Transcript Living Well with COPD (Title)

GOLD National Leaders
ERS Berlin 2008
Implementation of COPD management
programs in Québec, Canada
Jean Bourbeau, MD
Associate Professor
McGill University
Montréal, CANADA
Montreal Chest Institute
Royal Victoria Hospital
The beginning… 1997:
Description of the situation
COPD management
• Mounting evidence indicates that standard care
often fails to meet needs of patients with chronic disease
• Self-management education has proved to be effective
in chronic disease such as DM, CHF
• No self-management program specific to COPD patient
National (Canada)
1997 –
1998
Region
1998 –
2000
2003 –
To date
2004 –
2006
2005
2006
*
✝
±
§
Québec
Canada
Canada
Canada
Québec
Québec
Milestones
LWWCOPD 1st
Edition
Studies: RCT
Knowledge
translation
Program
development in
English and
French
1st edition:
7
home education
sessions, case
manager support
Involvement of
provincial
health board
Context
Pilot project: 16
patients and 5
health
professionals
Moderate to
Severe COPD
Program used
in 1st line and
PR programs
LWWCOPD 2nd
Edition
Development of
new edition and
website creation
Use as part of COPD
Integrated Care
programs (1st line)
National (Canada)
1997 –
1998
Region
Milestones
Knowledge
translation
Context
1998 –
2000
Québec
Québec
LWWCOPD 1st
Edition
Studies: RCT
Program
development in
English and
French
1st edition:
7 home
education
sessions, case
manager
support
Pilot project: 16
patients and 5
health
professionals
Moderate to
Severe COPD
2003 –
To date
2004 –
2006
2005
2006
*
✝
±
§
Québec
Canada
Canada
Canada
LWWCOPD 2nd
Edition
Involvement of
provincial
health board
Development of
new edition and
website creation
Program used
in 1st line and
PR programs
Study publication:
* Bourbeau 2003 (Reduction of hospital utilization in patients with COPD)
✝Bourbeau 2004(Self-management and behaviour modification in COPD)
± Gadoury 2005 (Self-management reduces both short- and long-term hospitalization in COPD)
§ Bourbeau 2006 (Economic benefits of self-management education in COPD)
Use as part of COPD
Integrated Care
programs (1st line)
Multicentre randomized clinical trial
Design
Patients
9
6
randomized 191
Self-Management
...….. 12
9
5
86
months F/U………..
Usual Care
79
Multicentre randomized clinical trial
Intervention “SM program”
“Living well with COPD©”
• Standardized education
– flipchart; patient workbooks
• Ongoing support by a trained health professional
– weekly teaching(60 min.) for 2-month period
– monthly telephone contact, and PRN
Probability of not being
Hospitalized
0.0 0.2 0.4 0.6 0.8 1.0
Multicentre randomized clinical trial:
Self-management in COPD
Self-management
Treatment B
Usual
Treatment
care
A
0
100
200
300
Days after Enrollment
Bourbeau J, et al. Arch Int Med 2003;163:585-91.
 40%
Self-management Education May Lead
to Cost Savings
$8,000
p=0.16
$6,674
p=0.046
$6,674
p=0.024
$6,674
Cost per patient ($)
Standard care
$6,000
$5,177
Self-management
$4,525
$4,246
$4,000
$2,000
30
50
70
Caseload (number of patients followed by the case-manager)
Cost per patient: All health care resources used
during the one year follow-up were considered.
All costs are expressed in year 2004 Canadian dollars.
Bourbeau J, et al. Chest 2006; 130(6):1704-1711.
Qualitative Evaluation of a Self-Management
Program «Living Well With COPD» offered to
Patients and their Caregivers
Qualitative study
(semi-structured interviews with 27 patients at12 months)
Results:
Self-management helping strategies

Energy conservation principles (81%)
 Pursed-lip

Action plan (69%)

breathing (62%)
Exercise program (58%)
Nault et al. Am J Respir Crit Care Med 2000; 161(3):A56.
Theorical foundation of the
self-management program « Living Well With COPD »
• Chronic Care Model (Wagner 2001)
 Self-Management
Model (Lorig & Holman, 2003)
 Self-Efficacy Theory (Bandura, 1981)
Key success elements of the SM
program «Living Well with COPD»
Chronic Care Model:
Wagner EH. http://www.improvingchroniccare.org
Community
Health System
Resources and Policies
Organization of Health Care
Self
Self-Management
Support
Delivery
System
Design
Decision
Support
Informed,
Activated
Patient
Clinical
Information
Systems
Prepared
Practice
Team
Improved Outcomes
Programs involving multiple chronic
care model components vs. SM alone
Hospitalizations (Relative Risk Ratio)
Hermiz 2002
Hernandez 2003
Bourbeau 2003
Rae 2004
Random-effect Estimate
Cockcroft 1987
Gourley 1998
Littlejohns 1991
Random-effect Estimate
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Multicomponent
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Self-management only
Adams SG. Arch Intern Med
Community
Health System
Organization of Health Care
Delivery System Design
 Practice team has defined roles
•
Partnership:




