The potential for integrated care programmes to improve quality of care as assessed by patients with COPD: early results from a real-world implementation study in The Netherlands

Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterised by progressive and incompletely reversible airflow limitation [1]. COPD is the leading cause of death from lung disease worldwide and the fourth leading cause of death overall [2], substantially contributing to the volume of emergency department visits and hospitalisations [3]. Early- and late-stage COPD remains under-diagnosed and under-treated [3, 4]. Historically, the medical community has focused on acute care and short-term goals that emphasise the management of acute exacerbations and complications and the reduction of recovery time. The ‘acute care model’ directs responsibility for problem solving to the clinician and responsibility for daily chronic-care management to the patient, typically without self-management support. A comprehensive approach to chronic-care management calls for multidisciplinary teams (e.g. nurses, therapists, social workers, pharmacists, dieticians) to support the individual over time and take responsibility for patient outcomes with general practitioners (GPs). Improved health status and outcomes have resulted from holistic and patient-centred programmes that offer self-management support services [5]. The literature strongly suggests that change may only be achieved through multicomponent interventions [6–8]. Integrated care models, such as disease-management programmes (DMPs), capture the complexity of coordinated healthcare provision for chronic conditions. DMPs aim to improve the effectiveness and economic efficiency of chronic-care delivery [9] by combining patient-related, professional, and organisational interventions [10].

Currently, the extent to which DMPs provide patients with better experiences and higher quality of care remains unclear. Assuming that the rationale underlying DMPs (i.e. evidence-based, structured care focused on patient activation) is legitimate and favours better outcomes, we should expect healthcare professionals participating in DMPs to provide higher-quality patient care than non-participating providers [11–13], and expect patients to perceive their care as such.

The Netherlands has implemented several parallel policies that target specific elements of the chronic-care continuum. To facilitate regulated competition, Dutch authorities have taken measures to improve information on healthcare quality, thereby supporting negotiations between healthcare purchasers and providers. Such measures have resulted in the development of a care standard for COPD that includes multidisciplinary evidence-based guidelines, process protocols, and performance indicators. Patients were involved in developing the measures to ensure patient empowerment within the context of regulated competition [14]. Furthermore, several health care reforms and a national health insurance system were implemented to stimulate integration of care [15, 16]. The introduction of the Health Insurance Act (Zvw) in 2006 was the most important, which set the foundations for a regulated market in the Dutch health care system [17].

The Dutch policies as well as most DMPs are based on the chronic care model (CCM) introduced by Edward Wagner [8, 18, 19]. The CCM was developed as a foundation for redesigning primary-care practices and forms the basis for effective chronic care management. It addresses shortcomings in acute care models by identifying essential elements that encourage high-quality chronic-disease care [8, 19] The model provides an organised multidisciplinary approach to the delivery of care for patients with chronic diseases, which involves the community and healthcare system and fosters communication between clinicians and well-informed patients. The goals of the CCM model are: (1) to improve chronic-disease management, (2) to facilitate the prevention of complications, and (3) to improve outcomes, including healthcare utilisation and quality of life.

The CCM has received widespread attention [20], including a recent evaluation of the elements that most improve care processes, costs, and clinical outcomes for patients with diabetes [21, 22]. The Patient Assessment of Chronic Illness Care (PACIC) instrument has been proven to be a reliable and valid tool [23] to measure quality of care according to the CCM. It addresses the extent to which provided care complies with the CCM from the patient’s perspective based on his or her experience. Because DMPs seek to structure care in accordance with the core elements of the CCM, we hypothesised that DMP-enrolled patients would achieve higher PACIC scores than non-enrolled patients, suggesting better quality of care. Specifically, we sought to determine whether patients with COPD who were enrolled in DMPs perceived quality of care to be better than patients with COPD who received regular care.

Methods

Results

Table 1 provides the sample characteristics for DMP-enrolled (n=665) and non-DMP-enrolled (n=227) COPD patients. Of the 892 respondents (out of 1654; 54% overall response rate; of which 50% response rate in the control group and 58% response rate in the intervention group), 46% were female, 50% had a lower educational level, and 33% were single. Mean age was 66.1±10.6 years (range: 20–92 years). We found no significant differences in patient characteristics between groups; the two patient groups (patients in DMPs and patients who received regular care) are comparable in age, gender, marital status, educational level and self-rated health.

