Disease Management & Health Outcomes

, Volume 16, Issue 5, pp 315–318 | Cite as

Integrated Chronic Obstructive Pulmonary Disease Management in Primary Care

  • Niels H. ChavannesEmail author
Expert Opinion


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.


Chronic Obstructive Pulmonary Disease Smoking Cessation Chronic Obstructive Pulmonary Disease Patient Disease Management Program Chronic Obstructive Pulmonary Disease Treatment 
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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.


  1. 1.
    ERS Task Force, Palange P, Ward SA, et al. Recommendations on the use of exercise testing in clinical practice. Eur Respir J 2007; 29(1): 185–209PubMedCrossRefGoogle Scholar
  2. 2.
    Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study. Am J Respir Crit Care Med 2007; 175: 458–63PubMedCrossRefGoogle Scholar
  3. 3.
    Wind LA, Chavannes NH, Kaper J, et al. Summary of the Dutch College of General Practitioners’ guideline for smoking cessation. Ned Tijdschr Geneesk 2008; 152(26): 1459–64Google Scholar
  4. 4.
    Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2007 Jan 24; (1): CD000031PubMedGoogle Scholar
  5. 5.
    Smeele IJM, van Weel C, van Schayck CP, et al. Dutch College of General Practitioners guideline for COPD diagnosis and treatment. Huisarts Wet 2007; 50(8): 362–79Google Scholar
  6. 6.
    Celli BR, MacNee W, Agusti A, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23: 932–46PubMedCrossRefGoogle Scholar
  7. 7.
    Casaburi R, Kukafka D, Cooper CB, et al. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Chest 2005 Mar; 127(3): 809–17PubMedCrossRefGoogle Scholar
  8. 8.
    Seemungal TA, Donaldson GC, Bhowmik A, et al. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 161: 1608–13PubMedGoogle Scholar
  9. 9.
    American Thoracic Society. COPD guidelines [online]. Available from URL: [Accessed 2008 Oct 10]
  10. 10.
    Chavannes N, Vollenberg JJ, van Schayck CP, et al. Effects of physical activity in mild to moderate COPD: a systematic review. Br J Gen Pract 2002; 52(480): 574–8PubMedGoogle Scholar
  11. 11.
    Kesten S, Casaburi R, Kukafka D, et al. Improvement in self-reported exercise participation with the combination of tiotropium and rehabilitative exercise training in COPD patients. Int J Chron Obstruct Pulmon Dis 2008; 3(1): 127–36PubMedGoogle Scholar
  12. 12.
    Celli BR, Cote CG, Marin JM, et al. The body mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004; 350(10): 1005–12PubMedCrossRefGoogle Scholar
  13. 13.
    Chavannes NH, Huibers MJH, Schermer TRJ, et al. Associations of depressive symptoms with gender, body-mass index and dyspnea in primary care COPD patients. Fam Pract 2005; 22: 604–7PubMedCrossRefGoogle Scholar
  14. 14.
    Wood-Baker RR, Gibson PG, Hannay M, et al. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005; 1: CD001288PubMedGoogle Scholar
  15. 15.
    Wilkinson TM, Donaldson GC, Hurst JR, et al. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004; 169(12): 1298–303PubMedCrossRefGoogle Scholar
  16. 16.
    Clinical COPD Questionnaire [online]. Available from URL: [Accessed 2008 Oct 10]
  17. 17.
    Zantinge EM, Devill’e WLJM, Heijmans MWJM. Foreigners with asthma, COPD or hay fever in the Netherlands: what is known [in Dutch]? Utrecht: NIVEL, 2006Google Scholar
  18. 18.
    Redelmeier DA, Bayoumi AM, Goldstein RS, et al. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997; 155(4): 1278–82PubMedGoogle Scholar
  19. 19.
    Chavannes NH, Grijsen M, van den Akker M, et al. Integrated disease management improves long-term quality of life in primary care COPD patients [abstract]. Eur Respir J 2007; 30(S51): 390Google Scholar

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© Adis Data Information BV 2008

Authors and Affiliations

  1. 1.Department of Public Health and Primary CareLeiden University Medical CenterLeidenthe Netherlands

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