www.pspbc.ca shared system of care (copd) learning session 1
TRANSCRIPT
www.pspbc.ca
Shared System of Care (COPD)
Learning Session 1
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“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
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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
Aim
4
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
How will we achieve this aim?
5
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
How will we achieve this aim?
6
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
How will we achieve this aim?
7
% 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
How will we know if we are implementing changes that will support our goal?
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% 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
How will we know if we are reaching our goal?
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Population
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Prevalence and Burden of COPD
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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.
Definition of COPD
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Asthma
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Global disease burden
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Trends in age-standardized death rates(Percent change between 1970 and 2002)
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Statistics (CTS report Feb 2010)
COPD now accounts for the highest rate of hospital admissions among major chronic illnesses in Canada (CIHI – 2008)
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Hospital costs: Example in Lower Mainland: $40 million
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Assume relatively linear increase in prevalence will continue to 2014
Source: Actual figures from COPD registry data, Ministry of Health
117,080113,436
109,792106,148
102,50498,860
95,21692,198
87,72584,226
80,26876,408
201520142013201220112010200920082007200620052004
Projection
Actual
ESTIMATES
Number of persons with COPD in BC
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COPD is underdiagnosed
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.
Diagnosed with chronic bronchitis or emphysema
Airflow limitation (mild through very severe2
)
Age (yr)
Rat
e p
er 1
,000
of
po
pu
lati
on
450
400
350
300
250
200
150
100
50
0
25–44 45–54 55–64 65–74 75
Un
dia
gn
osed
pote
ntia
l
Chronic Obstructive Pulmonary Disease Surveillance, United States, 1971–20001
Airflow Limitation, Mild Through Very Severe, Canada, 20052
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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.
Acute Exacerbations (AECOPD)
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Outcomes After Hospitalized AECOPD
0
5
10
15
20
25
30
35
40
45
50
Mo
rtal
ity
(%)
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
1,016 admissions
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Primary Care Physicians can treat COPD
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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?
Case Finding for Possible COPD
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FEV1/FVC < .70
Diagnosis
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Stepped Approach to Care
Individuals at Risk •Smokers•Environmental Exposure
All Patients:•Exercise Rehabilitation•Smoking Cessation•Healthy Lifestyle•Patient Education
Increasing severity of COPD
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Indications for specialist referral:
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What is Spirometry?
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Assessing Disability in COPD
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To accurately diagnose COPD at an earlier stage so that subjects maybe be motivated to stop smoking using such tools as the lung age.
Purpose
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???
Why perform spirometry?
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Survival in COPD – Relationship to Lung Function and Disability
Nishimura K, et al. Chest 2002; 121: 1434: 40
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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
What does Spirometry measure?
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Spirometry
FEV1
FVC
FEV1/FVC ratio
Bronchodilator change
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FEV1 change > 12% or 200ml Both asthma and smoking related COPD Post BD improvement = better prognosis No relationship to clinical response
Post bronchodilator change
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Aging FEV1/FVC ratio
Spirometry in COPD: False Positive
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Routine workup of dyspnea Confirm the diagnosis of asthma or COPD. Classification - prognosis of COPD Use detailed Pulmonary Function Tests selectively
Spirometry Summary
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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
The COPD – 6 - DEMONSTRATION
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Copd-6 – Live DEMO or Video Clip
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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
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Indication of bad blow
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The Copd-6 USB version’s printed report
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…and now it’s your turn.
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Todd Gale’s (RT) Results
Our measures
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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!
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Shared Care-COPD: Early Identification of COPD Patients at Dr. Andre Van Wyk's Practice June-Dec 2011
0
2
4
6
8
10
12
14
June July Aug Sep Oct Nov Dec
Month
# of Pateints who have been screened forCOPD using the COPD-6/ month
# of Screened Patients who have apositive COPD-6 Test
# of Patients who have a confirmed COPDdiagnosis
Referral to Specialist & Communication
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How does referral/consult/communication process work in your practice now?
Challenges
Suggestions for improvement
Table Discussion - Communication issues
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GP-Respirology Referral Form
The cohort will trial this form over the Action Period.
