Workshop on COPD 16th Nordic Congress of General Practice Copenhagen

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Workshop on COPD16th Nordic Congress of General
PracticeCopenhagen
How can we establish
a multidisciplinary team to help
patients with COPD in the
community?
Practice consultant in the
municipality of Gladsaxe


Practice consultant at the local hospital
Herlev
Lill Moll Nielsen The Danish
Primary Care Respiratory Group
IPCRG

Surgery in Søborg Copenhagen
Our practice team
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Dialogue

• Do You have acces to a spirometer ?
• Who performs spirometry in Your surgery?
• Can You refer to standardised COPD rehabilitation
  in Your local area?
• Do You have a smoking cessation programme?

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• New Health Act 2007-Obligatory, regional health
  care agreements
• Focus on chronical conditions
• What do our COPD patients need? How can we meet
  their needs?
• The annual COPD control a phrase for Your
  computer
• How patients may move through the system COPD
  stratification- or who does what?
• General practice as manager for the COPD patient
  ,can we cope with the chalenge?

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Danish structural reform 2007- New Health Act
14 Counties
5 Regions
The municipalities are responsible for
prevention, care and rehabilitation that do not
take place during hospitalisation. The
municipalities should be able to find new
solutions especially within prevention and
rehabilitation, e.g. in the form of health care
centres.
The municipalities and regions are obliged by
statute to cooperate about treatment,
training, prevention and care. Obligatory
health care agreements should include agreements
on the discharge procedure for weak, elderly
patients and for prevention and
rehabilitation
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Focus on Chronic conditionsthe 8 chronical
diseases

• Type 2 diabetes
• Cancer
• Ischaemic heart disease
• Osteoporosis
• Muscle and sceletal diseases
• Asthma/allergy
• Psyciatric diseases
• COPD
• The Danish Government Programme on public Health
  and Health promotion 1999-2008
• An action oriented programme for
  healthier settings in everyday life

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Wagner Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organizations
DeliverySystem Design
ClinicalInformationSystems
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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What matters to patients?
Information support to Self care
Empathy and respect
Continuity of care
Fast access
Involvement support of carers
Effective treatment
Smooth transitions
Involvement In decisions
Attention to environment
Emotional support
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What do our COPD patients needto prevent
progression of disease?

• COPD patients need to modify their behaviour
• Smoking
• Exercise
• Medication
• Self-management
• Diet

Disease knowledge
helps understand why
behaviour needs changing
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What do we needto meet our patients needs?

• What is a Prepared,Proactive
• Practice Team?

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Tools in Quality development of managing COPD
in DK
National Recommendations on earlier detection,
treatment and rehabilitation of COPD
Copenhagen National Board of Health
2007.

COPD quality indicators and stratification
The Danish Quality Unit  (DAK-E)
DSAM
The Danish College of
General Practitioners Guidelines Early
detection, management and pulmonary
rehabilitation of COPD ( 2008)

www.DSAM.dk (selfmanagement plans,
LINQ questionnaire,guide to Smokingcessation)
Regional COPD pathway programmes
Datacapture system for COPD General practice
Database
Implementation of guidelines and COPD pathway
programmes
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National Board of HealthRecommendations on
earlier detection of COPD

• The diagnosis COPD should be considered for any
  patient gt 35 years having one or more risk
  factors ,attending general Practice, presenting
  one or more of the following symptoms
• Cough
• Phlegm
• Dyspnoea at activity
• Recurring respiratory infections
• - Regardless of the primary reason for the
  consultation
• 
  National Recommendations on
  early detection, treatment and rehabilitation of
  COPD
• Copenhagen National Board of Health 2007.
• 
  

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Have You planned the annual control with Your
COPD patient?

