Quantifying sustained health system benefits of primary care-based integrated disease management for COPD: a 6-year interrupted time series study.

BACKGROUND: Severe exacerbation of chronic obstructive pulmonary disease (COPD) is a trajectory-changing life event for patients and a major contributor to health system costs. This study evaluates the real-world impact of a primary care, integrated disease management (IDM) programme on acute health service utilisation (HSU) in the Canadian health system. METHODS: Interrupted time series analysis using retrospective health administrative data, comparing monthly HSU event rates 3 years prior to and 3 years following the implementation of COPD IDM. Primary outcomes were COPD-related hospitalisation and emergency department (ED) visits. Secondary outcomes included hospital bed days and all-cause HSU. RESULTS: There were 2451 participants. COPD-related and all-cause HSU rates increased in the 3 years prior to IDM implementation. With implementation, there was an immediate decrease (month 1) in COPD-related hospitalisation and ED visit rates of -4.6 (95% CI: -7.76 to -1.39) and -6.2 (95% CI: -11.88, -0.48) per 1000 participants per month, respectively, compared with the counterfactual control group. After 12 months, COPD-related hospitalisation rates decreased: -9.1 events per 1000 participants per month (95% CI: -12.72, -5.44) and ED visits -19.0 (95% CI: -25.50, -12.46). This difference nearly doubled by 36 months. All-cause HSU also demonstrated rate reductions at 12 months, hospitalisation was -10.2 events per 1000 participants per month (95% CI: -15.79, -4.44) and ED visits were -30.4 (95% CI: -41.95, -18.78). CONCLUSIONS: Implementation of COPD IDM in a primary care setting was associated with a changed trajectory of COPD-related and all-cause HSU from an increasing year-on-year trend to sustained long-term reductions. This highlights a substantial real-world opportunity that may improve health system performance and patient outcomes.

Primary care-based integrated disease management for heart failure: a study protocol for a cluster randomised controlled trial.

INTRODUCTION: Heart failure (HF) is a common chronic disease that increases in prevalence with age. It is associated with high hospitalisation rates, poor quality of life and high mortality. Management is complex with most interactions occurring in primary care. Disease management programmes implemented during or after an HF hospitalisation have been shown to reduce hospitalisation and mortality rates. Evidence for integrated disease management (IDM) serving the primary care HF population has been investigated but is less conclusive. The aim of this study is to evaluate the efficacy of IDM, focused on, optimising medication, self-management and structured follow-up, in a high-risk primary care HF population. METHODS AND ANALYSIS: 100 family physician clusters will be recruited in this Canadian primary care multicentre cluster randomised controlled trial. Physicians will be randomised to IDM or to care as usual. The IDM programme under evaluation will include case management, medication management, education, and skills training delivered collaboratively by the family physician and a trained HF educator. The primary outcome will measure the combined rate (events/patient-years) of all-cause hospitalisations, emergency department visits and mortality over a 12-month follow-up. Secondary outcomes include other health service utilisation, quality of life, knowledge assessments and acute HF episodes. Two to three HF patients will be recruited per physician cluster to give a total sample size of 280. The study has 90% power to detect a 35% reduction in the primary outcome. The difference in primary outcome between IDM and usual care will be modelled using a negative binomial regression model adjusted for baseline, clustering and for individuals experiencing multiple events. ETHICS AND DISSEMINATION: The study has obtained approval from the Research Ethics Board at the University of Western Ontario, London, Canada (ID 114089). Findings will be disseminated through local reports, presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04066907.

Confronting complexity and supporting transformation through health systems mapping: a case study.

INTRODUCTION: Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat. STUDY DESCRIPTION: This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map. RESULTS: The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care. CONCLUSION: The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration.

Integrated Disease Management for Chronic Obstructive Pulmonary Disease in Primary Care, from the Controlled Trial to Clinical Program: A Cohort Study.

