Economic Benefits of Self-Management Education in COPD

Original Research COPD

Economic Benefits of Self-Management Education in COPD* Jean Bourbeau, MD, MSc; Jean-Paul Collet, MD, PhD; Kevin Schwartzman, MD, MPH; Thierry Ducruet, MSc; Diane Nault, RN, MSc; Carole Bradley, MSc; and the COPD axis of the Respiratory Health Network of the Fond de la recherche en sante´ du Que´bec†

Context: There is emerging evidence that disease management with self-management education provided by a case manager might benefit COPD patients. Objective: To determine whether disease management with self-management education is more cost-effective than usual care among previously hospitalized COPD patients. Design: Economic analysis in conjunction with a multicenter randomized clinical trial comparing patients conducting self-management with those receiving usual care over a 1-year follow-up period. Setting: Respiratory referral centers. Patients: One hundred ninety-one COPD patients who required hospitalization in the year preceding enrollment were recruited from seven respiratory outpatient clinics. Intervention: In addition to usual care, patients in the intervention group received standardized education on COPD self-management program called “Living Well with COPD” with ongoing supervision by a case manager. Main outcome measures: From the perspective of the health-care payer, we compared costs between the two groups and estimated the program cost per hospitalization prevented (incremental cost-effectiveness ratio of the program). We repeated these estimates for several alternate scenarios of patient caseload. Results: The additional cost of the self-management program as compared to usual care, $3,778 (2004 Canadian dollars) per patient, exceeded the savings of $3,338 per patient based on the study design with a caseload of 14 patients per case manager. However, through a highly plausible sensitivity analysis, it was showed that if case managers followed up 50 patients per year, the self-management intervention would be cost saving relative to usual care (cost saving of $2,149 per patient; 95% confidence interval, $38 to $4,258). With more realistic potential caseloads of 50 to 70 patients per case manager, estimated program costs would be $1,326 and $1,016 per prevented hospitalization, respectively. Conclusion: The program of self-management in COPD holds promise for positive economic benefits with increased patient caseload and rising costs of hospitalization. (CHEST 2006; 130:1704 –1711) Key words: integrated care; patient education; management; medical care delivery Abbreviations: CI ⫽ confidence interval; NIRRU ⫽ Niveau d’Intensite´ Relatif des Ressources Utilise´es

is one of the most common causes of ill C OPD health, disability, and mortality affecting adults worldwide.1 The clinical course of COPD is one of gradual impairment and episodes of acute exacerbations that contribute to the deterioration of patients’ health status.2,3 COPD is now well recognized as placing a heavy burden on patients and on the 1704

health-care system.1,4 – 6 In the later stages of disease, health services use increases, with frequent hospitalizations at substantial cost.6 – 8 Care gaps are not limited to pharmacologic therapy of COPD patients but extend to nonpharmacologic management as with other chronic conditions.9 –11 Disease management of chronic conditions Original Research

focuses increasingly on preventive strategies and on integrated, multidisciplinary care. Disease management is a systematic attempt to manage the consequences of disease, based on the partnership of patients and health professionals. However, resources devoted to disease management represent only a small fraction of health-care costs in North America and Europe. The potential returns to the health-care system of investment in disease management warrant careful evaluation. New evidence-based, nurse-led chronic disease management has emerged for the care of specific groups of COPD patients. In a multicenter randomized clinical trial12 among patients with moderate-tosevere COPD and previous exacerbation requiring hospitalization, we demonstrated the clinical effectiveness of disease management with self-management education program, “Living Well with COPD,” which integrates supervision and continuous support by a case manager. The program markedly reduced hospital service use12,13 and helped COPD patients perform self-health behaviors such as adopting energy conservation principles and using pursed-lip breathing techniques, implementing an action plan and physical activities at home.14 Our clinical trial included prospective documentation of all program and health-care costs. From the health-care payer perspective, we hypothesized that this program would be more cost-effective than usual care in this subgroup of COPD patients. We report the results of the economic analysis from this randomized trial.

