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Pauwels RA, et al. Lancet 2004; 364:616-620
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Jamal A, et al. JAMA 2005; 294:1255-1259
Optimizing Chronic Disease Management
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September 28th, 2006
#4
#7
#12
Optimizing Chronic Disease Management
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COPD Hospitalizations by sexCanada, 1979-2003 (projections to 2010)
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
Year
Sep
arat
ion
s p
er 1
00,0
00
Males Females Linear (Males) Linear (Females)
ICD10 codes: J40-J44. Note that the coding schemes for this condition changed in 1968, 1978 and 2000 and this may influence trends.Age-Standardized to the 1991 Canada Population. Prior to 1993, includes only the ten Canadian Provinces.Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Vital Statistics Data.
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SHR Hospitalizations
0
5
10
15
20
25
30
IHD CHF COPD DM RF
Percentage ofAdmissions
Saskatoon Health Region Statistics, 2005
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SHR Hospitalizations
Disease Length of Stay
Readmission Rate
COPD (02-03) 11.0 30%(03-04) 9.1 28%
Diabetes (02-03) 10.1 21%(03-04) 9.9 22%
CHF (02-03) 10.6 20%(03-04) 9.5 17%
IHD (02-03) 7.0 13%(03-04) 7.1 11%Saskatoon Health Region Statistics, 2005
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Exacerbations and Mortality
Time (months)
p<0.0001
p<0.0002A
B
C
p=0.069
0 10 20 30 40 50 60
1.0
0.8
0.6
0.4
0.2
0
Su
rviv
al p
rob
abil
ity
Group A: no exacerbationsGroup B: 1–2 exacerbationsGroup C: ≥3 exacerbations
n=304
Soler-Cataluna JJ, et al. Thorax 2005;60:925–931
Exacerbation = ER visit or hospital admission
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Acute Event MortalityMyocardial Infarction• 25% of men and 38%
of women will die within 1 year of a first recognized MI (5,6)
• The in-hospital acute MI mortality rate is 9.4% (1999) (5,6)
1. Eriksen N, et al. Ugeskr Laeger 2003;165:3499–3502. 2. Groenewegen KH, et al. Chest 2003;124:459–467. 3. Almagro P, et al. Chest 2002;121:1441–1448. 4. Connors AF, et al. Am J Respir Crit Care Med 1996;154:959–967. 5. Thom T et al. Circulation 2006. 6. Heart and Stroke Foundation of Canada
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Acute Event Mortality
COPD Exacerbation• 22-43% of patients
hospitalized with a COPD exacerbation will die within 1 year (1,2,3,4)
• The in-hospital mortality rate for COPD exacerbations is 7-11% (1,2)
Myocardial Infarction• 25% of men and 38%
of women will die within 1 year of a first recognized MI (5,6)
• The in-hospital acute MI mortality rate is 9.4% (1999) (5,6)
1. Eriksen N, et al. Ugeskr Laeger 2003;165:3499–3502. 2. Groenewegen KH, et al. Chest 2003;124:459–467. 3. Almagro P, et al. Chest 2002;121:1441–1448. 4. Connors AF, et al. Am J Respir Crit Care Med 1996;154:959–967. 5. Thom T et al. Circulation 2006. 6. Heart and Stroke Foundation of Canada
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Risk of Death - Exercise Capacity
Risk of death in subjects with risk factors and exercise capacity of <5 MET or 5-8 MET, compared with subjects with capacity >8 MET (MET = VO2 3.5 ml/kg/min)
Myers J et al, NEJM 2002; 346:793-801
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Rehab and HealthCare Utilization
Ries AL, et al. J Cardiopulm Rehabil 2004; 24(1): 52-62
Healthcare utilization over 18 months of follow-up. Data presented include physicians visits, telephone calls, hospital days, and urgent care visits over the preceding 3 months. The results are presented as mean + SE.
