In our organization, there were no formal quality indicators to evaluate chronic disease management. We therefore agreed that we needed a formal assessment that would help link our interventions with improvements to medical practice with respect to chronic disease management.

 

It was decided that the main focus of the evaluation of "gaps in care" will be on the chronic disease management, i.e., proper diagnosis with a spirometry test and optimal pharmacological and non-pharmacological treatments upon the patient's discharge from the hospital (e.g. stop smoking programs, pulmonary rehabilitation programs, respiratory services in the community, etc.). We used an evaluation of the gaps in care that was conducted based on a comparison between the actual care provided and guideline recommendations, i.e., recommendations made by the Canadian Thoracic Society for COPD management.

The gaps in care assessment was done as follows:

a) Selection of medical charts from three different years and covering the same period of the year (January to March): Medical charts were randomly selected to ensure that the results would be representative of the practices within our hospital:

• Patients admitted with a primary COPD diagnosis and discharged directly from the hospital to home.
• Patients who visited the ER where they complained about COPD, or COPD was the discharge diagnosis.

b) Chart review The chart review was done by the same person (medical record) using a standardized data collection form,

c) Assessment of COPD management "Gaps in care", 261 charts were reviewed; mean age 73.2 years and FEV^₁ 43.6%. The identification of patients and physicians was kept confidential. One respirologist and one specialized COPD case management nurse independently reviewed the data collected for each patient. They had to complete a discharge plan according to the following criteria:

The respirologist had to decide the most appropriate pharmacological treatment (maintenance) based on the recommendations of CTS COPD management. The respirologist and the COPD case manager had to decide whether the patient should have been referred to COPD community services, a consultation with a respirologist, a pulmonary rehabilitation program and/or a stop smoking program. The gap in care was then defined as the disconnect between the actual care provided and the best care that should have been provided, i.e., the recommendations from CTS COPD Guidelines.

Gaps in care vis-à-vis COPD patients seen in the emergency room or admitted to the hospital
	General hospitals		Respiratory hospital
Quality care indicators	GH1	GH2	RH
Spirometry test done during event	< 50%	< 50%	50-75%
Referral to a respirologist	50-60%	50-60%	> 75%
Using at least one long-acting bronchodilator	< 50%	< 50%	> 50%
Referral to Pulmonary rehabilitation program	< 25%	< 25%	25-50%
Referral to smoking cessation program	< 25%	< 25%	25-50%
Referral to respiratory community’s services	< 25%	< 25%	25-50%

 

We organized continuous education sessions where we drew attention to MUHC gaps in care. We reach more than 15 managers and over 120 residents, respirologists, nurses and pharmacists.  The care gaps study was a robust tool: it allowed us to convince key people at different levels that there was a problem and emphasize how important it was for them to get involved. Continuous education sessions mostly targeted GH1 and GH2 medical residents and respirologists.

There was agreement that the results adequately represented our practices and that there was a need to come up with some solutions.

Everyone bought into the idea that something had to be done. However, it is important at this stage to engage people in the steps that follow.

Do not assume that the best practices are in place in your institution, or that you know all about them; you need to do a formal assessment "Gaps in care".