Transcript Learning Session 1 Presentation Slides

Shared System of Care (COPD)
Learning Session 1
www.pspbc.ca
“The best way to predict your future is
to create it”
Abraham Lincoln
“The best way to predict your future is
to invent it”
Steve Jobs
2
Aim
 To create a shared system of care that improves the quality of
care and experience for patients at risk for and living with COPD
by:
› Identifying early
› Using a team-based approach
› Improving communication
› Improving management
3
How will we achieve this aim?
At the GP practice:
 Enhanced identification and diagnosis of COPD
 Appropriate risk stratification based on level of airflow obstruction
and symptoms and exacerbation history – followed by review of
prescriptions
 Appropriate use of evidence-informed treatments for COPD
based on GPAC guidelines
4
How will we achieve this aim?
In a shared care environment:
 Implementing more standardized referral and consult letters, and
improving relationships, hand offs and communication between
GPs and specialist physicians
 Developing relationships and care plans amongst
GPs, patients, and community services
5
How will we achieve this aim?
Across the continuum
 Supporting patients to quit smoking
 Enhancing patient self-management skills for patients to manage
their condition
 Improving the patient experience with the system of care
6
How will we know if we are implementing changes
that will support our goal?
 % of COPD on register having confirmed diagnostic spirometry
 % of COPD patients with an exacerbation plan
 % of smokers on with COPD offered smoking cessation support
 % patients with COPD who have been referred to pulmonary
programs where available
 % of patients with COPD with a coordinated care plan amongst
GPs, specialists, and/or community resources
7
How will we know if we are reaching our goal?
 % of registry patients reporting an Emergency Department visit or
having an unplanned GP visit for COPD since their last
appointment.
 % of registry patients reporting a hospital admission for
COPD since their last appointment
8
Population
Target Population
Case finding
• New pts according to BC
Guidelines
• Possible-Dx COPD, no
spirometry
Confirmed Dx of COPD
(Positive spirometry)
9
Prevalence and Burden of COPD
10
Definition of COPD
 COPD is a preventable and treatable disease
with some significant extra-pulmonary effects
that may contribute to the severity in
individual patients.
 Its pulmonary component is characterized by airflow limitation that
is not fully reversible.
 The airflow limitation is usually progressive and associated with
an abnormal inflammatory response of the lung to noxious
particles or gases.
11
Asthma
12
Global disease burden
 1990 : COPD was 6th leading cause of death
 2001: Approx. 2.7 million deaths from COPD (more than 5% of
total death worldwide)
 2020: COPD is projected to be the 3rd leading cause of death
(approx 4.5 million deaths) only after the IHD and CVA
Murray and Lopez. Lancet 1997
WHO Report 2002
13
Trends in age-standardized death rates
(Percent change between 1970 and 2002)
14
Statistics (CTS report Feb 2010)
COPD now accounts for the highest rate of hospital admissions among major chronic illnesses in Canada (CIHI – 2008)
15
Hospital costs: Example in Lower Mainland: $40
million
16
Number of persons with COPD in BC
ESTIMATES
Actual
Projection
76,408
2004
80,268
2005
84,226
2006
87,725
2007
92,198
2008
95,216
2009
98,860
2010
102,504
2011
106,148
2012
109,792
2013
113,436
2014
117,080
2015
Assume relatively linear increase in prevalence will continue to 2014
Source: Actual figures from COPD registry data, Ministry of Health
17
450
Diagnosed with chronic bronchitis or emphysema
400
2
Airflow limitation (mild through very severe )
Undiagnosed potential
Rate per 1,000 of population
COPD is underdiagnosed
350
300
250
200
150
100
50
25–44
45–54
55–64
65–74
75
0
Age (yr)
1
Chronic Obstructive Pulmonary Disease Surveillance, United2 States, 1971–2000
Airflow Limitation, Mild Through Very Severe, Canada, 2005
1. Mannino DM, et al. MMWR. 2002; 51:1-16. 2. O’Donnell DE, et al. Can Respir J. 2008;15 (Suppl A):1A-8A.
18
Acute Exacerbations (AECOPD)
 An event in the natural course of the disease characterized by a
change in the patient’s baseline dyspnea, cough, and/or sputum
that is beyond normal day-to-day variations, is acute in onset, and
may warrant a change in regular medication in a patient with
underlying COPD.”
