Population health management in chronic obstructive pulmonary disease: an official American Thoracic Society Workshop Report.

Abstract

Despite decades of research and advocacy, the quality of care for chronic obstructive pulmonary disease (COPD) remains poor. Millions of patients fail to receive appropriate care, and fundamental changes are needed to improve care quality and patient outcomes. Guided by the Triple Aim of (1) improving population health, (2) improving individual patient experience, and (3) reducing per capita costs for care, population health management strategies aim to redesign healthcare. By adapting the delivery, coordination, and payment of high-quality services, population health management strategies hold promise to improve care for the large and heterogeneous COPD population. This workshop included a multidisciplinary panel of patients, payers, health system leaders, pulmonologists, primary care providers, pharmacists, nurses, and researchers to envision future models of care that achieve population health management for COPD. Past research demonstrates the effectiveness of population-based health system interventions to improve COPD case finding, primary and specialty care integration, inpatient management, and postdischarge services among patients with COPD. Sustaining these interventions will require value-based payment arrangements and adaptations to clinical care processes. The field will need to define meaningful outcomes and tailor appropriate team member roles and responsibilities. As part of healthcare redesign, workshop members recommended adopting effective strategies to encourage personalized high-quality decision-making (eg, nudges) and employ study designs that rigorously and quickly test interventions (eg, pragmatic and adaptive designs). To ensure patient centeredness, it will be essential to incorporate patient and caregiver perspectives and leadership into redesign efforts.