1、Implementation of COPD management programs in Qubec, Canada,Jean Bourbeau, MD Associate ProfessorMcGill University Montral, CANADA,Montreal Chest Institute,Royal Victoria Hospital,GOLD National Leaders,ERS Berlin 2008,The beginning 1997: Description of the situation,COPD management Mounting evidence
2、 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),National (Canada),Study publication: * Bourbeau 2003
3、(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 rand
4、omized clinical trial,DesignPatientsrandomized . 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 workbooksOngoing support by a trained health professional weekly
5、teaching(60 min.) for 2-month period monthly telephone contact, and PRN,Multicentre randomized clinical trial: Self-management in COPD,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,$4
6、,246,p=0.16,p=0.046,p=0.024,Bourbeau J, et al. Chest 2006; 130(6):1704-1711.,Caseload (number of patients followed by the case-manager),Cost per patient ($),30,50,70,Standard care,Self-management,Cost per patient: All health care resources used during the one year follow-up were considered. All cost
7、s 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 S
8、elf-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 self-management program Living Well With COPD ,Chronic Care Model (Wagner 2001) Self-Management Model (Lorig & Holman, 2003) Self
9、-Efficacy Theory (Bandura, 1981),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,
10、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.
11、 http:/www.improvingchroniccare.org,Programs involving multiple chronic care model components vs. SM alone,Hospitalizations (Relative Risk Ratio),Adams SG. Arch Intern Med,Delivery System Design,Practice team has defined roles Partnership: Patient active participation in disease management Physician
12、 prescribed overall optimal treatment Case manager is the resource person for the patient Other health professionals as consultants, supportRegular follow up and coordination of care by physician and case manager Assess patients general condition and needs and define goals Help patient/family integr
13、ate 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,Decision Support,Evidence-based practice LWWCOPD Referrals to: Speci
14、alized 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,He
15、alth System,Organization of Health Care,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 patientsHospital Database of clinically useful and
16、timely information for ALL patients (in development) Provide reminders and feedback Facilitate care planning for individuals and populations,Health System,Organization of Health Care,National (Canada),Study publication: * Bourbeau 2003 (Reduction of hospital utilization in patients with COPD) Bourbe
17、au 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),Example of Settings and use of LWWCOPD,National (Canada),Study publication: * Bo
18、urbeau 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),Pati
19、ent 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 i
20、nto your life (2008) Using long term oxygen therapy (2009),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 gro
21、up 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,Websi
22、te, Password: copd,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,National (Canada),Study publication: * Bourbeau 2003 (Reduction of hospital util
23、ization 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),Self-Management: non mandatory and non supe
24、rvised exercise at home, WD,Absence of a supervised exercise program is a limitation to the effectiveness of the program on HRQL,Lvis (1 centre),Halifax (1 centre),Maria (1 centre),Quebec City (2 centres),Montreal (4 centres),Vancouver (1 centre),A Canadian, multicenter RCT of home-based versus outp
25、atient 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,Exercis
26、es 2 months,Maintenance 10 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 rehabil
27、itation, 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),Study publication: * Bourbeau 2003 (Reduction
28、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),International,Acknowledgmen
29、ts,Authors of the 2nd Edition of LWWCOPD: Jean Bourbeau, MD, MSc, FRCPC Maria Sedeo, 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,