PURPOSE: Integrated disease management (IDM) for COPD in primary care has been primarily investigated under clinical trial conditions. We previously published a randomized controlled trial (RCT) where the IDM intervention improved quality of life (QoL) and exacerbation-related outcomes. In this study, we assess the same IDM intervention in a real-world evaluation and identify patient characteristics associated with improved outcomes. METHODS: This historical cohort study included patients enrolled for 12 (±3 months) in the Best Care COPD IDM program. The main outcome was a ≥3 point improvement in COPD assessment test (CAT). Secondary outcomes were COPD exacerbations requiring antibiotics and/or prednisone, unscheduled physician visits, emergency department visits and hospitalizations. RESULTS: Data for 571 patients (all patients) were included, 158 met the reference RCT eligibility (RCT matched). Improved QoL was observed in 43% (95% CI:38.9,47.2) of all patients, 47% (95% CI:39.5,55.6) of RCT matched vs 92% (95% CI:79.2,95.1) in the reference RCT intervention arm (n=72). Reductions (12 months IDM vs prior year) were observed in the proportion of patients experiencing exacerbation-related events (all patients): antibiotics/prednisone (-9.0%,95% CI:-13.9,-3.9); unscheduled physician (-33.1%,95% CI:-38.2,-27.9); emergency department (-9.6%,95% CI:-13.5,-5); and hospitalizations (-6.8%,95% CI:-10.0,-3.7). For the RCT matched group all reductions were comparable to the reference RCT intervention arm. The strongest predictors of improved QoL were baseline CAT, CAT≥20 vs CAT<10 (OR 15.6,95% CI:7.91,30.83), GOLD group B (OR 6.4,95% CI:3.42,11.85) and D (OR 5.64,95% CI:2.80,11.37) vs GOLD group A. Patients with prior antibiotic/prednisone use, FEV1 <30% predicted and GOLD group D were less likely to have no urgent health service utilization (OR 0.5,95% CI:0.30,0.68), (OR 0.2,95% CI:0.07,0.78) and (OR 0.3,95% CI:0.14,0.51), respectively. CONCLUSION: Best Care COPD improved QoL and reduced exacerbation-related outcomes in a manner directionally similar to the RCT from which it emanated. Baseline QoL, exacerbation history, and GOLD category were identified as possible predictors of IDM impact and will inform future program development and resource allocation.

Effects of decomposition on carbon and nitrogen stable isotope values of muscle tissue of varying lipid content from three aquatic vertebrate species.

RATIONALE: Stable isotopes are a prominent tool in animal ecology where data is obtained from analyzing animal tissues, which are typically stored prior to analysis. However, the effect of decomposition on the reliability of stable isotope ratios from animal tissue prior to storage has been seldom studied. Here, we examine the long-term effects of freezing and decomposition of animal tissue on δ13 C and δ15 N values across three different aquatic species of varying lipid content. METHODS: Ringed seal, lake trout and Greenland shark muscle were divided into different treatment groups and analyzed for their δ13 C values, carbon content (%C), δ15 N values, and nitrogen content (%N) at specific time intervals. The intervals included days 0, 128 and 700 for the frozen storage treatment and at days 0, 1, 2, 4, 8, 16, 32, 64, 128 and 256 for the tissue decomposition treatment in open and closed vials at room temperature. RESULTS: The difference in δ13 C and δ15 N values between the control and days 128 and 700 for the frozen treatment was minimal and not significant for any species. Generally, significant decreases in carbon (%C) and nitrogen (%N) content and significant increases (>0.5‰) in δ13 C and δ15 N values occurred for muscle of each species left to decompose for 256 days, probably due to the preferential uptake of lighter isotopes during decomposition by microbes. However, the magnitude of change in the δ13 C and δ15 N values up to 8 days in both treatments was low (generally ≤0.1‰) and not significant across most species. CONCLUSIONS: Freezing for extended time periods (up to 700 days) is a viable storage technique for stable isotope analysis of aquatic animal muscle tissue across a range of lipid contents. Muscle tissue left to decompose at room temperature showed no significant change in δ13 C and δ15 N values after 8 days, and such tissues would still be reliable for ecological interpretations. However, caution should be used for decomposed tissue for >8 days as the δ13 C and δ15 N values will probably be artificially high. Copyright © 2016 John Wiley & Sons, Ltd.