*From the Respiratory Epidemiology and Clinical Research Unit (Drs. Bourbeau and Schwartzman), Montre´al Chest Institute of the Royal Victoria Hospital (Ms. Nault), McGill University Health Centre, Montre´al, QC; Randomized Clinical Trial Unit (Mr. Ducruet and Dr. Collet), Jewish General Hospital, McGill University, Montre´al, QC; and Manager Health Economics (Ms. Bradley), Boehringer-Ingelheim Canada, Burlington, ON, Canada. †Members of the COPD axis of the Respiratory Health Network of the FRSQ who have participated in the research project are listed in the Appendix. This study was made possible by an unrestricted grant from Boehringer Ingelheim Canada, Burlington, ON, in partnership with the Fonds de la recherche en sante´ du Que´bec, Montre´al, QC, Canada. Dr. Schwartzman is the recipient of a ChercheurBoursier Clinicien career award from the Fonds de la Recherche en Sante´ du Que´bec. Manuscript received December 1, 2005; revision accepted May 25, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Jean Bourbeau, MD, Respiratory Epidemiology and Clinical Research Unit, Montre´al Chest Institute, 3650 St.Urbain, Office K1.32, Montre´al, QC, Canada H2X 2P4; e-mail: [email protected] DOI: 10.1378/chest.130.6.1704 www.chestjournal.org

Materials and Methods The design and methods of this trial have been described in more detail elsewhere,12 and are briefly summarized below. Study Design One hundred ninety-one subjects with COPD were recruited from seven hospital outpatient clinics in the province of Que´bec, Canada. Eligible patients were at least 50 years old, had moderate-to-severe airflow obstruction (postbronchodilator FEV1 between 25% and 70% of the predicted value15 and FEV1/FVC ratio ⬍ 70%), a smoking history of at least 10 pack-years, and a history of hospitalization for at least one exacerbation in the preceding year. The study was approved by the research ethics board at each participating hospital. Participants were randomly assigned to the self-management education intervention or to usual care, in a 1:1 ratio, with blocked randomization stratified by study site. In both groups, subjects continued to be managed by their usual specialist and/or family physician, and had access to all their usual medications and health services. In addition, subjects in the intervention group received standardized education on the COPD self-management program as well as ongoing supervision by a case manager. The case manager had to be an experienced nurse or respiratory therapist, and specific training was provided for the application of the program. During the 2 weeks of training, the case managers had to become familiar with the content of the COPD selfmanagement program and competent to educate patients in regards to all aspects of the disease. The case managers had first to identify their specific learning needs in regards to COPD and patient education through a questionnaire and a group discussion. Half-day training sessions were dedicated to interactive lecturing sessions on each aspect of COPD given by different members of the multidisciplinary team. The rest of the training days included workshops oriented toward how to assess patient needs and the acquisition of motivational and teaching skills using group discussion, demonstration and practice of techniques, case scenarios, and role modeling. Case managers were handed a reference guide to assist in educating their patients that includes general and specific objectives, material resources needed, types of educative interventions, and patient outcomes expected for the different elements taught in the program. The patient education program included weekly skill-oriented teaching at home for 6 to 7 weeks, depending if the patient needed home oxygen and agreed to perform the home exercise program. Monthly follow-up telephone calls were made after the end of all teaching sessions. Patients assigned to the intervention group could reach the case manager during working hours via a pager or a dedicated telephone line. The teaching material included a flipchart designed for health educators, and seven skill-oriented patient workbooks covering the following topics: (1) basic information about COPD; breathing and coughing techniques, energy conservation during day-to-day activities, and relaxation exercises; (2) preventing and controlling symptoms through inhalation techniques; (3) understanding and using a plan of action for acute exacerbation; (4) adopting a healthy lifestyle (smoking cessation, nutrition, sleep habits, sexuality, managing emotion); (5) leisure activities and traveling; (6) a simple home exercise program, not supervised, except for an initiation visit; and (7) long-term oxygen therapy when appropriate. An audiotape was also given to every patient to be used at home in order to assist him/her in the implementation of relaxation techniques such as deep breathing, progressive muscular relaxation, and visualization. The written action plan for exacerbations included a list of contact persons, and a symptommonitoring list tailored to specific precipitants (stress, environCHEST / 130 / 6 / DECEMBER, 2006

