Long-term Outcomes of Disease Management in Chronic Obstructive Lung Disease: Results of VISN 23 Randomized Controlled Trial

Abstract

PURPOSE: A Canadian disease management (DM) study demonstrated short- and long-term reductions in all-cause hospitalizations in patients with COPD even after active DM stopped (Eur Respir J 2005;26:853). Using a simplified COPD DM program, we previously demonstrated significant reductions in hospital admissions and urgent care visits during DM (Am J Respir Crit Care 2010;182:890). The purpose of this study was to determine the long-term outcomes of our patients who underwent DM. METHODS: This was a prospective multi-center, randomized, controlled, 1-year study of simplified COPD DM compared to UC. Long term outcomes post-DM were monitored using the VA computerized database system and included all-cause mortality (up to 3.5 years post-study), all-cause hospital admissions (through 2 years post-study) and urgent care visits (through 2 years post-study). RESULTS: 743 patients (DM = 372 and UC = 371) were enrolled at 5 VA sites. There were no between-group differences in the number of patients ever admitted [DM 144 (38.6%) vs UC 150 (40.5%), P=0.59] or who had urgent care visits [DM 179 (48.0%) vs UC 187 (50.5%), P=0.49]. Time to first hospital admission or urgent care visit was also similar. All-cause mortality at 3.5 years post -study was not statistically different between the two groups [DM 146 (39.2%) vs UC 164 (44.2%), log-rank P=0.136]. Various time-dependent, composite endpoints combining hospital admissions, urgent care visits and mortality failed to demonstrate between-group differences. CONCLUSIONS: Although a recent multicenter VA study (the BREATH trial) was stopped early because of increased mortality in the COPD DM arm, a retrospective analysis of our prospectively collected data suggests that DM is safe. Long-term outcomes were similar between the two groups once DM was stopped. This suggests that DM needs to be continued to get long-term benefit. CLINICAL IMPLICATIONS: COPD DM needs to be further evaluated as a potential strategy to deliver rural health care and optimize long-term outcomes with potential for improved survival.