Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 3 , Pages 395-401, March 2009

A Specific Home Care Program Improves the Survival of Patients With Chronic Obstructive Pulmonary Disease Receiving Long Term Oxygen Therapy

  • Maurizio Rizzi, MD

      Affiliations

    • Servizio di Fisiopatologia Respiratoria, Ospedale Luigi Sacco, Via Grassi, Milano
    • ,
  • Mario Grassi, MD

      Affiliations

    • Dipartimento di Scienze Sanitarie Applicate, Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italy
    • ,
  • Marica Pecis, MD

      Affiliations

    • Servizio di Fisiopatologia Respiratoria, Ospedale Luigi Sacco, Via Grassi, Milano
    • ,
  • Arnaldo Andreoli, MD

      Affiliations

    • Servizio di Fisiopatologia Respiratoria, Ospedale Luigi Sacco, Via Grassi, Milano
    • ,
  • Anna Eugenia Taurino, MD

      Affiliations

    • Unità Operativa di Pneumologia Riabilitativa, Fondazione Salvatore Maugeri IRCCS, Istituto Scientifico di Montescano, Montescano, Pavia, Italy
    • ,
  • Margherita Sergi, MD

      Affiliations

    • Servizio di Fisiopatologia Respiratoria, Ospedale Luigi Sacco, Via Grassi, Milano
    • ,
  • Francesco Fanfulla, MD

      Affiliations

    • Unità Operativa di Pneumologia Riabilitativa, Fondazione Salvatore Maugeri IRCCS, Istituto Scientifico di Pavia, Pavia, Italy
    • Corresponding Author InformationCorrespondence to Francesco Fanfulla, MD, Unità Operativa di Pneumologia Riabilitativa, Fondazione Salvatore Maugeri IRCCS, Istituto Scientifico di Pavia, Via S. Maugeri 10, 27100 Pavia, Italy

Article Outline

Abstract 

Rizzi M, Grassi M, Pecis M, Andreoli A, Taurino AE, Sergi M, Fanfulla F. A specific home care program improves the survival of patients with chronic obstructive pulmonary disease receiving long term oxygen therapy.

Objectives

To analyze the influence of a home care (HC) program on outcomes of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) in comparison with outcomes of patients receiving standard care (SC).

Design

A 10-year follow-up study with 2 parallel cohorts (HC vs SC).

Setting

University hospital.

Participants

One hundred and eight patients in the HC program and 109 patients managed conventionally.

Interventions

The HC program consisted of outpatient clinical and functional evaluations every 6 months, and domiciliary assessments by a specific team including a pneumologist, a respiratory nurse, and a rehabilitation therapist every 2 to 3 months or more, as needed.

Main Outcome Measures

Mortality; exacerbation, hospital and intensive care unit admission rate.

Results

One hundred and eight patients entered the HC program and 109 patients were managed conventionally. The 2 groups of patients did not differ for age, sex, body mass index, COPD severity or comorbid conditions. The overall mortality during the follow-up was 63% and the median survival was 96±38 months. The survival curves for HC and SC patients were statistically significantly different (log-rank, −16.04; P=.0001). In the Cox proportional hazards model, inclusion in the HC program was associated with an increased survival rate, whereas comorbid conditions and requirement of mechanical ventilation during the follow-up were associated with a decreased survival rate. During the entire follow-up, HC patients had a lower number of exacerbations/year than SC patients.

Conclusions

A disease-oriented HC program is effective in reducing mortality and hospital admissions in COPD patients requiring LTOT.