The mean overall PACIC score of DMP patients was 2.94, significantly higher than non-DMP patients (2.73; p≤0.01; Table 2). Differences in the same direction were found in the subscales of patient activation (p≤0.01), delivery-system/practice design (p≤0.001), and problem solving/contextual (p≤0.001). Mean scores for goal setting/tailoring (2.75 vs. 2.65) and follow-up/coordination (2.23 vs. 2.17) were higher for DMP patients, but not significantly. The greatest nominal difference was for problem solving (0.36) and the smallest was for follow-up/coordination (0.06).

Discussion

In comparison with non-DMP-enrolees, patients enrolled in DMPs were more likely to receive CCM-directed, patient-centred, structured collaborative care. Our large cross-sectional study demonstrated significant differences in quality of care as assessed by the PACIC instrument. The differences were largest for the patient activation, delivery-system/practice design, and problem solving/contextual scales. Patients not participating in DMPs received lower levels of quality of care aspects measured by all subscales of the PACIC, albeit not all differences were statistically significant. In line with earlier research findings for diabetes patients enrolled in DMPs, DMP patients with COPD received better care than those who did not participate in such programmes [25, 26]. The higher but not significantly different mean scores of DMP patients for the goal setting/tailoring and follow-up/coordination subscales may be due to the early stage of DMP implementation. These two aspects of care typically provide benefits in the long-term, and we expect them to show significant improvement in future measurements. Other qualitative research also showed that a holistic approach is needed in the treatment of COPD, which includes an individual treatment plan aimed at smoking cessation, optimisation of pulmonary status by pharmacotherapy and exercise embedded in a new lifestyle [27].

The mean age of our study population is comparable to a study of Wensing and colleagues [28] who also studied PACIC scores among COPD patients in rural areas in the Netherlands. The mean age of COPD patients in their study population (n=77) was 67.2±11.7. Their study population contained fewer women (35%). They reported a mean overall PACIC score of 2.3 for COPD patients in 2008. Their COPD patients were recruited from general healthcare practices who did not implement a DMP or interventions to enhance structured/integrated care. The control practices in our study did implement the COPD care standard, which may explain the higher PACIC scores among both patient groups.

The most important limitation of this study is the cross-sectional nature of the data. Our findings will be updated and expanded when the results of the final evaluation of the national study become available. In particular, we will assess whether clinical parameters improve among DMP patients. Furthermore, the control practices were in the process of implementing interventions, such as the care standard that may have biased the measure of usual care (patients not enrolled in DMPs). We were also unable to determine whether improvements in quality of care delivery were caused by the DMPs or other factors, such as the implemented parallel policies that target specific elements of the chronic-care continuum in the Netherlands. A longitudinal study is necessary to establish whether implementation of a DMP leads to improved care for COPD patients on top of implementation of the COPD care standard or implementation of other innovations, such as self-management programmes or electronic patient record devices (e-health) [29]. In addition, future research is necessary investigating the effectiveness of DMPs for specific subgroups (e.g. high versus low educated/mild COPD versus severe COPD). To our knowledge, this is the first large study assessing different types of care (DMP versus non-DMP) in accordance with the CCM from COPD patients’ perspectives with the PACIC instrument. The evaluation of large-scale programmes during implementation was challenging. DMP professionals faced many barriers that delayed their implementation; a shift toward patient-centeredness and increased self-management support placed new demands on them and their organisations.

Conclusion

Our results suggest that DMPs for COPD as currently established in primary-care settings in the Netherlands may significantly improve care. Patients recognised the changes in daily practice induced by the DMPs as care that was more structured and reflected the core elements of the CCM to a greater extent than regular care. The differences in patients’ perceptions may influence clinical and economic outcomes [22], since integrated care programmes based on the CCM that offer self-management support services have been shown to improve health status and outcomes [5, 30]. What makes this finding particularly interesting is that earlier studies evaluating the implementation of CCM elements assessed provider structures or addressed process parameters. Our results contribute valuable insight to the on-going discussion that seeks to identify effective improvements in the quality of care for patients with chronic conditions. Our findings suggest that COPD care may be improved through the implementation of integrated DMPs.

Reviewers

Stephen Abbott, Research Fellow, Division of Health Services Management and Research, School of Health Sciences, City University London, Northampton Square, London EC1V 0HB, UK

Birthe Dinesen, Associate Professor, PhD, Master in Administration, SMI, Department of Health Science and Technology, Aalborg University, Denmark

Diego A. Rodríguez, MD, Respiratory Medicine Specialist, Barcelona, Spain

Nina Szczygiel, PhD Candidate, GOVCOPP-DEGEI, University of Aveiro, Portugal

Tables