 Acute Exacerbations are the leading cause of deaths,
hospitalization and ER visits.
19
Outcomes After Hospitalized AECOPD
50
45
1,016 admissions
40
35
Mortality (%)
30
25
20
15
10
5
0
Hospital
60-day
180-day 1 year
2 years
1 year MI
Connors AF et al. AJRCCM 1996;154:959-67.
Schiele F, et al. Eur Heart J 2005;26:873-80
20
21
Primary Care
Physicians can treat
COPD
22
Case Finding for Possible COPD
Smokers or Ex-Smokers > 40 years old
And answers yes to any 1 question below
 Do you cough regularly?
 Do you cough up plegm regularly?
 Do even simple chores make you short of breath?
 Do you wheeze when you exert yourself or at night?
 Do you get frequent colds that persist longer than those of other
people you know?
23
Diagnosis
FEV1/FVC < .70
24
25
Stepped Approach to Care
End of Life Care
Individuals at Risk
•
Smokers
•
Environmental Exposure
Surgery
Oxygen
All Patients:
•
Exercise Rehabilitation
•
Smoking Cessation
•
Healthy Lifestyle
•
Patient Education
Theophyline (in certain patients)
Inhaled corticosteroids (with ‘LABA’)
Referral for Pulmonary Rehabilitation
Initial referral to Pulmologist, Respirologist or Other Specialist
Additional therapy: long acting bronchodilators
First line therapy: Short-acting beta2 – Agonists and Anticholinergics
Care Plan & Exacerbation Plans Created & Shared
Influenza & Pneumococcal Immunizations in GP Office
Smoking Cessation Education & Self Management Exercise & Lifestyle
Referral for Diagnostic Spirometry
Case Finding Spirometry by Primary Care Physician
Increasing severity of COPD
26
Indications for specialist referral:
27
What is Spirometry?
28
Assessing Disability in COPD
29
Purpose
 To accurately diagnose COPD at an earlier stage so
that subjects maybe be motivated to stop smoking using
such tools as the lung age.
30
Why perform spirometry?
 ???
31
Survival in COPD – Relationship to
Lung Function and Disability
Nishimura K, et al. Chest 2002; 121: 1434: 40
32
What does Spirometry measure?
 Forced Vital Capacity (FVC): the largest amount of air that can
be breathe out after you take your biggest breath in.
 Forced Expiratory Volume (FEV1): the amount of air you can
force out of your lungs in one second
33
Spirometry




FEV1
FVC
FEV1/FVC ratio
Bronchodilator change
34
Post bronchodilator change




FEV1 change > 12% or 200ml
Both asthma and smoking related COPD
Post BD improvement = better prognosis
No relationship to clinical response
35
Spirometry in COPD: False Positive
Aging
 FEV1/FVC ratio
36
Spirometry Summary




Routine workup of dyspnea
Confirm the diagnosis of asthma or COPD.
Classification - prognosis of COPD
Use detailed Pulmonary Function Tests selectively
37
The COPD – 6 - DEMONSTRATION
 If you have a normal result
has the potential to
rule out COPD
 May have some false
positives due to 6
second exhalation
time reducing the
denominator
ie
FEV1/FEV6.
 If FEV1/FEV6 is low ,<0.7 ,then refer to
accredited lab for definitive diagnosis
38
Copd-6 – Live DEMO or Video Clip
39
Results of blow
Green ≥ 80%+ratio > 0.70 = Not COPD
Green ≥ 80%
= STAGE I
Yellow = 50 - 80%
= STAGE II
Orange = 30 - 49%
= STAGE III
Red
< 30%
= STAGE IV
40
Indication of bad blow
41
The Copd-6 USB version’s printed report
42
…and now it’s your turn.
