Integrated Chronic Obstructive Pulmonary Disease Management in Primary Care
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Increased attention has recently been paid to disease management programs in the primary care of chronic obstructive pulmonary disease (COPD). Key elements of these programs are reactivation, lifestyle change, and exacerbation management.
It is important that the patient is actively involved in the treatment plan. After diagnosis of COPD by repeated spirometry, a tailored disease management program should be designed in collaboration with the patient. Individual points of attention could be encouraging smoking cessation, improving inhaler technique, or improving exercise tolerance. Central to disease management of COPD is multidisciplinary implementation of an exacerbation rapid action plan. Research has shown that self-management of exacerbations reduces their duration, which presents a further argument for the active involvement of the patient in developing their treatment plan.
A region-wide implementation plan based on the ‘Kroonluchter’ multidisciplinary disease management plan has been initiated in Rotterdam, the Netherlands. In this program, patients enrolled in eligible primary care practices are invited to participate in a repeated pulmonary function test. Depending on their individual disease burden, patients may receive optimization of their medication by their primary care physician, a tailored 6-month specific training program with a physiotherapist, or medication compliance monitoring and repeated inhalation instruction by a pharmacist. Patients who were obese or had muscular depletion could also receive a dietary intervention with a specialized dietitian in addition to the training program. In cases where the diagnosis was uncertain or patients had very severe lung pathology, access to specialist pulmonary physicians was available at short notice. All patients who participated in the 6-month training program received an annual BODE (Body mass index, airway Obstruction, Dyspnea, Exercise capacity) index and administration of the Clinical COPD Questionnaire to assess the effectiveness of the program. Extra attention was given to following up patients immediately after an exacerbation.
At present, approximately 2.8% of the total practice population is participating in the program. Almost all participants in the 6-month training program have reported perceptible and measurable improvements in exercise tolerance, and a strong collaboration has developed between primary care providers, patients, and secondary care.
KeywordsChronic Obstructive Pulmonary Disease Smoking Cessation Chronic Obstructive Pulmonary Disease Patient Disease Management Program Chronic Obstructive Pulmonary Disease Treatment
No sources of funding were used to assist in the preparation of this article. The author has no conflicts of interest that are directly relevant to the content of this article.
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