COPD Disease Management

Introduction

Disease management is a systematic approach to the long-term management of patients with chronic illnesses. Chronic illnesses are viewed from their impact on the individual, society, a population and the economics of the healthcare system. Most of the diseases or conditions that lend themselves to a disease management approach are chronic and progressive with episodes (or exacerbations) that require acute intervention. Both the chronic nature and the exacerbations are controllable. Such control relies heavily on the patient. How skillfully these patients care for themselves on a daily basis is central to such control. Regular and consistent self-care, monitoring for exacerbations and patient-initiated rapid response when an impending exacerbation is detected will help control the disease, avert medical emergencies and forestall disease progression. Thus, patient self-management in collaboration with the healthcare team should reduce/prevent the need for acute interventions and hospitalizations.

While standard medical care focuses on acute interventions, disease management attempts to limit or prevent the need for such intervention. For example, diabetic crises can be averted, asthmatics need not be symptomatic or endure exacerbations, and hospitalizations for congestive heart failure can be avoided. In planning a disease management approach, it is necessary to understand the disease, how it affects the individual, how it progresses over time, and which disease benchmarks have a clinical and physiological impact.

Conditions commonly managed by disease management include diabetes, obesity, arthritis, hypertension, asthma and congestive heart failure. These are conditions that lend themselves to daily management by the patient with self-care, self-monitoring and action plans. Chronic obstructive pulmonary disease (COPD) is a recent addition to chronic disease management.

The greatest stakeholders in instituting disease management programs are those who bear the financial burden for populations of patients with chronic conditions: insurance companies, health plans, Medicare, Medicaid and national health plans of various countries. There is also a growing interest among pharmaceutical companies, whose medications are utilized in Disease Management programs. Thus, in most cases disease management programs are driven by an economic need to manage costs. While individual healthcare providers offer some disease management, most organized efforts are contracted through commercial companies whose nurses call patients at risk for acute events to help maintain disease control. They are evidence based and utilize large computer data bases. Large corporations are major stakeholders and invest heavily in such programs. Recognizing that 20% of the COPD population generates 66% of costs (1), the diagram below shows a typical approach to triaging patients within health plans to receive various levels or complexities of disease management intervention

Figure 1. Proportions of Disease Management Interventon.

The Disease Management Association of America (DMAA) http://www.dmaa.org/ (website described in detail in a later section), is an organization of disease management companies, health plans, benefits administrators, employers, pharmaceutical manufacturers, pharmacy benefit managers and home health providers. It has been instrumental in setting standards. The goal is to “effectively manage disease and prevent complications through adherence to medication regimens, regular monitoring of vital signs and healthful diet, exercise and other lifestyle choices.”  On their website the DMAA describes six components to effective disease management: 

• Identification of population
• Evidence-based practice guidelines
• Collaborative practice models to include physician and support-service providers
• Patient self-management education
• Outcomes measurement
• Routine reporting/feedback loop

About the Chronic Care Model

An alternate approach to the foregoing Disease Management model focuses on how and when healthcare is delivered. The chronic care model as advanced by Ed Wagner, MD, of the MacColl Institute (http://www.centerforhealthstudies.org/research/maccoll.html), focuses on the health care delivery system. Basically the present healthcare system is not ideally suited to manage chronic illness. Instead of attempting to improve the quality of healthcare delivered by the present system, the model seeks to change the system itself. Evidence-based guidelines must be instituted in a systematic and predictive manner utilizing patient-centered protocols that are regularly reinforced. It recognizes that didactic patient education is largely ineffective in modifying and maintaining self-management behavior. Instituting a chronic care model may be more likely to include the patient’s physician. 

