title: A bundled care approach to patients with idiopathic pulmonary fibrosis improves transplant-free survival.
abstract: Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease with poor prognosis and limited therapeutic options. The 2011 ATS/ERS/JRS/ALAT consensus statement provided a number of recommendations for the management of IPF patients. The primary objective of this study was to determine if "bundling" these recommendations in the management of patients with IPF impacts clinical outcomes.
  
  
  
  We conducted a single center, retrospective cohort study of 284 patients diagnosed with IPF. The proposed bundle of care (BOC) components were: (1) visits to a specialized interstitial lung diseases clinic with evaluation of pulmonary function tests at least twice yearly; (2) referral to pulmonary rehabilitation yearly; (3) timed walk test yearly; (4) echocardiogram yearly; and (5) gastroesophageal reflux therapy. Each component of the BOC was given a score of "1" per year of follow up, and the average sum of the scores (ranging from 0 to 5) was determined for the entire period of follow-up (BOCS), as well as during the first year of follow-up (BOCY1). The primary outcome measure was transplant-free survival.
  
  
  
  Age, gender, smoking status, BMI, %FVC, %DLCO did not differ between levels of BOCS and BOCY1. Lowest BOCS (≤1) was associated with a lower transplant-free survival independent of age and %FVC compared to patients with the highest BOCS (>4) (HR 2.274, CI 1.12-4.64, p = 0.024). Lower BOCY1 was associated with a higher risk for transplant or death independent of age and %FVC in comparison to patients with highest BOCY1 (≤1 vs. >4, HR 2.23, p = 0.014; >1 to 2 vs. >4, HR 1.87, p = 0.011; >2 to 3 vs. >4, HR 1.72, p = 0.019).
  
  
  
  IPF patients with higher BOC scores had improved transplant-free survival. Prospective studies are needed to confirm these findings and determine the best strategies for the management of patients with IPF.
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States; Birmingham VA Medical Center, 700 South 19th Street, 6th Floor, Rm 6318, Birmingham, AL 35233, United States.
authors.forename: Tejaswini
authors.initials: T
authors.lastname: Kulkarni
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States.
authors.forename: John
authors.initials: J
authors.lastname: Willoughby
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States; Birmingham VA Medical Center, 700 South 19th Street, 6th Floor, Rm 6318, Birmingham, AL 35233, United States.
authors.forename: Maria Del Pilar
authors.initials: Mdel P
authors.lastname: Acosta Lara
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States; Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Medical Towers, Suite 621, 1720 2nd Ave South, Birmingham, AL 35294, United States; Birmingham VA Medical Center, 700 South 19th Street, 6th Floor, Rm 6318, Birmingham, AL 35233, United States.
authors.forename: Young-Il
authors.initials: YI
authors.lastname: Kim
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States; Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Medical Towers, Suite 621, 1720 2nd Ave South, Birmingham, AL 35294, United States.
authors.forename: Rekha
authors.initials: R
authors.lastname: Ramachandran
authors.affiliation: Department of Pathology, University of Alabama at Birmingham, P210 West Pavilion, 619 South 19th Street, Birmingham, AL 35233, United States.
authors.forename: C Bruce
authors.initials: CB
authors.lastname: Alexander
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States.
authors.forename: Tracy
authors.initials: T
authors.lastname: Luckhardt
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States; Birmingham VA Medical Center, 700 South 19th Street, 6th Floor, Rm 6318, Birmingham, AL 35233, United States.
authors.forename: Victor J
authors.initials: VJ
authors.lastname: Thannickal
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States; Birmingham VA Medical Center, 700 South 19th Street, 6th Floor, Rm 6318, Birmingham, AL 35233, United States. Electronic address: joao@uab.edu.
authors.forename: Joao A
authors.initials: JA
authors.lastname: de Andrade
mesh_terms: D000368:Aged; D004452:Echocardiography / Q000379:methods; D005260:Female; D005764:Gastroesophageal Reflux / Q000628:therapy; D019983:Guideline Adherence; D006801:Humans; D054990:Idiopathic Pulmonary Fibrosis / Q000175:diagnosis* / Q000401:mortality / Q000534:rehabilitation / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D064872:Patient Care Bundles / Q000379:methods*; D012129:Respiratory Function Tests / Q000379:methods; D012189:Retrospective Studies; D015996:Survival Rate; D019737:Transplants; D000070857:Walk Test / Q000379:methods
keywords: Bundled care; Idiopathic pulmonary fibrosis; Transplant-free survival