Impact of Multidisciplinary Care, Structured and Targeted on the COPD Patient's Clinical Pathway.

Chronic obstructive pulmonary disease (COPD) is a chronic, irreversible respiratory illness with a poor prognosis, associated with several comorbidities such that its burden on quality of life is heavy. In 2009, its prevalence was estimated at 7.6% of the world's population, with the elderly the most affected, accounting for 14.2% of people over 65. In 2020 it was the 4th leading cause of death worldwide, and projections put it in 3rd place. In France, its annual cost was estimated at 4366 euros per patient, including 25% related to the management of exacerbations and 33% to hospitalization. In 2014, the prevalence of COPD in France was estimated at 7.5% of the population. Projections of the epidemiological evolution of COPD systematically predict an increase in the prevalence of moderate to very severe COPD, notably due to an increase among women and subjects aged ≥ 75 years. Management of COPD patients, aimed at slowing the progression of the disease and improving patients' quality of life, is multi-dimensional and multi-professional. In January 2020, with this in mind, the French National Authority for Health (HAS) issued recommendations for comprehensive management of the disease. These include smoking cessation, influenza and pneumococcal vaccinations, therapeutic training on the use of inhalation devices, and pulmonary function tests. In 2022, the French health insurance scheme also measured quality indicators to assess the care pathway for COPD patients. Among these indicators, two concerned the management of stable patients: influenza vaccination, performed on only 52.7% of patients, and PFT or annual spirometry in 34.2% of patients. Indicators concerning post-hospitalization medical follow-up were also deemed insufficient, with only 41.9% of patients receiving medical follow-up within 7 days of hospitalization for COPD exacerbation, and 30.9% receiving follow-up by a pulmonologist within 60 days. Recently, in 2023, an observational study was carried out at Nîmes University Hospital, and is currently under review for publication. The aim of the study was to assess the profile of hospitalized COPD patients, as well as compliance with HAS management recommendations. Of the 85 patients included, 59 (69.5%) had a COPD-VQ-11 score ≥ 22, reflecting poor COPD-related quality of life, and 30 (35.3%) were not followed by a pulmonologist. Twenty-five patients had not quitted smoking (32.9%), and pneumococcal vaccination coverage was only 34% (10% in patients not followed by a pulmonologist).Thanks to their daily presence and expertise in care departments, hospital clinical pharmacists can carry out targeted interventions tailored to individual patients, in addition to their usual tasks such as medication conciliation and pharmaceutical analysis. During a hospital stay, for example, they can identify shortcomings in the care of certain chronic diseases and, if necessary, intervene with the patient or the care team.

As part of their new missions, clinical pharmacists can also take part in day hospitalizations (DHs) by doing pharmaceutical consultations with patients. For example, since 2021, a respiratory insufficiency DH has been set up at Nîmes University Hospital. This DH, coordinated by an advanced practice nurse (APN), enables multi-professional reassessment of the care of COPD patients, and targeted interventions such as PFTs or stress tests, vaccination prescriptions, help with quitting smoking and training on the use of inhalation devices. Based on these findings, and using the tools and resources available at Nîmes University Hospital, the aim is to evaluate the impact of a structured, multi-disciplinary care process for hospitalized COPD patients, focusing on changes in their quality of life, a reflection of their state of health, as well as on their care pathway. The hypothesize is that this targeted intervention could improve patients' COPD-related quality of life, and reduce mortality, exacerbations, hospitalizations, cardiovascular events, emergency room visits and consultations with general practitioners (GPs). This intervention could improve smoking cessation and vaccination coverage among patients. Finally, the medico-economic efficiency of this process will be assessed via a cost-utility analysis. More generally, the national supply of care for certain chronic diseases is currently limited and saturated, leading to difficulties in management and medical follow-up, and resulting in an unfavorable trend in patients' state of health. It is in response to this problem that this study, focusing on COPD, aims to assess the feasibility and effectiveness of a structured, multidisciplinary care concept hitherto never implemented in this region. Such an approach could make it possible to detect patients suffering from chronic diseases not only like COPD, but also heart failure or diabetes, and optimize their care through interventions and the organization of a dedicated care pathway. This care would be based on the various clinical pharmacy missions carried out during the hospital stay, and the deployment of optimized DH pathways for high-performance global care. This pilot study aims to obtain the initial indicators required to set up future comparative multicenter studies with a high level of evidence on efficacy and costs.