Quebec COPD initiative casts a wide net in area with many aging, low income smokers

The Challenge

Across Canada, an estimated 800,000 Canadians live with chronic obstructive pulmonary disease (COPD), a progressive disease characterized by debilitating breathlessness. This population is among the highest users of hospital care. Of all chronic diseases, COPD is the number one reason for hospitalizations, accounting for the largest number of return visits to emergency departments (EDs) and the highest volume of hospital readmissions. Often, patients end up seeking care in the ED to manage their chronic illnesses because more appropriate care isn’t available in the community. The situation is expected to worsen as one-infour Canadians is set to develop the disease in their lifetime.

In 2014, the Canadian Foundation for Healthcare Improvement partnered with Boehringer Ingelheim (Canada) Ltd. on INSPIRED Approaches to COPD, a pan-Canadian quality improvement collaborative that provided funding, training, coaching and resources for a network of 19 interprofessional teams from healthcare organization across Canada. Through this collaborative, the teams adapted, adopted and evaluated the INSPIRED COPD Outreach Program, a coordinated, proactive approach to improving care for people with COPD and supporting their caregivers.

19 percent of admissions to the local hospital in 2013-14 were for patients with a diagnosed respiratory disease, compared to an estimated national rate of 13 percent.

The INSPIRED COPD Outreach Program™ was developed by respirologist Dr. Graeme Rocker and his team at Capital Health (now Nova Scotia Health Authority) in Halifax. CFHI set out to spread this comprehensive approach to COPD care across Canada.

When the Integrated Health and Social Services Centre for Montérégie-Est (the CISSS Montérégie-Est) in the Pierrede- Saurel catchment area northeast of Montreal joined the collaborative, it decided to cast a wide net. Their INSPIRED team decided to focus, not just on improved services for people with relatively severe forms of the debilitating condition, but also on early detection.

A 2012 study found that this area of Montérégie-Est had no formal COPD program, few initiatives for early intervention or prevention, poor access to diagnostic services and gaps in coordination of care.

Yet there is a high prevalence of COPD in this northern region of the CISSS Montérégie-Est. Hospital admissions for COPD increased steadily from 2011 to 2014 (from 200 to 289), as did ED visits (from 324 to 390). Moreover, 19 percent of admissions to the local hospital in 2013-14 were for patients with a diagnosed respiratory disease, compared to an estimated national rate of 13 percent.

The relatively high rate of hospital visits for COPD is associated with the prevalence of key risk factors among the population in the Saurel catchment area: smokers comprise more than a quarter (26.2 percent) of the population of almost 51,000 people; 20 percent of the population is over 65, 15.3 of the population is low income, and 11 percent are on social assistance. In comparison, smoking rates for the entire province of Quebec1 are at 17 percent, much lower.

A target was set to reduce hospital admissions for COPD by 15 percent, and reduce emergency department visits/ readmissions for acute exacerbations of COPD by 30 percent.

The Solution

Teams participating in the INSPIRED collaborative identified patients who visited the ED or were hospitalized with advanced COPD, and then invited them into a supportive program that provided them with: a written action plan for managing their disease; a phone call after they were discharged home; at-home self-management education and psychosocial support; and advance care planning when needed. Patients in the program were also given a telephone number to call for support.

Supported by CFHI’s INSPIRED collaborative and Boehringer Ingelheim, the team worked on developing a service continuum between the patient, the hospital, home care, the family doctor, the community pharmacists and the local community health and social service centre (in Quebec this is the CLSC or centre local de services communautaires).

Family physicians were offered a place to conduct lung functions tests (spirometry) outside the hospital and provided with resources to help them develop action plans for their COPD patients. These plans were designed to assist patients with recognizing flare ups of COPD and guide their decisions about treatment. As well, a standard order set was adopted for spirometry referral. The team also developed a model action plan to help people with severe COPD to manage breathlessness.

A protocol was developed for respiratory therapists to contact patients discharged from hospital after being treated for a serious worsening of their condition, known as an acute exacerbation (AECOPD). Also, a pathway was created for patients who have no family doctor. At the time of the initiative, one in five people in Pierre-de-Saurel territory did not have a family doctor.

