Background: The effectiveness of pulmonary rehabilitation in advanced COPD is well established, but few data are available in less advanced disease. Methods: In a 2 year randomised controlled trial, 199 patients with an average moderate airflow obstruction but impaired exercise capacity (mean (SD) forced expiratory volume in 1 s (FEV 1 ) 60 (16)%, peak work load (Wmax) ,70%) were randomised to the INTERdisciplinary COMmunity-based COPD management programme (INTERCOM) or usual care. Intervention consisted of 4 months multidisciplinary rehabilitation followed by a 20-month maintenance phase. Outcomes (4, 12, 24 months): health-related quality of life (St George's Respiratory Questionnaire (SGRQ)), exacerbation frequency, MRC dyspnoea score, cycle endurance time (CET), 6-minute walking distance (6MWD), skeletal muscle strength and patients' and caregivers' perceived effectiveness. Conclusions: This study shows that a multidisciplinary community-based disease management programme is also effective in patients with COPD with exercise impairment but less advanced airflow obstruction. Trial registration number: NCT00840892In patients with advanced chronic obstructive pulmonary disease (COPD), beneficial effects of pulmonary rehabilitation programmes on exercise capacity, dyspnoea and quality of life are well established.

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The study aimed to estimate the cost-effectiveness of interdisciplinary communitybased chronic obstructive pulmonary disease (COPD) management in patients with COPD.We conducted a cost-effectiveness analysis alongside a 2-yr randomised controlled trial, in which 199 patients with less advanced airflow obstruction and impaired exercise capacity were assigned to the INTERCOM programme or usual care. The INTERCOM programme consisted of exercise training, education, nutritional therapy and smoking cessation counselling offered by community-based physiotherapists and dieticians and hospital-based respiratory nurses. Allcause resource use during 2 yrs was obtained by self-report and from hospital and pharmacy records. Health outcomes were the St George's Respiratory Questionnaire (SGRQ), exacerbations and quality-adjusted life years (QALYs).The INTERCOM group had 30% (95% CI 3-56%) more patients with a clinically relevant improvement in SGRQ total score, 0.08 (95% CI -0.01-0.18) more QALYs per patient, but a higher mean number of exacerbations, 0.84 (95% CI -0.07-1.78). Mean total 2-yr costs were J2,751 (95% CI -J632-J6,372) higher for INTERCOM than for usual care, which resulted in an incremental cost-effectiveness ratio of J9,078 per additional patient with a relevant improvement in SGRQ or J32,425 per QALY.INTERCOM significantly improved disease-specific quality of life, but did not affect exacerbation rate. The cost per QALY ratio was moderate, but within the range of that generally considered to be acceptable.

This study showed that the use of self-reported data or data from registrations effected within-group costs, but not between-group costs or the cost utility.

Introduction:In contrast with the frequency distribution of chronic obstructive pulmonary disease (COPD) stages in the population, in which the majority of the patients is classifi ed as GOLD 2, much less information is available on the prevalence and implications of systemic manifestations in less severe patients relative to GOLD 3 and 4. Aim: To characterize local and systemic impairment in relation to disease burden in a group of GOLD 2 COPD patients (n = 127, forced expiratory volume in one second (SD): 67 (11)% pred) that were eligible for the Interdisciplinary Community-based COPD management (INTERCOM) trial. Methods: Patients were included for this lifestyle program based on a peak exercise capacity (Wmax) Ͻ70% of predicted. Metabolic and ventilatory response to incremental cycle ergometry, 6 minute walking distance (6MWD), constant work rate test (CWR), lung function, maximal inspiratory pressure (Pimax), quadriceps force (QF), quadriceps average power (QP) (isokinetic dynamometry), handgrip force (HGF) and body composition were measured. Quality of life (QoL) was assessed by the St. George's Respiratory Questionnaire (SGRQ) and dyspnea by the modifi ed Medical Research Council (MRC) dyspnea scale. Exacerbations and COPD-associated hospital admissions in 12 months prior to the start of the study were recorded. Burden of disease was defi ned in terms of exercise capacity, QoL, hospitalization, and exacerbation frequency. GOLD 2 patients were compared with reference values and with GOLD 3 patients who were also included in the trial. Results: HGF (77.7 (18.8) % pred) and Pimax (67.1 (22.5)% pred) were impaired in GOLD 2, while QF (93.5 (22.5)% pred) was only modestly decreased. Depletion of FFM was present in 15% of weight stable GOLD 2 patients while only 2% had experienced recent involuntary weight loss. In contrast to Wmax, submaximal exercise capacity, muscle function, and body composition were not signifi cantly different between GOLD 2 and 3 subgroups. Body mass index and fat-free mass index were signifi cantly lower in smokers compared to ex-smokers. In multivariate analysis, QF and diffusing capacity (DLco) were independently associated with Wmax and 6 MWD in GOLD 2 while only 6 MWD was identifi ed as an independent determinant of health-related QoL. HGF was an independent predictor of hospitalization. Conclusions: This study shows that also in patients with moderate COPD, eligible for a lifestyle program based on a decreased exercise capacity, systemic impairment is an important determinant of disease burden and that smoking affects body composition.