(Video presentation http://www.researchchannel.org/prog/displayevent.aspx?rID=3877)

Chronic Care Delivery Components

1. Patient-centered (informed and activated to be wise participants)
2. Team involvement of physician and non-physician
3. Shift from the acute to the planned visit – designed to be a productive interaction.
   1. Individually or in groups
   2. Protocol driven
   3. Active sustained follow up with proactivity
   4. Intense monitoring and timely and effective interventions
4. Clinical case management services
5. Integration of guidelines into the flow of decision making
   1. Involvement of specialist
   2. Share guidelines with patients

Figure 2. The chronic care model (http://www.improvingchroniccae.org/index.php?p=The_Chronic_Care_Model&s=2)

COPD – Basis for Disease Management Approaches

COPD is a mosaic of chronic bronchitis, emphysema, bronchiectasis and partially reversible asthmatic bronchitis components that limit bronchial airflow and cause hyperinflation. The proportional inclusion of each of these components may well determine the clinical presentation, the specific impact of the disease and consequently the best intervention. The natural course of the disease is chronic and progressive physiological deterioration punctuated by acute-on-chronic exacerbations. Abnormal chronic and acute inflammation and oxidative stress play important roles in this process. Prevention and early management of exacerbations will likely ameliorate the impact of the disease. Left unchecked, the physiological deterioration will drive clinical impact and deterioration. As the disease evolves, its impact on the patient and family becomes part of the disease itself. Hence, the clinician must consider not only the pathophysiology and multiple exacerbations but psychosocial factors as well.

However, every aspect of the disease including comorbid conditions may be treatable and thus, lend themselves to a disease management or a chronic care model approach. Exacerbations can be prevented or detected early and dealt with through pre-prescribed rapid action plans, thus preventing respiratory failure and the need for hospitalization. The evidence base can be accessed from the pulmonary rehabilitation, physiology and pharmacology literature. Pulmonary rehabilitation and its associated tools, including exercise, are critical to the success of self management, active lifestyle and quality of life (http://www.chestjournal.org/cgi/reprint/112/6/1630).

Chronic disease control is facilitated by training and reinforcing the effective self-administration of inhaled medications, oxygen and an exercise program to help maintain an active lifestyle.  The disease management diagram from the ATS/ERS COPD Guidelines Disease Management Section (Figure 3) describes the physiological deterioration and modifiable components affecting disease progression in the bottom panel. However, the clinical presentation in the top panel describes clinically distinct disease benchmarks. Interventions can be determined by this clinical presentation as shown in the center panel.

Figure 3. Disease management diagram from ATS/ERS COPD Guidelines.
(http://www.thoracic.org/sections/copd/for-health-professionals/index.html).

Last Update: October 2009

Search

A Google™ Search using the term disease management, turned up 67 million hits. The term chronic disease management turned up 13.3 million hits. Searching with quotation signs, disease management yielded 1.34 million hits. Searching for chronic care model for COPD brought up 687,000 hits.  Since COPD disease management is not a mainstream field, known authors in the area were included as part of the search.
  
A Google search for "disease management" and “pulmonary rehabilitation” yielded 43,500 hits. Websites consisted of descriptive sites, research and review articles, national organizations, boards of quality assurance and commercial sites. Since a substantial number of players in this field are commercial, their detailed information tends to be proprietary and unavailable. However, it is helpful to search authors known for their work in disease management/pulmonary rehabilitation.

Google advanced search was easier, more specific and more precise. The top section “Find Results” allows the searcher to specify whether you are searching for all of the words, exact phrase, which words to specifically include or exclude. For example, you can search for a particular subject but always include or exclude a particular author. The Advanced Search Tips at the top-right section of the opening Google page is very helpful and will save hours of searching time.

Bookmarking favorites and organizing information into folders enables the retention of search items and methodology. Such organization will often be a practical reminder of why you embarked on that search.

The websites below are assembled to reflect the diverse approaches to disease management and chronic care as created and presented by the various stakeholders. We are not endorsing any specific organization by including them.

Best Websites

Institute of Medicine

Category: Healthcare Models. This is a not-for-profit, nongovernmental organization chartered in 1970 as a part of the National Academy of Sciences. Its purpose is to provide national advice on issues relating to biomedical science, medicine and health. The Institute funded a report, Crossing the Quality Chasm (http://www.iom.edu/CMS/8089.aspx), which criticizes the fragmentation of healthcare requiring patients to jump through hoops in complex medical situations and that people with chronic conditions receive recommended care only about 50% of the time. The goal is to integrate a fragmented system by building strong information pathways between all the stakeholders: patient, physician, family members, caregivers and payers while facilitating an organized team approach.

