Background

The Montreal Chest Institute has been leading important clinical and evaluative research in COPD over the last decades. Some of these applied clinical research projects have been carried out at a provincial level with the goal of developing and evaluating the impact of a self-management program specific to Chronic Obstructive Pulmonary Diseases (COPD) within a context of integration of care. One of these studies published is recognized as a landmark in the approach of care of COPD patients. A multicenter randomized clinical trial was carried out at 7 hospitals in 3 cities of the province of Quebec from February 1998 to July 1999. Patients assigned to the self-management program « Living Well with COPD© » (developed in partnership with the Health Respiratory Network of the FRSQ and Boehringer Ingelheim Canada) with follow-up by a case manager over 1 year experienced an improvement on their quality of life and a reduction of 40% and more in the number of visits to the emergency room and hospitalizations and up to 60% in the number of unscheduled physician visits, compared to the usual care group.

Given the importance of these results, in 2003 the Health Agency of Montreal decided to set out a recurrent budget in order to consolidate an integrated approach of care and first line services, with the objective to reduce the number of hospitalizations and the frequency of emergency room visits. This project would include the addition of different resources and services for COPD patients, among them a medical guard for a respiratory therapist and nursing care offered 24/7, and a strong training component for the various case managers at the first line services.

The Montreal Health Agency also decided to support a specific quality improvement project called "Rehabilitation, Education for COPD and Added-value to the Medical Practice" (RECAP) at the McGill University Health Centre (MUHC).

 

Build a successful team

Considering the number of patients with chronic diseases admitted to the MUHC, a team agreed to work together to initiate a process of quality improvement to evaluate the quality of care during the hospitalization phase or during an emergency visit.

1. Healthcare manager (1)
2. Healthcare providers (1 physician and 1 nurse)
3. Project coordinator (1)

 

Target Population

The MUCH comprises 5 sites. We decided to focus our analysis on the 2 general adult hospitals, and the specialized respiratory hospital. From now on, statistics presented for the MUHC represent the compiled data for these 3 sites.

An initial search revealed that COPD was approximately just as common as congestive heart failure for justifying hospital admissions across the MUHC. COPD admissions plus acute lower respiratory tract infection admissions were the most common causes of admissions to the hospital.

ICD codes used: A COPD admission was defined as (1) most responsible diagnosis with ICD-10 for COPD: codes J42, J440, J441, J448 or J4449; for pneumonia/COPD: J151, J181 or J189 and for CHF/COPD: code 1500 collected from the quality hospital department. We record separately the two general hospitals (GH1 and GH2) and a respiratory hospital (RH)

COPD Hospital Admissions Statistics at MUHC Sites  (COPD, CHF/COPD and Pneumonia/COPD)
Hospital	General		Respiratory	Number of Admissions
Fiscal year	GH1	GH2	RH
2003-2004	161	128	325	614
2004-2005	166	169	354	689
2005-2006	127	204	267	598

 

There was also a general impression that the care provided to COPD patients was primarily "if not exclusively" delivered during the acute phase of the disease. The priority from the health care providers for patients with a chronic condition should not be only on acute events.

Chronic disease management and optimal care designed to prevent COPD complications, such as recurrent exacerbations, recurring visits to the ER, or hospital admissions did not appear to be part of the current practice in our institution. These were the concerns in view of the evidence in the literature that a chronic care approach to COPD, in terms of both pharmacological and non pharmacological treatments, results in benefits to patient outcomes and a reduction in the use of health care services.

The COPD clientele admitted to the hospital or visiting the ER was chosen as the target clientele for our CDM Quality Care .

Do not assume that you know the impact of COPD on your institution before you have done a formal assessment.