COPD Care Program

1
COPD Care Program

• Dr Yuk Lung KWOK
• Division of Respiratory Medicine, Department of
  Medicine Geriatrics,
• Tuen Mun Hospital, Hong Kong
• Clinical Audit Conference
• NTWC, Hospital Authority
• February 2005

2
Characteristics of COPD management in NTWC before
start of CCP

• All COPD exacerbations were managed by the
  general team.
• Aim at solving the acute problems for that
  particular admission and discharge ASAP.
• Usually no specific probing into the reasons for
  repeated admissions and blame the natural
  deterioration of the disease (which in fact is
  not true).

3
Characteristics of COPD management in NTWC before
start of CCP

• No Chest Hospital in the region.
• No existing structured convalescent care.
• Lack of organization of all the work and inputs
  from the paramedical teams in POH.
• In-patient pulmonary rehabilitation in TMH since
  2002 can only accommodate a small volume of
  highly selected patients.

4
COPD hospitalization episodes in HA Hospitals
(2002)
NTWC ?1.06 million
5
COPD Hospital Outcomes 2002
6
COPD Care Program (CCP TMH/POH)

• Q3 2003

7
COPD Care Program - Essence

• COPD Care Program (CCP) Respiratory
  physicians-led multidisciplinary disease
  management program for managing hospitalized COPD
  exacerbations in the NTWC of HA.
• Acute phase in Respirology Cubicle, TMH
• Extended-care phase Integrated Patient Care
  Pathway (IPCP) in POH

8
COPD Care Program (CCP TMH/POH)

• To deliver specialists-directed, effective and
  comprehensive COPD management
• COPD exacerbations are perceived as a window of
  opportunity for holistic evaluation.
• Protocol/management model ? comprehensiveness.
• Respiratory physicians-directed ? specialized
  care.
• Standardize investigations and treatments.
• Optimize recovery time.
• Improve patient outcomes/satisfaction.
• Utilize resources effectively and reduce hospital
  costs while maintaining care quality.
• Evidence-based local practicability.

9
COPD Care Program (CCP TMH/POH)

• Acute phase/TMH
• Collection of patients in a Sub-specialty ward
  cubicle for focused care and expertise
  development among nursing staff.
• 10 beds for male patients from Sep 03 Jun 04
  increase to 14 beds from Jul 04 onwards (3-4 all
  acute medical beds).
• Recruit all COPD new admissions within 24 hours
  (by a random process) until beds are fully
  occupied.

10
COPD Care Program (CCP TMH/POH)

• Acute phase/TMH
• A team of Respirology physicians directed all
  medical treatment.
• Nurse specialists assessment/education.
• Physiotherapists and occupational therapists
  referral.
• Smoking cessation program referral.
• Nutritional scoring and refer to dietitian for
  supplements
• CCP Booklet and standardized education materials.
• A single CCP booklet for each patient.
• Review and update progress by all disciplines,
  during each subsequent admissions and by
  community nurses.

11
COPD Care Program (CCP TMH/POH)

• Indications for referral to POH Extended-care
  Phase high risk for early readmission
• Slow symptom resolution after initial treatment.
• Multiple social domestic disabilities/handicaps
  due to physiological impairment.
• Repeated unplanned re-admissions (gt2 in 12
  months) due to exacerbations for further
  exploration by a multidisciplinary approach.
• Other clinical situations that make a
  multi-disciplinary management program likely to
  be beneficial, as assessed by Respirology
  specialists.

12
COPD Care Program (CCP TMH/POH)

• Extended-care phase/POH
• Collaboration between Divisions of Respiratory
  Medicine and Rehabilitation Medicine
• 15-20 beds assigned for CCP Extended-care Phase
  in POH.
• Weekly re-assessment of the extended-care phase
  COPD patients in POH by the TMH CCP Respiratory
  physicians.
• Multidisciplinary protocol-based evaluation and
  intervention of disease-related medical,
  physical, and psychosocial handicaps.
• Walking exercise program interval exercise
  capacity assessment (6MWT).
• ADL training and assessment.
• Comprehensive education.
• Interface with community services.

13
(No Transcript)
14
COPD Care Program (CCP TMH/POH)

• Outcomes measurements
• Hospital outcomes
• LOS, morbidity, mortality
• Physiological outcomes
• Lung function tests, exercise capacities
• Clinical outcomes
• Dyspnoea, ADL, social function, leisure
  activities
• Health care resources utilization
• AED visits, unplanned readmissions

Clinical Management System (CMS)
15
COPD Care Program (CCP TMH/POH)

• Auditing standards
• NTWC historical data
• Outcomes data from other HA clusters/hospitals
• Re-audit cycle annually

16
COPD Care Program Outcomes Audit at 1 year
17
CCP Outcomes (Acute Phase/TMH Sep 03 Sep 04)
18
CCP Outcomes(Acute Phase/TMH Sep 03 Apr 04)

• Distribution of GOLD Staging for PFT Impairment

19
CCP Outcomes(Acute Phase/TMH Sep 03 Aug 04)
Average length of stay in TMH (Days)
(SARS in 2003)
20
CCP Outcomes(Acute Phase/TMH 2002-2004)
Monthly COPD emergency hospitalizations TMH
(Number of episodes)
Start of CCP ?
?SARS?
21
COPD hospitalization episodes in HA Hospitals
(2002 2004)
Projected from data of Jan to Sep 2004
22
CCP Outcomes(Acute Phase/TMH Sep 03 Sep 04)