1. Authority: The organization behind this website is clearly identified and are leaders in the field. Their mission is clear. The cited article, Crossing the Chasm, is referenced throughout the literature and helped to establish the field of chronic care. The basis of information is clear. Their bibliography and research documents are high quality and their opinions are authoritative. Their studies are well referenced. There is no indication of financial bias. Their links reflect reliable authorities including major boards and quality research. Rating: 5

2. Currency: Their material is up to date. It is date referenced and timely. Rating: 5

3. Accuracy: The content comes from multiple sources that have authority and respect in the field. It is based on evidence in some cases and expert opinion in others. Speculative areas are generally identified and relevant to their messages. Rating: 5

4. Navigation & Readability: The layout is clear and links are well identified. It is easy to find what you want and the site is searchable. The material is understandable and well presented. It is easy to navigate the site and the “Find Feature” on the computer can be utilized to find keywords. Graphics are excellent. Crossing the Chasm is easily located by searching for disease management. Rating: 5

5. Utility: The material is free and available. Downloads are easy and no sign-in is required. Much of their material is not available from other sources. It is a great teaching resource and you do not need to be a member or even sign in. We would return to the site. It is useful to ATS members who wish to expand their vision of healthcare delivery. It is a great teaching source. Rating: 5

Summary: This site is an excellent initial and basic resource for disease management and chronic care.

Disease Management Association of America (DMAA)

Category: Healthcare Models. This is both a professional and trade organization of the disease management industry. Their website focuses on disease management, research support, advocacy, news and publications including their journal. Their website provides considerable insight into the field, stakeholders and where they see the field heading.

1. Authority: Their contributors, organizations and stakeholders are clearly identified in the section about its members with links to their websites. The DMAA and its Board are clearly leaders in the field of disease management rather than medical subspecialties of the diseases managed. They are powerful representatives of a large industry that may not be generally known by clinical specialists in the field they represent. There is an appropriate “About Us” that identifies the DMAA and its leaders. Some of their content is evidence based. The area of disease management along with some of its outcomes may be a subject of controversy (http://www.cochrane.org/reviews/en/ab002990.html ), but it is addressed in the website publications - see Disease Management: A Leap of Faith to Lower-Cost, Higher-Quality Health Care (http://www.hschange.org/CONTENT/607/ ). The missions of DMAA are clearly identified. There is a strong commercial influence in many of the stakeholders represented. However, the material is useful, informative and provides an important insight into the field of disease management. There are links to reliable authorities. One of the most useful links is to a testimony by Christobel Selecky to the U.S. House Ways and Means Committee Subcommittee on Health The New Chronic Care Improvement Program within Medicare (http://www.dmaa.org/pdf/seleckytestimony.pdf). Rating: 4

2. Currency: Their content is up to date. It is well dated. Rating: 5

3. Accuracy: The material is accurately presented and is evidence based. Controversies are discussed and claims regarding the benefits of disease management are well referenced. Speculative areas are identified. Rating: 4

4. Navigation & Readability: Navigation is excellent. The layout is clear and simple. The website is searchable and the material is understandable to the audience with good graphics. The links work well and provide rapid response. Rating: 5

5. Utility: Some of the material is free and accessible. Access to the journal, Population Health Management, disease management is generally limited to their members. The problem with this is that a significant amount of information in disease management does not fall into the usual path of medical literature inquiry. Their national meetings appear comprehensive but expensive and attendance consists of disease management organizations and support organizations, health plans, pharmaceutical manufacturers, pharmacy benefit managers, software providers, hospitals and home health providers. The DMAA website is a great and central reference to this important and developing healthcare area and very useful to ATS members interested in learning what services health plans may be providing their patients. Rating: 5

Summary: This site is a good resource to understand the field of disease management and the major players in the field.

Life Masters Supported SelfCare

Category: Commercial Disease Management Companies. Life Masters Supported SelfCare provides programs and services that create healthcare partnerships among individuals, their physicians and payors. They offer programs for patients with diabetes, congestive heart failure, coronary artery disease, hypertension, COPD and asthma. They work with 600,000 patients.

