title: Multidisciplinary COPD disease management program: impact on clinical outcomes.
abstract: OBJECTIVE
  We hypothesized performance improvement interventions would improve COPD guideline-recommended care and decrease COPD exacerbations in primary care clinic practices.
  
  
  METHODS
  We initiated a performance improvement project in 12 clinics to improve COPD outcomes incorporating physician education, case management, web-based decision support (CareManager(TM)), and performance feedback. We collected baseline and one-year follow up data on 242 patients who had COPD with acute exacerbations. We analyzed data by two methods. First, the 12 clinics were cluster randomized to 4 intervention (117 patients) and 8 control (125 patients) clinics which all had access to CareManager(TM) but only intervention clinic physicians received case management, academic detailing, and decision support assistance. Exacerbation rates and guideline adherence were compared. Second, data from all 12 clinics were pooled in a quasi-experimental design comparing baseline and post-implementation of CareManager(TM) to determine the value of system-wide performance improvement during the study period.
  
  
  RESULTS
  In the randomized analysis, baseline demographics were similar. No differences (p = 0.79) occurred in exacerbation rates between intervention and control clinics although both groups had decreased numbers of exacerbations from baseline to follow up (p < 0.05). The pooled data from all 12 clinics demonstrated a reduction (p < 0.05) in mean exacerbations/patient from 2.3 (CI 2.0-2.6) during baseline to 1.4 (CI 1.1-1.7) at one-year follow up. Emergency department visits and hospitalizations/patient decreased (p = 0.003). Patients naïve at study start to depression screening, pneumococcal vaccination, inhaled control medications or smoking cessation had fewer (p < 0.05) exacerbations after these interventions.
  
  
  CONCLUSIONS
  We observed no difference in exacerbation rates between clinics receiving case management, academic detailing, and ongoing assistance with decision support and controls. Implementation of a web-based disease management system (CareManager(TM)) along with health system-wide COPD performance improvement efforts was associated with fewer COPD exacerbations and increased adherence to guideline recommendations.
authors.affiliation: a Pulmonary and Critical Care , The Oregon Clinic , Portland , OR , USA.
authors.forename: Melvin
authors.initials: M
authors.lastname: Morganroth
authors.affiliation: b Providence Medical Group , Portland , OR , USA.
authors.forename: Ginger
authors.initials: G
authors.lastname: Pape
authors.affiliation: c Providence Health and Services , Portland , OR , USA.
authors.forename: Yelena
authors.initials: Y
authors.lastname: Rozenfeld
authors.affiliation: d Department of Medical Education , Providence Portland Medical Center , Portland , OR , USA.
authors.forename: John E
authors.initials: JE
authors.lastname: Heffner
mesh_terms: D000368:Aged; D019090:Case Management; D016000:Cluster Analysis; D003625:Data Collection; D020000:Decision Support Systems, Clinical; D004502:Education, Medical, Continuing; D005260:Female; D005500:Follow-Up Studies; D000068156:Formative Feedback; D019983:Guideline Adherence; D006801:Humans; D020407:Internet; D008297:Male; D010348:Patient Care Team; D011320:Primary Health Care; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
keywords: COPD exacerbation; COPD guidelines; disease management; primary care