Key Words: COPD, Home care, Mortality, Rehabilitation, Respiratory failure, Survival

List of Abbreviations: BMI, body mass index, COPD, chronic obstructive pulmonary disease, GP, general practitioner, HC, home care, ICU, intensive care unit, LTOT, long-term oxygen therapy, MIP, maximum inspiratory pressure, MLE, maximum likelihood estimation, NIV, non-invasive ventilation, NS, not significant, SC, standard care

 

CHRONIC OBSTRUCTIVE PULMONARY disease is a progressive disorder that often leads to respiratory failure1 and is one of the few major causes of death whose prevalence is continuously rising in the world.2 The growing percentage of older people in western populations increases the number of people with chronic illness in whom recurrent hospitalization is common.3, 4, 5 These patients exert the greatest strain on health care resources and budgets. From 40% to 50% of patients with COPD discharged from hospitals are readmitted during the subsequent year6, 7 and 17% of patients discharged from emergency departments require hospitalization.8 The major cause of hospitalization in COPD patients is acute exacerbation9 and, despite optimal pharmacologic therapy, these patients often have symptoms that limit normal physical activities and impair their quality of life.10, 11

LTOT is the single treatment that has proven to be effective in increasing survival in COPD patients with chronic respiratory failure.12, 13 For this reason, health care systems in many countries provide funding for domiciliary oxygen for patients who require LTOT. Nevertheless, the life expectancy of COPD patients receiving LTOT is poor, with a 5-year survival rate of approximately 40%.13, 14 Numerous factors have been reported to influence prognosis, including spirometric indices, diffusion capacity for carbon monoxide, hypoxemia, hypercapnia, reduced exercise capacity, dyspnea, BMI, and health status as well as frequent episodes of acute exacerbation. These exacerbations represent a major burden for both patients and health care systems, because they are the most common reason for hospital admission. The inpatient mortality rate is about 10%7, 15 and during the year after admission to hospital, the mortality rate may be as high as 40%.7, 16 Furthermore, the readmission rate is typically high in these high-risk patients. A recent large study found a readmission rate of 63% during a mean follow-up of 1.1 years.17

A wide range of multidisciplinary programs for the management of chronic diseases have been developed to provide continuity of care from hospital to home and, potentially, to confer benefits in terms of improved disease control,18 reduced mortality,19 and less recurrent use of hospitals.20, 21 However, a recent long-term follow-up study of patients with chronic illnesses found that a nonspecific multidisciplinary home-based intervention failed to provide benefits in patients with COPD,22 supporting the need for disease- and patient-specific long-term care programs.

At the beginning of the 1990s, the local organization of the Italian Health System developed a specific HC program for patients with advanced COPD and chronic respiratory failure requiring LTOT. This program was developed in Milan and offered to all patients. Patients were asked to agree to this protocol or to continue to receive SC. We conducted a 10-year follow-up study with periodic clinical and functional assessments to evaluate the impact of this HC program on survival, exacerbation rate, and hospital admissions in COPD patients receiving LTOT and to compare these patients' outcomes with those of patients who choose to continue to receive SC.

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Methods 

Patients 

We enrolled 217 consecutive Caucasian COPD outpatients (128 men, age 70±6 years) in the 2-year period from January 1, 1994, until December 31, 1995, on the basis of the inclusion criteria described below. At the time of this study, all the patients were still being cared for (mean time 36.6±10.3mo) by the same respiratory team that performed the study.

For inclusion in the study, patients had: (1) to have a diagnosis of COPD, according to clinical assessment and the results of lung function tests; (2) to have already received LTOT for at least 1 year; (3) to have had at least 1 episode of exacerbation of COPD in the preceding year but to be in a stable condition at the time of enrollment (blood gases, respiratory symptoms, and medication unchanged for at least 3 months); (4) to be already treated with optimized pharmacologic therapy.

The exclusion criteria were: (1) presence, at potential enrollment, of a 15% or greater increase in forced expiratory volume in 1 second after inhalation of albuterol (200 μg) via a metered dose inhaler; (2) concomitant sleep apnea, the presence of which was confirmed or excluded by means of polysomnography; (3) uncontrolled coronary or cardiovascular diseases; (4) malignancy; (5) severe neurologic diseases, such as Parkinson disease, cerebrovascular diseases, and any type of dementia; (6) alcoholism or any type of drug abuse; and (7) severe psychiatric disorders.

