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Implementation of COPD management programs in Québec, Canada Jean Bourbeau, MD Associate Professor McGill University Montréal, CANADA Montreal Chest Institute.

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Presentation on theme: "Implementation of COPD management programs in Québec, Canada Jean Bourbeau, MD Associate Professor McGill University Montréal, CANADA Montreal Chest Institute."— Presentation transcript:

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

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 National (Canada) 1997 – – – To date 2004 – *±§ RegionQuébec Canada Milestones LWWCOPD 1 st Edition Studies: RCT LWWCOPD 2nd Edition Knowledge translation Program development in English and French 1 st 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 (1 st line)

4 National (Canada) 1997 – – – To date 2004 – *±§ RegionQuébec Canada Milestones LWWCOPD 1 st Edition Studies: RCT LWWCOPD 2nd Edition Knowledge translation Program development in English and French 1 st 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 (1 st 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 ……… Usual Care Self-Management

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 Days after Enrollment Probability of not being Hospitalized Treatment A Treatment B 40% Self-management Usual care Bourbeau J, et al. Arch Int Med 2003;163:

8 Self-management Education May Lead to Cost Savings $8,000 $6,000 $4,000 $2,000 $6,674 $5,177 $6,674 $4,525 $6,674 $4,246 p=0.16p=0.046p=0.024 Bourbeau J, et al. Chest 2006; 130(6): Caseload (number of patients followed by the case-manager) Cost per patient ($) Standard care Self-management 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.

9 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%) Qualitative Evaluation of a Self-Management Program «Living Well With COPD» offered to Patients and their Caregivers 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 » 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» Community Resources and Policies Health System Organization of Health Care Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Prepared Practice Team Improved Outcomes Community Resources and Policies Health System Organization of Health Care Self - Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Prepared Practice Team Improved Outcomes Chronic Care Model: Wagner EH.

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

13 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 patients 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 Health System Organization of Health Care Community

14 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 Community

15 Clinical Information System: Registry 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 Health System Organization of Health Care

16 National (Canada) 1997 – – – To date 2004 – *±§ RegionQuébec Canada Milestones LWWCOPD 1 st Edition Studies: RCT LWWCOPD 2nd Edition Knowledge translation Program development in English and French 1 st 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 (1 st 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 IndividualGroup # of participantsPatient (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 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 National (Canada) 1996 – – – To date 2004 – *±§ RegionQuébec Canada Milestones LWWCOPD 1 st Edition Studies: RCT LWWCOPD 2nd Edition Knowledge translation Program development in English and French 1 st 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 (1 st 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 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 National (Canada) 1997 – – – To date 2004 – – – *± § RegionQuébec Canada Milestones LWWCOPD 1 st Edition Studies: RCT LWWCOPD 2nd Edition Studies: RCT Knowledge translation Program development in English and French 1 st 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 Self-Management (Bourbeau Arch Int Med 2003) HRQL Pulm. Rehabilitation (Griffiths Lancet 2000) 6 MWTSGRQ Symptom & Actvity subscales WD WD Absence of a supervised exercise program is a limitation to the effectiveness of the program on HRQL

28 Lévis (1 centre) Lévis (1 centre) Halifax (1 centre) Halifax (1 centre) Maria (1 centre) Maria (1 centre) Quebec City (2 centres) Quebec City (2 centres) Montreal (4 centres) Montreal (4 centres) Vancouver (1 centre) Vancouver (1 centre) A Canadian, multicenter RCT of home-based versus outpatient pulmonary rehabilitation in patients with COPD 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 Directly-supervised rehab. Home rehab. 252 patients Exercises 2 months Maintenance 10 months Canadian Home Rehab RCT SELF-MANAGEMENT PROGRAM LWWCOPD Randomization

30 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 Home-based rehabilitation: what we know and what are the implications?

31 National (Canada) 1997 – – – To date 2004 – – – *± § RegionQuébec Canada Milestones LWWCOPD 1 st Edition Studies: RCT LWWCOPD 2nd Edition Studies: RCT Knowledge translation Program development in English and French 1 st 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 CountryNetherlandsSwitzerlandUSAUK France, Spain, Italy, Germany IrelandChina Study or Implemen- tation RCT Field implemen- tation RCT Propo- sal… Program Major content adaptation Translation Edition1 st 2 nd 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 2 nd 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


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