1705

mental changes, respiratory tract infections). The symptom list was linked to appropriate therapeutic actions, including prescription of antibiotics and oral corticosteroids to be kept at home and used in the event of an exacerbation (two of three cardinal symptom changes based on exacerbations classified as types 1 and 2 by Anthonisen et al16). To promote exercise at home, a stationary bicycle was provided for the first 2 months of follow-up to patients in the intervention group in order to establish the motivation and a way to buy their own stationary bicycle. Each participating center had a pool of three stationary bicycles that were brought to patients’ homes on a rotation basis through a free local transport. The present study has taken the perspective of the health-care payer. There is concern by the payers (Ministry of Health, health-care insurance company) that there might not be a return on their investment if running such a program. Thus, the main outcomes were the costs for each group, and program cost estimated per hospitalization prevented (incremental cost-effectiveness ratio of the program). Patients were assessed at baseline, 4 months, and 12 months. Standardized telephone interviews were conducted every 4 weeks to record items regarding exacerbation, non-COPD health problems, medication, and related health-care utilization. An independent evaluator blinded to group assignment was responsible for assessing patients at each study site. An acute exacerbation was defined as a change from baseline in respiratory symptoms lasting at least 24 h, with respect to worsened dyspnea, increased sputum volume, or increased sputum purulence. Economic Analysis We performed an intention-to-treat analysis; all randomized subjects were included regardless of their compliance. Costs were compared between the two groups from the perspective of the third-party payer for health care, the Que´bec Provincial Government. All costs are expressed in year 2004 Canadian dollars ($1 Canadian ⫽ $0.81 United States, average conversion rate). Costs may have increased over time (because of inflation), but the increment observed between the two groups will be maintained irrespective of the fact that these costs may not accurately reflect COPD treatment costs in 2006. All health-care resources used during the 1-year follow-up were considered. Intervention costs reflected resources used to administer the intervention (time spent for research data collection was not included). Real time spent with each patient was carefully documented by each study case manager. Case manager salary costs were estimated based on the average pay scale of the Federation of Nurses of Que´bec. Physician fees were those set by the Provincial Health Insurance Board.17 Total cost per emergency department visit was based on data18,19 from earlier studies conducted in the province of Que´bec. Emergency department visit was a separate resource item than hospitalization. Hospitalization costs were based on a Que´bec index called the Niveau d’Intensite´ Relatif des Ressources Utilise´es (NIRRU) [relative intensity level of resources used].20 In Que´bec, hospital costs are entirely covered by the Que´bec Provincial Government. The software was developed from a Maryland database of all patient refined diagnosis-related groups, adjusted for conditions particular to Que´bec. The algorithm included primary and secondary diagnosis, information about disease severity and comorbidity, allowance for prolonged duration of stay (because the daily hospital cost changes with length of stay), and for death (because death is associated with extra costs). For statistical comparisons of costs, we computed 95% confidence intervals (CIs) using sampling resampling methods (non1706

parametric bootstrapping methods).21,22 Statistical analysis was performed using statistical software (SAS for Windows, release 8.02; SAS Institute; Cary, NC). To enhance the applicability of our findings in other jurisdictions, we estimated program costs per hospitalization prevented. Here, we estimated an incremental cost-effectiveness ratio of the program (relative to no intervention) as the cost per hospitalization prevented with self-management education. We also repeated these estimates using various scenarios of patient load per case manager. We undertook this additional analysis since the average load of 14 subjects per case manager reflected the study design and organization, and is considerably lower than would be expected for real-world implementation. Based on the case managers’ tabulation of documented real time spent with each patient, including face-to-face visits, telephone calls, and travel, we calculated that in an outpatient clinic setting, the case manager would be able to supervise 70 patients per year, while 30 to 50 patients could be managed in a home care setting.