• Standard
• COPD patients should be offered an annual
  assessment of the severity of their disease
  including treatment according to
• The Danish College of General Practitioners
  Guidelines
• Early detection, management and pulmonary
  rehabilitation of COPD Special focus on
  fysical activity, nutrition, BMI, medicine and
  comorbidity
• Goal
• To support and maintain behavioral modifications
  
• To prevent progression of the disease
• To control correct and appropriate use of
  medicine
• To ensure that rehabilitation efforts are
  maintained.

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e
Stages and management of
stable COPD
2 Moderate
4 Very severe
1 Mild
3Severe
Stadium
FEV1/FVC lt 70 FEV1 lt 30
FEV1/FVC lt 70 FEV1 gt 80
FEV1/FVC lt 70 FEV1 50 - 80
FEV1/FVC lt 70 FEV1 30 - 50
Spirometri
. Cough/Phlegm . Dyspnoea
Cough/Phlegm . Dyspnoea /
Cough/Phlegm Dyspnoea
Cough/Phlegm . Dyspnoea
Symptoms
Smoking cessation Flue vaccination
Shortacting bronchodilator p.n. Control of
inhalation technique
Add one or more longacting bronchodilators Pulmona
ry rehabilitation
Treatment
Add inhaled corticosteroid if more exacerbations
Oxygen? Surgery? Specialist
FEV1 of predicted, according to gender, age
and height
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The downward spiral of breathlessness in COPD 
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Managing COPDin the stable

• Which 10 items do You find the most important
  for an annual check up of Your COPD patient?

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10 chosen COPD indicators according
to The Danish Quality Unit 

• 1) Registration of COPD patients
  
• 2) Accurate diagnosis (FEV1/FVC lt 70 post
  bronchodilator
• 3) Severity of the disease ( FEV1/FVC
  predicted)
• 4) Severity of dyspnoea related to activity MRC
• 5) Smokingstatus
• 6) Exacerbations
• 7) Flue vaccination
• 8) BMI
• 9) Registration of fysical activity
• 10 Annual control /planning of treatment and
  stratification
• including comorbidity (cardiovascular,anx
  iety/depression,
• osteoporosis status of medicine) need of
  oxygen? End stage?
• patient set treatment goals

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How to improve prognosis for our COPD
patients-The annual COPD control-a phrase based
on10 chosen COPD indicators according to
The Danish Quality Unit 

• 1) Registration of the diagnosis
• 2) Accurate diagnosis ( FEV1/FVC lt 70 post
  bronchodilator)
• 3) Severity of the disease based on spirometry(
  FEV1 pred. )
• 4) Severity of dyspnoea related to activity
  (MRC)
• 5) Smoking status and systematic approach to
  smoking cessation
• 6) Number of Exacerbations
• 7) Flu-vaccination
• 8) BMI
• 9) Physical activity
• 10 Annual assessment
• including comorbidity (cardiovascular,anxiety
  /depression, osteoporosis
• status of medicine) need of oxygen? End
  stage?
• patient set treatment goals and
  stratification

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Do You know how Your medicine functions, and how
to use it?
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1) Do You know Your COPD patients?

• Standard
• COPD diagnosis must be registered
• according to ICPC (R95)
• Goal
• To achieve better control and structured
  treatment of the disease

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2) Do Your COPD patients have
COPD ?

• Standard
• COPD patients must have their diagnosis (R95)
  proved by spirometry
• (FEV1/FVC lt 70)
• Post bronchodilator
• Reversibility test where indicated

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3) How ill is the patient?according to
spirometry

• Standard
• All COPD patients must annually be offered a
  spirometry
• On the basis of FEV1/FVC of predicted the
  disease shall be registered as
• mild, moderate ,severe or very severe

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Assessment of severity of the obstruction

• Mild FEV1 ? 80 (of predicted)
• Moderate 50 ? FEV1 lt 80 (of predicted )
• Severe 30 ? FEV1 lt 50 (of predicted)
• Very severe FEV1 lt 30 (of predicted )

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4) How ill is the patient according to degree of
dyspnoea?

