1. Implementation of COPD management programs in Québec, Canada
GOLD National Leaders
ERS Berlin 2008
Implementation of COPD management programs in Québec, Canada
Montreal Chest Institute
Jean Bourbeau, MD
Associate Professor
McGill University
Montréal, CANADA
Royal Victoria Hospital

2. 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

3. Program development in English and French
National (Canada)
1997 –
1998
1998 –
2000
2003 –
To date
2004 –
2006
2005 * ✝
Region
Québec
Canada
Milestones
LWWCOPD 1st Edition
Studies: RCT
LWWCOPD 2nd Edition
Knowledge translation
Program development in English and French
1st edition: home education sessions, case manager support
Involvement of provincial health board
Development of new edition and website creation
Context
Pilot project: 16 patients and 5 health professionals
Moderate to Severe COPD
Program used in 1st line and PR programs
Use as part of COPD Integrated Care programs (1st line)

4. 7 home education sessions, case manager support
National (Canada)
1997 –
1998
1998 –
2000
2003 –
To date
2004 –
2006
2005 * ✝
Region
Québec
Canada
Milestones
LWWCOPD 1st Edition
Studies: RCT
LWWCOPD 2nd Edition
Knowledge translation
Program development in English and French
1st edition:
7 home education sessions, case manager support
Involvement of provincial health board
Development of new edition and website creation
Context
Pilot project: 16 patients and 5 health professionals
Moderate to Severe COPD
Program used in 1st line and PR programs
Use as part of COPD Integrated Care programs (1st line)
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)

5. Multicentre randomized clinical trial
Design
Patients
randomized ...….. 12 months F/U……….. 96
Self-Management 86
191 95
Usual Care 79

6. 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

7. Multicentre randomized clinical trial: Self-management in COPD
100
200
300
Days after Enrollment
0.0
0.2
0.4
0.6
0.8
1.0
Probability of not being
Hospitalized
Treatment B
 40%
Treatment A
Self-management
Usual care
Bourbeau J, et al. Arch Int Med 2003;163:

8. Self-management Education May Lead to Cost Savings
p=0.16
p=0.046
p=0.024
$8,000
$6,674
$6,674
$6,674
Standard care
$6,000
$5,177
Self-management
$4,525
Cost per patient ($)
$4,246
$4,000
$2,000
Key Points:
Over a 1-year follow-up period, patients in the self-management group (n=96) (program: “Living well with COPD”) experienced a significantly lower frequency of hospital admission, hospital days per patient, emergency department visits, and unscheduled physician visits than the standard care group (n=95).1
No net savings were observed at the caseload used in the study (14 patients per case manager). However, at realistic caseloads of 50 or 70 patients, significant cost savings resulted due to the reduced per-patient cost of self-management intervention with larger numbers of patients. Most of these savings were the result of reduced hospitalization costs. 1
Although 1 year is a limited timeframe, another study using the same program showed the benefits of reduced hospitalization and emergency room visits extend beyond 1 year.2
References:
Bourbeau J, Collet J-P, Schwartzman K, Ducruet T, Nault D, Bradley C, et al. Economic benefits of self-management education in COPD. Chest 2006 (in press).
Gadoury M-A, Schwartzman K, Rouleau M, Maltais F, Julien M, Beaupré A, et al. Self-management reduces both short- and long-term hospitalisation in COPD. Eur Respir J 2005;26(5):853-7. 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):

9. 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 breathing (62%)
 Action plan (69%)  Exercise program (58%)
Nault et al. Am J Respir Crit Care Med 2000; 161(3):A56.

10. 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)

11. Key success elements of the SM program «Living Well with COPD»
Chronic Care Model:
Wagner EH.
Community
Community
Health System
Health System
Resources and Policies
Resources and Policies
Organization of Health Care
Organization of Health Care
Self
Self - -
Delivery
Delivery
Decision
Decision
Clinical
Clinical
Management
Management
System
System
Support
Support
Information
Information
Support
Support
Design
Design
Systems
Systems
Informed,
Informed,
Prepared
Prepared
Activated
Activated
Practice
Practice
Patient
Patient
Team
Team
Improved Outcomes
Improved Outcomes

12. Programs involving multiple chronic care model components vs. SM alone
Hospitalizations (Relative Risk Ratio)
Multicomponent
Self-management only
Adams SG. Arch Intern Med

13. Delivery System Design
Community
Health System
Organization of Health Care
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

14. Organization of Health Care
Decision Support
Community
Health System
Organization of Health Care
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