Baseline comorbid conditions were recorded using the Charlson Index.23 This index predicts the longitudinal impact of comorbidities on prognosis and assigns each disease a score of 1 to 6, which is proportional to the disease-related risk of death. For the purposes of the current study, COPD was excluded from the list of comorbid conditions.24

Patients enrolled in the HC program (n=108) were compared with those who chose to continue to receive SC, as shown in table 1. No differences were found between the 2 groups of patients for any of the variables presented in table 1, nor for the presence of caregivers (HC 78.7% vs SC 75.3%, P=NS).

Table 1. Characteristics of Patients Included in the Home Care and Standard Care Groups at Enrollment into the Study
HC (n=108)SC (n=109)P
Mean ± SDMean ± SD
Age (y)68±1066±12NS
BMI (kg/m2)28±527±4.8NS
Sex (M/F)78/4265/34NS
VC (% of predicted)68±869±10NS
FEV1 (% of predicted)30±1029±8NS
MIP (cmH2O)51±652±5NS
PaO2 (mmHg)50±551±7NS
PaCO2 (mmHg)49±348±6NS
Daily O2-therapy (h)22±221±3NS
Charlson index% of patients% of patients
046.841.7NS
131.231.5NS
216.517.6NS
35.59.2NS
Comorbidities% of patients% of patients
CHD3040NS
Arterial hypertension6366NS
Diabetes3128NS
Renal failure1516NS
GERD1815NS
Educational status
Primary school56NS
High school1819NS
College4845NS
Degree2930NS

Abbreviations: CHD, chronic heart diseases; FEV1, forced expiratory volume in 1 second; GERD, gastro-esophageal reflux; NS, not significant; PaO2, partial pressure of oxygen, arterial; PaCO2, partial pressure of carbon dioxide, arterial; VC, vital capacity.

Procedures 

This was a prospective follow-up study of 2 parallel cohorts of patients with severe COPD requiring LTOT, which was specifically designed, approved, and sponsored by the Local Committee of Italian National Health System. At the time of starting LTOT all the COPD patients with chronic respiratory failure were asked to choose between SC and the HC program. The 2 cohorts of patients were very similar for all the respiratory variables considered (see table 1), because the standard criteria for inclusion in the LTOT are very narrow.

All the patients, in both the HC and SC groups, were evaluated by the same clinical team at the initial consultation and during follow-up and gave their consent to analysis of their data for research purposes; no patients refused to participate.

Baseline Investigations 

Patients underwent standard lung function tests, measurement of MIP, and analysis of resting arterial blood gases.25, 26, 27

Home Care Program 

At the enrollment, patients and caregivers (if present) received a standard but specific educational program related to the management of COPD and LTOT that included information about the disease, the control of risk factors (ie, passive smoking, indoor and outdoor pollution, infections), weight control, management of devices, and management of drug and oxygen therapy. The patient's GP was informed and actively involved in the home management. The GP was asked to call the HC team every time he or she observed any change in the clinical status. The HC program incorporated various different kinds of services: (1) planned outpatient clinical and functional evaluations every 6 months, including history and examination, lung function tests, measurement of MIP and BMI, blood gases analysis, and an assessment of compliance to therapy, (2) home evaluations by the HC team, carried out on request from patients, caregivers (when present), or GP. The HC team included pneumologists, respiratory nurses, and rehabilitation therapists. The domiciliary assessment included a clinical evaluation, spirometry,a pulse oximetryb in room air and during oxygen therapy, and measurement of BMI. According to clinical and functional evaluations, the pneumologist could optimize both drug therapy and oxygen therapy, prescribe a specific rehabilitation program or refer the patient to hospital. The rehabilitation program included bronchial drainage (ie, autogenic drainage, positive expiratory pressure mask, expiration with the glottis open in the lateral posture–ELTGOL), inspiratory muscle training, and exercise training.