1. Authority: The website and its commercial mission are clearly identified and well presented. There is good contact information and an appropriate “About Us.” Their sources are well documented and their contact information is accessible. They are clearly leaders in the field with multiple contracts with Medicare, Medicaid and private insurers. Their methodology is described in general but like all disease management companies, the details are proprietary. The basis for the information provided is insurance data and outcomes studies. They provide appropriate references for data on chronic illnesses. They are a commercial company but have a section on their financial sponsorship. There are links to reliable authorities. Rating: 4

2. Currency: Their material and website is up to date. Rating: 5

3. Accuracy: Some of their references are evidence based. Their data are not based on randomized controlled studies but rather are outcomes data. However, financial investments in their services are based on outcome performance. Outcome methodology is subject to some controversy. Rating: 4

4. Navigation & Readability: This website is clear and easy to navigate from the homepage. A site map is unnecessary. The material is understandable and well presented and the layout is simple and aesthetically pleasing. The links work well and the graphics come up nicely. There is no search engine; however, a general Google search that includes the name of the website or organization will accomplish that goal. Rating: 5

5. Utility: The material is general, useful and free. You do not need to be a member to benefit from the website. It is useful for a better understanding of the disease management approach by a commercial firm and the numbers of individuals they serve. In that sense, it is useful for ATS members. Rating: 4

Summary: This site is an excellent resource to a commercial provider.

The National Pharmaceutical Council

Category: Pharmaceutical Industry. The National Pharmaceutical Council has written this excellent and comprehensive guide on Disease Management with a great set of references that provides some of the evidence base for Disease Management. The pharmaceutical industry has a keen interest in Disease Management.

1. Authority: The name of the sponsoring organization is clearly identified but the names of the contributors are not. There are excellent references and a good description of the problem and how disease management might work. There is no contact information. Some of the material is evidence based. Rating: 3

2. Currency: The material is dated 2003. There were significant advances and release of the newer ATS ERS guidelines and Canadian Guidelines since that time. Rating: 3

3. Accuracy: The content contains both evidence based materials and speculation. The speculation is clearly identified. Rating: 4

4. Navigation & Readability: This is a PDF document without a table of contents or bookmarks. The layout is good and the material is readable and understandable. PDF documents are easy to search using [control F] particularly using Adobe Acrobat 6 and later. Rating: 4

5. Utility: The material is free and serves as a good initial reference on the subject for members of the ATS. It introduces some of the major players in Disease Management. Rating: 4

Summary: This site enables the reader to better understand the interest of pharmaceutical firms in disease management.

OptumHealth

Category: Commercial Disease Management Companies. OptumHealth is a disease management company specializing in respiratory disease management including COPD. They publish white papers, case studies, reprints of published articles and other written materials to help expand and advance their messages about delivery of healthcare. Their COPD program provides education and support of self-management skills to help patients prevent exacerbations and disease progression. Their program is designed to improve quality of life while reducing unnecessary hospitalizations and healthcare costs.

1. Authority: The website and its commercial mission are well presented. They make a case for disease management programs that focus on the needs of the COPD patient rather than general disease management. They make assessments by specialty-trained registered nurses to determine the appropriate level of intervention - risk stratification. OptumHealth’s COPD program applies the best practices and clinical guidelines of Denver’s National Jewish Medical and Research Center. The reference the GOLD Guides on COPD, which does not focus on disease management. Rating: 4

2. Currency: Their material is date stamped and up to date. Rating: 4

3. Accuracy: Some of their references are evidence based. Their data are not based on randomized controlled studies, rather outcome data is cited. Outcome methodology is subject to some controversy. Rating: 4

4. Navigation & Readability: The site is easy to navigate and has a good search engine. Alternatively a general Google search that includes the name of the website or organization will accomplish that goal as well. The links work well. It would be nice to have more specific information on the methodology used. Rating: 4

5. Utility: Most material is free. Sign-in is not required. This site is a good source for ATS members because more than 50 million patient clients have been served in some way. Thus, it is possible that some of your patients on a particular health plan may be receiving their services. Rating: 4

Summary: This site is an excellent resource to a commercial provider.