Patient active participation in disease management
Physician prescribed overall optimal treatment
Case manager is the resource person for the patient
Other health professionals as consultants, support
 Regular follow up and coordination of care by physician and
case manager




Assess patient’s general condition and needs and define goals
Help patient/family integrate in daily life the skills and healthy
behaviours learned, evaluate and reinforce
Provide an Action Plan and support its use
Do proper referrals within hospital and in community
Community
Health System
Organization of Health Care
Decision Support
 Evidence-based practice  LWWCOPD
 Referrals to:
•
•
•
Specialized programs: Pulmonary Rehabilitation, Smoking
Cessation, Stress Management
Specialists to follow-up on co-morbidities
Health professionals from the multidisciplinary team and
community services
 Performance review and identification of barriers
•
•
Quality control studies
Contribution to research
Health System
Organization of Health Care
•
Provincial inter-establishment reference system



•
Clinical Information System:
Registry
Standardized criteria of reference for services in the
community
Electronic database
Specific formulary for COPD patients
Hospital Database of clinically useful and timely
information for ALL patients (in development)


Provide reminders and feedback
Facilitate care planning for individuals and populations
National (Canada)
1997 –
1998
Region
1998 –
2000
Québec
Québec
Milestones
LWWCOPD 1st
Edition
Studies: RCT
Knowledge
translation
Program
development in
English and
French
1st edition:
7 home
education
sessions, case
manager support
Context
Pilot project: 16
patients and 5
health
professionals
Moderate to
Severe COPD
2003 –
To date
2004 –
2006
2005
2006
*
✝
±
§
Québec
Canada
Canada
Canada
LWWCOPD 2nd
Edition
Involvement
of provincial
health board
Development of
new edition and
website creation
Program used
in 1st line and
PR programs
Study publication:
* Bourbeau 2003 (Reduction of hospital utilization in patients with COPD)
✝Bourbeau 2004(Self-management and behaviour modification in COPD)
± Gadoury 2005 (Self-management reduces both short- and long-term hospitalization in COPD)
§ Bourbeau 2006 (Economic benefits of self-management education in COPD)
Use as part of COPD
Integrated Care
programs (1st line)
National (Canada)
1996 –
1998
Region
1998 –
2000
2003 –
To date
2004 –
2006
2005
2006
*
✝
±
§
Québec
Canada
Canada
Canada
Québec
Québec
Milestones
LWWCOPD 1st
Edition
Studies: RCT
Knowledge
translation
Program
development in
English and
French
1st edition:
7 home
education
sessions, case
manager support
Involvement of
provincial
health board
Moderate to
Severe COPD
Program used
in 1st line and
PR programs
Context
Pilot project: 16
patients and 5
health
professionals
LWWCOPD
2nd Edition
Development
of new edition
and website
creation
Study publication:
* Bourbeau 2003 (Reduction of hospital utilization in patients with COPD)
✝Bourbeau 2004(Self-management and behaviour modification in COPD)
± Gadoury 2005 (Self-management reduces both short- and long-term hospitalization in COPD)
§ Bourbeau 2006 (Economic benefits of self-management education in COPD)
Use as part of COPD
Integrated Care
programs (1st line)
Patient Learning Modules
(2nd Edition LWWCOPD)
•
•
•
•
•
•
•
Managing your breathing and
saving your energy
Preventing your symptoms and
taking your medications
Integrating a plan of action into
your life
Managing your stress and anxiety
Keeping a healthy and fulfilling
lifestyle
Integrating a home exercise
program into your life (2008)
Using long term oxygen therapy (2009)
Reference guides
for health professionals
• Development of reference guides for
individual and group teaching
– Principles of adult education and group animation
– Reference guides for each specific element of
individual education and for each group education
session:
• General and specific objectives (Expected results in the
patient/family)
• Material and human resources needed
• Intervention and education methods used
• Examples of questions to evaluate knowledge and learned
skills
Flipchart & Patient Brochures
Patient Plan of Action
Posters
Website
www.livingwellwithcopd.com
Password: copd
Access to the Material
• Free access via Internet
