Rationale

Integrated care models have the potential to improve outcomes for patients with COPD. We therefore designed the COPDnet integrated care model and implemented it in two hospitals and affiliated primary care regions in the Netherlands. The COPDnet model consists of a comprehensive diagnostic trajectory ran in secondary care followed by a non-pharmacological intervention program of both monodisciplinary and multidisciplinary components.

Objective

To assess the clinical effectiveness of the COPDnet integrated care model on health status change in patients with COPD.

Methods

A total of 402 patients with COPD were offered care according to the COPDnet model. At baseline and between 7- and 9-months later health status was measured with the Clinical COPD Questionnaire (CCQ). Primary analysis was carried out for the sample at large. In addition, subgroup analyses were performed after stratification for the type of non-pharmacological intervention where patients had been referred to.

Results

The CCQ total score improved statistically significantly from 1.94 ± 1.04 to 1.73 ± 0.96 (P < 0.01) in the 154 patients with valid follow-up measurements. Subgroup analyses revealed significant improvements in the patients receiving pulmonary rehabilitation only. No change in health status was found in patients receiving pharmacotherapy only, carried out self-treatment or who participated in mono-disciplinary primary care offered by allied healthcare professionals.

Conclusions

An improved health status was found in patients with COPD who received care according to the COPDnet integrated care model. Subgroups participating in an interdisciplinary pulmonary rehabilitation program predominantly accounted for this effect.

中文翻译：

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COPDnet综合护理模型的临床有效性。

基本原理

综合护理模型具有改善COPD患者预后的潜力。因此，我们设计了COPDnet集成护理模型，并在荷兰的两家医院和附属的初级护理地区中实施了该模型。COPDnet模型由二级保健中的综合诊断轨迹组成，然后是由单学科和多学科组成部分组成的非药物干预计划。

目的

评估COPDnet综合护理模型对COPD患者健康状况变化的临床效果。

方法

根据COPDnet模型，总共为402名COPD患者提供了护理。在基线以及7个月至9个月之后，使用临床COPD问卷（CCQ）测量健康状况。对整个样本进行了初步分析。此外，在分层后，对转诊患者的非药物干预类型进行了亚组分析。

结果

 通过有效的随访测量，在154例患者中，CCQ总评分从1.94±1.04显着改善至1.73±0.96（P <0.01）。亚组分析显示，仅接受肺部康复的患者有明显改善。仅接受药物治疗，进行自我治疗或参加专职医疗保健人员提供的单学科基础护理的患者的健康状况没有发现变化。

结论

根据COPDnet综合护理模型，接受护理的COPD患者的健康状况得到改善。参加跨学科肺康复计划的亚组主要是这种作用。