The National Pharmaceutical Council

Category: Pharmaceutical Industry. The National Pharmaceutical Council has written this excellent and comprehensive guide on disease management with a great set of references that provides some of the evidence base for disease management. The pharmaceutical industry has a keen interest in disease management.

1. Authority: The name of the sponsoring organization is clearly identified but the names of the contributors are not. There are excellent references and a good description of the problem and how disease management might work. There is no contact information. Some of the material is evidence based. Rating: 3

2. Currency: The material is dated 2003. There were significant advances and release of the newer ATS/ERS guidelines and Canadian Guidelines since that time. Rating: 3

3. Accuracy: The content contains both evidence-based materials and speculation. The speculation is clearly identified. Rating: 4

4. Navigation & Readability: This is a PDF document without a table of contents or bookmarks. The layout is good and the material is readable and understandable. PDF documents are easy to search using control + f, particularly using Adobe Acrobat 6 and later. Rating: 4

5. Utility: The material is free and serves as a good initial reference on the subject for members of the ATS. It introduces some of the major players in disease management. Rating:

Summary: This site enables the reader to better understand the interest of pharmaceutical firms in disease management.

National Jewish COPD Disease Management Program (DMP)

Category: Nonprofit/Institutional Organizations The National Jewish COPD Disease Management Program (DMP) was introduced in 1998 and since then over 3000 people have participated. This site describes a successful approach and interventions which National Jewish utilizes on a daily basis (http://www.njc.org/disease-info/diseases/copd/progs/index.aspx). Specifically the Action Plan for COPD can be viewed on this website( http://www.njc.org/pdf/copd_action_plan.pdf).

1. Authority: National Jewish Medical and Research Center has been a long-standing resource for management of lung diseases. The names of the individuals responsible for their COPD treatment programs are clearly identified. Recognized experts review and approve materials placed on the site. National Jewish maintains the site and all materials are copyrighted. The site provides medical information and guidance regarding diagnostic and treatment options for COPD. There are links to federal data bases and information on lung disease that are of the highest level. The site contains most of the major topic areas for patients with COPD and is valuable if there is a need to refer patients or if you receive a patient who has used the services provided by National Jewish. Their Disease management overview is located at http://www.nationaljewish.org/disease-info/diseases/copd/progs/index.aspx and while there is a link, it is not obvious. Their action plan is located at http://www.njc.org/pdf/copd_action_plan.pdf and is up to date and user friendly. The site also includes research links on the right navigation bar for those interested, as well as, ongoing clinical trials for those who may qualify. The site lacks specific outcomes/research data with respect to their approach. However, searching by specific programs reveal scientific and lay information for specific clinical and research questions in the area. Contact information is presented. Rating: 5

2. Currency: The materials are current and have a copyright date located at the end of each page. Rating: 5

3. Accuracy: Few references are offered. Little original data is provided, yet what is offered is supported in the scientific literature. Rating: 5

4. Navigation & Readability: The site is easy to navigate and the layout is easy to follow. There are multiple layers of links to assist in moving from general discussions to specific details. There is a search engine in the upper-right corner to assist in locating specific information quickly. The material is written for the typical patient. There is a professional section that goes into detail. Rating: 5

5. Utility: The materials are free. Downloads are easy and PDF documents exist and can be saved and/or printed. It is a good resource for many questions that patients have and the site covers the need for a comprehensive approach and ongoing management of the disease. Most of the information is available from other sources and there is little that they have generated themselves. This site is a good reference for a comprehensive overview of a programmatic approach and easy-to-understand materials for patients. Rating: 5

Summary: This site is an excellent resource for COPD and disease management for chronic respiratory diseases.

Alpha Net’s Big Fat Reference Guide (BFRG)

Category: Nonprofit. Alpha Net’s Big Fat Reference Guide (BFRG) is the cornerstone of AlphaNet’s health management and disease prevention program for persons diagnosed with alpha-1 antitrypsin deficiency. It is a program or directed protocol that practically guides the patient or screening candidate for alpha-1 antitrypsin deficiency. It does require the reader to sign-in or obtain a new username and password.

