Www.pspbc.ca Shared System of Care (COPD) Learning Session 1

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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

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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?

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% 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?

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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)?

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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