FOR SASK RESPIRATORY SUMMIT ONLY DO NOT CIRCULATE

FOR SASK RESPIRATORY SUMMIT ONLY

DO NOT CIRCULATE

Pauwels RA, et al. Lancet 2004; 364:616-620


DO NOT CIRCULATE

Jamal A, et al. JAMA 2005; 294:1255-1259

Optimizing Chronic Disease Management


DO NOT CIRCULATE

September 28th, 2006

#4

#7

#12



DO NOT CIRCULATE

COPD Hospitalizations by sexCanada, 1979-2003 (projections to 2010)

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Year

Sep

arat

ion

s p

er 1

00,0

00

Males Females Linear (Males) Linear (Females)

ICD10 codes: J40-J44. Note that the coding schemes for this condition changed in 1968, 1978 and 2000 and this may influence trends.Age-Standardized to the 1991 Canada Population. Prior to 1993, includes only the ten Canadian Provinces.Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Vital Statistics Data.


DO NOT CIRCULATE

SHR Hospitalizations

0

5

10

15

20

25

30

IHD CHF COPD DM RF

Percentage ofAdmissions

Saskatoon Health Region Statistics, 2005



DO NOT CIRCULATE

SHR Hospitalizations

Disease Length of Stay

Readmission Rate

COPD (02-03) 11.0 30%(03-04) 9.1 28%

Diabetes (02-03) 10.1 21%(03-04) 9.9 22%

CHF (02-03) 10.6 20%(03-04) 9.5 17%

IHD (02-03) 7.0 13%(03-04) 7.1 11%Saskatoon Health Region Statistics, 2005

Optimizing Chronic Disease Management FOR SASK RESPIRATORY SUMMIT ONLY

DO NOT CIRCULATE

Exacerbations and Mortality

Time (months)

p<0.0001

p<0.0002A

B

C

p=0.069

0 10 20 30 40 50 60

1.0

0.8

0.6

0.4

0.2

0

Su

rviv

al p

rob

abil

ity

Group A: no exacerbationsGroup B: 1–2 exacerbationsGroup C: ≥3 exacerbations

n=304

Soler-Cataluna JJ, et al. Thorax 2005;60:925–931

Exacerbation = ER visit or hospital admission



DO NOT CIRCULATE

Acute Event MortalityMyocardial Infarction• 25% of men and 38%

of women will die within 1 year of a first recognized MI (5,6)

• The in-hospital acute MI mortality rate is 9.4% (1999) (5,6)

1. Eriksen N, et al. Ugeskr Laeger 2003;165:3499–3502. 2. Groenewegen KH, et al. Chest 2003;124:459–467. 3. Almagro P, et al. Chest 2002;121:1441–1448. 4. Connors AF, et al. Am J Respir Crit Care Med 1996;154:959–967. 5. Thom T et al. Circulation 2006. 6. Heart and Stroke Foundation of Canada



DO NOT CIRCULATE

Acute Event Mortality

COPD Exacerbation• 22-43% of patients

hospitalized with a COPD exacerbation will die within 1 year (1,2,3,4)

• The in-hospital mortality rate for COPD exacerbations is 7-11% (1,2)

Myocardial Infarction• 25% of men and 38%

of women will die within 1 year of a first recognized MI (5,6)

• The in-hospital acute MI mortality rate is 9.4% (1999) (5,6)

1. Eriksen N, et al. Ugeskr Laeger 2003;165:3499–3502. 2. Groenewegen KH, et al. Chest 2003;124:459–467. 3. Almagro P, et al. Chest 2002;121:1441–1448. 4. Connors AF, et al. Am J Respir Crit Care Med 1996;154:959–967. 5. Thom T et al. Circulation 2006. 6. Heart and Stroke Foundation of Canada


DO NOT CIRCULATE

Risk of Death - Exercise Capacity

Risk of death in subjects with risk factors and exercise capacity of <5 MET or 5-8 MET, compared with subjects with capacity >8 MET (MET = VO2 3.5 ml/kg/min)

Myers J et al, NEJM 2002; 346:793-801



DO NOT CIRCULATE

Rehab and HealthCare Utilization

Ries AL, et al. J Cardiopulm Rehabil 2004; 24(1): 52-62

Healthcare utilization over 18 months of follow-up. Data presented include physicians visits, telephone calls, hospital days, and urgent care visits over the preceding 3 months. The results are presented as mean + SE.