15. Clinical Information System: Registry
Health System
Organization of Health Care
Provincial inter-establishment reference system
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

16. Involvement of provincial health board
National (Canada)
1997 –
1998
1998 –
2000
2003 –
To date
2004 –
2006
2005 * ✝
Region
Québec
Canada
Milestones
LWWCOPD 1st Edition
Studies: RCT
LWWCOPD 2nd Edition
Knowledge translation
Program development in English and French
1st edition:
7 home education sessions, case manager support
Involvement of provincial health board
Development of new edition and website creation
Context
Pilot project: 16 patients and 5 health professionals
Moderate to Severe COPD
Program used in 1st line and PR programs
Use as part of COPD Integrated Care programs (1st line)
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)

17. Example of Settings and use of LWWCOPD
Individual
Group
# of participants
Patient (and close family member)
6-8 participants
# of sessions and duration
4 sessions
1.30 hour each
6-8 sessions
1 hour each
LWWCOPD tools for the Patient
Learning modules
Patient brochure
Written Plan of Action
LWWCOPD tools for the Health professional
Reference Guides for Individual Education
Flipchart
Reference Guides for Group Education
Posters
Board with markers

18. Development of new edition and website creation
National (Canada)
1996 –
1998
1998 –
2000
2003 –
To date
2004 –
2006
2005 * ✝
Region
Québec
Canada
Milestones
LWWCOPD 1st Edition
Studies: RCT
LWWCOPD 2nd Edition
Knowledge translation
Program development in English and French
1st edition:
7 home education sessions, case manager support
Involvement of provincial health board
Development of new edition and website creation
Context
Pilot project: 16 patients and 5 health professionals
Moderate to Severe COPD
Program used in 1st line and PR programs
Use as part of COPD Integrated Care programs (1st line)
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)

19. 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)

20. 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

21. Flipchart & Patient Brochures

22. Patient Plan of Action

23. Posters

24. Website
Password: copd

25. Access to the Material www.livingwellwithcopd.com
Free access via Internet
PDF Downloadable (printable) files for all the material
Modules, Educational Flipchart, patient Plan of Action, Summary Guide, posters, reference guides

26. Use as part of COPD Integrated Care programs
National (Canada)
1997 –
1998
1998 –
2000
2003 –
To date
2004 –
2006
2005 –
2008
2008 – *
✝± §
Region
Québec
Canada
Milestones
LWWCOPD 1st Edition
Studies: RCT
LWWCOPD 2nd 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
Development of new edition and website creation
Context
Pilot project: 16 patients and 5 health professionals
Moderate to Severe COPD
Program used in 1st line and PR programs
Use as part of COPD Integrated Care 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)

27. 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 ↔
Self-Management
(Bourbeau Arch Int Med 2003)
↑↑ HRQL
Pulm. Rehabilitation
(Griffiths Lancet 2000)
6 MWT
SGRQ Symptom & Actvity subscales
↑↑ WD

28. A Canadian, multicenter RCT of home-based versus outpatient pulmonary rehabilitation in patients with COPD
Maria
(1 centre)
Quebec City
(2 centres)
Halifax
(1 centre)
Vancouver
(1 centre)
Lévis
(1 centre)
Montreal
(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)

29. Canadian Home Rehab RCT
Randomization
Exercises
2 months
Maintenance
10 months
252 patients
Home rehab.
SELF-MANAGEMENT
PROGRAM LWWCOPD
Directly-supervised rehab.

30. 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

31. Use as part of COPD Integrated Care programs and home PR
National (Canada)
1997 –
1998
1998 –
2000
2003 –
To date
2004 –
2006
2005 –
2008
2008 – *
✝± §
Region
Québec
Canada
Milestones
LWWCOPD 1st Edition
Studies: RCT
LWWCOPD 2nd 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
Development of new edition and website creation
Context
Pilot project: 16 patients and 5 health professionals
Moderate to Severe COPD
Program used in 1st line and PR programs
Use as part of COPD Integrated Care programs and home PR
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)

32. International ✔ 2004 – 2005 – 2006 – 2007 – N/A 2008 – 2010 Country
Netherlands
Switzerland
USA UK
France, Spain, Italy, Germany
Ireland
China
Study or Implemen-tation
RCT
Field implemen-tation
Propo-sal…
Program
Major content adaptation ✔
Translation
Edition
1st
2nd
Population
COPD as part of a family physician network
Veteran Affairs hospitals, moderate to severe COPD
Outpatient clinic: mild to severe COPD
Severe COPD: LTOT users, SM education at home

33. 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