• 28-day COPD Re-admission Rate in TMH ()

()
Start of CCP ?
?SARS?
23
COPD 28-day readmission rate () in HA Hospitals
(2002 2004)
()
24
Percentage change of COPD 28-day readmission rate
in HA hospitals from 2002 to 2004
()
25
CCP Outcomes(Acute Phase/TMH Sep 03 Sep 04)

• TMH COPD In-patient Mortality

26
COPD Care Program Retrospective case-controlled
cohort analysis
27
COPD Care Program Retrospective case-controlled
cohort analysis
28
COPD Care Program Retrospective case-controlled
cohort analysis
Exacerbation pattern (AED visits,
hospitalizations, acute hospital days)
6 months before
29
COPD Care Program Retrospective case-controlled
cohort analysis
Exacerbation pattern (AED visits,
hospitalizations, acute hospital days)
6 months before
6 months after
Exacerbation pattern, morbidity, mortality
30
COPD Care Program Oct to Dec 03 cohort analysis
31
(No Transcript)
32
COPD Care Program Oct to Dec 03 cohort analysis
33
COPD Care Program Oct to Dec 03 cohort analysis
(p0.10)
(p0.76)
(p0.27)
34
Exacerbation pattern among 6-month survivors in
the CCP and non-CCP groups
24.6 ?
(p0.03)
(p0.63)
AED visits 6 months before and after index
admission (episode/patient/six months)
(p0.45)
(p0.001)
(p0.06)
(plt0.001)
Total number of exacerbations 6 months before
and after index admission (episode/patient/six
months)
Emergency hospitalizations 6 months before and
after index admission (episode/patient/six
months)
35
Acute hospital days among 6-month survivors in
the CCP and non-CCP groups
38.4 ?
(plt0.001)
(p0.08)
Acute hospital days 6 months before and after
index admission (days/patient/six months)
36
Infrequent exacerbators 2 or less exacerbations
in 6 months Frequent exacerbators 3 or more
exacerbations in 6 months
Statistically Significant
37
Infrequent exacerbators 2 or less exacerbations
in 6 months Frequent exacerbators 3 or more
exacerbations in 6 months
Statistically Significant
38
COPD Care Program Conclusions
39
COPD Care Program

• Improve quality
• When compared with non-CCP management
• No change in hospital as well as 6-month
  mortality rates.
• CCP recruitment ? 24.6 reduction in exacerbation
  frequency within 6 months.
• TMH 28-day readmission rate for COPD dropped from
  an average of 39.2 in 2002 to 24.1 in 2004.

40
COPD Care Program

• Reduce healthcare cost
• Estimated cost of a Medical Ward hospital day in
  2002/03
• TMH Medical Ward 2400
• POH 1300
• After commencement of COPD Care program
• CCP recruitment ? 38.4 reduction in acute
  hospital days within 6 months.
• Average monthly reduction of 90.5 episodes
  (?38.4) of COPD admission comparing with
  historical data of similar months in TMH.
• Involves re-organization of existing manpower.
• Only took up 3-4 of all acute medical beds.
• No sacrifice in average LOS in the participating
  acute and convalescent hospitals.

41
Members of CCP/IPCP TMH/POH
Project Leader Dr YL Kwok, Respirologist,
TMH Core Members Dr CY Tam, CONS, Respirologist,
TMH Dr KM Sin, SMO, Respirologist, TMH
Dr SL Chow, A/C, Rehabilitation Director,
NTWC Miss Hilda Li, Respirology Nursing
Specialist, TMH
Other Members Dr JS Lee, MO, TMH Dr CL Lau, MO,
TMH Dr CC Leung, MO, TMH Dr KY Ng, MO, TMH Dr KC
Leung, MO, TMH Mr. Aaron Kwok, DOM, TMH Ms SC
Cheung, NO, TMH Mr. Sammyy Sun, WM, TMH
Ms YM Chan, WM, TMH Ms YL Fong, RN, TMH Ms WL
Law, WM, POH Mr. Charles Cheung, Physiotherapist,
TMH Mr. Manfield Chan, Physiotherapist, POH Ms.
Peg Cheung, Occ Therapist, TMH Ms. Pinkie Cheung,
Occ Therapist, POH Ms. Sally Ng, Dietitian, TMH
Ms. Vivian Wong, Dietitian, POH. Ms. Connie
Chan, MSW, TMH. Ms. KY Pang, MSW, POH. Ms. YW
Tang, Smoking Cessation Counselor Ms. Fanny
Wong, Community Rehab Network Ms. Fonny Ng,
Health Resource Center.
Coordinators Miss Betty Au, IPCP Subject Officer,
NTWC Miss Vivian Chan, IPCP Coordinator, NTWC.
Miss PF Tang, IPCP Facilitators, NTWC.
42

• Dr Yuk Lung Kwok
• CCP (TMH/POH)
• Clinical Audit Conference
• NTWC, Hospital Authority
• February 2005