Chronic Obstructive Pulmonary Disease (COPD)

1. Chronic Obstructive Pulmonary Disease (COPD) Dr Ian Williams Greater Metro South Brisbane Medicare Local

2. Aim of presentation 1 Setting the scene 2 Early results of literature review 3 Suggested research project

3. For the last 20 years, COPD rates have remained unchanged for hospital admissions … Why?

4. Chronic disease in GMSBML Greater Metro South Brisbane ML population = 915, 859 20% of the Queensland population 11.2% aged 65 years and over Chronic disease statistics 3.4% diagnosed with Type 2 Diabetes 26.5% with Respiratory system disorders 15.5% with Circulatory system diseases 11.8% with Psychological distress

5. The scene … In 2013, it is estimated that there are ~ 29,000 symptomatic COPD patients in GMSBML region. Less than 50 per cent of symptomatic patients are currently diagnosed and managed. There are another 27,000 patients with early stage, asymptomatic COPD. Source: Boehringer Ingelheim, Data on COPD and Asthma nationally and in the Greater Metro South Brisbane Medicare Local, 2013

6. Avoidable hospital admissions 8.9% (~ 8000) of all admissions could be managed in Primary Care Male rate of hospitalisation ~ 38% higher than female Avoidable presentation is category 4 or 5 4semi-urgent such as a minor cut requiring sutures seen within 1 hour 5 medical condition which has been long standing and unchanging

7. Admissions – chronic conditions 51% (~ 4000) of potentially avoidable admissions are related to chronic conditions 25% with diabetes complications 20.3% with COPD 16.6% with Angina 15% with congestive heart failure

8. Models of care for COPD in primary care There is certainly a lack of evidence regarding the effectiveness of Chronic Care Model/Integrated Care Models in the primary care setting. There is some evidence that supports implementation of an Integrated Care Model, e.g. improvement in quality of life, functional exercise capacity, and more planned preventive-consultations have been shown in primary care.

9. Research needed to determine the best way/s of managing COPD in Greater Metro South Brisbane region In 2010-11, COPD ranked as the second highest chronic condition in the GMSBML region for potentially preventative patient episodes of care for chronic conditions in public hospitals1 1 Metro South Hospital and Health Service, 2012 COPD ED presentations, GMSBML region, Queensland Health

10. COPD models in general A shift from an acute care to a chronic care approach: Current models of care for COPD rely mainly on Wagner’s Chronic Care Model (CCM) As an extension to the CCM, other (but very related) models have been developed as well: Disease management programs or Integrated care models for COPD.

11. Chronic care model (CCM) Components of CCM Self-management Delivery system design Decision support Clinical information system  Adams et al. (2007) showed that patients with COPD who received interventions with 2 or more CCM components had lower rates of hospitalizations and emergency or unscheduled visits and a shorter length of stay compared with control groups .

12. More evidence … There is certainly a lack of evidence regarding the effectiveness of CCM/Integrated Care Models in the primary care setting There is some evidence that supports implementation of an Integrated Care Model: • The Cochrane review on Integrated Disease Management (IDM showed in a subgroup analysis (primary care studies) a clinically relevant and statistically significant difference in quality of life and functional exercise capacity of in favour of IDM. • The same authors recently published a protocol of an intervention study on the cost-effectiveness of an IDM for COPD in primary care, as there is no evidence yet.

13. Bourbeau et al. (2013): In a narrative review on the Integrated Care Model in primary care, Bourbeau et al. highlight several relevant themes Increasing number of studies on Integrated Care show positive outcomes for patients with COPD. These studies have in common a self-management intervention including an action plan Education alone is not enough: a self-management programme should aim at behaviour change Self-management will not suit all patients. Self-management programme in primary care does not have a great uptake yet

14. Bourbeau et al. (2013): Recently published trials have brought controversy with respect to the effectiveness of self-management programmes,especially in patients with high burden of disease and co-morbidities. It may be more challenging to make the patient with high burden of disease a partner and not without risk of serious adverse events. Bourbeau et al. propose an integrated care model with stratification according to disease severity.

15. Research proposal Partner with a local University with a view to 1 Systematic review of the literature regarding models of care for COPD patients in the primary care setting. 2 Investigate current models being used in GMSBML Mixed methods: Social Network Analysis How does this compare to phase 1 3 Trial proposed models of care in GMSBML Informed by phase 1 and 2 Guided by implementation science Sustainability

16. Thank You