Results Study Subjects The clinical results of our trial have been described elsewhere.12 Of the 469 eligible COPD patients, 251 refused to participate, while 27 agreed but could not be enrolled because they lived too far away from the study sites. The main reason for patient refusal was the perceived burden of studyrelated evaluations, given the 50% likelihood of remaining with usual care. Potential eligible patients who did not participate were similar to the 191 study participants with respect to sex, age, and severity of airflow obstruction. Hence, 96 subjects were assigned to the self-management group and 95 to the usual care group. Baseline characteristics of the two groups were similar with respect to sociodemographic variables, disease severity and previous use of health services (Table 1). In the self-management group, there were 10 dropouts (including five deaths), so that 86 patients completed the full year of follow-up. In the control group, there were 16

Table 1—Baseline Characteristics of Study Patients*

Characteristics

Usual Care Group (n ⫽ 95)

Self-management Group (n ⫽ 96)

Age, yr Female gender Living alone Education ⬍ 12th grade Currently smoking Pack-years of smoking Postbbronchodilator FEV1, L FEV1/FVC ratio Dyspnea† Six-minute walking test, m

69.6 ⫾ 7.4 56 (59) 40 (48) 73 (77) 25 (26) 56.1 ⫾ 31.3 0.98 ⫾ 0.31 0.45 ⫾ 0.12 55 (58) 275.1 ⫾ 94.3

69.4 ⫾ 6.5 50 (52) 46 (42) 79 (82) 24 (25) 57.8 ⫾ 40.6 1.00 ⫾ 0.33 0.46 ⫾ 0.10 56 (58) 274.6 ⫾ 98.8

*Data are presented as mean ⫾ SD or No. of patients (%). †American Thoracic Society-Division of Lung Diseases grade 5. Original Research

dropouts (including nine deaths), so that 79 patients completed a full year of follow-up. Use and Costs of Health Resources During the 1-year follow-up period, the frequency of hospital admission was significantly lower in the self-management group than in the usual care group, as were hospital days per patient, emergency department visits, and unscheduled physician visits (data not shown). Use of bronchodilators and inhaled corticosteroids did not differ between the groups at baseline and during follow-up (data not shown). This has already been shown in a previous article.12 Table 2 shows the intervention-related resources. Total per-patient cost of the self-management intervention ($3,778) stemmed largely from the case manager’s salary ($3,402 per patient). Table 3 shows the mean health-care costs. After excluding the cost of the self-management intervention, the mean health-care cost was $3,338 lower for the self-management group than the usual care group. As expected, differences in costs were largely driven by hospitalization costs, which represented ⬎ 90% of the overall cost for each group. Table 4 shows the cost comparisons repeated based on several hypothetical scenarios for patient caseload. With the study subject caseload of 14 per case manager, the intervention did not demonstrate a statistically significant difference in costs between the two groups. Assuming more realistic patient caseloads per case manager (30, 50, or 70 patients), the mean difference between the two groups reached statistical significance at a caseloads of 50 patients and 70 patients per case manager. This could represent cost savings ⬎ $2,000 per patient. Figure 1 presents the incremental cost-effectiveness ratios per hospitalization prevented according to several scenarios of patient caseloads (sensitivity

analysis). The observed incremental cost-effectiveness ratio was $4,214 per hospitalization prevented for a caseload of 14 patients per case manager, as compared to usual care. With assumed caseloads of 30, 50, and 70 patients per case manager, the estimated incremental cost-effectiveness ratios were $2,053, $1,326, and $1,016 per hospitalization prevented, respectively. Discussion This study has demonstrated that a multicomponent self-management education program with ongoing supervision by a case manager can reduce the use of health services among previously hospitalized patients with moderate-to-severe COPD. This reduction is primarily the result of fewer hospitalizations, emergency department visits, and unscheduled physician visits. Although the 1-year time frame may seem short to policy makers, we have recently shown that the benefit of our program is sustained past the first year.13 The program holds promise for positive economic benefits with increased patient caseload and rising costs of hospitalization. From the third-party payer perspective, we estimated that the program could become cost saving ($2,300 per patient on average) over a 1-year period. Despite the considerable burden and cost of COPD and hence the relevance of economic evaluations of interventions in this context, very few such evaluations of COPD care have been published.23 Most economic evaluations of nonpharmacologic interventions considered education to be part of pulmonary rehabilitation.24,25 Only a small number of randomized clinical trials have addressed the economic impact of disease management through self-management education.26 –28 Tougaard et al26 reported a saving of $4,051 (US dollars) over 1 year

