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

Implementation of COPD management programs in Québec, Canada

Jean Bourbeau, MD Associate Professor

McGill UniversityMontréal, CANADA

Montreal Chest Institute Royal Victoria Hospital

GOLD National LeadersGOLD National LeadersERS Berlin 2008

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

1998 –

2000

2003 –

To date

2004 –

20062005 2006

* ✝ ± §

Region Québec Québec Québec Canada Canada Canada

MilestonesLWWCOPD 1st

EditionStudies: 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)

National (Canada)

1997 –

1998

1998 –

2000

2003 –

To date

2004 –

20062005 2006

* ✝ ± §



EditionStudies: RCT

LWWCOPD 2nd Edition



English and French

1st edition:

7 home education

sessions, case manager support


health board


Context





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)

Multicentre randomized clinical trial

Design

Patientsrandomized ...….. 12 months F/U………..

96

86

95

79

191

Usual Care

Self-Management

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

Multicentre randomized clinical trial:Self-management in COPD

0 100 200 300

Days after Enrollment

0.0

0.2

0.4

0.6

0.8

1.0

Pro

bab

ilit

y o

f n

ot

bei

ng

H

osp

ital

ized

Treatment A

Treatment B 40%Self-management

Usual care

Bourbeau J, et al. Arch Int Med 2003;163:585-91.

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=0.16 p=0.046 p=0.024

Bourbeau J, et al. Chest 2006; 130(6):1704-1711.

Caseload (number of patients followed by the case-manager)

Cos

t pe

r pa

tien

t ($

)

30 50 70

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.

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.

Theorical foundation of the 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)

Key success elements of the SM program «Living Well with COPD»

CommunityResources and Policies

Health SystemOrganization of Health Care

Self-Management

Support

Delivery System Design

Decision Support

Clinical Information

Systems

Informed, Activated Patient

Prepared Practice Team

Improved Outcomes

CommunityResources and Policies


Self -Management

Support


Decision Support

Clinical Information

Systems

Informed, Activated Patient

Prepared Practice Team

Improved Outcomes

Chronic Care Model: Wagner EH. http://www.improvingchroniccare.org

Programs involving multiple chronic care model components vs. SM alone

Multicomponent Self-management only

Hospitalizations (Relative Risk Ratio)

Adams SG. Arch Intern Med

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 1.4 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0


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

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


Community

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


National (Canada)

1997 –

1998

1998 –

2000

2003 –

To date

2004 –

20062005 2006

* ✝ ± §



EditionStudies: RCT

LWWCOPD 2nd Edition



English and French

1st edition:

7 home education


Involvement of provincial health board


Context





programs (1st line)


National (Canada)

1996 –

1998

1998 –

2000

2003 –

To date

2004 –

20062005 2006

* ✝ ± §



EditionStudies: RCT

LWWCOPD 2nd Edition



English and French

1st edition:

7 home education



health board

Development of new edition and website

creation

Context





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 guidesfor 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.comPassword: 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

1998 –

2000

2003 –

To date

2004 –

2006

2005 –

20082008 –

* ✝± §



EditionStudies:

RCTLWWCOPD 2nd

EditionStudies:

RCT



English and French

1st edition:

7 home education



health board


Context





programs


Self-Management: non mandatory and non supervised exercise at home

↔↔Self-Management

(Bourbeau Arch Int Med 2003)

↑↑ HRQLPulm. Rehabilitation

(Griffiths Lancet 2000)

6 MWTSGRQ Symptom & Actvity subscales

↑↑ ↑↑ WDWD

Absence of a supervised exercise program is a limitation to the effectiveness of the program on HRQL

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)

Directly-supervised rehab.

Home rehab.252 patients

Exercises2 months

Maintenance10 months

Canadian Home Rehab RCT

SELF-MANAGEMENT PROGRAM LWWCOPD

Randomization

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?

National (Canada)

1997 –

1998

1998 –

2000

2003 –

To date

2004 –

2006

2005 –

20082008 –

* ✝± §



EditionStudies:

RCTLWWCOPD 2nd

EditionStudies:

RCT



English and French

1st edition:

7 home education



health board


Context





programs and home PR


International2004 – 2005 – 2006 – 2007 –

N/A2008 –

2010

2008 –

2010

2008 –

2010

Country Netherlands Switzerland USA UKFrance,

Spain, Italy, Germany

Ireland China

Study or Implemen-tation

RCT RCT RCTField

implemen-tation

RCTPropo-sal…

Propo-sal…

Program

•Major content adaptation ✔ ✔

•Translation ✔ ✔ ✔•Edition 1st 1st 2nd 2nd 2nd

Population

COPD as part of a family physician network

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

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

Documents

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