well with copd （title） gold the global initiative for 慢性阻塞性肺疾病以及生活（标题）金全球倡议课件

Implementation of COPD management programs in Qubec, Canada Jean Bourbeau, MD Associate Professor McGill University Montral, CANADA Montreal Chest Institute Royal Victoria Hospital GOLD National LeadersGOLD National Leaders ERS 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 2006 20052006 * RegionQubecQubecQubecCanadaCanadaCanada Milestones LWWCOPD 1st Edition Studies: 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 2006 20052006 * RegionQubecQubecQubecCanadaCanadaCanada Milestones LWWCOPD 1st Edition Studies: 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) 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 Patients randomized. 12 months F/U 9 6 86 9 5 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 0100200300 Days after Enrollment 0.00.81.0 Probability of not being Hospitalized 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 $4,246 p=0.16p=0.046p=0.024 Bourbeau J, et al. Chest 2006; 130(6):1704-1711. Caseload (number of patients followed by the case-manager) Cost per patient ($) 305070 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. TheoricalTheorical foundationfoundation of the of the self-management program Living self-management program Living WellWell WithWith COPD COPD Chronic Care Model (Wagner 2001) vSelf-Management Model (Lorig & Holman, 2003) vSelf-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 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. Programs involving multiple chronic care model components vs. SM alone MulticomponentSelf-management only Hospitalizations (Relative Risk Ratio) Adams SG. Arch Intern Med Delivery System Design Practice team has defined roles Partnership: vPatient active participation in disease management vPhysician prescribed overall optimal treatment vCase manager is the resource person for the patient vOther health professionals as consultants, support Regular follow up and coordination of care by physician and case manager vAssess patients general condition and needs and define goals vHelp patient/family integrate in daily life the skills and healthy behaviours learned, evaluate and reinforce vProvide an Action Plan and support its use vDo proper referrals within hospital and in community Health System Organization of Health Care 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 Health System Organization of Health Care Community Clinical Information System: Registry Provincial inter-establishment reference system vStandardized criteria of reference for services in the community vElectronic database vSpecific formulary for COPD patients Hospital Database of clinically useful and timely information for ALL patients (in development) vProvide reminders and feedback vFacilitate care planning for individuals and populations Health System Organization of Health Care National (Canada) 1997 1998 1998 2000 2003 To date 2004 2006 20052006 * RegionQubecQubecQubecCanadaCanadaCanada Milestones LWWCOPD 1st Edition Studies: 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) 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) Example of Settings and use of LWWCOPD IndividualGroup # of participantsPatient (and close family member) 6-8 participants # of sessions and duration 4 sessions 1.30 hour each 6-8 sessions 1 hour each LWWCOPD tools for the Patient Learning modules Patient brochure Written Plan of Action Learning modules Patient brochure Written Plan of Action LWWCOPD tools for the Health professional Reference Guides for Individual Education Flipchart Reference Guides for Group Education Posters Board with markers National (Canada) 1996 1998 1998 2000 2003 To date 2004 2006 20052006 * RegionQubecQubecQubecCanadaCanadaCanada Milestones LWWCOPD 1st Edition Studies: 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) 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) 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 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 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 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) 1997 1998 1998 2000 2003 To date 2004 2006 2005 2008 2008 * RegionQubecQubecQubecCanadaCanadaCanada Milestones LWWCOPD 1st Edition Studies: RCT LWWCOPD 2nd Edition Studies: RCT 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 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) Self-Management: non mandatory and non supervised exercise at home Self-Management (Bourbeau Arch Int Med 2003) HRQL Pulm. Rehabilitation (Griffiths Lancet 2000) 6 MWTSGRQ Symptom & Actvity subscales WD 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 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 Exercises 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 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 2008 2008 * RegionQubecQubecQubecCanadaCanadaCanada Milestones LWWCOPD 1st Edition Studies: RCT LWWCOPD 2nd Edition Studies: RCT 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 Contex