Table 2—Intervention-Related Resources, Cost per Patient Self-management Group (n ⫽ 96)

Intervention-Related Resources

Unit Cost, $

Total No. of Units for Seven Participating Centers

Bicycle Pager Telephone line Program Tape Travel Salary (registered nurse), training (2 wk)* Salary (registered nurse), intervention* Total

300 (per U) 120 (1 yr) 116 (1 yr) 15 (per U) 7 (per U) 0.32 (per km) 58,340 (per yr) 58,340 (per yr)

20 7 7 95 95 33,000 7 ⫻ 2/52 yr 7 ⫻ 4/5 yr

Cost per Patient, $ 62 9 9 15 7 110 164 3,402 3,778

*Salary included 2 weeks of training at the beginning of the program and 4 days per week for patient teaching and follow up. www.chestjournal.org

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Table 3—Health-Care Resources, Mean Costs per Patient* Usual Care Group (n ⫽ 95) Items Physician visits Family physician Specialist Emergency department visits For acute exacerbation For other health problems Hospitalizations For acute exacerbation For other health problems Total

Self-management Group (n ⫽ 96)

Difference per Patient, $

Unit Cost, $

No.

Cost, $

No.

Cost, $

44.3 (per visit) 81.5 (per visit)

112 26

47 22

46 24

19 20

⫺ 28 ⫺2

226 (per visit) 226 (per visit)

161 74

383 ⫾ 540 176 ⫾ 313

95 57

224 ⫾ 461 134 ⫾ 229

⫺ 159 ⫺ 42

NIRRU index† NIRRU index†

117 50

3,934 ⫾ 5,919 2,112 ⫾ 4,490 6,674 ⫾ 8,946

71 20

2,099 ⫾ 4,440 840 ⫾ 2,240 3,336 ⫾ 5,435

⫺ 1,835 ⫺ 1,272

*Data are presented as mean ⫾ SD unless otherwise indicated. †Index of hospital health resources utilization.18

with a program administered during the patients’ hospital stay. This benefit was due primarily to reductions in hospitalization and use of emergency services. Gallefoss and Bakke29 were not able to show a significant effect on level of hospital use that was low, but family physician visits were significantly reduced in the intervention group. In the economic analysis taken from a societal perspective,27 they showed a cost benefit resulting from a reduction in use of primary and secondary care use. In a more recent study, Monninkhof et al28 were not able to demonstrate cost savings attributable to self-manage-

ment education. Subjects had milder airflow obstruction and better health status than the subjects of our study; their subjects were also not enrolled based on a previous hospitalization for COPD. In addition, the “control” subjects received standardized pharmacologic treatment for exacerbations, and they were instructed to call in case of worsening symptoms, a procedure similar to the one offered to the selfmanagement group. The major potential economic benefit of a disease management program is the prevention of hospitalization. Hence, the attributable saving will reflect the

Table 4 —Cost Comparison Between Study Groups According to Several Scenarios of Patient Caseload* Patient Caseload per Case Manager, No.†

Usual Care Group (n ⫽ 95) Cost per Patient, $

Self-management Group (n ⫽ 96) Cost per Patient, $

p Value

14 Health-care cost Intervention-related cost Total Mean difference

6,674 ⫾ 8,946‡

3,336 ⫾ 5,435‡ 3,778 6,674 ⫾ 8,946 7,114 ⫾ 5,435 ⫹ 440 (95% CI, ⫺ 1,670 to 2,551)