Standard Care 

Patients in the SC group were evaluated by the same clinical team at the initial consultation and during follow-up. The frequency of the consultations and changes in treatment were at the discretion of each attending chest physician or the patient's GP, according to the clinical status of the patient. Neither physicians nor patients received specific instructions about emergency room visits or hospital admissions.

Outcomes 

For both groups of patients considered, we recorded the number of: prescriptions of home mechanical ventilation, emergency department visits, number and duration of hospital admissions in either a respiratory ward or the ICU (reported to the HC team and subsequently confirmed from the hospital registers), and the causes of death (obtained from the death certificates or review of clinical records).

As recommended by an international statement,28 all patients (HC and SC) who developed chronic carbon dioxide retention (PaCO2 >55mmHg in a stable condition) with nocturnal desaturation and symptoms related to sleep hypoventilation received NIV in addition to previous care.

Statistical Analysis 

Data are expressed as means ± SD. The survival curves and enrollment into home ventilation therapy in the 2 groups of patients were estimated using the Kaplan-Meier product limit method and compared by the log-rank test. Univariate and multivariate comparisons of mortality rates by risk factors were performed using Cox proportional hazards regression analysis. The selection of independent variables for multivariate analysis was based on statistical significance shown in the univariate analysis. A forward stepwise procedure was used for the best signed multivariate model, and results were expressed as hazard ratios with 95% confidence intervals.

Two-level random regression models with level 1 units (time) nested in level 2 units (subjects) were also fitted to assess the trajectories in the number of exacerbations, number of accesses to the emergency department, and the number of admissions to hospital (both respiratory ward, and the ICU) between the 2 groups of survivors over time (10-y points). A log-link and a Poisson-distribution were chosen for the response variables, and for each outcome the model assumes 2 random effects factors, i.e. (1) the individual “baseline” and (2) the individual “trend” (linear, quadratic, or cubic) over time.

The means, variance, and covariance parameters of the random variables across the two groups of survivors were fitted by MLE via numerical deterministic integration with 15 nodes. The MLE procedure was performed considering the presence of missing data during the follow-up time points (a reduction of about 8% of patients per year) under the assumption of missing at random, and using an Expectation-Maximization algorithm.

For both Cox regressions and 2-level random regression modeling the P-values of the parameter estimates were evaluated by t test (=parameter/SE), and the significance level was set at P<.05, 2 sided. Descriptive and Cox regression statistics were performed by STATISTICA softwarec and 2-level random regression statistics were performed by Mplus 5.1 software.d

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Results 

All the patients (excluding deaths) completed the follow-up. Neither the daily prescription of oxygen therapy nor compliance to oxygen therapy differed between the HC and SC groups of patients (daily duration 22.2±2h vs 21±3h, respectively; P= NS; compliance to LTOT 90% vs 88% of time prescribed, respectively; P=NS). Likewise, bronchodilator therapy was similar in the 2 groups of patients, as reported in table 2. The number of domiciliary assessments for each year of follow-up were 6.4±3.1, 6±2.8, 5.3±2.8, 5.5±3, 4.8±2.6, 5.1±2.4, 4.5±2, 4.8±2.3, 4.5±2, and 4.3±2.3 from the first to the tenth year of the study, respectively.

Table 2. Pharmacological Treatment at Enrollment in the 2 Groups of Patients Considered in the Study
HC (% of patients)SC (% of patients)P
Anticholinergic inhalers4042NS
(% of patients receiving associated ICS)(25)(29)
Beta-2 agonist5044NS
(% of patients receiving associated ICS)(35)(38)
Slow-release theophylline1014NS

NOTE: Data are presented as % of the respective group. No patients received treatment with oral corticosteroids.

Abbreviation: ICS, inhaled corticosteroids.