1. Authority: The name of the organization is clearly identified and they are the true leaders in alpha-1 advocacy, research and education. The website has a well-defined mission and there is excellent contact information. The list of contributors are leading experts in the area and there are links to other reliable organizations and authorities. Sponsorship is clearly identified with separate links to their websites. Rating: 5

2. Currency: The material is dated and current. Rating: 5

3. Accuracy: The content is evidence based and boiled down to management approaches. Speculative areas are clearly identified. Rating: 5

4. Navigation & Readability: The layout is simple and clear. There are several opportunities to search the site including a search engine on the left side of the site. There are some links that occasionally do not work. Rating: 4

5. Utility: This site is not only informative but instructive. It provides the patient the opportunity to create their own self-management program and tells the professional how to support that effort. The material is free but you have to sign in. You do not need to be a member in order to fully benefit from the information and instructions. However, you receive a more complete version if you sign in and receive a number than by signing in as a guest. Downloads are easy and available. This site is essential for its mission: training patients, family and professionals on the nuts and bolts of detecting and managing alpha-1. This site should be bookmarked by all ATS members. Rating: 5

Summary: This site is an excellent resource for all alpha-1 patients and the professionals who work with them.

Improving Chronic Illness Care (ICIC)

Category: Chronic Care Model The chronic care model is described in this website in the ICIC organization of the MacColl Institute. Clicking on model talk in the left column allows the reader to view a lecture on the chronic care model by Ed Wagner, MD. This website is a part of the MacColl Institute. It is included because it is the best representation of the chronic care model in one location. They do not address COPD.

1. Authority: The organization and its contributors are clearly identified. They are recognized leaders in this area. This website presents the Chronic Care Model. Its identified mission is to teach and create partnerships through its link to http://www.newhealthpartnerships.org. It is free from commercial bias. There are links to reliable authorities. Rating: 5

2. Currency: The material is up to date. Rating: 5

3. Accuracy: The content is derived from a firm evidence basis. Rating: 5

4. Navigation & Readability: The site leads from beginning to end. It is easy to navigate. A search engine is unnecessary. The material is understandable and workable. Graphics are good. Rating: 5

5. Utility: The material is free. It is a very useful site for anyone wanting to develop a chronic care program or partner with the institute. It is highly recommended as a resource for ATS members. Rating: 5

Summary: This site is an excellent resource for the understanding, working and partnering with the Chronic Care Model. Unfortunately, COPD is not included.

MacColl Institute for Healthcare Innovation

Category: Chronic Care Model MacColl Institute for Healthcare Innovation. http://www.centerforhealthstudies.org/research/maccoll.html The mission of the MacColl Institute for Healthcare Innovation is to "bridge the worlds of research and clinical care." The institute develops, evaluates and disseminates information regarding innovations in healthcare delivery.

1. Authority: The contributors and leaders are identified; they are leaders in the field. Their mission is clear and contact information is provided. Their materials are evidence based and free from commercial bias. They have an excellent bibliography and their links go to reliable authorities. Rating: 5

2. Currency: The material is up to date and timely. Rating: 5

3. Accuracy: Their content is evidence based and speculative areas are clearly identified. Rating: 5

4. Navigation & Readability: The site is relatively easy to navigate and the layout is aesthetically pleasing. The site has a responsive search engine. The links work and the graphics are good. Rating: 4

5. Utility: The material is free and available. Downloads are easy. This is an excellent source for a better understanding of chronic care models for patients with chronic illness. In spite of the fact that there is little focus on COPD, it is a very useful site for ATS members interested in improving healthcare delivery. It is an excellent alternative site to the commercial disease management approaches. Rating: 5

Summary: This site is an excellent resource for the understanding, working and partnering with the chronic care model. Unfortunately, COPD is not included.

