STEP 5

Evaluate your target interventions and results

Case study from the program RECAP (Rehabilitation, Education for COPD and Added value to the medical practice)

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...

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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 therapists 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).

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Evaluation methods

In the course of our different meetings and focus groups, key people agreed that it was important to use quality indicators to evaluate our care delivery process, particularly at the time of discharge from hospital.

The targets to reach were defined in terms of two main outcomes:

The % completion of the D/C planning tool with regard to the total number of COPD admissions
The "best practice" using the previously defined Quality of Care Indicators of practice as set out in the evidence-based guidelines (see following table)

Since this was about a new implementation, and the only previous data we had was what we had obtained through a chart review (step 2), we determined that the best design for our evaluation would be post-only/no control group.

Components of the evaluation plan

	Target intervention	Outcomes
	Target intervention	Intermediate (Care delivery and practice-oriented)	Ultimate (Patient and use of healthcare services-oriented)
Intervention Population: Patients admitted to the medical units with a primary Rx of COPD (general and respiratory hospitals)	Implement a discharge planning (D/C) tool Indicator: % of patients admitted for COPD for which a D/C planning tool has been completed	Increase referrals to respiratory home services Increase evaluations of the pulmonary rehabilitation program Education for inhalation techniques Increase the use of spirometry tests Increase stop smoking interventions Indicator: % of admissions with these interventions done	Reduce 30-day re-admission rates Indicator: In a given caseload of patients for which we have used the D/C planning tool, % of re-admission rates for COPD after 1-month
Referent group	Because this is a new intervention, we can only compare subsequent years after implementation	Previous years (by chart review) As of the year where the D/C tool is used, compare previous year to the next year.	Previous years for same caseload (from database)
Confounding factors	# of patients codified as a COPD admissions, but who actually have other diagnosis (e.g. asthma)	Patient choices (e.g. refusal)	- H1N1A - Progress of the disease

The RECAP-MUHC Committee developed the following evaluation plan. In order to make this evaluation operational, these indicators were integrated into the day-to-day management of the clientele by the use of a standardized tool across the MUHC: the D/C Planning tool. At the same time, we had a number of meetings with the Quality Department to see how they could help us evaluate these indicators (from hospital databases).

Carrying out our evaluation

Data was obtained from the D/C planning tool and with the support of the Hospital Quality Department.

Results

At the General Hospitals, the D/C planning tool was only completed for less than 25% of COPD admissions, compared to the Respiratory Hospitals where the tool was completed in more than 70% of the cases. When we added all the completed D/C planning tools from the three different hospitals, we obtained the following results for each of our indicators:

Quality of Care Indicator	Target (defined success)	2007-2008
1. D/C planning tool completed	Above 80%	General Hospitals <25% Respiratory Hospital 73%
2. Increase referrals to respiratory home services	Above 80%	97%
3. Increase evaluations of the pulmonary rehabilitation program	Above 60%	82%
4. Education for inhalation techniques	Above 80%	87%
5. Increase the use of spirometry tests	Above 80%	81%
6. Increase stop smoking interventions	Above 60%	65%
7. 30-day re-admission rates	Below 10%	13%