CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Care in the Community for Adults

Resources The Quality Standard In Brief Advisory Committee About

Summary

Scope of This Quality Standard

This quality standard addresses care for people with chronic obstructive pulmonary disease (COPD), including the assessment of people who may have COPD. It provides guidance on the diagnosis, management, and treatment of COPD in community-based settings. The scope of this quality standard applies to primary care, specialist care, home care, and long-term care. This quality standard does not address care provided in an emergency department or hospital inpatient setting for the management of acute exacerbations of COPD.

In 2015, Health Quality Ontario and the Ministry of Health and Long-Term Care published an updated Quality-Based Procedures: Clinical Handbook for COPD (Acute and Postacute), a document that provides guidance on the care of people with COPD while they are in hospital and after being discharged. The COPD quality standard aligns with this clinical handbook, which can be used in conjunction with the quality standard.

In partnership with in the Ontario Palliative Care Network, Health Quality Ontario has also developed the quality standard Palliative Care: Care for Adults With a Progressive, Life-Limiting Illness, which can be used together with the COPD quality standard throughout the care journey of people with COPD. It is common for people with COPD to also have other health conditions. Health Quality Ontario has quality standards for some of these conditions, such as dementia, heart failure (in development), and asthma (in development).

Terminology Used in This Quality Standard

In this quality standard, “caregiver” refers to an unpaid person who provides care and support to a person with COPD. This may be a family member, friend, or anyone identified by the person with COPD.

The term “primary care provider” refers to a family physician or nurse practitioner.

“Interprofessional care” occurs when multiple health care professionals from different professional backgrounds work together to provide comprehensive health services for a person by working with the person, their family, caregivers, and community to deliver the highest quality of care across settings.

Why This Quality Standard Is Needed

Chronic obstructive pulmonary disease (COPD) is a progressive illness characterized by irreversible or partially reversible airflow obstruction in the lungs. The main risk factor for COPD is current or past tobacco smoking. The condition is characterized by progressive shortness of breath, often associated with cough or sputum production, resulting in decreases in exercise tolerance, the ability to carry out activities of daily living, and quality of life. As the disease progresses, many people with COPD have more frequent or more severe acute exacerbations of COPD, also called flare-ups or lung attacks.

Worldwide, COPD is a leading cause of morbidity and mortality. The disease results in a social and economic burden that is both substantial and increasing. Despite declining smoking rates in Ontario, COPD is one of the most common chronic conditions. The overall estimated prevalence of physician-diagnosed COPD in Ontario was 11.8% in 2014/15. In addition, more people are living with COPD in Ontario than in the past: The prevalence of COPD increased by 36.6% from 1996/97 to 2014/15. However, it is also estimated that only 41% of people with COPD have received spirometry testing to confirm their diagnosis. In 2014/15, this varied between 30% in the North East Local Health Integration Network (LHIN) and 48% in the Toronto Central LHIN (Physician-Billed Services, Institute for Clinical Evaluative Sciences, 2014–15).

People with COPD also frequently require health care services. COPD is the second-most common reason for hospitalization in Ontario, after childbirth (Hospital Morbidity Database and Ontario Mental Health Reporting System, Canadian Institute for Health Information, 2014–2016). However, there is also variation across LHINs in the rate of hospitalizations and emergency department visits attributable to COPD. In 2014/15, there was a 2.2-fold difference between the highest rate of hospitalization (37.6 per 1,000 person-years in the North West LHIN) and the lowest rate (17.3 per 1,000 person-years in the Central LHIN). Also in 2014/15, the rate of emergency department visits was 5 times higher in the North East LHIN (52.5 per 1,000 person-years) than in the Mississauga Halton LHIN (10.5 per 1,000 person-years). In Ontario, from 2008 to 2011, people with COPD accounted for 24% of hospitalizations, 24% of emergency department visits, 21% of ambulatory care visits, 30% of home care services, and 35% of long-term care residence places. In 2011, the total economic burden of COPD in Ontario, comprising direct and indirect costs, was estimated to be $3.9 billion (direct health care costs alone were estimated to be $3.3 billion).

Although COPD is a progressive illness, there are significant opportunities to improve the quality of life of people with the disease through the delivery of high-quality health care. As most people with COPD are not diagnosed until the disease is well advanced, earlier identification and testing of symptomatic individuals at risk of developing COPD is an essential first step in managing this chronic condition. The goals of COPD management include slowing the progression of airflow limitation; reducing the frequency and severity of and treating acute exacerbations; relieving symptoms such as breathlessness and anxiety; improving exercise tolerance, the ability to carry out activities of daily living, and overall health status; managing comorbidities; and reducing mortality.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity.

