Practice Support Program in COPD: South Okanagan Project

COPD CARE AlgorithmSouth Okanagan, Interior Health

Patricia Rattee RRT, CRE

Shannon Walker MD, FRCPC Respirology

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COPD is under-diagnosed.

COPD is a chronic progressive respiratory disease for which guidelines recommend a chronic disease management approach through a multi-disciplinary team and patient self-management endpoints.

GPs may not have the time nor skills to promote self-management disciplines to their patients with COPD.

Tools currently exist for AECOPD discharge planning but not for early identification or management of the COPD outpatient.

Why did we do this project?

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To promote early diagnosis of COPD in the community with a case finding approach and registry

To improve the care pathway of patients with COPD or suspected COPD through the GPs office

Develop relationships and care plans amongst family physicians, patients, specialists and acute care / community services

To promote and encourage optimal management of COPD patients according to national Canadian Thoracic Society COPD guidelines

What do we hope to achieve?

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VISIT 1: Patient Registry

Burden of COPD

Identification of Persons at RiskVISIT 2: Screening of Persons at Risk

Smoking cessation

COPD-6 or SpirometryVISIT 3: Confirmation

Spirometry interpretation

Assessment of level of disabilityVISIT 4: Management

CTS guidelines for pharmacologic and non-pharmacologic treatment, ACTION PLAN

VISIT 5+: Continuing Care

Follow up, Rehab, Co-morbidities, End of Life

5 step OFFICE APPROACH

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BE AWARE OF THE BURDEN OF COPD in Canada and world-wide

WHO IS AT RISK?› Formulate a patient registry› Identify smokers and ex-smokers in the practice› Have smoking cessation tools and contacts at

hand› Bring patient at risk back for screening

Visit 1: Identification

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To screen for COPD, airflow obstruction not fully responsive to BD needs to be demonstrated

Physical exam, Xray, nor smoking history alone confirms the diagnosis

COPD-6 is useful office tool for screening in suspected patients

Differentiate from other airway diseases, and other causes of SOBOE

Visit 2: Screening

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Does spirometry confirm fixed airflow obstruction post-bronchodilator?

Is the patient still smoking? How severe is the FEV1? How severe are symptoms and/or disability?

Visit 3: Confirmation of COPD and Assessment of Severity

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Lung function Level of symptomatology Level of disability Co-morbidities Exacerbations and hospitalizations Systemic effects

What constitutes “Severity”?

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1. Do they have COPD?2. Are they still smoking?*3. Do they have symptoms?4. Have they had an exacerbation in the past year?5. Answers to the above determines the starting

point for the management of COPD…6. CTS management guidelines

Visit 4: Management of COPD

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Comprehensive Management of COPD

GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

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Optimal Pharmacotherapy

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Prevention and Treatment of AECOPD Management of progressive symptoms Compliance and Medication Side-effects Pulmonary Rehab Respiratory Education Patient Self-management and Action Plans Re-assessment of lung function Management of Co-morbidities End of Life Care

Visit 5+: Continuing COPD Care and Tools

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Questions ???