The following goals were set: to promote early detection by soliciting referrals from local health care providers of people suspected of having COPD in order to confirm a diagnosis; to provide action plans for prevention of AECOPD to five percent (about 60) of patients with COPD; to implement an action plan for episodes of breathlessness for five patients and measure the impact on hospital visits; and to provide follow up within three to 10 days for 80 percent of patients who are admitted to hospital for a COPD related issue; and to have a respiratory therapist navigator available five days a week.

Odette Arseneault stressed the social gains from early detection, as it can help people stay healthy enough to be able work longer and support their families.

Odette Arseneault, who acted as the initial team lead on this project, stressed the social gains from early detection, as it can help people stay healthy enough to be able work longer and support their families.

The Results

Forty percent of local health professionals referred at least one patient for a confirmation of a COPD diagnosis and, as of October 2015, 278 patients had been seen or registered for diagnostic spirometry. Surprisingly COPD was not confirmed as a diagnosis for some of the referrals. Hence, for some patients the treatment was not justified and recommendations were made to review the diagnosis and treatment.

Action plans to help prevent acute exacerbations of COPD (AECOPD) were developed for 55 people by October 2015 (ahead of the 60 targetted by April 2016). Unplanned readmissions among that group fell from 14 to one since enrolment began in April 2015. As targeted, five patients have adopted action plans for breathlessness, an end stage feature of COPD plans include patients having standing orders for anti-anxiety medication and for morphine (to be taken to prevent serious episodes).

Local resident Jean Provencher had been hospitalized four times for AECOPD before he was admitted to the COPD program. Previously an active man, his condition had left him exhausted, with difficulty moving. After his last hospitalization Jocelyne Trudel, the respiratory therapist/COPD educator of the COPD Program, called him two days after his discharge and arranged for him to attend the COPD program. While there, they created his own action plan, which helped him avoid at least two emergency department visits.

Mr. Provencher has not been hospitalized since and in summer 2016, just over a year after he joined the program, he drove his three-wheel motorcycle about 2000 kilometers to Gaspésie and back and arranged to regularly mow a neighbour’s lawn as well as his own. Mrs. Trudel said that in all of her career, one of the places she felt most useful was in the COPD program: “I accompany them in the pursuit of their life after the diagnosis of COPD.”

Sustainability and Spread

Dr. Eric Sauvageau, the head of the regional department of general medicine who was on the INSPIRED development team, was invited by his peers from other CISSS of Montérégie region to present on the COPD program.


There have been several media reports about the COPD initiative and the team wants the provincial health ministry make COPD programs mandatory at CISSS, just as programs for diabetes and cancer prevention are mandatory.

Patients continue to be enrolled in the various streams of the COPD initiative today. As of late summer 2016, 95 patients have created their action plans to prevent readmission (up from 55), and 437 people have had confirmatory spirometry tests (up from 178).

In Sept. 2016, another respiratory therapist (pivot-RT) has joined the team and is responsible for identifying COPD patients who visit the ED and/or have been admitted to hospital.

CISSS Montérégie-Est has confirmed that the COPD program continues in the Pierre-de-Saurel catchment area.

CISSS Montérégie-Est would like to take this opportunity to thank all the people who contributed directly or indirectly to the creation of this program : Mrs. Odette Arseneault, Mrs. Martine Bouchard, Dr. Bich Dao Can, Dr. Natalie Chevalier, Mrs. Nadia Cournoyer, Mrs. Sylvie Cusson, Dr. Gérald Désaulniers, Dr. Martine Dulude, Dr. Jacques Godin, Mrs. Martine Guilbault, Mrs. Annie Lemoine, Mrs. Guylaine Marchand, Mrs. Carole Parent, Mrs. Christelle Pelbois, Mrs. Mélanie Rousseau, Dr. Éric Sauvageau, Mrs. Christine Théroux, Mrs. Jocelyne Trudel, Mrs. Sonia Santerre (Boehringer Ingelheim), the CFHI team as well as all the patients in the program and their families.

1 2013 figures from page 22 in this report :