COPD 的慢性照護邁向全人醫療 時間 : 民國 102 年 9 月 15 日地點 : 高雄長庚紀念醫院兒童醫院 6 樓紅廳主辦 : 台灣慢性阻塞性肺病學會講師 : 彰基胸腔科林慶雄主任.

Transcription

1 COPD 的慢性照護邁向全人醫療 時間 : 民國 102 年 9 月 15 日地點 : 高雄長庚紀念醫院兒童醫院 6 樓紅廳主辦 : 台灣慢性阻塞性肺病學會講師 : 彰基胸腔科林慶雄主任 @cch.org.tw

2 Speech Outline 1 COPD Care Gap 2 Current Guideline 3 Integrated Care Model 4 Future Perspective

3 Speech Outline 1 COPD Care Gap 2 Current Guideline 3 Integrated Care Model 4 Future Perspective

4 為何 COPD 治療無感?? 1 醫師 2 病人 3 醫療體系 1. 悲觀及錯誤認知 1. 藥物遵從性不佳 1. 臨床指引未實行 2. 訓練不足 \ 儀器不足 2. 無法戒菸 2. 給付不足 3. 非藥物治療不足 3. 自我照䕶能力不足 3. 缺乏團隊整合 4. 共病處理不足 4. 疾病知識不足 4. 缺乏疾病登記 5. 被動 reactive or proactive 6. 病人溝通教育 5. 疾病嚴重度認知 6. 吸入藥物使用錯誤 5. 缺乏溝通機制 6. 缺乏品質監控機制

5 Patients referred for exercise training or pulmonary rehabilitation % COPD Care Gap Evaluation 100 肺部復健 80 Total (n = 548) Quebec (n = 192) Ontario (n = 356) COPD severity 0 Moderate Severe All groups

6 Patients receiving annual influenza vaccination, % COPD severity COPD Care Gap Evaluation 感冒疫苗

7 Smokers receiving smoking cessation intervention, % COPD severity COPD Care Gap Evaluation 戒菸介入

8 Patients having ever received spirometry, % COPD Care Gap Evaluation 肺功能診斷

9 Patients prescribed appropriate COPD treatment, % COPD Care Gap Evaluation 適當的處方用藥

10 CCH COPD Care Gap 早期診斷治療策略呼吸衰竭肺部復健再入院率 Case Finding CCPC Certification NIV Unit Rehabilitation center Computerized System

11 FEV 1 (% of value at age 25) Traditional view of disease progression Smoked regularly and susceptible to its effects Disability Death Age (years) Never smoked or not susceptible to smoke Stopped at 45 Stopped at 65 Adapted from Fletcher & Peto. Br Med J 1977;1:

12 THE ECLIPSE STUDY EVALUATION OF COPD LONGITUDINALLY TO IDENTIFY PREDICTIVE SURROGATE ENDPOINTS

13 FEV 1 Decline: ECLIPSE >20mL increase 20mL increase to 20mL decrease 21mL decrease to 40mL decrease 31% 23% 8% Increase in lung function No change >40mL decrease 38% Decrease in lung function N Engl J Med Sep 29;365(13):

14 FEV 1 Decline: Decline by GOLD Category Rate of decline reduced with increasing disease severity Significantly less decline in GOLD 4 vs. GOLD 2 or 3 GOLD 2 vs. GOLD 3, p=0.17; GOLD 2 vs. GOLD 4, p<0.001; GOLD 3 vs. GOLD 4, p=0.009

15 Rate of Decline in FEV 1 by GOLD Stage Post-bronchodilator FEV 1 GOLD Stage Tiotropium (ml/yr) Control (ml/yr) Tio - Con P-value 早期診斷 n Mean (SE) n Mean (SE) Mean (SE) II (2) (2) 6 (3) 0.02 III 早期治療 (2) (2) 0 (3) 0.87 IV (5) (5) -9 (7) 0.24 P-value for subgroup by treatment interaction = 0.07

16 小結 1. COPD 病人的肺功能下降變化是多樣性的 2. 在良好的治療下超過一半病人肺功能不會急速惡化 3. 抽菸是肺功能惡化的最重要因子

17 Speech Outline 1 COPD Care Gap 2 Current Guideline 3 Integrated Care Model 4 Future Perspective

18 Definition of COPD COPD A common preventable and treatable disease Characterized by persistent airflow limitation Enhanced chronic inflammatory response Exacerbations and comorbidities GOLD 2011 Revision