DO NOT CIRCULATE

Bronchodilators and Rehabilitation

Casaburi R, et al. Chest 2005; 127:809-817

8

12

16

20

24

0 2 4 6 8 10 12 14 16 18 20 22 24

**

Rehabilitation

Study Drug

16%

32% 42%

End

ura

nce

Tim

e (

min

s)

FOR SASK RESPIRATORY SUMMIT ONLYDO NOT CIRCULATE

Placebo

Tiotropium


Weeks on Treatment* p<0.05

Comprehensive COPD Management

0 50 100 150

Admissions the year before the study

Admissionsfor exacerbations

for other reasons

Number of hospital admissions

- 40%

- 57%

+ 4%

0 50 100 150

Admissions

- 40%

- 57%

+ 4%

0 50 100 150

Admissions the year before the study

Admissionsfor exacerbations

for other reasons

Number of hospital admissions

- 40%

- 57%

+ 4%

0 50 100 150

Admissions

- 40%

- 57%

+ 4%

0 50 100 150 200

Emergencies forother diseases

Emergency for exacerbations

- 41%

- 23%

- 59%

0 50 100 150 200

Number of ER visits

Non-scheduledvisits

- 41%

- 23%

- 59%

0 50 100 150 200

Emergencies forother diseases

Emergency for exacerbations

- 41%

- 23%

- 59%

0 50 100 150 200

Number of ER visits

Non-scheduledvisits

- 41%

- 23%

- 59%


FOR SASK RESPIRATORY SUMMIT ONLYDO NOT CIRCULATE

Bourbeau J, et al. Arch Int Med 2003, 163:585-91*Can Respir J 2004; 11(Suppl B): 7B-59B

Comprehensive COPD Management

• benefits persist over 2 years(Gadoury MA, et al. Eur Resp J 2005; 26:853-857)

• a caseload of 50 patients equals cost-savings (program vs usual care) of $2,149 – $2,300 /year

• concluded that a caseload of 70 patients was achievable and reasonable (additional savings of $310 /year)

• reduced hospitalizations, reduced exacerbations, and reduced healthcare costs

Bourbeau J, et al. Chest 2006; in press


DO NOT CIRCULATE

Ezekowitz, JA, et al. CMAJ 2005; 172:189-194

Comprehensive CHF Management


DO NOT CIRCULATE

Knowler WC, et al. NEJM 2002; 346:393-403

Preventing Type 2 Diabetes

n= 3234 non-diabetics with elevated fasting

glucose


DO NOT CIRCULATE


DO NOT CIRCULATE• team-based, multidisciplinary program to

help COPD pts and their families improve self-management of their disease

• focused on outcomes• increased Pulmonary Rehabilitation capacity

– home site (Field House) is full– assisted with establishing program in Regina– established 1st satellite in part of Saskatoon with

the highest incidence of chronic diseases– additional satellites rolled out (Humboldt and

Prince Albert) and other’s planned (Lawson Heights/Soccer, Saskatoon core, Yorkton, Moose Jaw)

“Inspire” COPD Program

What Have We Seen So Far?

Saskatoon Health Region Statistics, 2006


DO NOT CIRCULATE

• reduced COPD re-admissions - net cost savings of ~129,000 in 2005, and ~$79,000 in 2006

• re-admission rates of 1 : 1.9 : 2.1 (2004), changed to 1 : 1.6 : 1.2 (2006) with recent programming at 3 acute-care sites in SHR

• decreased ICU days by 44% (2006), with a cost savings in 2005 of $261,333, and in 2006 of $308,333.

• Community-based supervised exercise programming

• Group education

• Socialization

Group Exercise and

Rehabilitation


• Group education

• Socialization

Group Exercise and

Rehabilitation • “Live-Well with a Chronic Condition”

• Patient-led group classes / support

• Enhanced self-management skills and decision-making

Patient Self-Management

Skills


• Group education

• Socialization

Group Exercise and

Rehabilitation • Nurse-Clinician working with the patient, their Family Physician and/or Specialist

• Evidence-based optimal care delivery

Disease-Specific Management

Patient Self-Management

Skills• “Live-Well with a Chronic Condition”

• Patient-led group classes / support

• Enhanced self-management skills and decision-making

Live Well™ Program

• a cost-effective, integrated [provincial] program - centralized coordination with both urban and rural delivery

• strategic, focused design and delivery

• “the right person doing the right job”

• cement the relationship between the patient [and family] and their family physician

• interventions that are not evidenced-based will not be utilized or promoted

Live Well™ Program (cont’d)

• ongoing evaluation of both patient and program outcomes is necessary

• an electronic data management system is used for patient care, and also to facilitate communication, coordination and evaluation

• the program philosophy, design and delivery is common [ie. efficient] for many medical conditions – only Pillar 2 is “disease-specific”

• the model works and borrows on the learning's of others

Live Well™ Program (cont’d)

• proposed Centers of Excellence in Regina and Saskatoon, but with comprehensive program delivery in every health region, using an achievable phased implementation

• benefits to patients are coupled with significant cost savings

• targeted funding would best be provided “provincially” to the health regions with the expectation of tangible deliverables and appropriate evaluation/reporting

Documents

FOR SASK RESPIRATORY SUMMIT ONLY DO NOT CIRCULATE