Optimising COPD Management in Primary Care - ADHB region

Transcription

1 Optimising COPD Management in Primary Care - ADHB region Auckland PHO 4 th November 2014 Acknowledgement of J Bycroft GP Liaison and P Birch Physio Specialist ADHB for some content of this presentation.

2 Why focus on COPD? 1. 4 th leading cause of death in NZ & rising 2. Avoidable hospitalisation - 3 rd leading cause 3. Health disparities - Māori 5 x more likely to die from COPD-related causes & affected up to 20 years earlier 4. Under-diagnosed & late presentations 50-75% undiagnosed Lost about 50% of lung function (1 lung!) by time symptomatic - damage irreversible 5. Advances in treatment for COPD offer real opportunities to improve your patient's quality and length of life 6. New COPD Clinical Pathway 90% PREVENTABLE! primary care has key role

3 Prevalence Estimated prevalence of COPD in NZ is 14% in adults 40 years and older This increases to 32% of those aged over 70 years (Shirtcliffe P, et al. 2007) Higher rates for Maori and Pacific, so numbers will be much higher for some practices Population Total with COPD (Approx) Admissions/yr Auckland DHB 458,000 36,000? Practice A *? Practice B *? Practice C *? Practice D 10, *? * Figures calculated based on Age/Sex registers showing an average of 56% are aged 40 or over for 14 West AKL practices and 14% of these patients potentially have COPD

4 What s the problem with current care? Quality gap - best practice vs usual care - approx 50% on ideal therapy < 40% were prescribed inhalers, medicines or tablets for their COPD. Most adults with COPD, 59.6% did not use any treatment. (NZ Adult Health Study) Pulmonary rehabilitation - <1% referrals/year Missed opportunity for early diagnosis and improving quality of life Palliative care & Advance Care Plans low rates

5 Risk Factors & Time Course Risk Factors Smokers Passive smoking Fuel cooking (immigrants, & refugees) Occupational exposure Alpha 1 antitrysin Time Course

6 COPD Pathway Online at

7 Assessment Tools Targeted Case-Finding For patients at risk consider following: CAT Tool validated self assessment tool Quick and easy to use 50+ languages Severity Assessment Tools CAT Tool COOP ESOL patients MRC Dyspnoea Scale Lung Function Age Checklist Australasian Website ware09/lung-healthchecklist?view=onepage&catid=3

8 Targeted Case Finding Algorithm Clinical correlation always required Adapted from: The Australian Lung Foundation Position Paper - Use of COPD Screening Devices in the Community 24 July 2011.

9 Lung Age Estimator Lung Age RCT Study Telling patients their lung age increased quit rates Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ. 2008;336: n=bfaf7069cd3fd1771d18a94b99a86adb

10 Spirometry Diagnostic Spirometry Gold standard is pre and post bronchodilator measurement for diagnosis by trained, accredited providers Need printout or software for PMS Training & Equipment Requirements Accreditation Calibration On-going maintenance Referral Options Locality hubs Asthma AKL DHBs Private Labs/Specialists Lung Screening Devices Ongoing monitoring NOT for diagnostic spirometry

11 Spirometry Screening Device Useful in primary care Can be used for targeted case finding then go onto diagnostic Ongoing monitoring of trend in lung function Special authority applications for Tiotropium Quick and easy Diagnostic Spirometry Needed to confirm diagnosis Pre and post bronchodilator Flow volume loop & warns about inadequate blows Sometimes used if significant change Requires accredited provider Ongoing calibration and portfolio requirements to maintain standards Takes approx minutes

12 Spirogram normal vs COPD Chronic Obstructive Pulmonary Disease (COPD) Australian and New Zealand Management Guidelines and the COPD Handbook, 2002

13 Severity based on COPDX Guidelines Having confirmed COPD on the basis of FEV1/FVC < 70%, severity grading is based on the post bronchodilator FEV1 result. Grade FEV1 Functional Assessment Complications Mild 60-80% predicted Moderate 40-59% predicted Few symptoms, no effect on daily activities Increasing dyspnoea Breathless on the flat Increasing limitation of daily activities Nil Exclude complications; consider sleep apnoea if there is pulmonary hypertension Severe <40% predicted Dyspnoea on minimal exertion Daily activities severely curtailed Severe hypoxaemia (Pao2 45mmHg, or 6kPa) Pulmonary hypertension Heart failure Polycythaemia FEV1=forced expiratory volume in one second. Paco2=partial pressure of carbon dioxide, arterial. Pao2=partial pressure of oxygen, arterial.

