July 24, 2024

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Primary Care COPD Clinic Could Be a Model for Lasting Survival Benefit

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A regional primary care, nonphysician-based program for chronic obstructive pulmonary disease (COPD) was associated with improved longer-term survival, a propensity-matched cohort study in Hong Kong showed.

COPD patients seen in family medicine and general outpatient clinics that participated in Nurse and Allied Health Clinic-Respiratory Care (NAHC-Respiratory) had lower risks of all-cause mortality through roughly 7 years of follow-up compared with patients who had usual care at other public outpatient clinics (32.1% vs 37.2%, HR 0.84, 95% CI 0.78-0.90), reported Kailu Wang, PhD, of the Prince of Wales Hospital in Hong Kong, and co-authors.

NAHC-Respiratory was also associated with significant reductions in various cause-specific deaths:

  • Pneumonia mortality (9.6% vs 11.3%, HR 0.85, 95% CI 0.74-0.97)
  • Respiratory mortality (14.6% vs 16.8%, HR 0.86 95% CI, 0.77-0.96)
  • Cardiovascular mortality (3.2% vs 4.3%, HR 0.74, 95% CI 0.59-0.93)

Exposure to the NAHC-Respiratory program was further associated with reduced rates of both visits to the emergency department (incidence rate ratio [IRR] 0.92, 95% CI 0.86-0.98) and hospitalizations through the emergency department (IRR 0.89, 95% CI 0.83-0.95), Wang and colleagues said in JAMA Health Forum.

“This study provides evidence that the care model involving nurses and allied health professionals can facilitate COPD treatment, highlighting that health care professionals other than physicians are important in patient follow-up and disease management in the primary care setting,” the authors concluded.

The report adds longer-term benefits to the existing evidence of improved lung function and quality of life among NAHC-Respiratory participants after 6 and 12 months.

NAHC-Respiratory was introduced to Hong Kong primary care settings in 2009 as a program — primarily coordinated by nurses, physiotherapists, and occupational therapists — for patients with COPD and those with a high risk of developing COPD referred by physicians.

The public sector program offered patient education on physical exercise and lifestyle, smoking cessation, vaccinations, and pulmonary rehabilitation for enrolled patients with a relatively low baseline mortality risk.

Wang and colleagues suggested that the benefits they observed may be attributed to influenza and pneumococcal vaccinations and smoking cessation.

Notably, the all-cause mortality benefit hinged on age, being statistically significant only for patients 60-79 years old at baseline (HR 0.82, 95% CI 0.74-0.90) and ever smokers (HR 0.75, 95% CI 0.68-0.84). Associations with all-cause mortality were not significant among patients who were under the age of 60, were 80 years old or above, were non-smokers, or for patients without smoking status records.

“These findings indicate the program’s potential to improve long-term health outcomes of patients with COPD and save health care resources of hospitals through a primary care intervention, although improvement of service provision may be needed for patients younger than 60 years,” researchers wrote.

COPD is associated with a number of other conditions, including respiratory failure and cardiovascular disease. While it cannot be cured, it can be managed and its severity reduced.

Wang and colleagues conducted the study using electronic health records from Hong Kong’s public health care services.

Patients who joined NAHC-Respiratory in 2010-2014 were counted in the treatment group. Propensity score matching paired 3,093 people in this group with 5,955 people from the reference cohort of patients who received usual care at various general and specialist clinics from 2010 to 2019.

Average patient age was nearly 70 in both groups, and the population was about 91% men. An average of 0.6 years elapsed between COPD diagnosis and index date, the first attendance date in the NAHC-Respiratory program or usual care. Approximately 45% of participants were known smokers.

Exposure to the NAHC-Respiratory clinic was not associated with significant changes in pneumonia, respiratory failure, lung cancer, pulmonary heart disease, pneumothorax, anemia, polycythemia, and depression.

Study results were supported by sensitivity analyses restricted to patients who had survived for a minimum of 2 years after the index date.

Wang’s team acknowledged that NAHC participants, having voluntarily attended the program, may have been disproportionately motivated to manage their health conditions. Other limitations included potential unmeasured confounding from the study’s observational design, and a lack of comprehensive spirometry and other lung function data.

  • author['full_name']

    Elizabeth Short is a staff writer for MedPage Today. She often covers pulmonology and allergy & immunology. Follow

Disclosures

No disclosures were reported.

Primary Source

JAMA Health Forum

Source Reference: Wang K, et al “Outcomes and hospital service use among patients with COPD in a nurse- and allied health–led clinic” JAMA Health Forum 2024; DOI:10.1001/jamahealthforum.2024.1575.


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