Health-care cost Intervention-related cost Total Mean difference

6,674 ⫾ 8,946‡

0.68

30 3,336 ⫾ 5,435‡ 1,841 6,674 ⫾ 8,946 5,177 ⫾ 5,435 ⫺ 1,496 (95% CI, ⫺ 614 to 3,606)

0.16

50 Health-care cost Intervention-related cost Total Mean difference

6,674 ⫾ 8,946‡ 6,674 ⫾ 8,946 ⫺ 2,148 (95% CI, 38 to 4,258)

3,336 ⫾ 5,435‡ 1,189 4,525 ⫾ 5,435 0.046

70 Health-care cost Intervention-related cost Total Mean difference

6,674 ⫾ 8,946‡

3,336 ⫾ 5,435‡ 910 6,674 ⫾ 8,946 4,246 ⫾ 5,435 ⫺ 2,428 (95% CI, 1,538 to 3,174)

0.024

*Data are presented as mean ⫾ SD or absolute number. †The base-case scenario of 14 patients per case manager reflects the organization of the multicenter study. Scenarios of 30 to 50 patients and 70 patients: home and outpatient settings were based on tabulation of the average time spent for patient visits, travel, and telephone contacts. ‡Health-care costs per patient are assumed to remain constant, regardless of case manager load. 1708

Original Research

Figure 1. Incremental cost-effectiveness ratios per hospitalization prevented according to several scenarios of patient caseloads (sensitivity analysis). The base-case scenario of 14 patients per case manager reflects the organization of the multicenter study. Scenarios of 30 to 50 patients and 70 patients and home and outpatient settings were based on tabulation of the average time spent for patient visits, travel, and telephone contacts.

baseline frequency of hospitalizations for exacerbations, as well as the effectiveness of the intervention itself. We recalculated the cost analysis with different patient caseloads per case manager in order to more accurately capture real-life clinical practice outside the research setting. Our caseload scenarios reflected the actual time devoted by each case manager to patient care, including clinic visits, telephone calls, and home visits. This information was carefully documented by each study case manager. These greater patient caseloads should not affect the quality of care, so the benefit of the program should remain. Furthermore, our actual experience of disease management in a similar clinical setting supports a caseload of 50 to 70 COPD patients per case manager. We did not analyze medication costs in detail because subjects in both groups had similar prescription profiles at baseline and throughout the 1-year follow-up period. However, self-management may entail more tests and drug therapy, which will potentially drive up costs. Despite these hidden costs that we left out because they were not documented, we believe that the cost-effectiveness analysis is still conservative, as we considered the perspective of the third-party payer rather than the societal perspective. Hence, we did not consider lost productivity by subjects and/or family members related to subjects’ illness and hospitalization. However, we emphasized the perspective of the health-care system, so as to www.chestjournal.org

help health-care payers set priorities on the basis of costs/savings for them, as well as clinical effectiveness. Finally, a sensitivity analysis was not done with respect to different jurisdictions. Although costs may not reflect the difference between jurisdictions, differential costs between salary scales and costs for hospitalization are likely to be maintained. Data provided in the article are instructive enough to allow the reader to estimate costs according to the specific practice environment. In our study as in any clinical trial, participants were a select group.30 Previous studies in diabetes31 and heart disease32 have shown that approximately 50% of outpatients will take part in a year-long intensive self-management education program. It may be that an even higher percentage of people would be willing to participate in self-management programs that are not research studies, although this information has never been formally documented in real-life settings. In our study, participants and eligible patients who refused participation were similar with respect to most sociodemographic and disease characteristics. We demonstrated the impact of an intensive intervention among patients with moderate-to-severe COPD, relatively poor self-reported health status, and a high risk of exacerbations leading to hospitalization. For patients with milder illness, cost savings from an intervention of this type are likely to be modest at best. Self-management interventions are never double CHEST / 130 / 6 / DECEMBER, 2006