19 新版 GOLD Guideline 三大重點 1 強調治療要兼顧短期及長期目標 2 病人評估變成多面向 - 症狀 - 肺功能 - 惡化 3 評估和治療的密切配合, 達到個人化醫療境界

20 (GOLD classification of airflow limitation) Risk (Exacerbation history) Risk Combined assessment of COPD 4 3 (C) (D) or more 2 2 (A) (B) mmrc 0-1 CAT<10 Symptoms mmrc 2+ CAT10+

21 慢性阻塞性肺病評估測試

22 (GOLD classification of airflow limitation) Risk Risk (Exacerbation history) Combined assessment of COPD 4 3 生活品質尚可 肺功能不良或 時常惡化 生活品質不良 肺功能不良或 時常惡化 or more 2 2 生活品質尚可 生活品質不良 1 肺功能還好 不常惡化 肺功能還好 不常惡化 1 0 mmrc 0-1 CAT<10 Symptoms mmrc 2+ CAT10+

23 Exacerbations per year Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy, 2011 FIRST CHOICE GOLD 4 GOLD 3 C ICS + LABA or LAMA ICS + LABA or LAMA D > 2 GOLD 2 GOLD 1 A SAMA prn or SABA prn LABA or LAMA B 1 0 mmrc 0-1 CAT < 10 mmrc > 2 CAT > 10

24 (GOLD classification of airflow limitation) Risk Risk (Exacerbation history) Combined assessment of COPD 4 3 C1. 生活品質尚可或 C2. 肺功能不良或 C3. 時常惡化 D1. 生活品質不良 D2. 肺功能不良或 D3. 時常惡化 or more 2 2 生活品質尚可 生活品質不良 1 肺功能還好 不常惡化 肺功能還好 不常惡化 1 0 mmrc 0-1 CAT<10 Symptoms mmrc 2+ CAT10+

25 C patients: Low symptoms D patients: High symptoms 80% 60% 70% 80% 60% 63% 40% 18% 40% 28% 20% 13% 20% 9% 0% C1 FEV1 C2 ECOPD C3 FEV1 & ECOPD 0% D1 FEV1 D2 ECOPD D3 FEV1 & ECOPD FOOD FOR THOUGHT 1. If the main reason for being classified as a C or D patient is low FEV1: Dual bronchodilation? Inhaled corticosteroids? 2. How to progress towards personalized medicine?

26 GOLD 2011 GOLD2006 Combined Assessment of GOLD, 2011 Exacerbations (proportion free) Hospitalizations (proportion without) All-cause mortality (proportion alive) 1.00 II III IV II 0.9 II III 0.7 III IV IV A B C D 1.00 A B 0.7 C D A C B D Follow-up time, days

27 Persistent Systemic Inflammation in COPD: A Novel Phenotype ( ECLIPSE Cohort )

28 WBC Hs-CRP TNFα IL-8 IL-6 Fibrinogen 1-5% 6-10% 11-15% Non-smokers (n = 202) Smokers (n = 297) 63% current smokers COPD (n = 1755) 36% current smokers 5% 4% 24% 6% 31% 20% 4% 5% 7% 28% 24% 18% 5% 5% 6% 19% 30% 14% * p<0.001 vs. Non-smokers + p<0.005; ++ p<0.001 vs. Smokers

29 Longitudinal Change of Systemic Inflammation 2+ 56% Persistent Inflamed vs. 1 Non-inflamed 24% 0 20% 0% 20% Year 1 40% 60% Total 16% 7% 6% Recruitment 2+ 28% 1 Mortality: 29% 13% vs. 2% 0 43% 0% 20% 40% 60% % 36% 41% 0% 20% 40% 60% 7% 10% 12% Exacerbation: 1.5 vs. 0.9 per year % 18% 0% 20% 40% 60% 80% 5% 8% 70% 30%

30 Comorbidities & Mortality comorbidity 死亡危險比 10 共病比肺功能影響更大 2 comorbidity 1 comorbidity 0 comorbidity 1 GOLD 3/4 GOLD 2 GOLD 1 R GOLD 0 Normal

