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Shared System of Care
COPD/Heart Failure
Learning Session 1
www.pspbc.ca
Please complete your
Evaluation Survey
before we begin
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Welcome! (20, include 10 for discussion)
 Housekeeping
 Agenda
 Introductions
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Agenda
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Welcome and Introductions (20)
Video Clip or Patient Story (15)
COPD 101 (85)
Local respiratory services
COPD-6 training
QuitNow
Integrate into Practice Workflow
Break (15)
Heart Failure 101 (40)
Local HF clinic services and cardiologist referral
Integration of HF into practice workflow (10)
Action Planning Expectations (5)
Planning for action Period (20)
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CME Accreditation
Choice of:
 10.5 Mainpro C credits IF post reflective activity submitted 2-3
months after module completion and at least one action period
completed (M1 credits issued too)
 10.5 Mainpro M-1 credits based on attendance hours
 10.5 Maincert Section 1
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Module Structure
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COPD / HF Shared Care Module
Learning Sessions
3 x ½ day ( 10.5 hours max)
GP
Session x 3
MOA
10.5 hrs
$1,235.70
$ 240
Action Periods
1 •Planning & initial implementation in practice
•Report on experiences and successes at LS2
•Reported testing of tools (see Action Period Activities
sheet, in package)
$ 823.80
2 •Refine implementation, embed and sustain the change
•Report on experiences and successes at LS3
•Reported testing of tools
$ 617.85
Potential Total: $2,917.35
Participant Funding GPs: COPD/HF Module
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How is a collaborative different than CME?
 Action-oriented: try what you learn – “What are you going to do
next Tuesday?”
 Test change on small population
 Track data to evaluate changes
 When satisfied spread to the larger population
 Discussion with colleagues
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AIM
To create a system of care that improves the
quality of care and experience for patients at
risk for and living with COPD and/or HF
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How will we achieve this aim?
 Identifying patients earlier who have COPD and/or HF using a
case-finding approach
 Developing relationships and care plans amongst family
physicians, specialists, patients, and community services
 Implementing more standardized referral and consult letters, and
improving relationships, hand offs, and communication between
GPs and specialists
 Improving the management of COPD and HF by putting the
GPAC guidelines into practice
 Supporting patients to quit smoking
 Enhancing patient self-management skills for patients to manage
their condition
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Action Period 1 Measurement
 Develop patient registries for COPD and HF.
 Case-finding and testing with COPD-6 device – Minimum 6 pts.
 Referred for Ejection Fraction or Brain Natriuretic Peptide (BNP)
Diagnostic testing - Minimum 2 patients.
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Patient Story
(15 minutes)
COPD 101
(25 minutes)
Guidelines
Definition of COPD
 COPD is a preventable and treatable disease
with some significant systemic effects
that may contribute to the severity in
individual patients.
 Its pulmonary component is characterized by airflow limitation that
is not fully reversible. This leading to significant exercise
limitation.
 The airflow limitation is usually slowly progressive over time. This
is accelerated in cases of continued smoking, frequent ‘lung
attacks’ or with AAT deficiency.
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Asthma
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Clinical Course of COPD
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Our Aims
 To foster a shared system of care that improves the quality of
care and experience for patients at risk for and living with COPD
by:
› Identifying subjects with COPD earlier
› Using a team-based approach
› Improving communications between patients and care team as
well as within the care team
› Developing strategies to prevent progression of COPD as well
as its optimal Improving management
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How will we achieve this aim?
In the FP practice:
 Enhanced identification and diagnosis of COPD
 Appropriate risk stratification based on level of airflow obstruction
and symptoms and exacerbation history – followed by review of
prescriptions and including a flare-up plan
 Appropriate use of evidence-based therapies for COPD based on
GPAC, CTS guidelines, including the development of a flare-up
plan
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How will we achieve these aims?
 In a shared care environment:
 Improving relationships, hand-offs and communication between
FPs and specialist physicians
 Developing relationships and care plans amongst
FPs, patients, and community services
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How will we achieve this aim?
Across the continuum
 Supporting subjects to quit smoking.
 Enhancing patient self-management skills to allow better
management of their lung health.
 Improving the patient experience within the system of care.