Mediline Plus from the National Library of Medicine

N/A

1. Authority: The contributors are leaders and organizations representing major medical care organizations such as the American Academy of Family Physicians, NIH and National Jewish are trusted resources. They provide a wide range of information and resource materials for patients, families and healthcare professional. Their materials are evidence based and free from commercial bias. They have an excellent bibliography and their links go to reliable authorities. Rating: 5

2. Currency: The material is up to date and timely. Rating: 5

3. Accuracy: Their content is evidence based and speculative areas are clearly identified. Rating: 5

4. Navigation & Readability: The site is relatively easy to navigate and the layout is well categorized. The site has a responsive search engine. The links work and the graphics are good. Rating: 4

5. Utility: The material is free and available. Downloads are easy. This is an excellent source for a better understanding of the disease and how it affects patients. The focus is entirely on COPD and asthma. Tutorials are especially useful. It is an excellent resource. Rating:

Summary: This site is an excellent resource for the understanding, working and partnering with the healthcare professional. Patients seeking further up-to-date information will find this site very useful.

Other Important Sites

• Brown & Toland Medical Group
  http://http://www.brownandtoland.com/publish/en/visitors/ourmedicalservices/disease_management/asthma___copd_management.html

  Category: Other Commercial Companies Providing Disease Management Services. The Brown & Toland Medical Group is a physician network in the San Francisco Bay Area, California. It provides comprehensive and coordinated healthcare to patients. They provide disease management for COPD and asthma patients. Click on reasons to choose Brown & Toland then click on #8.

• McKesson Corporate: CareEnhance® COPD Program
  http://http://www.mckesson.com/en_us/McKesson.com

  McKesson Corporate: CareEnhance® COPD Program helps control avoidable costs by educating members/beneficiaries with chronic obstructive pulmonary disease (COPD) and helping them manage their accompanying health issues. They have programs to reduce the frequency of exacerbations. They have 24/7 phone access to nurse assessment services which advocates earlier symptom recognition and timely intervention. Home > For Payors > Public Sector > Disease Management and Nurse Triage Services > CareEnhance® COPD Program or Home > For Healthcare Providers > Hospitals > Contact Center Management > CareEnhance Call Center Modules > CareEnhance Call Center Disease Management.

• Matria Healthcare Inc.
  http://www.matria.com/

  Category: Other Commercial websites Matria Healthcare Inc. This site provides a comprehensive set of health enhancement solutions that include a combination of preventive, educational and care management services and programs designed to curb costs while improving employee health. The diagram on the home page describes what they do. Proceed to the Disease Management section of the website by clicking on the horizontal bar.

• Cardium Health Inc
  http://www.cardiumhealth.com/

  This directs you to Alere. This site provides a comprehensive set of health enhancement solutions that include a combination of preventive, educational and care management services and programs designed to curb costs while improving employee health. The menu on the top of the home page directs you to the disease management section of the website.

• Medicare
  http://www.medicare.gov

  Surprisingly, there is very little information on Medicare interest in COPD disease management via Google search, or by searching www.medicare.gov or www.cms.gov. However, a Medicare demonstration project that evaluated the effects of disease management in 15 programs yielded disappointing results as described in the following website: http://www.mathematica-mpr.com/health/bestprac.asp.

• Medicare Physician Group Practice Demonstration
  http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/PGP_Fact_Sheet.pdf

  This is a PDF file of a description dated January 31, 2005 of a Medicare project. Clinics involved are included. There is little emphasis on COPD in these projects.

• Testimony by Christobel Selecky, DMAA President, to the U.S. House Ways & Means Committee Subcommittee on Health "The New Chronic Care Improvement Program within Medicare"
  http://www.dmaa.org/pdf/seleckytestimony.pdf

  Testimony by Christobel Selecky, DMAA President, to the U.S. House Ways & Means Committee Subcommittee on Health The New Chronic Care Improvement Program within Medicare.

• Pulmonary Education and Research Foundation
  http://www.Perf2ndwind.org
• COPD Alert
  http://www.copd-alert.com/

Disclaimer

The author has no personal or financial interest in any of the websites discussed above. The authors have no financial interest in the websites cited in this Best of the Web. BT participated in the COPD Guideline Committee and website development and is a member of the board of Pulmonary Education and Research Foundation. He has also had a disease management practice for 12 years.

References

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8. Tom MA, Wilkinson A, Gavin C. Donaldson GC , Hurst JR, Seemungal TAR, Wedzicha JA. Early Therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004;169:1298-1303.
9. Turnock AC, Walters EH, Walters JAE, Wood-Baker. Action plans for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005;4:CD005074.
10. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1:2-4.
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