Survival Data 

The overall mortality during follow-up was 63%. The median survival time was 96±38 months (84 and 108 months, respectively, for SC and HC group). The causes of death were mainly related to the respiratory disease (69% in the HC group and 70% in the SC group). No differences in causes of death were found between the HC and SC patients.

The survival curves for the HC and SC patients were statistically significantly different (log-rank −16.04; P=.0001) and diverged from the third year of follow-up (fig 1). Because patients with Charlson index 1 and 2 showed the same survival rate, we categorized patients into 3 groups: group 0 (Charlson index 0), group 1 (Charlson index 1 and 2), group 2 (Charlson index 3). Both in the univariate and multivariate analyses (table 3), inclusion in the HC program was independently associated with an increased survival rate, whereas higher Charlson index group (fig 2), and requirement of mechanical ventilation (fig 3) during the follow-up were independently associated with a decreased survival rate. Age, sex, BMI, blood gases, and spirometric indices recorded at enrollment were not independent predictors of mortality in either the whole group of patients or in the HC or SC subgroups. Similarly, the presence or absence of a family caregiver was not associated with a different mortality in the overall group of patients or in the separate HC or SC group.

Table 3. Prognostic Factors According to Cox Models
Prognostic FactorUnivariate AnalysisMultivariate Analysis
Hazard Ratio (95% CI)PHazard Ratio (95% CI)P
Charlson index1.75(1.36–2.25)<0.0011.844(1.422–2.391)<0.001
Home care program0.553(0.403–0.759)<0.0010.519(0.377–0.715)<0.001
NIV1.885(1.22–2.92)0.0051.609(1.037–2.495)0.033

NOTE: Charlson index: categorized Charlson index (see text for more details). Home care program: inclusion in HC program. NIV: requirement for mechanical ventilation.

Abbreviation: CI, confidence interval.

  • View full-size image.
  • Fig 2. 

    Kaplan-Meier survival curves according to comorbid conditions, expressed by the categorized Charlson index in group 0 (Charlson index 0), group 1 (Charlson index 1 and 2), group 2 (Charlson index 3). ° difference between group 0 and 1 (P= .001); * difference between group 0 and 2 (P=.0002); ^ difference between group 1 and 2 (P=.02).

During the follow-up, 24 patients required home mechanical ventilation. The percentage of patients requiring mechanical ventilation was higher in the SC group than in the HC group, although this difference was not statistically significant (14.7% vs 7.4%, χ2=2.92, P=.08). All the patients requiring NIV died before the end of the follow-up.

Exacerbations Trajectory Data 

Along the 10-year follow-up, the 2-level random regression analysis indicates that a linear slope was needed to describe the trajectory of exacerbation, emergency, ordinary admission numbers, whereas a quadratic curve was appropriate for the ICU admission numbers, for patients both in the control and in the intervention condition.

The observed mean and the expected model means on the lines or quadratic curves are displayed in Fig 4, Fig 5, Fig 6, Fig 7. At baseline the HC patients had a lower number of exacerbations (about −1 unit, P<.008), of emergency department visits (about −2 unit, P<.001), and of admissions to the ICU (−0.5 unit, P<.001), than the SC patients, but no statistically significant difference was observed between groups as to the number of admissions to the respiratory ward.

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  • Fig 4. 

    Observed and expected means trajectories based on 2-level random regression model of the numbers of exacerbations during 10-year follow-up. Baseline HC–SC difference, −0.761 (P=.008); 10y HC–SC difference, −2.752 (P<.001).

  • View full-size image.
  • Fig 5. 

    Observed and expected means trajectories based on 2-level random regression model of the numbers of emergency visits during 10-year follow-up. Baseline HC–SC difference, −1.877 (P<.001); 10y HC–SC difference, −1.529 (P=.009).

  • View full-size image.
  • Fig 6. 

    Observed and expected means trajectories based on 2-level random regression model of the numbers of ordinary admissions during 10-year follow-up. Baseline HC–SC difference, −0.196 (P=.125); 10y HC–SC difference, −0.616 (P<.001).