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Prevalence and Burden of COPD
Global Disease Burden
 1990 : COPD was 6th leading cause of death
 2001: Approx. 2.7 million deaths from COPD (more than 5% of
total death worldwide)
 2020: COPD is projected to be the 3rd leading cause of death
(approx 4.5 million deaths) only after the IHD and CVA
Murray and Lopez. Lancet 1997
WHO Report 2002
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Trends in age-standardized death rates
(Percent change between 1970 and 2002)
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Number of persons with COPD in BC
ESTIMATES
Actual
Projection
76,408
2004
80,268
2005
84,226
2006
87,725
2007
92,198
2008
95,216
2009
98,860
2010
102,504
2011
106,148
2012
109,792
2013
113,436
2014
117,080
2015
Assume relatively linear increase in prevalence will continue to 2014
Source: Actual figures from COPD registry data, Ministry of Health
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COPD is under diagnosed
Diagnosed with chronic bronchitis or emphysema
400
2
Airflow limitation (mild through very severe )
Undiagnosed potential
450
Rate per 1,000 of population
350
300
250
200
150
100
50
25–44
45–54
55–64
65–74
75
0
Age (yr)
1
Chronic Obstructive Pulmonary Disease Surveillance, United States,
1971–2000
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Airflow Limitation, Mild Through Very Severe, Canada, 2005
1. Mannino DM, et al. MMWR. 2002; 51:1-16. 2. O’Donnell DE, et al. Can Respir J. 2008;15 (Suppl A):1A-8A.
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Key Message
“Most patients with COPD are not diagnosed until the disease is well
advanced. Spirometry targeted at individuals who are at risk for
COPD can establish an early diagnosis.”
Can Respir J 2008;1 5 (Suppl A):1A-8A
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Fletcher Curve - the Effect of Smoking on FEV1
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Acute Exacerbations (AECOPD) or Lung Attacks
 An event in the natural course of the disease characterized by a
change in the patient’s baseline dyspnea, cough, and/or sputum
that is beyond normal day-to-day variations, is acute in onset, and
may warrant a change in regular medication in a patient with
underlying COPD.”
 Acute exacerbations are THE LEADING CAUSE* of
hospitalizations and ER visits among COPD patients.
 COPD and CHF are the #1 and #2 causes of admission to
hospital in BC.
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Local respiratory services
COPD-6 training
The COPD6
 If you have a normal result has the potential to rule
out COPD
 May have some false positives due to 6 second
exhalation time reducing the denominator ie
FEV1/FEV6.
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 If FEV1/FEV6 is low ,<0.7 ,then refer to accredited
lab for definitive diagnosis
 Walk in spirometry clinics
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COPD-6
Accurate enough for FEV6 & Ratios
(And multi-patient use. Exceeds ATS/ERS guidelines)
Simple to use – just turn unit on
(enter Age, Height; Sex and blow for 6 seconds
Press Enter to view best)
Detach flow
head
for cleaning
Includes predicted value sets
Built-in quality of blow indicator
Large, full colour
branding area
Large easy to read display
Displays FEV1 and % predicted
Displays FEV6 and % predicted
Lung Age indicator
Displays FEV1/FEV6 and % predicted
Provides GOLD COPD classification
(Class I; II; III; IV)
Obstructive Index and
displays degree of obstruction
AAA Batteries
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COPD-6 (continued)
Built-in quality of blow indicator
Slow Start Warning: Vext >5% or 150mL of FEV6
Abrupt End: Change of volume is > 25mL in the last
stsec
No coughing: 50% drop & recovery in flow in the 1 sec
If Blow <1 sec FEV1 = 0.00
Result out of Range FEV6 (0-8L)
Obstructive Index (Measured FEV1/Pred FEV1) & COPD Stage I - IV
(with ratio FEV1/FEV6 > 70%)
AAATurns
batteries
off after 4 minutes
Low battery indicator
Green ≥ 80%+ratio > 0.70
Green ≥ 80%
Yellow = 50 - 80%
Orange = 30 - 49%
Red
< 30%
All boundaries can be reset
= Not COPD
= STAGE I
= STAGE II
= STAGE III
= STAGE IV
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COPD-6 (continued)
1. Turn on
(Age Symbol and 50 appears on
screen)
2. Scroll up/down
To adjust age (if the buttons are kept
depressed, the values will scroll faster)
3. Press Enter
(Height Symbol and 60 appears on
screen)
4. Scroll up/down
To adjust height in inches
5. Press Enter
(Male Symbol appears on screen)
6. Scroll up/down
For Female symbol
7. Press Enter
(Population Group Symbol appears on
screen)
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Entering subject data continued
8. Scroll up/down to select:
 C - Caucasian NHANES III
 AA - African-American NHANES III
 HA - Mexican-American NHANES III
 Note: use C for all other races
9. Press Enter
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Copd-6 is now ready for blow
• Place a SafeTway Mouthpiece into the
Copd-6
• Hold your head up, breathe in as deeply
as possible, place the mouthpiece in
your mouth, biting it lightly while sealing
your lips firmly around it.
