Features of the organization of medical care for patients with chronic obstructive pulmonary disease at the outpatient stage

The respiratory diseases (RD) are one of the main causes of morbidity and mortality worldwide. A special place belongs to chronic obstructive pulmonary disease (COPD), which is most often detected at 3-4 stages of the disease. Today, COPD is the 3- rd leading cause of death in the world, about 2.8 million people die from COPD every year, it is 4.8% of all causes of death. COPD leads to disability, a direct and indirect costs and represent significant economic and social damage [1].

COPD has increasing attention by the medical community in recent years, but this disease remains relatively unknown or of little significance for the general population, as well as for official representatives of the healthcare.

The treatment of patients with COPD requires an individual approach in accordance with the clinical characteristics of patients, the severity of the disease and the response to various types of therapy. The concept of self-management disease (SM) leads to disease control in order to achieve stability of its course. Stability of the disease is a condition characterized by the absence of exacerbations or changes in assessment tests (COPD Assessment Test or Clinical COPD Questionnaire scores) [2]. In recent years, there has been an accelerated development of modern technology in medical clinics. This leads to a general intensification of their activities based on the intro- duction of progressive and information technologies. SM was proposed as a key tool in COPD care and was represented by an action plan for patients to exacerbations thus the treatment can be initiated early [3].

The aim of the study. To conduct an expert analysis of the organization medical care for the outpatient patients with COPD and to assess of effectiveness SM telemedicine programs to improve the quality of life (QOL), the course of the disease and its prognosis.

Methods. An expert analysis was conducted of 92 outpatient cards of patients with COPD in 3 outpatient departments of St. Petersburg for the period from 01.01 to 31.12.2023 in accordance with the standard of medical care for adults with COPD [4]. The special telemedicine program was used for 34 patients with COPD (3 stage) during one year. The patient filled out an electronic diary (EXACT-PRO questionnaire) [5] on a special digital platform every day. SM of the exacerbation COPD was based on an assessment of his symptoms and treatment recommendations developed for the patient [3]. The MOS SF-36 questionnaire was used to assess the quality of life (QOL) [6].

Results. The study was conducted in 2 stages. In the first stage in first group was included 23 patients with stage 2 disease (moderate severity), the second group was included 69 patients with stage 3 disease (severe) according to the GOLD criteria, 2023 [1]. In 58% of cases, the disease was diagnosed at 3 stage, i.e. at the stage when treatment programs do not allow to slow down the steady progression of the disease. The average age of patients in 1 group was 61.45±1.02 years (M, SD), in the second - 66.65±1.28 years, in both groups there were a predominance of men (89%). Average duration of the disease: in 1group – 2.3±0.21 years; in 2 group – 6.2±0.98. Smokers accounted for 87% of the entire cohort, the average smoking index (SI) was 29.2±3.8 pack-years in 1 group and 36.5±2.4 pack-years in 2 group.

Table 1. The quality of medical observation of patients with COPD

The standard of medical care for adults with COPD [4] provides for the following: frequency of visits to a pulmonologist - once a year, visits to a general practitioner – once a year in the remission phase, the spirometry - once a year. In study was found that the number of visits to a pulmonologist per year was in the 1 group – 0.5 ± 0.12; in the 2 group – 0.75 ± 0.12 times, i.e., both in the first group and in the second group, patients did not receive the consultation with specialist in sufficient volume (table 1). At the same time, patients visited to general practitioner (GP) 1.7 ± 0.34 and 3.47 ± 0.71 times in the first and second groups, respectively. Moreover, the majority of all visits to GP (53.2% in 1group and 78% in 2group were unscheduled and were due to worsening of the disease (exacerbation) and followed hospitalization in a 24-hour hospital. The number of hospitalizations due to exacerbations per year was: in 1 group – 1.12 ± 0.34 cases; in 2 group – 2.35 ± 0.28. According to the GOLD definition, 2023 [1], each exacerbation of COPD increases the risk of an unfavorable outcome of the disease. The number of spirometry tests performed over the past year was 1.17 ± 0.33 in patients of 1group; 0.53 ± 0.15 in 2group (table 1). Preventive examination in the 1 group was 0.33 ± 0.08 per year; in the 2 group – 1.33 ± 0.25. Only 23% of patients in the 1 group and 28% in the 2 group are registered with active monitoring. Thus, the volume of outpatient medical care was lower in the first group. While medical intervention is most effective in preventing disease progression, disability and mortality in patients with COPD 2 stage.

Таble. 2. Assessment of rehabilitation measures in patients with COPD

Rehabilitation measures (resort, exercise therapy) was extremely low. Educational programs were attended by only 11.2% and 14.3% in the first and second groups, respectively (table 2). In both groups, insufficient work was done with patients to stop smoking, which was the main factor in the onset and progression of the disease. There was not the information about disease, no train- ing of patients in self-control skills. Within 2-3 years in 42% of cases the disease from 2 stage transformed into 3 stage. That indicates an insufficient volume of treatment and rehabilitation. Consequently, the current organization of medical care for patients with COPD at the outpatient stage is not satisfactory.

In most of patients at ordinary course of chronic obstructive pulmonary disease (COPD) arise acute episodes (the exacerbation). COPD exacerbations are important because they are associated with significant morbidity, healthcare costs and mortality. The Exacerbations of Chronic Obstructive Pulmonary Disease Tool-Patient-Reported Outcomes (EXACT-PRO) is a tool designed to assess the frequency, severity and duration of COPD exacerbations. The EXACT tool assesses patients' shortness of breath, cough and sputum production, chest symptoms, difficulty clearing sputum, feeling tired or weak, sleep disturbance and fear or worry about their condition using a 14-item questionnaire and a personal digital assistant.

At the next stage, to improve the quality of observation and reduce the number of exacerbations of the disease in 34 patients with 3 stage COPD we used motivational interview [7] and a telemedicine program SM for 12 months. Patients filled out an electronic diary on a special digital platform (EXACT-PRO questionnaire) daily, followed by SM of exacerbations based on an assessment of disease symptoms and developed treatment recommendations. If the patient encountered any difficulties, it was possible to contact medical personnel. Compared with the control group observed in the usual mode (32 patients, 3-d stage COPD, equal in age and gender), the number of exacerbations and hospitalizations in the study group decreased by 35% and 42%, respectively. QOL improved in terms of "activity" from 46.6±7.25 to 31.7±3.2 points, "total" – from 52.4±1.8 to 37.0±1.6 points. While in the control group it remained at the same values.

Systematic reviews and articles [3, 8] show that SM is recommended worldwide for patients with COPD, but interventions are heterogeneous and evidence of their effectiveness is contradictory. It is noted that a significant role in SM belongs to the patients themselves and their relatives.

Conclusion . Our study concluded that currently organization of medical care for patients with COPD at the outpatient stage is unsatisfactory. A priority area to optimize medical care for patients with COPD is further research development of a disease management system and criteria for assessing its effectiveness. This should ultimately lead to a decrease in the real burden of the disease for the patient, the health care system and the state system as a whole. We believe that SM is an integral part of modern patient-oriented medical care.