43
Our measures
Spirometer
COPD 6
FEV1
FEV1 % pred
FVC
FEV1/FVC
Result
GOLD Class
4.91
111%
6.32
0.78
Normal
Normal
3.31
88%
4.13
0.8
Normal
Normal
2.87
75%
4.63
0.62
Mild
Stage 2
1.69
66%
3.91
0.66
Mild
Stage 2
1.47
79%
2.26
0.65
Mild
Stage1
4.07
91%
5.48
0.74
Normal
Normal
1.84
88%
2.41
0.76
Normal
Normal
2.47
68%
4.11
0.6
Mild
Stage 2
0.96
61%
1.49
0.64
Mild
Stage 2
Test:
Performed 11 COPD-6 + Spirometry tests
on the same 11 patients to check for
correlation
Result:
Good correlation…pretty good tool!
Todd Gale’s (RT) Results
44
44
Shared Care-COPD: Early Identification of COPD Patients at Dr. Andre Van Wyk's
Practice June-Dec 2011
14
12
# of Pateints who have been screened for
COPD using the COPD-6/ month
10
8
6
# of Screened Patients who have a
positive COPD-6 Test
4
# of Patients who have a confirmed COPD
diagnosis
2
0
June
July
Aug
Sep
Oct
Nov
Dec
Month
45
Referral to Specialist &
Communication
Table Discussion - Communication issues
 How does referral/consult/communication process work in your
practice now?
 Challenges
 Suggestions for improvement
47
GP-Respirology
Referral Form
The cohort
will trial
this form
over the
Action
Period.
48
Consult
49
Developing an Office Approach
Office re-design for proactive shared care
 Need to understand work flow and processes as they exist and
improve --> MOA is the expert
 CDM Office System:
› Registry
› Clinical tool for care management and
monitoring (e.g. Flow sheet; Action-exacerbation
plan)
› Recall
› Analysis: Run charts
51
Office re-design for proactive shared care
 Shared Care
Communication
Referral  Consultation
New ways of working - e.g. telephone
Handoffs: Discharge, Re-Referrals
52
The patient registry
 A list of all patients with a particular condition
› e.g. Diabetes, COPD
 Based on registry, can set up system to organize care and
monitor patients’ progress (e.g. using flow sheets)
 Can recall patients per the patient registry
53
Identify eligible patients-interim registry
A.
Categories
1.
2.
3.
Case-finding-New patients per guideline-Simple spirometry
Case-finding-Dx COPD-no spirometry – simple spirometry
/Diagnostic spirometry
Confirmed COPD (spirometry positive)
B. Methodology to Identify Those Dx with COPD (#2 and 3
above):
1.
2.
3.
4.
Billing software (COPD Code: XX)
Paper chart review
EMR
Physician Profile Analysis Report
54
Identify eligible patients-final registry-confirmed
COPD
1.
New patients with Dx confirmed by spirometry (Dx code: 496)
2.
Dx COPD, no initial spirometry, Dx now confirmed with
spirometry
3.
Dx COPD, had confirmatory spirometry
55
Physician Profile Analysis






Secure and confidential report
Practice demographics
Complexity of patient population
Identifies potential gaps in care
Comparison to BC patients as a whole
Highlights your chronic disease patients
› Diabetes, Hypertension, CHF, COPD, kidney disease
56
Smoking Cessation
 Strategies and tools
 QuitNow
 Group discussion – how do you do it in your practice?
57
Smoking Cessation Objectives
1) How to approach and discuss smoking cessation with a smoker at
the various stages of change
2) Understand the efficacy of the most common cessation strategies
3) Be aware of the various community resources for smoking
cessation
4) Be able to offer a timely and effective smoking intervention
58
59
30-Second Assessment
 Do you smoke?
 Do you want to quit? Would you like some help?
 Ask yourself: Where are they in the Stages of Change/ Readiness
to Quit?
 CONVICTION/Importance (0-10)?
