A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial.

BACKGROUND: Improving a patient's ability to self-monitor and manage changes in chronic obstructive pulmonary disease (COPD) symptoms may improve outcomes. OBJECTIVE: To determine the efficacy of a comprehensive care management program (CCMP) in reducing the risk for COPD hospitalization. DESIGN: A randomized, controlled trial comparing CCMP with guideline-based usual care. (ClinicalTrials.gov registration number: NCT00395083) SETTING: 20 Veterans Affairs hospital-based outpatient clinics. PARTICIPANTS: Patients hospitalized for COPD in the past year. INTERVENTION: The CCMP included COPD education during 4 individual sessions and 1 group session, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. Patients in both the intervention and usual care groups received a COPD informational booklet; their primary care providers received a copy of COPD guidelines and were advised to manage their patients according to these guidelines. Patients were randomly assigned, stratifying by site based on random, permuted blocks of variable size. MEASUREMENTS: The primary outcome was time to first COPD hospitalization. Staff blinded to study group performed telephone-based assessment of COPD exacerbations and hospitalizations, and all hospitalizations were blindly adjudicated. Secondary outcomes included non-COPD health care use, all-cause mortality, health-related quality of life, patient satisfaction, disease knowledge, and self-efficacy. RESULTS: Of the eligible patients, 209 were randomly assigned to the intervention group and 217 to the usual care group. Citing serious safety concerns, the data monitoring committee terminated the intervention before the trial's planned completion after 426 (44%) of the planned total of 960 patients were enrolled. Mean follow-up was 250 days. When the study was stopped, the 1-year cumulative incidence of COPD-related hospitalization was 27% in the intervention group and 24% in the usual care group (hazard ratio, 1.13 [95% CI, 0.70 to 1.80]; P= 0.62). There were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00 [CI, 1.46 to 6.17]; P= 0.003). Cause could be assigned in 27 (71%) deaths. Deaths due to COPD accounted for the largest difference: 10 in the intervention group versus 3 in the usual care group (hazard ratio, 3.60 [CI, 0.99 to 13.08]; P= 0.053). LIMITATIONS: Available data could not fully explain the excess mortality in the intervention group. Ability to assess the quality of the educational sessions provided by the case managers was limited. CONCLUSION: A CCMP in patients with severe COPD had not decreased COPD-related hospitalizations when the trial was stopped prematurely. The CCMP was associated with unanticipated excess mortality, results that differ markedly from similar previous trials. A data monitoring committee should be considered in the design of clinical trials involving behavioral interventions.

Curious case of muscle spasm.

KEY CLINICAL MESSAGE: If no improvement is seen with ongoing treatment for current diagnosis, then diagnosis should be questioned. History taking and physical examination remain essential tools in care of the patient in addition to the current technological advancement.

Trends in hospice referral and length of stay at a veterans hospital over the past decade.

INTRODUCTION: Hospice decreases the fear of dying alone, reduces the agony of death, and helps in maintaining dignity at the end of life. Physicians are encouraged to offer hospice to terminally ill patients early on in their end-of-life care to maximize these benefits. However, there is limited data on the changes and characteristics of hospice utilization. We performed a study to determine the changes in the hospice utilization over the last decade in our hospital. METHODS: A chart review of all veterans referred to hospice during the years 2001 and 2010 was performed and subsequently analyzed. Analyses were performed with SPSS 19.0 for Windows. RESULTS: Referral to hospice increased significantly but the duration of stay did not change in 2010 in comparison with 2001. Factors associated with increased length of stay were full-code status, receiving hospice at home, hospitalization during enrollment in hospice, referral to hospice by oncologist, and a diagnosis of cancer. CONCLUSION: Hospice referrals need to be considered earlier in their disease process for terminally ill patients. In addition, requirement of a do-not-resuscitate order as a condition for hospice at some agencies needs to be revisited, and patients should not be discouraged to seek treatment for reversible medical conditions even when enrolled in hospice.