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blinded. It is impossible to blind study participants, and those administering the intervention likewise are not blinded. In our study, as in most good selfmanagement studies, outcome assessment was totally separated from the intervention. It is not clear which components of the selfmanagement intervention are most beneficial. This information might allow the design of a briefer, yet effective intervention. Recently, we have shown that patients in the intervention group were in large part compliant with the action plan.33 This information suggests that self-management program helps COPD patients to follow a self-care regimen. Thus, it is unlikely that the difference between the two study groups was only related to a sense of greater caring due to the case manager. Previous interventions that were less highly structured than ours have not shown reduction in hospital admissions.34 The relative contribution of specific components may be less important than the integration of proactive self-management—and expert supervision—into the patients’ existing health-care resources. Skilled case managers with self-management support and adjustment of therapy by protocol have been shown to be critical components of effective chronic disease care.35–37 It was also shown that to be effective, care in chronic diseases such as arthritis and diabetes requires self-management education with a mutually understood care plan, with careful and continuous communication with a case manager when there is evidence of difficulties.38 – 40 However, the interactivity with the case manager was not evaluated in our study, as in most of the studies. This represents an important challenge for future research in the field of patient education. During a 1-year follow-up period, a disease management program that combined self-management education with supervision by a case manager reduced health services use—and potentially costs— among patients previously hospitalized with moderate-to-severe COPD. We believe this reflects the capacity of such a program to meet the changing needs of patients with a major chronic illness.

Appendix Participating members of the COPD axis of the Respiratory Health Network of the Fond de la Recherche en Sante´ du Que´bec were as follows: Jean Bourbeau, MD and Diane Nault, RN, Montre´al Chest Institute of the Royal Victoria Hospital, McGill University Health Centre; Paolo Renzi, MD, Hoˆpital Notre-Dame, Centre hospitalier affilie´ de l’Universite´ de Montre´al; Marcel Julien, MD, Hoˆpital du Sacre´-Cœur, Centre hospitalier affilie´ de l’Universite´ de Montre´al; Alain Beaupre´, MD, Centre hospitalier affilie´ de l’Universite´ de Montre´al; Michel Rouleau, MD, Hoˆpital de l’Enfant-Je´sus, Centre hospitalier affilie´ de l’Universite´ Laval; Francois Maltais, MD, Hoˆpital Laval, 1710

Institut universitaire de cardiologie et de pneumologie de l’Universite´ Laval; and Raymond Be´gin, MD, Centre universitaire de sante´ de l’Estrie. Other participants included the following: Grace Gerardi, BSc; Vitalie Perreault, RN, MSc; Jose´e Dagenais, RN; Cathy Fuge`re, RN; Livia Fargolia, RRT; and Palmina Mancino, BSc, Montre´al Chest Institute of the Royal Victoria Hospital; Guylaine Leboeuf, RRT; and Francine Richard, RN, Hoˆpital Notre-Dame, Centre hospitalier affilie´ de l’Universite´ de Montre´al; Suzanne Valois, RN; Lyne Pineau, RRT; and He´le`ne Laflamme, RRT, Hoˆpital du Sacre´-Cœur, Centre hospitalier affilie´ de l’Universite´ de Montre´al; Louise Dumont, RN; Marielle Gauthier, RN; and Danielle St-Jules, MSc; Hoˆpital Maisonneuve-Rosemont, Centre hospitalier affilie´ de l’Universite´ de Montre´al; Louise Page´, RRT; Claudia Fournier, RRT; Denise Chre´tien, RRT; and Danielle Montreuil, RRT Hoˆpital de l’Enfant-Je´sus, Centre hospitalier affilie´ de l’Universite´ Laval; Louise Beaudoin, RN; Marie-Jose´e Breton, RN; and Marthe Be´langer, RN; Hoˆpital Laval, Institut universitaire de cardiologie et de pneumologie de l’Universite´ Laval; and Bozena Pietrowski, PhD; and Francine Lalonde, RN, Centre universitaire de sante´ de l’Estrie.

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