Effective transmural co-operation between the pulmonologists in an average peripheral general hospital and the referring GPs in Zutphen The Netherlands

摘要

The number of patients with COPD is strongly on the rise. This leads to a sharp increase of related workload for both the pulmonologist as well as the GP. In The Netherlands during 2001 the organisations of the GP's (NHG) and the pulmonologists (NVALT) have reached an national co-operative agreement (LTA) on how to effectively and efficiently manage the trias of increase in demand, limited human and financial resources and need for quality of care. This LTA comprises diagnosis, treatment and follow-up and defines both the specific tasks of GP and pulmonologist as well as the areas of co-operation.In The Netherlands (local) experiments to improve the healthcare system have been numerous, but most of these experiments have remained local, due to the original customisation or to its complexity. Therefore the distribution of improvements has been poor and patchy and the effects of the learning curve have been limited.Following a number of pilot experiments, the pulmonologists of the general hospital Het Spittaal in Zutphen decided in December 2001 to develop a transmural care system for COPD patients, which should adhere to the following principles:1. Approach based upon national clinical COPD guidelines (NHG, LTA).2. Organisation of a COPD Knowledge Centre in the Hospital to train, coach and assist GP's and their practice assistants or nurse practitioners.3. Transmural co-operation with at least 50% of all referring GP's.4. Implementation of a categorical COPD surgery in the participating GP practices to concentrate all routine care (actual organisational work done by an outside agency).5. Delegation of routine COPD care from the GP to the practice assistant or nurse practitioner with support from the nurse-specialist in the COPD Knowledge Centre.6. Implementation of a protocolised electronic COPD patient record (DiseaseControl© by Diagnosis4Health), shared between GP and pulmonologist, enabling TeleAdvice by the pulmonologist (software and implementation done by an outside agency).7. Development of detailed scripts of all principles for easy copying by other hospitals.Globally our care system uses the following approach (supported by the DiseaseControl© software),: COPD patients are invited to the categorical surgery every 6 months for a routine check of their pulmonary status (incl. spirogram) and their well-being. The practice assistant or nurse practitioner executes this check. Every 12th month the GP evaluates key clinical parameters. Only when the patient, the assistanturse or the software give a specific reason, the GP is involved for his/her expert opinion. In case the GP is in need of support, he/she can push a software button for a TeleAdvice by the pulmonologist. The logistics and software are supplied by an outside agency, financed by health insurance companies and sponsors. The pulmonologists and the COPD nurses from the COPD Knowledge Centre in Het Spittaal supply the technical know-how.The most important intervention with many COPD patients is to quit smoking. The COPD Knowledge Centre in Het Spittaal offers a Quit Smoking Support programme. Both GPs as well as the pulmonologists may refer smoking COPD patients to this programme. The COPD nurses execute the programme.The objectives of this approach are:1. COPD patients will suffer fewer exacerbations and preserve their pulmonary function.2. COPD patient will experience improvements in their quality of life.3.These results will be reached without additional efforts from GP and pulmonologist. id="__p17">All data will be (anonymously) collected in a dedicated database. This will provide the opportunity to evaluate the results compared to the objectives. Additionally each participating GP is provided with mirror information and benchmarking information. id="__p18">1. Folmer H. et al: Landelijke Transmurale Afspraak COPD. Huisarts Wet 2001;44(5):220-5 id="__p19">2. Geijer R.M.M. et al: NHG-Standaard COPD en Astma bij Volwassenen: Diagnostiek. Huisarts Wet 2001;44(3):107-17 id="__p20">3. Geijer R.M.M. et al: NHG-Standaard COPD: Behandeling. Huisarts Wet 2001;44(5):209-19 id="__p21" class="p p-last">4. Lugt H.A.M.M. van der et al: Behandeling van COPD kan beter, integrale aanpak biedt voordelen. Medisch Contact 2000;55;10:351-2