Comprehensive Care Management in Conjunction with Sputum Cytometry-Guided Pharmacotherapy in a Post-Discharge Clinic for Patients with COPD.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are amongst the most common reasons for hospital admission, and recurrent episodes occur frequently. Comprehensive care management (CCM) strategies have modest effect in preventing re-admissions. The objectives of this study were to examine the utility of optimizing anti-inflammatory therapy guided by sputum cytometry in the post-hospitalization setting, and to assess the feasibility and effectiveness of a clinic combining CCM and sputum-guided therapy. This is an observational study examining patients who received open-label CCM and sputum cytometry-guided pharmacotherapy in a COPD post-discharge clinic. Referral was based on high risk for readmission after hospitalization for AECOPD. The primary outcome was the change in COPD-related healthcare utilization before and after Visit 1, and this was analyzed with a mixed-effects negative binomial model controlling for age, number of follow-up clinic visits, pack years, current smoking and FEV1. Of 138 patients referred to the clinic, 73% attended at least one visit. Mean FEV1 was 42.8 (19.3) % predicted. Of the patients attending clinic, 42.6% produced an adequate sputum sample, and 32.7% had an abnormal sputum. By individual, infectious bronchitis was the most common (25.7%), followed by eosinophilic bronchitis (13.9%). Comparing the 6-months prior to and after the first clinic visit, there was a lower incidence rate ratio after visit 1 for COPD-related healthcare utilization (0.26 (95%CI 0.22,0.33; p < 0.001)). A COPD post-discharge clinic combining sputum-guided treatment and CCM was feasible and associated with a nearly 75% reduction in the incidence of COPD-related healthcare utilization.

Effects of a 12-month multi-faceted mentoring intervention on knowledge, quality, and usage of spirometry in primary care: a before-and-after study.

BACKGROUND: Asthma is among the most common chronic diseases in adults. International guidelines have emphasized the importance of regular spirometry for asthma control evaluation. However, spirometry use in primary care remains low across jurisdictions. We sought to design and evaluate a knowledge translation intervention to address both the poor quality of spirometry and the underuse of spirometry in primary care. METHODS: We designed a 1-year intervention consisting of initial interactive education and hands-on training followed by unstructured peer expert mentoring (through an online portal, email, telephone, videoconference, fax, and/or in-person). We recruited physician and allied health mentees from across primary care sites in Ontario, Canada. We compared spirometry-related knowledge immediately before and after the 1-year intervention period and the quality of spirometry testing and the usage of spirometry in patients with asthma in the year before and the year of the intervention. RESULTS: Seven of 10 (70 %) invited sites participated, including 25/90 (28 %) invited allied health mentees and 23/68 (34 %) invited physician mentees. We recruited 7 physician mentors and 4 allied health mentors to form 3 mentor-mentee pods. Spirometry knowledge scores increased from 21.4 +/- 3.1 pre- to 27.3 +/- 3.5 (out of 35) (p < 0.01) post-intervention. Spirometry acceptability and repeatability criteria were met by 59/191 (30.9 %) spirometries and 86/193 (44.6 %) spirometries [odds ratio 1.7 (1.0, 3.0)], in the pre-intervention and intervention periods, respectively. Spirometry was ordered in 75/512 (14.6 %) and 129/336 (38.4 %) respiratory visits (p < 0.01), and in 20/3490 (0.6 %) and 36/2649 (1.4 %) non-respiratory visits (p < 0.01), in the pre-intervention and intervention periods, respectively. CONCLUSIONS: A mentorship-based intervention involving physicians and allied health team members can enhance knowledge, quality, and actual use of spirometry in real world primary care settings. A future controlled study should assess the impact of this intervention on patient outcomes, its cost-effectiveness, and its sustainability.

Novel Interprofessional Mentoring Intervention to Improve Spirometry in Primary Care: Uptake, Feedback, and Effects on Behavioral Intention.

INTRODUCTION: Little is known about the nature and effects of mentoring interventions on evidence-based clinician behaviors. We sought to design and evaluate a novel mentorship-based intervention to improve the usage of spirometry in primary care. METHODS: This was a prospective one-year study of a pragmatic intervention across Canadian primary care sites. We established mentor-mentee pods, each including physician and nurse/allied health mentors and mentees, and enabled communication through a secure online portal; email; telephone; teleconference; videoconference; fax; and/or in person. We measured (1) change in intention to perform spirometry (through a questionnaire based on the theory of planned behavior, administered before and after the intervention); (2) mentoring uptake; and (3) feedback/satisfaction. RESULTS: Twenty-five of 90 (28%) nurse/allied health and 23/68 (34%) physician mentees consented across seven sites. There were no statistically significant changes in behavioral intention after the intervention. Mentors logged 56.5 hours, with most preferred communication modalities being in person (6/11; 55%) and email (4/11; 36%). Mentees most commonly used email (9/18; 50%), followed by in-person communication (6/18; 33%). Mentees were highly satisfied with the experience, and most (89%) would participate in a similar program again. DISCUSSION: A mentorship-based intervention can successfully engage physicians, nurses, and allied health practitioners through multiple communication platforms. Email seems to be an important medium for this activity. Such interventions can be highly satisfying and may affect certain constructs underlying mentees' behavioral intentions. Such a program can be replicated across diseases, and future research should measure effects on behavior, patient outcomes, and the sustainability of effects.