ABSTRACT
BACKGROUND: The Halifax-based INSPIRED COPD Outreach Program™ is a facility-to-community home-based novel clinical initiative that through improved care transitions, self-management, and engagement in advance care planning has demonstrated a significant (60%-80%) reduction in health care utilization with substantial cost aversion. By assessing the feasibility of expanding INSPIRED into the emergency department (ED) we anticipated extending reach and potential for positive impact of INSPIRED to those with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who avoid hospital admission. METHODS: Patients were eligible for the INSPIRED-ED study if >40 years of age, diagnosed with AECOPD and discharged from the ED, willing to be referred, community dwelling with at least one of: previous use of the ED services, admission to Intermediate Care Unit/Intensive Care Unit, or admission to hospital with AECOPD in the past year. We set feasibility objectives for referral rates, completion of action plans, advance care planning participation, and reduction in ED visit frequency. RESULTS: Referral rates were 0.5/week. Among eligible patients (n=174) 33 (19%) were referred of whom 15 (M=4, F=11) enrolled in INSPIRED-ED. Mean (SD) age was 68 (7) years, post-bronchdilator FEV1 44.2 (15.5) % predicted, and Medical Research Council (MRC) dyspnea score 3.8 (0.41). We met feasibility objectives for action plan and advance care planning completion. Frequency of subsequent ED visits fell by 54%. Mean (SD) Care Transition Measure (CTM-3) improved from 8.6 (2.0) to 11.3 (1.3), P=0.0004, and of 14 patients responding 12 (86%) found the program very helpful. An additional 34 patients were enrolled to our regular program from those referred but ineligible for INSPIRED-ED (n=27) or unwilling to participate (n=7). CONCLUSIONS: INSPIRED-ED outcomes were generally positive, however referral and enrollment rates were lower than anticipated. Despite the potential of early self-management education, the ED may not be the ideal recruitment setting for home-based programs. Our findings underline the importance of conducting preliminary work to ascertain best settings for implementing new self-management education initiatives.
Subject(s)
Community Health Services/organization & administration , Community-Institutional Relations , Delivery of Health Care, Integrated/organization & administration , Emergency Service, Hospital/organization & administration , Health Resources/organization & administration , Pulmonary Disease, Chronic Obstructive/therapy , Aged , Community Health Services/economics , Cost Savings , Cost-Benefit Analysis , Delivery of Health Care, Integrated/economics , Disease Progression , Emergency Service, Hospital/economics , Feasibility Studies , Female , Health Care Costs , Health Knowledge, Attitudes, Practice , Health Resources/economics , Health Resources/statistics & numerical data , Health Services Research , Humans , Male , Middle Aged , Nova Scotia , Patient Acceptance of Health Care , Patient Admission , Patient Education as Topic/organization & administration , Patient Selection , Program Evaluation , Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/economics , Pulmonary Disease, Chronic Obstructive/physiopathology , Self CareABSTRACT
The 'Number Needed to Treat' (NNT) is a useful measure for estimating the number of patients that would need to receive a therapeutic intervention to avoid one of the adverse events that the treatment is designed to prevent. We explored the possibility of an adaption of NNT to estimate the 'Number Needed to $ave' (NN$) as a new, conceptual systems metric to estimate potential cost-savings to the health system from implementation of a treatment, or in this case, a program. We used the outcomes of the INSPIRED COPD Outreach ProgramTM to calculate that 26 patients would need to complete the program to avoid healthcare expenditures of $100,000, based on hospital bed days avoided. The NN$ does not translate into 'cost savings' per se, but redirection of resource expenditures for other purposes. We propose that the NN$ metric, if further developed, could help to inform system-level resource allocation decisions in a manner similar to the way that the NNT metric helps to inform individual-level treatment decisions.
Subject(s)
Delivery of Health Care/economics , HumansABSTRACT
Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.
Subject(s)
Chronic Disease/therapy , Comorbidity , Organizational Innovation , Patient-Centered Care/organization & administration , Canada , Chronic Disease/prevention & control , Delivery of Health Care/organization & administration , Humans , Models, Organizational , Quality Improvement/organization & administrationABSTRACT
BACKGROUND: Dyspnea that is refractory to conventional treatments affects up to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). Although professional societies recommend opioids in this setting, evidence supporting their use over months is limited. We conducted a multicentre mixed-methods study to understand patients' experiences when opioids are added to optimized conventional treatments for advanced COPD. METHODS: A total of 44 patients (median age 74, range 51-89 years) agreed to participate in this 6-month study. After baseline assessments, immediate-release morphine sulfate syrup (initially 0.5 mg twice daily) was slowly titrated upward based on weekly assessments of symptoms. We conducted semistructured interviews and collected contemporaneous measures of health-related quality of life, severity of dyspnea, anxiety, depression, global ratings of opioid "helpfulness" and adverse effects before, at 2 months and at 4-6 months after opioids were started. RESULTS: Of the 44 patients, 32 (73%) completed the trial; 27 (90%) of 30 patients reported the opioid treatment as very (43%) or somewhat (47%) helpful. Three main themes emerged from the patients' overall positive experiences: small gains have big impact; realign hopes with reality; and "try it." Significant improvements were observed in median (interquartile range) scores between baseline and 4-6 months' assessment for health-related quality of life (Chronic Respiratory Questionnaire: 3.5 [2.8-4.0] v. 4.2 [3.6-4.8]; and Chronic Respiratory Questionnaire-Dyspnea domain: 2.8 [2.3-3.6] v. 3.9 [2.8-4.5]) and decreases in severity of dyspnea (numerical rating scale: 7.0 [5.0-8.0] v. 5.0 [4.0-6.0]). Adverse effects were minimal for most patients. INTERPRETATION: Opioids were a helpful and acceptable intervention for refractory dyspnea in patients with advanced COPD. Many of the patients experienced sustained benefits over months, which supports recent recommendations to consider opioids in this setting. TRIAL REGISTRATION: ClinicalTrial.gov, no. NCT00982891.
