living 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

Implementation of COPD management programs in Qubec, Canada,Jean Bourbeau, MD Associate ProfessorMcGill UniversityMontral, CANADA,Montreal Chest Institute,Royal Victoria Hospital,GOLD National Leaders,ERS Berlin 2008,The beginning 1997: Description of the situation,COPD managementMounting evidence indicates that standard care often fails to meet needs of patients with chronic diseaseSelf-management education has proved to be effective in chronic disease such as DM, CHFNo self-management program specific to COPD patient,National (Canada),National (Canada),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,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 educationflipchart; 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,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,$4,246,p=0.16,p=0.046,p=0.024,Bourbeau J, et al. Chest 2006; 130(6):1704-1711.,Caseload (number of patients followed by the case-manager),Cost per patient ($),30,50,70,Standard care,Self-management,Cost per patient: All health care resources used during the one year follow-up were considered. All 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.,Theorical foundation of the self-management program Living Well With COPD,Chronic Care Model (Wagner 2001)Self-Management Model (Lorig & Holman, 2003)Self-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,Hospitalizations (Relative Risk Ratio),Adams SG. Arch Intern Med,Delivery System Design,Practice team has defined rolesPartnership: Patient active participation in disease managementPhysician prescribed overall optimal treatmentCase manager is the resource person for the patientOther health professionals as consultants, supportRegular follow up and coordination of care by physician and case managerAssess patients general condition and needs and define goalsHelp patient/family integrate 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: Specialized programs: Pulmonary Rehabilitation, Smoking Cessation, Stress ManagementSpecialists to follow-up on co-morbiditiesHealth professionals from the multidisciplinary team and community servicesPerformance review and identification of barriersQuality control studiesContribution to research,Health System,Organization of Health Care,Community,Clinical Information System: Registry,Provincial inter-establishment reference systemStandardized criteria of reference for services in the community Electronic database Specific formulary for COPD patientsHospital Database of clinically useful and timely information for ALL patients (in development) Provide reminders and feedbackFacilitate 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)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,National (Canada),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 energyPreventing your symptoms and taking your medicationsIntegrating a plan of action into your lifeManaging your stress and anxietyKeeping a healthy and fulfilling lifestyleIntegrating a home exercise program into your life (2008)Using long term oxygen therapy (2009),Reference guidesfor health professionals,Development of reference guides for individual and group teachingPrinciples 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 neededIntervention and education methods usedExamples 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),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, 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,Exercises2 months,Maintenance10 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 tri