 CONFIDENCE (0-10)?
61
Comparing the Effectiveness (at 6 months or longer)
of Various Tobacco Cessation Interventions
Cessation or Quit Method
Varenicline (Champix)
3.22 (2.43-4.27)
Intensive Physician Counselling
2.04 (1.60-2.60)
Group Counselling
2.04 (1.60-2.60)
Bupropion (Zyban, Wellbutrin)
1.94 (1.72-2.19)
Nicotine Replacement Therapy
1.77 (1.66-1.88)
Telephone Helplines
1.41 (1.27-1.57)
Odds ratio of Cessation (95% Confidence Interval)
62
The Three Strategies Proven to Help Smokers Quit
1)
Brief advice – support from themselves, their family and their
physician, as well as groups (NA), Helplines and web-based
resources
2) Medication
3) Behavioral therapies – quitting skills, Cognitive Behavioral
Therapy skills (PSP Mental Health Module), Quit Quitting
Hospital Bedside Intervention movie (YouTube). Referral to a
smoking cessation clinic, i.e. Central Island Smoking
Intervention Clinic (CISIC), IHN programs, etc.
63
The Three Strategies Proven to Help Smokers Quit
1)
Brief advice – support from themselves, their family and their
physician, as well as groups (NA), Helplines and web-based
resources
64
Advising Patients to Quit
 In a clear, strong and personalized manner, urge every tobacco user to
quit at least once per year
› Clear
 “As your doctor, I believe it is important for you to quit smoking, and I can help
you.”
› Strong
 “I need you to know that quitting smoking is very important to protecting your
health now and in the future.”
› Personalized
 Tie tobacco use to health/illness (reason for office visit, i.e. URTI/bronchitis),
social/economic costs and impact on values (e.g., children)
65
Fiore MC et al. Clinical practice guideline: treating tobacco use and dependence. US Department of Health and Human Services. Public Health Service; 2000. Available at:
The Three Strategies Proven to Help Smokers Quit
1)
Brief advice – support from themselves, their family and their
physician, as well as groups (NA), helplines and web-based
resources
2)
Medication
66
Comparing Medications
Medication
Nicotine gum
Nicotine
patch
Treatment
length
1-3 months
8-12 weeks
Main side
effects
• Upset
stomach
• Hiccups
• Headache
• Disturbed
sleep
• Site rash
Dosage
2 mg, 4 mg
7 mg,
14 mg,
21 mg
Effectiveness
at six months
or longer
(OR [CI])
1.66
(1.52-1.81)
1.81
(1.63-2.02)
Nicotine
inhaler
12-24
weeks
• Irritation
of throat
and nasal
passages
• Sneezing
• Coughing
Bupropion
Varenicline
7-12 weeks
12 weeks
• Insomnia
• Nausea
6-12
cartridges
per day
150-300
mg/day
0.5 mg qd to
1 mg bid
2.14
(1.44-3.18)
2.06
(1.77-2.40)
2.83*
(1.91-4.19)
OR = odds ratio; CI = confidence interval
67
ev 2004; 4:CD000031; Jorenby DE et al. JAMA 2006; 296(1):56-63; Silagy C et al. Cochrane Database Syst Rev 2004; 3:CD000146.
The Three Strategies Proven to Help Smokers Quit
1)
Brief advice – support from themselves, their family and their
physician, as well as groups (NA), helplines and web-based
resources
2) Medication
3) Behavioural therapies – quitting skills, Cognitive Behavioural
Therapy skills (PSP Mental Health Module), Quit Quitting
Hospital Bedside Intervention movie (YouTube). Referral to a
smoking cessation clinic, i.e..
68
69
Cessation Pearls







“Become a nonsmoker again”
No failure, it’s like riding a bike
Determine a Quit or FREEDOM Day
REASONS (+/-) list – increases Importance
Past SUCCESSES – increases Confidence
Increase CONFIDENCE (+1 point)
Way to CO (monitor) - increases Importance and Confidence after
24 hours!
