GARD in Northern Brazil, Netherlands, Northern India and Nepal.. Niels Chavannes MD PhD IPCRG
Diagnostic achievement and case finding in Brazilian primary care RL Hamers1, STh Bontemps1, M van den Akker1, RG Souza2, J Penaforte3, NH Chavannes1
1 2 3
Maastricht University, The Netherlands Federal University of Roraima, Brazil School of Public Health of Ceará, Brazil
COPD in Brazil
• Research is scarce, no data on primary care level • Smoking prevalence: 31.0% – Men 35.4% and women 26.9% – Great regional variability • COPD prevalence: 4.1%
From: Tobacco control country profiles (TCCP) 2003, and Global Initiative for Obstructive Lung Disease (GOLD)
Study objectives
• To describe the local distribution of respiratory disease in North & Northeast Brazil
• To assess the level of diagnostic service delivery for COPD in primary care; to validate GP diagnosis with ‘gold standard’ spirometry
• To develop a patient profile for case finding
Study design Organigramtitel
Target population: Adults (>15 yrs) Cough and/or shortness of breath Family Health Program 34 GPs 5 urban and rural areas in Ceará and Roraima states Patient form (n=350) (GP diagnosis)
Spirometry (n=157) American Thoracic Society criteria Baseline and reversibility testing Valid spirometries (n=142)
Results: Distribution
Main results
• In current practice diagnostic achievement for COPD is poor, while burden is considerable • Spirometry: – More than four-fold increase of case finding – 70% falsification of GP diagnosis • Efficient case finding by identifying those at risk – E.g. testing 2.8 ever smokers detects 1 at risk
Geïntegreerd COPD Management
Netherlands:
Controlled clinical trial on longterm effects of integrated COPD disease management programme on QoL in primary care patients1
1 IPCRG World Conference, Oslo 2006
Geïntegreerd COPD Management
Design • 150 ‘real-life’ primary care COPD patients – 75 patients optimal care – 75 patients usual care • Two years’ treatment with integrated disease management programme, including optimal medication, reactivation, personal goals and rapid action plans
Belangrijke Gegevens Name:_____________ Naam
Dosis
Medicijnen
Voorschrift
Naam
Dosis
Voorschrift
1. __________________________________ 9. _________________________________
COPD Management Plan
Patiënten Informatie Brian Tiep MD, Richard Knowles PhD, Mary Barnett RN, Richard Murray RN RRT, Mark Ung RT, Niels Chavannes MD
Dagelijkse Routine
2. __________________________________ 10._________________________________ 3. __________________________________ 11._________________________________ 4. __________________________________ 12._________________________________ 5. __________________________________ 13._________________________________ 6. __________________________________ 14._________________________________ 7. __________________________________ 15._________________________________ 8. __________________________________ 16._________________________________
•Opstaan en Aankleden •Up and Dressed (evt zuurstof) •Pufjes nemen + meds + Oxygen •Inhalers •Hoesten slijmsecretions huffen •Cough + +clear •Getuite ademhaling •Pursed lippen lips breathing (let opfor vaste afstand) •Wandelen flare -up) •Walk(then check •Opflakkerings •Flare-up checkCheck: Meer Kort? Piepen? Vastzitten? More SOB? Tel tot 20 aan Count to 20 ateinde end ofwandeling the walk
Allergieën Medicatie:____________________________________________________ ___________
Voedsel: _______________________________________________________ __________
Verandering slijm? Any change in sputum? Dikkeswelling enkels? Ankle ?
Anders, nl:______________________________________________________ __________
Telefoonnummers GC Zuiderkroon
010-2931404
Spoedlijn Apotheek
010-2102549 010-2931440
Fysiotherapeut Thuiszorg Huisartsenpost
010-2931420 010-2931430 010-2909888-
Persoonlijk Streefdoel:…… ………………… …………………
Wat mee te brengen naar het Periodiek Praktijk Bezoek? Breng deze instructie, pompjes, voorzetkamer, medicatie en al uw vragen mee
General Algemene Guide informatie and Disclaimer This Dit Management guide is a tool Plan to support is bedoeld good omlung de gezondheid health maintenance. van uw longen Th te helpen. Your Het isspecific een algemeen prescription hulpmiddel. is determined Uw specifieke by your doctor. voorschrift are If you komt having van a flare de-up, arts. immediately Als u een opflakkering beginning bemerkt, your rapidbiedt action hetplan Direkt should Actiehelp. Plan r Ifflare snel you -up uitkomst. is severe, Als and het Direkt your Rapid Actie Action Plan echter Plan is niet nothelpt, working, zijn er you andere may receive maatregelen byhelp dialing nodig. 911 or going Bel altijd to Emergency! de praktijk bijIf een you opflakkering! are having another In de avonden health problem, en llweekenden your cadoctor. belt u When de huisartsenpost. in doubt seekAls help! u aarzelt: vraag om hulp! Disease COPD management managementisisspecifiek specifically ontworpen designed voor to manage uw longziekte. your disease. lung Voor al Alluw other health andereissues gezondheidsproblemen must be directed to kunt your u gewoon doctor. op de praktijk terecht.