People with COPD should receive services that are respectful of their rights and dignity and that promote self-management in alignment with the chronic disease management framework for Ontario.

People with COPD should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, linguistic, ethnic, and religious backgrounds), and disability. Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly English-speaking settings, services should be actively offered in French and other languages.

Health care professionals should be aware of the historical context of the lives of Indigenous peoples throughout Canada and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides good access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

How Success Can Be Measured

The COPD Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

In this section, we list indicators that can be used to monitor the overall success of the standard provincially given currently available data. If additional data sources are developed, other indicators could be added.

Process indicators:

Percentage of people with COPD whose diagnosis is confirmed by spirometry
Percentage of people hospitalized for COPD who had an in-person follow-up assessment with a physician within 7 days of discharge
Percentage of people with COPD who have filled a prescription for long-acting bronchodilator therapy (measurable for people aged 65 years and older only)

Outcome indicators:

Percentage of people with COPD with one or more urgent acute-care visits for COPD in the past year:
- Emergency department visits
- Nonelective hospitalizations
Percentage of people with COPD who smoke cigarettes daily

In addition to the overall measures of success, each quality statement within the standard is accompanied by one or more indicators. These indicators are intended to guide the measurement of quality improvement efforts related to the implementation of the statement.

How Success Can Be Measured Locally

You may want to monitor your own quality improvement efforts and assess the quality of care you provide to people with COPD. It may be possible to do this using your own clinical records, or you might need to collect additional data. We recommend the following indicators to measure the quality of care patients are receiving; these indicators cannot be measured provincially using currently available data sources:

Percentage of people with COPD whose disease has a low or medium impact on their life (stratification: low, medium, high, and very high impact)
Percentage of people with moderate to severe COPD who have access to a pulmonary rehabilitation program (stratification: community-based and inpatient rehabilitation)

To assess the equitable delivery of care, the statement-specific indicators and the overall indicators can be stratified by patient socioeconomic and demographic characteristics, such as income, education, language, age, sex, and gender.

What Does It Mean for Patients and Caregivers?

I was diagnosed with severe chronic obstructive pulmonary disease (COPD) in 2015, and it took 8 months after referral before I could get in to see a respirologist. During that time, I experienced a major exacerbation, which resulted in hospitalization for 10 days. I felt left in the dark; it was a new diagnosis, a new disease [to me], and I was not provided with information that would help me control flare-ups or help me understand what I could expect. I felt as though my primary care provider could have done more in the way of information sharing and coaching; perhaps I could have avoided the exacerbation, which was frightening.

During my hospitalization I became a patient of the COPD Outreach Program and following discharge I was referred to an ongoing respiratory program, which has been a lifesaver. Education, respiratory exercises, and self-management are so important, and patients need to be provided with information and tools that will ultimately help them improve their quality of life. I think the quality standard for COPD is important because it highlights the needs of newly diagnosed patients—namely a realistic time frame for referral to specialist and resources and tools to help them understand and manage their condition. As a patient living with COPD, I can say that knowledge is power. A quality standard will ensure health care providers give patients the information they need to become proactive advocates for their care.

- S. Johnson, Lived Experience Advisor, Chronic Obstructive Pulmonary Disease Quality Standard Advisory Committee

What Does It Mean for Providers?

I have been providing care for patients with chronic obstructive pulmonary disease (COPD) for more than 40 years, and I’ve watched how our management of COPD has shifted from reactive (helping patients who have acute symptoms) to proactive—preventing and managing a chronic disease. Previously, I would see people who smoke come in with severe bouts of what appeared to be bronchitis, and I would treat them without considering the next steps. Confirming a COPD diagnosis and starting preventive treatment would have better enabled them to control their disease and improve their quality of life. This quality standard will help health care professionals proactively optimize management of their patients with COPD and help patients with COPD optimize their care.

One of the most important statements in the quality standard that will affect quality of patient care is the reminder for physicians of the importance of spirometry, not only for diagnosis but also along the course of the patient’s illness to discern whether treatments are effective or not. Another key statement is pulmonary rehabilitation. In my local hospital, where patients are treated for COPD, pulmonary rehabilitation is not even an option. These statements will encourage planners, physicians, and funders of health care to build pulmonary rehabilitation programs across the province and grant better access to spirometry. The standard also focuses on advance care planning, goals of care, and the importance of a substitute decision-maker, which will make a difference toward the end of life.

This quality standard condenses internationally accepted guidelines into a simple format that professionals can use going forward to create a comprehensive program for patients with COPD.

- Kenneth Hook, Chronic Obstructive Pulmonary Disease Quality Standard Advisory Committee member

Timeline for This Quality Standard

This quality standard was completed in December 2018.

Evidence to Improve Care