70
Fletcher-Peto curve illustrating the effect of
smoking on FEV1
71
72
73
Measurement and Action Planning
Module Structure
75
The Framework
 There are three things that will increase our likelihood of success:
› Being clear on why we are doing this work
› Being clear in which areas we are going to try improvements
› Being clear on how we will know if we are making a difference
76
Aim
 To create a shared system of care that improves the quality of
care and experience for patients at risk for and living with COPD
by:
› Identifying early
› Using a team-based approach
› Improving communication
› Improving management
77
How will we achieve this aim?
At the GP practice:
 Enhanced identification and diagnosis of COPD
 Appropriate risk stratification based on level of airflow obstruction
and symptoms and exacerbation history – followed by review of
prescriptions
 Appropriate use of evidence-informed treatments for COPD
based on GPAC guidelines
78
How will we achieve this aim?
In a shared care environment:
 Implementing more standardized referral and consult letters, and
improving relationships, hand offs and communication between
GPs and specialist physicians
 Developing relationships and care plans amongst
GPs, patients, and community services
79
How will we achieve this aim?
Across the continuum
 Supporting patients to quit smoking
 Enhancing patient self-management skills for patients to manage
their condition
 Improving the patient experience with the system of care
80
How will we know if we are implementing changes
that will support our goal?
 % of COPD on register having confirmed diagnostic spirometry
 % of COPD patients with an exacerbation plan
 % of smokers on with COPD offered smoking cessation support
 % patients with COPD who have been referred to pulmonary
programs where available
 % of patients with COPD with a coordinated care plan amongst
GPs, specialists, and/or community resources
81
How will we know if we are reaching our goal?
 % of registry patients reporting an Emergency Department visit or
having an unplanned GP visit for COPD since their last
appointment.
 % of registry patients reporting a hospital admission for
COPD since their last appointment
82
Where can we focus in Action Period 1 (AP1)?





Case finding
Screening with your COPD-6
Populating a COPD registry
Improving the referral system for COPD patients
Applying clinical tobacco intervention techniques
83
How will you be supported: Regional Support Team
 Structure
› Physician Practice Leaders
› Respirologists
› Respiratory Therapists
› PSP Coordinators
 What we do
› Co-facilitate learning sessions
› Provide Action Period support
 Funded by General Practice Services Committee (GPSC) and
Shared Care Committee (SCC), joint committees of BCMA and
Ministry of Health
84
Action Period Checklist –
Required for AP1 and 2 funding:
 10 Screenings using COPD 6
 5 smoking cessation interventions
 5 COPD exacerbation plans
 Develop a COPD registry
 Hold a conversatoin about the referral processes with internist
and/or respirologists
85
AP1 - COPD Data Collection sheet
Please fill this form out and return via fax to your local coordinator
86
COPD-6 USB usage and results
Physician Name
COPD
registry?
Yes/No
Number of
patients on
‘registry
(optional)
Number of
patients
identified via
the COPD-6
as requiring
diagnostic
spirometry
Number of
patients
avoiding
diagnostic
spirometry
due to COPD6
Health
Authority
City
Egan
Yes
5
2
4
VIHA
Victoria
VIHA
Victoria
Comments
 Do you have a registry on COPD?: Yes/No
 Number of patients on your COPD registry (optional):
 Number of patients identified via the COPD-6 as requiring diagnostic spirometry:
 Number of patients avoiding diagnostic spirometry
due to COPD-6:
87
Your opportunity to try something new
 Create your plan with your MOA or other team members
 What is one thing you can you try in your office tomorrow?
 What can you try in the next week?
88
Evaluations and invoices
 Please fill out our Session Evaluation form
 Fax your Sessional invoice directly to BCMA
 Do not hesitate to contact the PSP team should you require
module support:
Thank you for participating in this module.
89
For more information
Practice Support Program
115 - 1665 West Broadway
Vancouver, BC V6J 5A4
Tel: 604 736-5551
www.pspbc.ca
www.pspbc.ca