Rapid Plan Direkt Action Actie Plan Call Doctor CallPraktijk: Bel Doctor 010-2931404 Prednisone 40 Prednisone30 Prednison 40mgX mgX 57 5 days days dg Antibiotic prescribed Antibiotic–– start Antibiotica - volgens recept Inhalers hourly for Inhalerstijdelijk Pufjes: hourly verdubbelen for 33 hrs hrs Cough Cough ++ clear Hoesten + clear slijmsecretions secretions huffen Sip Sip hot Slokjes hot fluids fluids warme dranken Pursed breathing Pursed lips Getuite lips lippen breathing ademhaling
Dagelijkse Instructies Daily Ritual Instructions Wees actief & leef Up and Dressed – zo normaal mogelijk Opstaan en Aankleden Inhalers Pufjes Usingnemen: a chamber No Chamber Gebruikwell de voorzetkamer Shake Shake well Pompje goed schudden Voorzetkamer aanShoot mond Shoot Geef 1 puf met pompje 5-10x to rustig Count 10 in- en uitademen Count to 10 OEFEN VOOR DE SPIEGEL Exhale slowly Exhale slowly Voel uwINluchtwegen openen PRACTICE FRONT OF MIRROR Hoesten +Feel slijmyour huffen: airways opening Diep inademen & inhouden; voel druk; Cough Hoest explosief Laat klinken als hoest uw -luchtwegen openen CoughVoel explosively Feel ademhaling: your airways opening Getuite lippen Pursed lips breathing Adem rustig door uw neus in; Inhalelangzaam slowly through nose; Adem uit metyour getuite lippen; Ontspan uw ademhaling RelaxVoel your uw breathing luchtwegen openen Feel your airways opening Wandelen: Walk Neem pufjes, adem met getuite lippen Begin met ommetje, verleng per dag Probeer te ontspannen; geniet ervan Try to opflakkering relax and enjoy your walk Check Check Flare - wordt; ↓ pufjes nodig Voel dat for u sterker Opflakkerings - -up checkCheck: Flare Meer Kort? Piepen? Vastzitten? MoreSOB? Wheezing? Tightness? Tel tot 20 aan einde wandeling Count to 20 at end of the walk Verandering Slijm? Any change sputum in ? Dikke Enkels?
Ankleswelling ? Opflakkering? Direkt Aktie Plan Flare-up?Rapid Action Plan
Algemeen: leefan een actieflife, leven, vermijd prikkels zoals or rook of parfum, In general: live active avoid triggers like smoke perfumes, shwa was handen om infecties nietofteinfection, verspreiden, neem griepspuit, youruw hands to avoid the spread get flu shot,de preve nt/stop flarestop op tijd, en doeeach iedere dag iets aangenaams. ups, opflakkeringen and do something enjoyable day. Copyright RDMI 2003 Respiratory Disease Management Institute 5467 2nd St, Irwindale, CA 91706 626 851-2553
Training program
Jaar maand week
2
0
0
5
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
februari maart april mei juni juli individueel
iedere patient heeft een op zijn eigen lijf geschreven schema
bevordering mucusklaring verbetering algehele conditie perifere/ ademhalingsspieren dyspneu
- / ademregulatie +
therapietrouw, ZR, ZI
+
hart/longen uithoudingsvermogen, lenigheid, reactievermogen
+
kracht algemeen, snelkracht, uithoudingsvermogen
22
23
24
25
26
27
28
29
30
Geïntegreerd COPD Management
Control
No. patients
79
73
Age
65
65
% F/M
41/59
33/67
Packyears
37
33
BMI
27
27
FEV1 pre-BD
62
66
FEV1 post-BD
66
68
FEV1/FVC
65
65
SGRQ
29.6
34.5
CCQ
1.3
1.6
MRC>2
36%
32%
p> 0.
Intervention
05
Baseline
Geïntegreerd COPD Management
Results MRC-Dyspnea intervention vs control Intervention baseline vs 1 yr
MRC 1-2
64%
87%
MRC 3-5
36%
13%
diff
-23%
Control baseline vs 1 yr 68%
56%
32%
44%
diff
+12%
Geïntegreerd COPD Management
Results Effects at 1 yr in FEV1/FVC<0.7 (paired samples T-test)
Bocholtz
Simpelveld
SGRQ1
-5.9
p=0.002
-0.78
ns
CCQ2
-0.39
p=0.003
+0.08
ns
1 MCID SGRQ = -4
J Clin Epid 2003;56:1170-6
2 MCID CCQ = -0.4
Resp Research 2006;7:62
Geïntegreerd COPD Management
Results
Effects at 1 yr in FEV1/FVC<0.7 and MRC3-5 (paired samples T-test)
Bocholtz
Simpelveld
SGRQ1
-13.4
p=0.002
-0.29
ns
CCQ2
-0.90
p=0.002
0.00
ns
1 MCID SGRQ = -4
J Clin Epid 2003;56:1170-6
2 MCID CCQ = -0.4
Resp Research 2006;7:62
Conclusions
• • • •
COPD increasing problem Integrated team approach necessary Patient involvement crucial Reactivation, personal goals and action plans are key • Quality of life can improve!
FRESH AIR Study
Free Respiratory Evaluation and Smokeexposure reduction by primary Health cAre Integrated gRoups
International Primary Care Respiratory Group Practical Action Nepal Asian Allergy & Asthma Foundation
Study design & setting
1. Cross-sectional diagnostic intervention 2. Prospective therapeutic intervention • Nepal and Northern India • Smoke-reduction
Proposal: • Linking of different GARD demonstration project teams and national coordinators • Exchange of experiences and approaches • GARD-worldmap interactive? • Forum on GARD-website?
