The contribution of nurses in integrated primary cares for chronic obstructive pulmonary disease outpatient: first results from an ongoing trial in a health district in northern Italy

摘要

The study assesses the role and impact of nursing in an ongoing trial of integrated primary cares, carried out in a health district in northern Italy, started in 2004. The goals were to establish a joint collaboration with general practitioners (GP), in order to improve the follow-up of chronic patients. As a first stage, the trial focuses on COPD (chronic obstructive pulmonary disease), diabetes mellitus, hypertension, cardiovascular failure and patients following anticoagulant therapy. The district’s project covers up to 60,000 patients treated by the team of GPs and nurses. Benefits for users are represented by easier access to cares, dedicated projects for chronic disease, follow-up, health education and multidisciplinary work. This first reports presents the questionnaire data according to patients’ satisfaction and the results achieved so far on COPD patients: 101.6% of COPD patients followed by teams have had at least 1 spirometry/year (vs. 43.2% of all the COPD affected—regional data) Hospital admissions are lower according to people attending a COPD integrated program and it is getting lower in time (health district’s rate: 0.125% in 2005–0.115% in 2007; regional data).