Integrated disease management for adults with COPD-We still have a lot to learn about how to make it work in primary care

摘要

Chronic obstructive pulmonary disease (COPD) places an enormous burden on patients, families, and healthcare systems. Optimal care of COPD patients requires a patient centered approach that recognizes and treats all aspects of the disease and integrates medical care among healthcare professionals and across healthcare sectors. Integrated disease management, a system of coordinated healthcare interventions and communications for patients with chronic disease in which self management by patients is important, has been proposed as a model. A recent Cochrane review found clinically relevant reductions in admissions and days in hospital and improvements in exercise tolerance and health related quality of life, mostly for adults with severe COPD, with integrated disease management programs in secondary care.1 However, we should not assume that programs with proven effectiveness in secondary care transfer readily to primary care settings.