www.livingwellwithcopd.com
• PDF Downloadable (printable) files for all
the material
– Modules, Educational Flipchart, patient Plan of
Action, Summary Guide, posters, reference
guides
National (Canada)
1997 –
1998
Region
1998 –
2000
2003 –
To date
2004 –
2006
*
✝± §
Québec
Canada
Québec
Québec
Milestones
LWWCOPD 1st
Edition
Studies:
RCT
Knowledge
translation
Program
development in
English and
French
1st edition:
7 home
education
sessions, case
manager support
Involvement of
provincial
health board
Moderate to
Severe COPD
Program used
in 1st line and
PR programs
Context
Pilot project: 16
patients and 5
health
professionals
LWWCOPD 2nd
Edition
2005 –
2008
2008 –
Canada
Canada
Studies:
RCT
Development of
new edition and
website creation
Study publication:
* Bourbeau 2003 (Reduction of hospital utilization in patients with COPD)
✝Bourbeau 2004(Self-management and behaviour modification in COPD)
± Gadoury 2005 (Self-management reduces both short- and long-term hospitalization in COPD)
§ Bourbeau 2006 (Economic benefits of self-management education in COPD)
Use as part of COPD
Integrated Care
programs
Self-Management: non mandatory and
non supervised exercise at home
Absence of a supervised exercise program is a limitation to the
effectiveness of the program on HRQL
SGRQ Symptom &
Actvity subscales
Pulm. Rehabilitation
(Griffiths Lancet 2000)
Self-Management
(Bourbeau Arch Int Med 2003)
↑↑ HRQL
↔
6 MWT
↑↑ WD
↔
A Canadian, multicenter RCT of home-based versus
outpatient pulmonary rehabilitation in patients with COPD
Maria
Quebec City
(1 centre)
(2 centres)
Halifax
Vancouver
(1 centre)
(1 centre)
Montreal
Lévis
(1 centre)
(4 centres)
Maltais F, Bourbeau J, Shapiro S et al.
Effects of home-based pulmonary rehabilitation in patients with COPD:
a non-inferiority, randomized clinical trial. Ann Intern Med 2008 (in press)
Canadian Home Rehab RCT
Randomization
Exercises
2 months
Maintenance
10 months
252 patients
SELF-MANAGEMENT
PROGRAM LWWCOPD
Home rehab.
Directly-supervised rehab.
Home-based rehabilitation:
what we know and what are the implications?
Our trial suggests that home-based
pulmonary rehabilitation is non inferior to
outpatient hospital-based pulmonary
rehabilitation in patients with COPD.
Self-monitored home-based pulmonary
rehabilitation, as proposed in our trial, is
interesting because
• easily implemented in many countries.
• improve accessibility to PR by
addressing different individual needs
National (Canada)
1997 –
1998
Region
1998 –
2000
2003 –
To date
2004 –
2006
*
✝± §
Québec
Canada
Québec
Québec
Milestones
LWWCOPD 1st
Edition
Studies:
RCT
Knowledge
translation
Program
development in
English and
French
1st edition:
7 home
education
sessions, case
manager support
Involvement of
provincial
health board
Moderate to
Severe COPD
Program used
in 1st line and
PR programs
Context
Pilot project: 16
patients and 5
health
professionals
LWWCOPD 2nd
Edition
2005 –
2008
2008 –
Canada
Canada
Studies:
RCT
Development of
new edition and
website creation
Study publication:
* Bourbeau 2003 (Reduction of hospital utilization in patients with COPD)
✝Bourbeau 2004(Self-management and behaviour modification in COPD)
± Gadoury 2005 (Self-management reduces both short- and long-term hospitalization in COPD)
§ Bourbeau 2006 (Economic benefits of self-management education in COPD)
Use as part of COPD
Integrated Care
programs and home
PR
International
Country
Study or
Implementation
2004 –
2005 –
2006 –
2007 –
N/A
2008 –
2010
2008 –
2010
2008 –
2010
Netherlands
Switzerland
USA
UK
France,
Spain, Italy,
Germany
Ireland
China
RCT
Field
implementation
RCT
Proposal…
Proposal…
RCT
RCT
Program
✔
•Major content
adaptation
•Translation
✔
✔
•Edition
1st
1st
2nd
COPD as part
of a family
physician
network
Veteran
Affairs
hospitals,
moderate to
severe
COPD
Population
COPD as part
of a family
physician
network
✔
✔
2nd
Outpatient
clinic: mild
to severe
COPD
2nd
Severe
COPD: LTOT
users, SM
education at
home
Acknowledgments
• Authors of the 2nd Edition of LWWCOPD:
– Jean Bourbeau, MD, MSc, FRCPC
– Maria Sedeño, BEng, MM
– Diane Nault, RN, BSc
• Special Thanks to:
– MCI multidisciplinary team
– Respirologists, health professionals and patients from many
regions in Canada
•
•
•
•
BI-Pfizer
FRSQ respiratory network – COPD axis
The Lung Association
RQAM