• Blow out as HARD and FAST as you
can for a full 6 seconds.
• Repeat 2 more times when the blow
icon appears.
• Hold down the enter key to bring up the
last session results
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Results of blow
Blow is classified as Green, Yellow, or Red
Obstructive Index (Measured FEV1/Pred FEV1) & COPD Stage I - IV (with
ratio FEV1/FEV6 > 70%)
Green ≥ 80%+ratio > 0.70 = Not COPD
Green ≥ 80%
= STAGE I
Yellow = 50 - 80%
= STAGE II
Orange = 30 - 49%
= STAGE III
Red
< 30%
= STAGE IV
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Indication of bad blow

The blow icon with an
exclamation point indicates a
bad blow.

Possible reasons are coughing,
slow start, blow less than 3
seconds in duration, abrupt
stop, or blocking the back of
copd-6 unit with hand.
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Test results after three blows
Press Enter to display the best of the
session
 Press enter to display the best FEV1
and percent predicted of all blows
 Press the down arrow to see Lung
Age
 Press the down arrow again to see
FEV1/FEV6 Ratio & percent
predicted
 Press the down arrow again to see
FEV6 & percent predicted
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The Copd-6 USB version’s printed report
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Training
 http://www.youtube.com/watch?v=syXXEgZSTOQ
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QuitNow
Integrate into the workflow
discussion
Break
(15 minutes)
Heart Failure 101
(40 minutes)
Guidelines
Definitions and Nomenclature
 Heart Failure
 A clinical diagnosis
 Inability for the heart to deliver sufficient blood/oxygen to
meet the demands of the peripheral tissues, or to do so at
abnormally high filling pressures, or both
 Characterized by signs and symptoms of decreased
cardiac output and/or volume overload
 Does not suggest a cause or underlying pathological state
 Cardiomyopathy
 Disease of the heart muscle due to any number of causes
 Clinically characterized by heart failure
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Definitions and Nomenclature
 Systolic Heart Failure
 Poor systolic performance of the heart resulting in
decreased cardiac output and increased venous pressures
 Typically occurs in association with impaired left ventricular
systolic function due to any number of causes
 Left ventricular ejection fraction (LVEF) of <40%
 Heart Failure with Preserved Ejection Fraction (HF-PEF)
 Poor diastolic performance of the heart resulting in
decreased cardiac output and increased venous pressures
 May occur in association with preserved (LVEF >40%) or
decreased LVEF
 Systolic and Diastolic heart failure frequently co-exist
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Heart Failure in BC
100,000
90,000
80,000
70,000
60,000
Incidence
Prevalence
Mortality
50,000
40,000
30,000
20,000
10,000
0
2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Ministry Data 2010
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Prevalence of Heart Failure
12
10
10.0
Incidence:
8
Patients in Millions
Estimated 10M in 2037
550,000 new cases/yr
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Prevalence:
4
2% in 40 – 60 year olds
4.8
3.5
10% in those aged 70+
2
0
1991
2001
2037
Year
adapted from McMurray and Pfeffer, 2003
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Projected Annual Incident HF Hospitalizations in
Canada
160000
Number of Cases
140000
120000
100000
ADHF Diagnosis
80000
60000
40000
20000
0
1996
2005
2015
2025
2035
2045
Year
Johansen L et al., Can Journal of Cardiol
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HF Readmissions
 Hospital readmission rates are high, and mainly
due to recurrent heart failure
Lee DS et al. Can J Cardiol 2004;20(6):599-607.