  • View full-size image.
  • Fig 7. 

    Observed and expected means trajectories based on 2-level random regression model of the numbers of ICU admissions during 10-year follow-up. Baseline HC–SC difference, −0.560 (P<.001); 10y HC–SC difference, −0.049 (P=.425).

The linear trajectories of exacerbations diverged (P<.001) over time indicating a decline in the HC group (from 3.5 to 2.4 unit per 10y), and a rise in the SC group (from 4.3 to 5.9 unit per 10y); on the contrary, the linear trends for the emergency department visits were different (P<.009) indicating an increase (from 4.1 to 5.4 unit per 10y) in the control group, and a constant emergency of 2 units during the 10 years in the intervention group. The lines of admissions to the respiratory ward were statistically different (P<.001), but the linear trend declined in the HC group (from 1.2 to 0.5 unit per 10y), and remains constant of 1.3 unit in the SC group. Finally, the quadratic trajectories of ICU admissions were similar for control and intervention groups indicating that the difference observed at baseline was uniform along the follow-up.

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Discussion 

The main finding of our study is that an HC protocol, specifically designed for patients receiving LTOT for chronic respiratory failure related to COPD, is effective in reducing mortality in comparison with conventional care. This increase in survival rate among patients in the HC program seemed to be mainly related to a reduction in exacerbations as well as fewer admissions to the ICU and stabilization of lung function; the need for domiciliary mechanical ventilation appeared to be lower among patients enrolled in the HC protocol. Respiratory function, age, sex, BMI, and blood-gas values at enrollment were not predictors of mortality in the 2 cohorts considered.

Along the follow-up, survivors in the HC group had a better physiologic status than survivors in the SC group, as indicated by higher BMI, higher MIP, and lower PaCO2 in the former.

To the best of our knowledge this is the first study that evaluates the impact on survival of an HC program specifically designed for COPD patients treated with LTOT. Several studies were performed in the past to analyze the effects of nonspecific HC programs on the outcomes and needs of COPD patients. Their results vary: some showed a decrease in hospital admissions and an increase in savings,29, 30, 31, 32, 33 although others found no differences in the number of hospital admissions34, 35, 36 or exacerbations37 and some even reported an increase in health care costs.34, 38, 39 However, all these studies were extremely heterogeneous for type of HC assistance (self-care, programs supervised by a pneumologist, GP, nurse, or therapist), outcomes (improvement of symptoms, quality of life, respiratory function, rate of hospital admissions, cost), type of assistance (monitoring respiratory function, rehabilitation program at home) and sample size; this marked variability probably accounts for the different results. In contrast, our study was designed to assess the impact of an HC program on survival in a cohort of COPD patients requiring LTOT in comparison with the impact of SC in a similar cohort of patients.

Few data are available about mortality in patients with severe COPD and chronic respiratory failure. The life expectancy of these patients is poor, with a 5-year survival rate of about 40% or less.13, 14, 24, 40 This high rate of mortality has been related to several factors, including sex, age, respiratory function, BMI, comorbidity, and compliance to treatment. In our series, univariate analysis showed that the 2 variables associated with a higher rate of mortality were the Charlson index and the requirement for mechanical ventilation because of chronic carbon dioxide retention. In accordance with previous reports, the majority of patients died of respiratory causes (70%) and comorbidity also proved to be a factor associated with death from respiratory causes. Comorbidity may have an influence on the severity of the acute respiratory complications that lead to death in these patients.41 The annual rate of exacerbations was lower among the patients enrolled in the HC program than among those receiving SC; the difference became statistically significant in the third year of follow-up. The rate of exacerbations in the SC group was close to that previously reported in a group of COPD patients.42 In that study, Seemungal et al42 showed that only 80.2% of exacerbations were followed by a complete recovery of respiratory function after 91 days and that in 3.4% of cases, the next exacerbation occurred before the respiratory function had recovered completely. Furthermore, they found that only 50% of exacerbations are reported directly by patients to the clinical team.

