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

2. 2 “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

3. 3  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

4. 4 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. 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. 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?

7. 7  % 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?

8. 8  % 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?

9. 9 Population Target Population Case finding New pts according to BC Guidelines Possible-Dx COPD, no spirometry Confirmed Dx of COPD (Positive spirometry)

10. 10 Prevalence and Burden of COPD

11. 11  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

12. 12 Asthma

13. 13  1990 : COPD was 6th leading cause of death  2001: Approx. 2.7 million deaths from COPD (more than 5% of total death worldwide)  2020: COPD is projected to be the 3rd leading cause of death (approx 4.5 million deaths) only after the IHD and CVA Murray and Lopez. Lancet 1997 WHO Report 2002 Global disease burden

14. 14 Trends in age-standardized death rates (Percent change between 1970 and 2002)

15. 15 Statistics (CTS report Feb 2010) COPD now accounts for the highest rate of hospital admissions among major chronic illnesses in Canada (CIHI – 2008)

16. 16 Hospital costs: Example in Lower Mainland: $40 million

17. 17 Assume relatively linear increase in prevalence will continue to 2014 Source: Actual figures from COPD registry data, Ministry of Health 201520142013201220112010200920082007200620052004 Projection Actual ESTIMATES Number of persons with COPD in BC

18. 18 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 severe 2 ) Age (yr) Rate per 1,000 of population 450 400 350 300 250 200 150 100 50 0 25–4445–5455–6465–74  75 Undiagnosed potential Chronic Obstructive Pulmonary Disease Surveillance, United States, 1971–2000 1 Airflow Limitation, Mild Through Very Severe, Canada, 2005 2

19. 19  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)

20. 20 Outcomes After Hospitalized AECOPD Mortality (%) 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

21. 21

22. 22 Primary Care Physicians can treat COPD

23. 23 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

24. 24 FEV 1 /FVC <.70 Diagnosis

25. 25

26. 26 Stepped Approach to Care End of Life CareSurgeryOxygenTheophyline (in certain patients)Inhaled corticosteroids (with ‘LABA’)Referral for Pulmonary RehabilitationInitial referral to Pulmologist, Respirologist or Other SpecialistAdditional therapy: long acting bronchodilators First line therapy: Short-acting beta2 – Agonists and Anticholinergics Care Plan & Exacerbation Plans Created & Shared Influenza & Pneumococcal Immunizations in GP OfficeSmoking Cessation Education & Self Management Exercise & LifestyleReferral for Diagnostic SpirometryCase Finding Spirometry by Primary Care Physician Individuals at Risk Smokers Environmental Exposure All Patients: Exercise Rehabilitation Smoking Cessation Healthy Lifestyle Patient Education Increasing severity of COPD

27. 27 Indications for specialist referral:

28. 28 What is Spirometry?

29. 29 Assessing Disability in COPD

30. 30  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

31. 31  ??? Why perform spirometry?

32. 32 Survival in COPD – Relationship to Lung Function and Disability Nishimura K, et al. Chest 2002; 121: 1434: 40

33. 33  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?

34. 34 Spirometry  FEV1  FVC  FEV1/FVC ratio  Bronchodilator change

35. 35  FEV1 change > 12% or 200ml  Both asthma and smoking related COPD  Post BD improvement = better prognosis  No relationship to clinical response Post bronchodilator change

36. 36 Aging  FEV1/FVC ratio Spirometry in COPD: False Positive

37. 37  Routine workup of dyspnea  Confirm the diagnosis of asthma or COPD.  Classification - prognosis of COPD  Use detailed Pulmonary Function Tests selectively Spirometry Summary

38. 38  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 FEV 1 /FEV6 is low,<0.7,then refer to accredited lab for definitive diagnosis The COPD – 6 - DEMONSTRATION

39. 39 Copd-6 – Live DEMO or Video Clip

40. 40 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

41. 41 Indication of bad blow

42. 42 The Copd-6 USB version’s printed report

43. 43 …and now it’s your turn.

44. 44 Todd Gale’s (RT) Results Our measures 44 SpirometerCOPD 6 FEV1 FEV1 % predFVCFEV1/FVCResultGOLD Class 4.91111%6.320.78Normal 3.3188%4.130.8Normal 2.8775%4.630.62MildStage 2 1.6966%3.910.66MildStage 2 1.4779%2.260.65MildStage1 4.0791%5.480.74Normal 1.8488%2.410.76Normal 2.4768%4.110.6MildStage 2 0.9661%1.490.64MildStage 2 Test: Performed 11 COPD-6 + Spirometry tests on the same 11 patients to check for correlation Result: Good correlation…pretty good tool!

45. 45

46. Referral to Specialist & Communication

47. 47  How does referral/consult/communication process work in your practice now?  Challenges  Suggestions for improvement Table Discussion - Communication issues

48. 48 GP-Respirology Referral Form The cohort will trial this form over the Action Period.

49. 49 Consult

50. Developing an Office Approach

51. 51  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

52. 52  Shared Care  Communication  Referral  Consultation  New ways of working - e.g. telephone  Handoffs: Discharge, Re-Referrals Office re-design for proactive shared care

53. 53  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

54. 54 A.Categories 1.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

55. 55 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

56. 56  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

57. 57  Strategies and tools  QuitNow  Group discussion – how do you do it in your practice? Smoking Cessation

58. 58 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

59. 59

60. 60

61. 61  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

62. 62 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) 3.22 (2.43-4.27)

63. 63 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

64. 64 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

65. 65  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:

66. 66 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

67. 67 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. MedicationNicotine gum Nicotine patch Nicotine inhaler BupropionVarenicline Treatment length 1 - 3 months8 - 12 weeks 12 - 24 weeks 7 - 12 weeks12 weeks Main side effects Upset stomach Hiccups Headache Disturbed sleep Site rash Irritation of throat and nasal passages Sneezing Coughing Insomnia Nausea Dosage2 mg, 4 mg 7 mg, 14 mg, 21 mg 6 - 12 cartridges per day 150 - 300 mg/day 0.5 mg qd to 1 mg bid Effectiveness at six months or 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

68. 68 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

69. 69

70. 70  “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

71. 71 Fletcher-Peto curve illustrating the effect of smoking on FEV1

72. 72

73. 73

74. Measurement and Action Planning

75. 75 Module Structure

76. 76  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

77. 77  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. 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. 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. 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. 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. 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?

83. 83  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)?

84. 84  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

85. 85 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 –

86. 86 Please fill this form out and return via fax to your local coordinator AP1 - COPD Data Collection sheet

87. 87 COPD-6 USB usage and results Physician NameCOPD 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 CityComments EganYes524VIHAVictoria VIHAVictoria  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:

88. 88  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

89. 89  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

90. www.pspbc.ca For more information Practice Support Program 115 - 1665 West Broadway Vancouver, BC V6J 5A4 Tel: 604 736-5551 www.pspbc.ca