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Consult
Developing an Office Approach
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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
Office re-design for proactive shared care
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Shared Care
Communication
Referral Consultation
New ways of working - e.g. telephone
Handoffs: Discharge, Re-Referrals
Office re-design for proactive shared care
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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
The patient registry
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A. Categories1. Case-finding-New patients per guideline-Simple spirometry
2. Case-finding-Dx COPD-no spirometry – simple spirometry /Diagnostic spirometry
3. Confirmed COPD (spirometry positive)
B. Methodology to Identify Those Dx with COPD (#2 and 3 above):
1. Billing software (COPD Code: XX)
2. Paper chart review
3. EMR
4. Physician Profile Analysis Report
Identify eligible patients-interim registry
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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
Identify eligible patients-final registry-confirmed COPD
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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
Physician Profile Analysis
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Strategies and tools QuitNow Group discussion – how do you do it in your practice?
Smoking Cessation
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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
Smoking Cessation Objectives
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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)?
30-Second Assessment
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Comparing the Effectiveness (at 6 months or longer)
of Various Tobacco Cessation Interventions
Varenicline (Champix)
Intensive Physician Counselling
Group Counselling
Nicotine Replacement Therapy
Bupropion (Zyban, Wellbutrin)
Telephone Helplines
Cessation or Quit Method
Odds ratio of Cessation (95% Confidence Interval)
1.41 (1.27-1.57)
1.77 (1.66-1.88)
1.94 (1.72-2.19)
2.04 (1.60-2.60)
2.04 (1.60-2.60)
3.22 (2.43-4.27)
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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.
The Three Strategies Proven to Help Smokers Quit
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1) Brief advice – support from themselves, their family and their physician, as well as groups (NA), Helplines and web-based resources
The Three Strategies Proven to Help Smokers Quit
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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)
Advising Patients to Quit
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:
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1) Brief advice – support from themselves, their family and their physician, as well as groups (NA), helplines and web-based resources
2) Medication
The Three Strategies Proven to Help Smokers Quit
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Comparing Medications
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.
Medication Nicotine gumNicotine
patchNicotine inhaler
Bupropion Varenicline
Treatment length
1-3 months 8-12 weeks12-24 weeks
7-12 weeks 12 weeks
Main side effects
• Upset stomach
• Hiccups
• Headache• Disturbed sleep• Site rash
• Irritation of throat and nasal passages• Sneezing• Coughing
• Insomnia • Nausea
Dosage 2 mg, 4 mg7 mg,
14 mg, 21 mg
6-12 cartridges per day
150-300 mg/day
0.5 mg qd to 1 mg bid
Effectivenessat six monthsor longer (OR [CI])
1.66 (1.52-1.81)
1.81(1.63-2.02)
2.14 (1.44-3.18)
2.06 (1.77-2.40)
2.83* (1.91-4.19)
gh 24 follow-up
OR = odds ratio; CI = confidence interval
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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..
The Three Strategies Proven to Help Smokers Quit
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“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!
Cessation Pearls
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Fletcher-Peto curve illustrating the effect of smoking on FEV1
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Measurement and Action Planning
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Module Structure
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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
The Framework
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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
Aim
78
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
How will we achieve this aim?
79
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
How will we achieve this aim?
80
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
How will we achieve this aim?
81
% 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
How will we know if we are implementing changes that will support our goal?
82
% 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
How will we know if we are reaching our goal?
83
Case finding Screening with your COPD-6 Populating a COPD registry Improving the referral system for COPD patients Applying clinical tobacco intervention techniques
Where can we focus in Action Period 1 (AP1)?
84
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
How will you be supported: Regional Support Team
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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
Action Period Checklist –
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Please fill this form out and return via fax to your local coordinator
AP1 - COPD Data Collection sheet
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COPD-6 USB usage and resultsPhysician 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 COPD-6
Health Authority
City Comments
Egan Yes 5 2 4 VIHA Victoria
VIHA Victoria
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:
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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?
Your opportunity to try something new
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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.
Evaluations and invoices
www.pspbc.ca
For more informationPractice Support Program
115 - 1665 West BroadwayVancouver, BC V6J 5A4
Tel: 604 736-5551www.pspbc.ca