We hypothesized that the lower rate of mortality observed in the HC group was mainly related to reduction in the number of exacerbations and/or their severity expressed by requirement of emergency room evaluations, ICU, or respiratory ward admission. Exacerbations are a major cause of morbidity, mortality, impaired quality of life, and increased health care costs for COPD patients.43, 44, 45 In particular, Soler-Cataluña et al,45 in a 5-year follow-up study, showed that acute exacerbations of COPD were independent indicators of a poor prognosis and that patients with the greatest mortality risk were those who had had 3 or more acute COPD exacerbations. The mean number of exacerbations in the HC group fell below 3 episodes/year from the third year of follow-up and remained constant until the end of the study; in contrast, patients in the SC group had 4 to 5 exacerbations per year. The survival curve in the 2 cohorts of patients diverged significantly from the third year of follow-up, just at the time when the difference in the rates of exacerbation became statistically significant. Because the patients enrolled in the HC program received regular evaluations by a clinical respiratory team or GP, they may have had earlier specialist assessment, a prompt diagnosis of exacerbations, appropriate changes in therapy, and regular monitoring of symptoms and spirometric indices thus minimizing negative effects on respiratory function and reducing the occurrence of acute decompensations requiring a visit to the emergency department or a hospital admission. HC patients had statistically significantly lower rates of emergency department use and ICU admissions already from the first year of follow-up; the rate of admission to a general ward became statistically significantly lower starting from the fourth year of follow-up.

Study Limitations 

Our study has some limitations. First of all, although the study was prospective, the patients were not allocated randomly to the 2 cohorts. That said, the 2 groups of patients were comparable at baseline, because we found no statistically significant differences for any of the variables widely considered to affect the survival of patients with COPD (ie, age, BMI, respiratory function, blood-gas values at enrollment, comorbidities, presence/absence of caregivers, availability of health care). Furthermore, patients were followed up by the same clinical team, so they were all treated according to the same diagnostic and therapeutic criteria. Although there was a potential important bias due to nonrandomization, we found a clear improvement in survival of patients receiving a disease-specific HC protocol as well as clear reductions in exacerbations, readmissions to hospital, and decline in respiratory function.

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Conclusions 

The increasing burden of chronic conditions such as COPD, chronic heart failure, or diabetes mellitus has been accompanied by the development of chronic disease management programs that provide continuity of care such that patients' outcomes are improved and unnecessary re-admissions to hospital are avoided. Recently, Pearson et al22 found that a non-specific HC program provided long-term benefits for patients with a range of chronic diseases, but not for those with COPD suggesting that patients with advanced respiratory disease have complex needs that require specific programs. The impetus to prevent readmissions in order to increase the availability of acute care beds is considerable, but is matched by an equally demanding imperative that innovative health-service interventions do not threaten patients' quality of care by increasing the risk of adverse outcomes. Our study suggests that an HC program, specifically designed for patients with advanced COPD and respiratory failure, leads to better survival and functional status than conventional care by reducing the exacerbations rate, ICU admission, emergency department visits, and ordinary hospital admissions. Because we collected data on quality of life of patients as well as all the economic costs, future analyses will establish the impact of the 2 models of assistance on these outcomes.

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  • a Spirodoc; Medical International Research, Via Del Maggiolino, 125, Rome, Italy.
  • b NONIN 8500; Nonin Medical Inc, 13700-A 1st Ave N, Plymouth, MN 55441.
  • c Statistica; StatSoft, 2300 East 14th St, Tulsa, OK 74104.
  • d Mplus 5.1 software (www.statmodel.com). Muthén & Muthén, 3463 Stoner Ave, Los Angeles, CA 90066.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

 Reprints are not available from the author.

PII: S0003-9993(08)01703-6

doi:10.1016/j.apmr.2008.08.223

Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 3 , Pages 395-401, March 2009

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