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Bronchodilators and Rehabilitation
Casaburi R, et al. Chest 2005; 127:809-817
8
12
16
20
24
0 2 4 6 8 10 12 14 16 18 20 22 24
**
Rehabilitation
Study Drug
16%
32% 42%
End
ura
nce
Tim
e (
min
s)
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Placebo
Tiotropium
Optimizing Chronic Disease Management
Weeks on Treatment* p<0.05
Comprehensive COPD Management
0 50 100 150
Admissions the year before the study
Admissionsfor exacerbations
for other reasons
Number of hospital admissions
- 40%
- 57%
+ 4%
0 50 100 150
Admissions
- 40%
- 57%
+ 4%
0 50 100 150
Admissions the year before the study
Admissionsfor exacerbations
for other reasons
Number of hospital admissions
- 40%
- 57%
+ 4%
0 50 100 150
Admissions
- 40%
- 57%
+ 4%
0 50 100 150 200
Emergencies forother diseases
Emergency for exacerbations
- 41%
- 23%
- 59%
0 50 100 150 200
Number of ER visits
Non-scheduledvisits
- 41%
- 23%
- 59%
0 50 100 150 200
Emergencies forother diseases
Emergency for exacerbations
- 41%
- 23%
- 59%
0 50 100 150 200
Number of ER visits
Non-scheduledvisits
- 41%
- 23%
- 59%
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Bourbeau J, et al. Arch Int Med 2003, 163:585-91*Can Respir J 2004; 11(Suppl B): 7B-59B
Comprehensive COPD Management
• benefits persist over 2 years(Gadoury MA, et al. Eur Resp J 2005; 26:853-857)
• a caseload of 50 patients equals cost-savings (program vs usual care) of $2,149 – $2,300 /year
• concluded that a caseload of 70 patients was achievable and reasonable (additional savings of $310 /year)
• reduced hospitalizations, reduced exacerbations, and reduced healthcare costs
Bourbeau J, et al. Chest 2006; in press
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Ezekowitz, JA, et al. CMAJ 2005; 172:189-194
Comprehensive CHF Management
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Knowler WC, et al. NEJM 2002; 346:393-403
Preventing Type 2 Diabetes
n= 3234 non-diabetics with elevated fasting
glucose
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Optimizing Chronic Disease Management FOR SASK RESPIRATORY SUMMIT ONLY
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help COPD pts and their families improve self-management of their disease
• focused on outcomes• increased Pulmonary Rehabilitation capacity
– home site (Field House) is full– assisted with establishing program in Regina– established 1st satellite in part of Saskatoon with
the highest incidence of chronic diseases– additional satellites rolled out (Humboldt and
Prince Albert) and other’s planned (Lawson Heights/Soccer, Saskatoon core, Yorkton, Moose Jaw)
“Inspire” COPD Program
What Have We Seen So Far?
Saskatoon Health Region Statistics, 2006
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• reduced COPD re-admissions - net cost savings of ~129,000 in 2005, and ~$79,000 in 2006
• re-admission rates of 1 : 1.9 : 2.1 (2004), changed to 1 : 1.6 : 1.2 (2006) with recent programming at 3 acute-care sites in SHR
• decreased ICU days by 44% (2006), with a cost savings in 2005 of $261,333, and in 2006 of $308,333.
• Community-based supervised exercise programming
• Group education
• Socialization
Group Exercise and
Rehabilitation
• Community-based supervised exercise programming
• Group education
• Socialization
Group Exercise and
Rehabilitation • “Live-Well with a Chronic Condition”
• Patient-led group classes / support
• Enhanced self-management skills and decision-making
Patient Self-Management
Skills
• Community-based supervised exercise programming
• Group education
• Socialization
Group Exercise and
Rehabilitation • Nurse-Clinician working with the patient, their Family Physician and/or Specialist
• Evidence-based optimal care delivery
Disease-Specific Management
Patient Self-Management
Skills• “Live-Well with a Chronic Condition”
• Patient-led group classes / support
• Enhanced self-management skills and decision-making
Live Well™ Program
• a cost-effective, integrated [provincial] program - centralized coordination with both urban and rural delivery
• strategic, focused design and delivery
• “the right person doing the right job”
• cement the relationship between the patient [and family] and their family physician
• interventions that are not evidenced-based will not be utilized or promoted
Live Well™ Program (cont’d)
• ongoing evaluation of both patient and program outcomes is necessary
• an electronic data management system is used for patient care, and also to facilitate communication, coordination and evaluation
• the program philosophy, design and delivery is common [ie. efficient] for many medical conditions – only Pillar 2 is “disease-specific”
• the model works and borrows on the learning's of others
Live Well™ Program (cont’d)
• proposed Centers of Excellence in Regina and Saskatoon, but with comprehensive program delivery in every health region, using an achievable phased implementation
• benefits to patients are coupled with significant cost savings
• targeted funding would best be provided “provincially” to the health regions with the expectation of tangible deliverables and appropriate evaluation/reporting