• Standard
• COPD patients must annually have assessed
  their degree of dyspnoea related to activity,
  by use of the
• Medical Research Council score (MRC)

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MRCdyspnoea score( Medical Research Council )

• 1 )Not troubled by breathlessness except on
  strenuous exercise
• 2) Short of breath when hurrying or walking up a
  slight hill
• 3) Walks slower than contemporaries on the level
  because of
• breathlessness ,or has to stop for
  breath when walking at own
• pace.
• 4) Stops for breath after walkingabout 100 metres
  or after a few
• minutes on the level.
• 5) Too breathless to leave the house or
  breathless when dressing or
• undressing

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5) Is Your patient at risk -still smoking?

• Standard
• COPD patients should annually have registered
  their smoking status.
• As smoking is the most important single factor
  for development or deterioration of COPD ,the
  team in General Practice should encourage smokers
  with COPD for smoking cessation and help
  x-smokers keep on stopping

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6) Has the patient started getting exacerbations?

• Standard
• COPD patients must annually have registered
  their number of exacerbations within the last year

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What is a COPD exacerbation ?A deterioration
from the stable symptoms,leading to a changeor
increase of treatment

• Increased breathlessness, wheeze, and chest
  tightness
• Increased sputum volume
• Increased sputum purulence (white becoming yellow
  or green green sputum usually points to a
  bacterial cause)
• Non-specific symptoms such as fever, malaise,
  fatigue, sleepiness, and confusion.
• Anthonisen NR, Manfreda J, Warren CP, Hershfield
  ES, Harding GK, Nelson NA. Antibiotic therapy in
  exacerbations of chronic obstructive pulmonary
  disease. Ann Intern Med 1987 Feb106(2)196-204.

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Keep attention to the colour of the sputum!
Stockley RA et al. Thorax 2001 56(5)366-72 Pye
A. Stockley RA. Journal of Clinical Pathology
1995 48(8)719-24.
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Why should we aim to reduce exacerbation rate in
COPD?

• High mortality
• Faster progression of disease
• Decline in lungfunction
• Reduction of muscle strength
• Development of bronchiectasies
• Necessary treatments that in the long run may
  harm
• Prednisolon antibiotics
• Fear and depression

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COPD exacerbation Prognosis after admittance to
hospital

• DK
• (n300)
• Death during hospital admittance 9
• Mortality after 3-months 19
• Mortality after 1 year 36
• Readmittance within 3 months 14
• Readmittance within1year 46

Eriksen et al, Ugeskr Læger 2003
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A Cross sectional COPD audit in the County of
Copenhagen 2002

• 
  
  Hospital informations
• 4 of 45 patients were admitted by their
• own GP, the rest by the doctor on duty or
  
• via casualty department
  
• 4 were offered a follow up in the
• outdoor clinic
• 20 contact to home care nurses
• 0 were offered a Pulmonary rehab. Programme

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How can we prevent COPD exacerbations?

• Smokingcessation
• Standardised pulmonary rehabilitation does not
  reduce risk of exacerbations, but reduces illness
  during exacerbation
• Inhaled steroids can reduce the number of
  exacerbations in patients having FEV1 lt 1,2
  liters or
• lt 50 of predicted 2 or more exacerbations
  within the last year
• Flu-vaccination

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7) Has the patient got the annual
flu-vaccination?

• Standard
• COPD patients should annually have a
  flu-vaccination
• Flu-vaccination reduces severe illness and
  mortality by about 50  in COPD patients
  during a flu epidemic
• Flu-vaccination reduces the number of
  exacerbations in COPD patienter during a flu
  epidemic
• Poole PJ, Chacko E, Wood-Baker RW,
  Cates CJ. Influenza vaccine for patients with
  chronic obstructive pulmonary disease. Cochrane
  Database Syst Rev 2000(4)CD002733.

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8) How ill is the patientHas there been a
decrease in weight gt 5 ?