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Survival After Admission to Hospital for Heart
Failure in BC
100
Percentage Alive
80
50% survival at 30 months
60
40
20
0
0
5
10
15
20
25
30
35
40
45
50
Months
http://www.healthservices.gov.bc.ca
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Heart Failure is a Malignant Disease
100
Breast Ca (adjuvant tamoxifen)
Percentage Surviving
80
SOLVD treatment (on enalapril)
60
Metastatic Prostate Ca
40
20
Lung Ca
0
0
6
12
Cleland and MacFadyen, 2002
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24
30
36
42
48
54
60
Months
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Heart Failure Stats
 89,343 reported cases of HF in BC (2008/09)
 Hospital cost ~$300 M
 MSP cost ~$130 M
 Pharmacare ~$100 M
$500M per year
 Heart Failure is the most common cause of hospitalization of
people over 65 years of age
 Average 1 year mortality rate of 33%
 Higher rates associated with more advanced disease and
poor functional capacity
 Hospitalization rates are high and associated with poor outcomes
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NYHA Classification of Heart Failure
1 Year
Classes
Description
Survival Rate
Grade I
Grade II
Grade III
Grade IV
Early failure
no symptoms with regular exercise or restrictions
> 95%
Ordinary activity results in mild symptoms,
but comfortable at rest
80 - 90%
Advanced failure,
comfortable only at rest;
increased physical restrictions
55 - 65%
Severe failure;
patient has symptoms at rest
5 - 15%
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ACC/AHA HF Classification
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Basic Pathophysiology of Heart Failure
 I. Causes of Systolic and Diastolic Heart Failure
 II. Ventricular Remodeling
 III. Neurohormonal Activation
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Important Causes of Cardiomyopathy and
Heart Failure
SYSTOLIC
DIASTOLIC
Myocardial Infarction
Myocardial Infarction
Mitral and Aortic Regurgitation
Aortic Stenosis
Alcohol
Hypertension
Thyroid Disease
Infiltrative Disorders
Chemotherapy
Radiation Therapy
Familial/Genetic Cardiomyopathies
Hypertrophic Cardiomyopathy
Nutritional Deficiencies
Amyloidosis
Systolic and Diastolic Dysfunction Frequently Co-Exist
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Local Data
2005/06
2006/07
2007/08
2008/09
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
ACE/ARB %
68%
66%
64%
62%
60%
58%
56%
2009/10
Region/ year
64
2005/06
2006/07
2007/08
2008/09
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Beta Blocker %
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
2009/10
Region/ year
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Care Gap
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Why do Patients with HF do so Poorly?
 (1) Natural history of disease process
 Pump failure
 Arrhythmic death
 (2) Limited access to HF treatment
 Poor adherence with evidence based therapies
care gap
 Education, Self Management & Multidisciplinary Care
 Patient and provider
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The Care Gap
 Efficacious evidence based therapies have not
been consistently integrated into clinical practice
 Barrier to better outcomes in HF patients
 New therapies continue to roll-out
 Heart Failure Process of Care Measures
 Associated with improved outcomes in HF patients
 ACE/ARB, BB, ICD/CRT, aldosterone anatagonists (MRA), HF
education and anticoagulation for AF
 Strategy for implementation of best practices
 PSP and Provincial HF Strategy
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Local HF Clinic Services
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When and Who Should I refer to an
HF Clinic?
 New onset heart failure NYD
 Recurrent hospitalizations
 Difficult to manage using standard therapies
 Young age
 Advanced functional symptoms
 Consideration for aggressive therapies
 ICD or CRT
 Coronary angiography
 Surgery
 Consideration for cardiac transplant
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Local HF services
Integrate into the workflow
discussion
Action Period Planning
(20 minutes)
Action Period 1 Measurement
 Develop patient registries for COPD and HF.
 Case-finding and testing with COPD-6 device – Minimum 6 pts.
 Referred for Ejection Fraction or Brain Natriuretic Peptide (BNP)
Diagnostic testing - Minimum 2 patients.
74
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