Skip to main content

Optimizing integrated care for older adults with Chronic Obstructive Pulmonary Disease

Thomas Rotter, PhD, Associate Professor, Queen's School of Nursing
Joan Tranmer, RN PhD, Professor Queen's School of Nursing
Michael Green, MD MPH CCFP FCFP, Queen's Department of Family Medicine
Denis O’Donnell, MD FRCP(C) FCCP, Professor, Queen's Department of Medicine
Leigh Kinsman, PhD MHlthSc BHlthSc RN, Professor, University of Newcastle Australia School of Nursing and Midwifery
Darcy Marciniuk, MD FRCPC, Professor University of Saskatchewan Department of Respirology, Critical Care and Sleep Medicine

What? Chronic obstructive pulmonary disease (COPD) is a chronic lung disease, associated with high rates of emergency use and hospital admissions. Care of patients with COPD is complex as patients require comprehensive assessment, monitoring and evaluation of pharmacological management.  Care is provided by both family physicians in the primary care setting and specialists. Ideally, the patient is able to access the most appropriate level of care from this team of providers. However, barriers, such as geographical distance, specialist access and poor coordination, influence the provision of care. Thus, we aim to determine the characteristics of this team that are associated with the best outcomes for patients newly diagnosed with COPD.

Why? The overall aim of this project is to describe and understand the network of care provided by both primary care and repiratory specialist physician providers to patients newly diagnosed with COPD. We will determine if certain characteristics of this team of providers influence health care utilization and outcomes. The overall goal of this project is to inform strategies for improvement of integrated care for patients with COPD.

How? We will carry out a population level study using health administrative data housed at the Institute for Clinical Evaluative Sciences (ICES). We will identify Ontario adult patients newly diagnosed with COPD and describe health care contacts, medications prescribed (in patients over 65 years), and health care use during the first 5 years after COPD has been confirmed. Our study is designed to describe the characteristics of the network of healthcare providers and the influence of these provider network characteristics on patient care and outcomes.

Impact of the findings: This project has the potential to improve the lung health of all adult Ontario residents by identifying gaps in COPD care in terms of health service use and medical management. We will provide information relevant to the strategies to optimize integrated care for patients with COPD.

Funded By
the Canadian Lung Association and the Canadian Institutes of Health Research (Institute of Circulatory and Respiratory Health)