• Standard
• COPD patients having severe and moderate COPD
  should annually have assessed their BMI
• BMI lt 25 og gt20,5
• Losing weight and under weight is associated with
  increased mortality
• Losing weight and especially losing muclemass
  implies significant increase in mortality, and
  disability in COPD patients
• In severe COPD energy balance as well as protein
  balance may be disturbed.
• Nutritional supply must be combined with
  fitness.
• Focus on early prevention and treatment of
  weightloss.
• Landbo C, Prescott E, Lange P, Vestbo J,
  Almdal TP. Prognostic value of nutritional status
  in chronic obstructive pulmonary disease. Am J
  Respir Crit Care Med 1999 Dec160(6)1856-61.

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9) Fysical activity

• Standard
• COPD patients should annually have assessed
  their physical activity and need for
  intervention by a standardised schedule
• All COPD patients can benefit from exercise and
  shall already in the early stages be informed
  and motivated for being fysically active.
  Individually standardised rehabilitation
  programmes shall be offered for patients having
  moderate, severe and very severe COPD and (MRC ?
  3)
• National Recommendations on
  earlier detection, treatment and rehabilitation
  of COPD
• 
  Copenhagen National Board of Health
  2007.

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Fysical training

• Improves
• circulation
• oxygen uptake in the muscles
• musclemass and strength
• body consciousness and confidence
• quality of life

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A candidate for long term oxygen?
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COPD and Long Term Oxygen Supply

• Who should be screened for hypoxaemia?
• Patients suffering from very severe
  airwaysobstruction (FEV1 lt 1,0 l eller FEV1 lt 40
  of predicted)
• Patients having dyspnoea at rest or very slight
  strain
• Patients with cyanosis
• Patients with hæmatokrit gt55
• Patients having peripheral oedema
• Patients having raised jugular venous pressure

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GP - the manager all the way through
COPD stratification
according to
Hospital admission- NIV
/respirator Outpatientsclinic
Visiting respiratory nurse
Long Term Oxygen treatment
Specialised COPD
rehabilittion
End stage COPD
Other partners At all levels Lungassociation Farma
cy AOF
Primary care rehabilitation
Physical therapist , Occupational
therapist Doctor, Dietician
,Psycologist Specialist consultation
when needed

• Local community settings
• 1) Patient education
• Focus on riskfactors and lifestyle
• 2) Evaluation of working capacity advice on
  fysical activity
• Living a Healthy Life With Chronic Conditions
• Chronic Disease Self-Management Program

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General practice as manager for the COPD
patient Can we cope with the challenge?
My waiting room
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General practice asmanager for the COPD
patientCan we cope with the chalenge?
Barriers Economy Time Competences
Support Fee for providing annual asessment of
COPD 010623047113 Organisation of The Practice
Team Education
Gain Better patient pathways Overview Short cut
to the good referral A joyfull teamwork
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Key points of learning

• Which ideas can You use in Your surgery?
• How can You make them implemented in your routine
  work with the COPD patients?
• When will You do it?

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A better life with COPD
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IPCRGInternational Primary Care Respiratory
Group

• The ONLY international primary care respiratory
  organisation
• The ONLY international primary care
  organisation with a respiratory research mission
• www.theipcrg.org

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IPCRG The International Primary Care
Respiratory Group

• a charity registered in Scotland working
  internationally
• (SC No 035056)
• a company limited by guarantee
• Company number 256268)
• a Special Interest Group of Wonca Europe
• an Organisation in Collaborative Relations with
  Wonca Global

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• Scientific meeting 5 June 2009 Stansted,  UK
  http//www.theipcrg.org/sci_conf_2009/
• Biennial conference in Toronto 2-5 June 2010
  website
• http//www.ipcrg-toronto2010.org/

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• An individualised
• rehabilitation programme for COPD

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Pulmonary rehabilitationDefinition

• a multidisciplinary programme of care for
  patients with chronic respiratory impairment ,
  that is individually tailored and designed to
  optimise physical and social performance and
  autonomy
• Amercican Thoracic Society - Statement on
  Pulmonary rehabilitation

