted screening for patients with known COPD or risk factors for the disease should be implemented using screening questionnaires and spirometry, as indicated.
Since COPD is a progressive, heterogeneous disease affecting different patients in different ways, COPD management and treatment should be based on an individualized patient assessment taking into account comorbidities, prognosis, life expectancy, and preferences. A combined COPD assessment involving symptomatic assessment, spirometric classification, the risk of exacerbations, plus assessment of comorbidities, would give a better picture of the complexity of COPD. Common comorbidities are cardiovascular diseases (ischemic heart disease, congestive heart failure, hypertension, atrial fibrillation), and lung cancer which share smoking as a risk factor. Others include osteoporosis, normocytic anemia, diabetes, metabolic syndromes, and depression.
A multidisciplinary team and a combination of interventions are recommended for optimal management. Smoking cessation is the most important single intervention for preventing and treating COPD. Other evidence-based interventions include: pharmacological interventions (inhaled therapy, oral therapy, and combined oral and inhaled therapy); non-pharmacological interventions such as pulmonary rehabilitation, patient education/self-management programs, advanced care planning, nutrition counseling, and influenza and pneumococcal vaccination; as well as adjunct therapy if appropriate such as supplemental oxygen therapy, mechanical ventilation, treatment of comorbidities according to appropriate treatment guidelines, palliative care consultation and intervention, and surgery.
Prevention or early diagnosis and treatment of an acute exacerbation are imperative as hospitalization for acute exacerbations greatly contributes to the high economic burden of COPD. Preventive measures include smoking cessation, pneumococcal and influenza vaccinations, education and case management, as well as pharmacotherapy.
The treatment setting for COPD depends on the severity. Most patients with an exacerbation (80%) could be treated out of the hospital(7). Factors to consider when deciding where to manage a patient are summarized in Appendix 5.
Applicability of the Evidence/Implementation
Spirometry is the most objective measurement of airflow limitation available. It should be used to confirm the diagnosis of COPD in any patient at least 35 years old presenting with dyspnea, chronic cough, chronic sputum production and a history of exposure to risk factors such as smoking. These symptoms are not only characteristic of COPD; they may be present in other cardiovascular and respiratory conditions that are common in elderly patients. Therefore, differential diagnoses and comorbidities should be considered when assessing patients for COPD.
Since COPD affects different people in different ways, all of the guidelines recommend an individualized patient care plan guided by the assessment of severity, the impact on the patient’s health status, the risk of exacerbations, assessment of comorbidities and the patient’s preferences. Although smoking cessation is the most important single intervention for preventing and treating COPD it should not be used alone. The use of other stand-alone interventions such as education, and case management, in isolation, has been shown to be ineffective in preventing COPD exacerbations and are discouraged. Therefore, a combination of at least two interventions should be used to manage COPD depending on the specific patient’s assessment and preferences. There are limited indications for surgery in the long-term care setting because of the life expectancy and comorbidities of most patients in this setting.
Strengths and Limitations of the Evidence Review
The objective of this review was to identify evidence about the effectiveness of integrated management of COPD in long-term care.
The only included systematic review on integrated disease management in COPD patients did not consider the long-term care setting as patients in long-term care or nursing homes were usually excluded from the trials. However, the patients were elderly patients (mean age 68 years) and different combinations of interventions were assessed which were in agreement with those recommended in the guidelines.
Only one guideline was specific for the long-term care setting but we found similar recommendations across all the included guidelines. Many recommendations in the long-term care guideline were based on expert opinion due to limited evidence in the long-term care population.
- All health professionals managing patients with COPD should have access to spirometry and they must be competent in the interpretation of the results. Spirometry is the most accepted means of reliably and objectively diagnosing COPD, in combination with assessments of disease severity and routine symptom screening.
- The effective management of patients with COPD, or risk factors for developing COPD, should include an integrated disease management approach that includes both pharmacologic and non-pharmacologic interventions. This should include education, advanced care planning, access to services such as pulmonary rehabilitation, and access to specialist consultations (such as palliative care specialists and respirologists).
- Prevention and prompt treatment of acute exacerbations is important in slowing disease progression and improving the quality of life of COPD patients. Staff should be trained to recognize and implement treatment promptly as well as determine if patients should be hospitalized or treated in the long-term care facilities.
- Many patients with COPD will require long-term care or admission to a nursing home. More research on COPD management that includes patients in the long-term care setting is necessary.
Please download the PDF of the report for references and appendices.