31 Next Generation COPD Care

32 Speech Outline 1 COPD Care Gap 2 Current Guideline 3 Integrated Care Model 4 Future Perspective

33 咳 痰 喘 罪惡感 經濟壓力 人際疏離 憂鬱 失能 沮喪 孤立 無助 害怕 一直惡化 死亡

34 Quality Improvement

35 A story of success: continuous quality improvement in cystic fibrosis care in the USA 網路資料收集入口 Thorax 2011;66:1106e1108 網路資料收集入口 作業指引 病人衛教 自我處置計畫 品質指標 標竿學習

36 COPD 的績效測量 Chest 2010;137; 分類測量標準機構 臨床評估 >18 歲 COPD 病人每年預估 COPD 比率 AHRQ, NHS, PCPI 肺功能診斷 Inpatients COPD 病人以肺功能確診比率 AHRQ, NCQA, NHS, NQF, PCPI 肺功能追蹤 15 個月內有 FEV1 記錄 AHRQ, NHS 肺炎疫苗 >18 歲每年 COPD 病人打肺炎疫苗比率 AHRQ, PCPI 感冒疫苗 >18 歲 COPD 病人每年打感冒疫苗比率 AHRQ, NHS, PCPI 氧氣飽和度 COPD 病人每年接受氧氣飽和度檢測比率 AHRQ, NQF, PCPI Transitional care 住院某一組群或時間間隔住院人次 AHRQ, NQF 運動訓練 >18 歲 COPD 病人合併呼吸困難接受運動訓練比率 AHRQ, NQF 肺復原 : 急性惡化住院 COPD 病人出院 6 個月內接受肺復原比率 AHRQ, PCPI 藥物 : 支氣管擴張劑 COPD 病人接受支氣管擴張劑比率 AHRQ Outpatients 藥物 : 急性惡化 COPD 急性惡化住院後開立支氣管擴張劑比率 AHRQ, NQF, PCPI 藥物 : 急性惡化 COPD 急性惡化住院在 14 天內接受類固醇治療比率 ANRQ, NCQA, NQF 戒菸 COPD 病人 ( 抽菸者 ) 接受戒菸治療比率 AMRQ, PCPI

37 Readmission

38 COPD Discharge Care Bundle 戒菸介入 病人出院前 肺復健介入病人自我處置計畫藥物吸入技巧出院後約診 順利出院

39 Readmisison rate (%) COPD Discharge Care Bundle 天再入院率 Thorax2012; 67:90-92

40 Medication adherence in COPD?

41 Probability of Death (%) 藥物遵從性和死亡率的關係 <=80% >80% 26.4% % 5 0 Number at Risk <=80% 1232 >80% Time to Death (Weeks)

42 醫療遵從性 Presence of psychological problems, particularly depression Presence of cognitive impairment Treatment of asymptomatic disease Inadequate follow-up or discharge planning Side effects of medication Patient's lack of benefit of treatment Patient's lack of insight into the illness Poor provider-patient relationship Presence of barriers to care or medications Missed appointments Complexity of treatment Cost of medication, copayment, or both NEJM, 2005

43 Non-Invasive Ventilation

44 NIV Indication

45 AE of COPD 族群受益程度有多大? Level A 每 3 到 8 位就有 1 人得到好處 Lightowler at el BMJ 2003;326:185

46 預測 NIV in COPD 成功與否 最安全族群 最危險族群 N =1033 Confalonieri et al ERJ 2005

47 預測 NIV in COPD 成功與否 最危險族群 黃金 2 小時 最安全族群 N =1033 Confalonieri et al ERJ 2005

48 COPD 病人賦權計畫 步驟說明 Step1:primary concern 請病人說出來擔心什麼? Step2:feeling Empowerment Step3:solution Step4:step to solution Step5:what happened? 請病人說出來這事件中她的感受, 鼓勵病人說 不必解決, 因為情緒感受能成為行為改變的動力對話, 透露真正關心的事情 dialogue, 此時衛教人員的重點在傾聽 請病人將詳細的狀況畫出來 說清楚反思 Reflection, 並且思考有沒有想到任何的解決方案 訂定計畫 5W 追蹤 傾聽 listening 行動 Action

49 Speech Outline 1 COPD Care Gap 2 Current Guideline 3 Integrated Care Model 4 Future Perspective

50 Integrated care is more than the sum of its parts

51

52 COPD 病例分享 21-Jul-2012