Innovating the Treatment of Chronic Obstructive Pulmonary Disease Exacerbations: A Phone Telesystem to Increase Action Plan Adherence - European Medical Journal
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Innovating the Treatment of Chronic Obstructive Pulmonary Disease Exacerbations: A Phone Telesystem to Increase Action Plan Adherence

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3 Mins
Authors:
Raquel Farias,1 Maria Fernanda Sedeno,1 Pei Zhi Li,1 Alexandre Joubert,2 Isabelle Drouin,2 Rita Abi-maroun,2 Isabelle Ouellet,2 Mira Abou-Rjeili,1 Meena Patel,1 Danielle Beaucage,1 *Jean Bourbeau1,2
Disclosure:

Funding for this project was provided by GlaxoSmithKline as an investigator-initiated research. (ClinicalTrials.gov identifier: NCT02275078). The information in this abstract was presented at the 2017 American Thoracic Society International Conference, Washington DC, USA; the 12es Journées Francophones Alvéole, 2018, Nantes, France; the Canadian Respiratory Conference 2018, Vancouver, Canada; and the European Respiratory Society International Congress 2018, Paris, France.  Acknowledgements: The chronic obstructive pulmonary disease interactive phone telesystem was developed and provided by TelASK Technologies (Ottawa, Canada). We would like to thank all the patients participating in the study.

Citation
EMJ Respir. ;6[1]:82-84. Abstract Review No. AR8.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

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RATIONALE

Chronic obstructive pulmonary disease (COPD) exacerbations are major contributors to the burden of the disease, reducing patients’ quality of life, leading to hospitalisations and increasing mortality.1-3 Prompt treatment accelerates recovery and prevents hospitalisation.4 To achieve prompt treatment, patients need to identify when their symptoms are worsening and seek medical attention. These skills are known as self-management strategies.5,6 When supported by a Written Action Plan and communication with a case manager coaching the patient, self-management strategies can prevent up to 40% of COPD-related hospitalisations.7 However, Written Action Plan adherence rates remain low, with studies reporting adherence <50%.8 Adherence can be improved through more frequent communication, particularly telephone calls from case managers, at the cost of an increased amount of time spent supporting patients.9 Telehealth technologies are a promising strategy to enhance communication with healthcare professionals in severe COPD patients.10 The objectives of our study were to determine whether the use of an interactive phone telesystem increased Written Action Plan adherence to manage exacerbations, which can further reduce hospitalisations in patients from a specialised centre with routine COPD self-management intervention practices.

METHODS

Pilot Study

Forty patients from the COPD clinic at the Montreal Chest Institute, McGill University Health Centre, Montreal, Canada, were enrolled in an initial study. Patients received regular automated phone calls from the telesystem and could contact the telesystem at any time. The telesystem issued alarms to case managers during acute exacerbations. Nurse case managers accessed telesystem call information through a secured online database. Patients kept a symptom diary, recording dates of symptom worsening, treatment use and contact with healthcare professionals. Detailed data from patients’ behaviours during exacerbations were recorded monthly by a third party. Adherence was defined as the patient’s ability to initiate their Action Plan medication by themselves and/or contacting their case manager within 72 hours.

Implementation Scaling-Up Study

The telesystem was then implemented on a large scale to cover >250 patients from a COPD clinic. Healthcare use was assessed with hospital databases.

RESULTS

Thirty-three patients completed the 1-year initial study (12 males/21 females; mean age: 69.0±6.9 years; post-bronchodilator forced expiratory volume in 1 second [FEV1]: 41±13% predicted). A total of 93 symptom-based exacerbations were reported, with the majority of patients reporting ≥2 exacerbations during the year of initial evaluation. Fifty-three percent of patients initiated their Action Plan medication by themselves and 38% contacted their case manager within 72 hours. Overall Action Plan adherence, which includes taking medication as prescribed in the Written Action Plan and/or contacting a healthcare professional within 72 hours, was observed in 72% of exacerbation cases. Exacerbation recovery time was significantly faster for those episodes in which patients adhered to their Written Action Plan (10±6 days for adherent versus 16±10 days for non-adherent patients; p<0.001). Following the large-scale implementation, the use of the telesystem was extended to the caseload of the COPD clinic for a total of 256 patients (117 males/139 females; mean age: 70±9 years; prebronchodilator FEV1: 0.42±0.20% predicted) enrolled in the telesystem. After 1 year of telesystem use, we observed a significant decrease in the number of patients with ≥1 respiratory-related emergency room visits and COPD-related hospitalisations (Table 1).

Table 1: Healthcare utilisation before and after telesystem enrolment.
*p<0.05 was considered statistically significant.
COPD: chronic obstructive pulmonary disease; ER: emergency room.

CONCLUSION

Patients already on a self-management programme from a COPD clinic using the COPD telesytem demonstrated higher Action Plan adherence rates than previously reported. The large-scale implementation of the telesystem resulted in a further reduction of COPD-related hospitalisations.

References
Blasi F et al. The clinical and economic impact of exacerbations of chronic obstructive pulmonary disease: A cohort of hospitalized patients. PLoS One. 2014;9(6):e101228. Anzueto A, Miravitlles M. Chronic obstructive pulmonary disease exacerbations: A need for action. Am J Med. 2018;131(9S):15-22. Connors AF et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med. 1996;154(4):959-67. Wilkinson TM et al. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;169(12):1298-303. Bourbeau J et al. Comprehensive self-management strategies. Semin Respir Crit Care Med. 2015;36(4):630-8. Zwerink M et al. Self management for patients with  chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014;3:CD002990. Bourbeau J et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: A disease-specific self-management intervention. Arch Intern Med. 2003;163(5):585-91. Bischoff EW et al. Effects of written action plan adherence on COPD exacerbation recovery. Thorax. 2011;66(1):26-31. Bourbeau J et al. Making collaborative self-management successful in COPD patients with high disease burden. Respir Med. 2013;107(7):1061-5. Kessler R et al. COMET: A multicomponent home-based disease-management programme versus routine care in severe COPD. Eur Respir J. 2018;51(1).