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Outcomes from pulmonary rehabilitation

• Improvement in exercise tolerance (Evidence A)
• Increase in
• functional walking distance (Evidence A)
• peripheral and respiratory muscle strength
• Improvement in health status(Evidence A)
• (dyspnoe, fatigue, emotional function)
• Prevention of complications
• Reduction in hospital days for exacerbations
  (evidenceA)
• Lacasse Y, Brosseau L, Milne S, Martin
  S, Wong E, Guyatt GH et al. Pulmonary
  rehabilitation for chronic obstructive pulmonary
  disease. Cochrane.Database.Syst.Rev 2002CD003793
  

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Components of pulmonary rehabilitation?

• Individually taylored
• Supervised exercise-training
• Endurance
  training
• Strengh
  training
• Education

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Educational componentand the multidisciplinary
team

• Disease character and background
  ( physician)
• Management of relapse
• How to use medication?
  ( nurse)
• Inhaling techniques
• Exercise ,Breathing Control
• Sputum clearance
  ( physical therapist)
  
• Energy conservation and
• work simplification
  (occupational
  therapist)
• Nutritional therapy
• When and what to eat?
  
  (dietician)
• Psycho social intervention
  ( psychologist)
• Stressmanagement
• Instruction in progressive muscle
  relaxation
• Panic control

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Exercise component

• Inividually dosed
• physical training including aerobic training of
  big muscle groups
• at an intensity of 85 of maximal oxygen
  consumption ( walking or biking)

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How to assure the right level of exercise?

• The Shuttle test a test of walking capacity in
  which the patient walks 10 meter shuttles at
  standardised incremental speeds until they cannot
  keep up
• 
  Incremental test
• Endurance test

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Rehabilitation programmeMinimal demand

• Twice a week for 7 weeks
• Individually organised training
• Education in connection with exercise
• Training to be continued at home
• Endurancetest after 3, 6 and 12 months

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3 ways of training

• Warming up and stretching out
• Endurance training
• Biking
• Power walking
• Walking stairs
• Strength training

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Training

• Improves circulation all over the body
• Increases Oxygen uptake in the muscles
• Increases muscle mass and strength
• Increases body consciousness and confidense in
  physical strength
• Gives psychological strength and panic control
• Improves quality of life

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Exercise regime to be followed at home

• Easy to perform
• Demanding few tools
• Patient must learn to keep the training intensity
  BORG-scale
• Training diary must be filled in
• Results to be followed and progressed

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Who may benefit from pulmonary rehabiliation?

• Patients with moderate, severe and very severe
  COPD
• being motivated
• for whom dyspnoea causes functional limitation
• having no contraindications
• 1) risk causing as unstable angina,
  aortastenosis
• 2) interfering with the rehabilitation proces
  as disabling arthritis

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MRCdyspnoea score( Medical Research Council )

• 1 )Not troubled by breathlessness except on
  strenuous exercise
• 2) Short of breath when hurrying or walking up a
  slight hill
• 3) Walks slower than contemporaries on the level
  because of
• breathlessness ,or has to stop for
  breath when walking at own
• pace.
• 4) Stops for breath after walkingabout 100 metres
  or after a few
• minutes on the level.
• 5) Too breathless to leave the house or
  breathless when dressing or
• undressing

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Pulmonary rehabilitation settings in DKapril
2004
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Key features of Danish General Practice

• Population 5.500.000
• Semi-private sector
• GPs 3.500
• List system
• Gate-keeping the GPs refer
• Tax-financed, no patient fees

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GP clinics

• Small units 1/3 of the GPs are single handed,
  1/3 two GPs and 1/3 3 GPs or more
• Ratio between GPs and staff 0.7
• The clinic income comprise
• 25 capitation
• 75 fee for service

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GP organisations

• PLO - Danish General Practitioners Organisation
• DSAM The Danish College of General Practitioners
  is the scientific college of general practice.
  Purposes
• Education research - international contacts -
  quality development