14 When to refer to Clinic? In diagnosis Moderate COPD with poor symptom control Severe COPD needing specialist assessment Oxygen etc.

15 Pharmacy Related Issues Inhaler use, ability of patients to use the product and coordinate the breath with the inhaler Prescription pick up rates, regularity of inhaler use and overuse, alignment of prescriptions Awareness of action plans Promotion of COPD rehab to patients, flu vaccination, smoking cessation to ensure alignment of the health message Cleaning of delivery devices!

16 MEDICATION RELATED QUESTIONS

17 Systemic effects of COPD A vicious cycle Fear / Anxiety You avoid activities that make you breathless You get more breathless with less activity You do less Decreased Fitness Your muscles become weaker and less efficient

18 Benefits of Pulmonary Rehabilitation Statement 1: PR reduces Dyspnoea (1a) Statement 2: PR improves exercise training (1a) Statement 3: PR improves Quality of Life (1a) Statement 4:PR reduces Anxiety & Depression and Improves Mood (1b) Statement 5: PR reduces Hospitalisation / LOS (2C) Statement 6: PR is more Effective than drugs (1a) Statement 7: PR Is Cost Effective (2C) Statement 7: Improves Survival The COPDX Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease Version Retrieved April 9, 2011

19 Patient Selection Criteria Recognised and Established Criteria for Safety and Success NICE Guidelines for COPD Management 2010

20 Pulmonary Rehabilitation Resources E-Referral or Fax To Central Referrals (09)

21 Self-Management Programmes For mild COPD patients, refer to self management programmes and green prescription Prevent deterioration by following good self management plans, smoke cessation, exercise, good nutrition, exacerbation management, fluvax+/- pneumovax etc (see guidelines)

22 COPDX D develop support network and self management skills Build self management skills Education in the following key areas: Physical activity Dietary advice Medication Refer to self management education classes where available Build support network Help build support network refer to support groups where available Eg COPD West Auckland Support Group run thru Asthma Auckland

23 COPDX Use of action plans and a supply of antibiotics and prednisone at home where appropriate

24 Consequences of exacerbations Impact on symptoms and lung function Negative impact on Quality of life Exacerbations Increased economic costs Accelerated lung function decline Increased mortality

25 Hospital or Home Consider severity of infection Additional tests available at hospital xray, ABG Coping at home Severity of underlying disease

26 Optimising Care Transitions Medication Self- Management Shared Care Record Red flags Support Network & ADLs Planned care with regular follow up Med rec on discharge All members of MDT on same page Review action plan Care Plus, CCM, Palliative Care etc Check within first 72 hours has medication, and ask patient to describe how and when they take their meds Care Plan used and updated at each visit/contact Review understanding and confidence Check for social isolation Check for depression & anxiety Recalls in place See when well

27 Improving overall performance READ coding of all patients with Long-Term Conditions Use population audit tools & reports to monitor progress Move to planned, proactive care use recalls, letters to prepare patients prior to visit etc Ensure all COPD patients have a care plan Consider enrolment onto Shared Care Plan Programme

28 Prompt Follow - Up very important COPD patients who had a follow-up visit had a significantly reduced risk of an ER visit (HR, 0.86; 95% CI, ) and readmission (HR, 0.91; 95% CI, ) Patients lacking timely Primary care follow-up were 10 times more likely to be readmitted (21% vs. 3%, P=0.03) Sharma G, et al. Outpatient Follow-up Visit and 30-Day Emergency Department Visit and Readmission in Patients Hospitalized for Chronic Obstructive Pulmonary Disease. Archives of internal medicine 2010;170(18):1664.

29 Additional Resources HealthPoint clinical pathway, specialist services information Health Navigator NZ public & provider resources, videos etc COPDX and GOLD websites Asthma Respiratory NZ & Australian Lung Foundation