An Official American Thoracic Society Workshop Report: The Integrated Care of the COPD Patient

Abstract

The optimal care of the patient with chronic obstructive pulmonary disease (COPD) requires an individualized, patient-centered approach that recognizes and treats all aspects of the disease, addresses the systemic effects and comorbidities, and integrates medical care among healthcare professionals and across healthcare sectors. In many ways the integration of medical care for COPD is still in its infancy, and its implementation will undoubtedly represent a paradigm shift in our thinking. This article summarizes the proceedings of a workshop, The Integrated Care of the COPD Patient, which was funded by the American Thoracic Society. This workshop included participants who were chosen because of their expertise in the area as well as their firsthand experience with disease management models. Our summary describes the concepts of integrated care and chronic disease management, details specific components of disease management as they may apply to the patient with COPD, and provides several innovative examples of COPD disease management programs originating from different healthcare systems. It became clear from the discussions and review of the literature that more high-quality research in this area is vital. It is our hope that the information presented here provides a "call to arms" in this regard.

Chronic Obstructive Pulmonary Disease: Official diagnosis and treatment guidelines of the Czech Pneumological and Phthisiological Society; a novel phenotypic approach to COPD with patient-oriented care

“…It should cover all aspects of this multi-organ syndrome, simultaneously its systemic consequences and associated comorbidities. It is essential that the treatment includes participation of the patient and the attending pulmonologist, but also involves the patient's family members and other healthcare professionals such as general practitioners, physiotherapists, psychologists and nutritionists 115 . Educational interventions are needed to improve the implementation of guideline-based management.…”

“…A necessary assumption is the interaction between the patient and physician, and patient's continual education and training. If the disease develops as far as the terminal stage, it is advisable to further expand the relationship and to determine the future treatment care boundaries in time 55,61,115 . …”

The knowledge level of chest physicians about the pulmonary rehabilitation topic

“…Bu hasta grubun farmakolojik tedavinin yanında PR desteği verilmesi; kişinin günlük aktiviteleri bağımsız olarak yapabilmesi ve böylece hayatın için-de daha fazla olmayı hedefler [4]. Kronik solunum hastalığı olan kişilerde optimum farmakoterapiye rağmen hastalar halen semptomatikse, bir rehabilitasyon programı düşünülmelidir [6]. İlk değerlen-dirme aşamasında, bir rehabilitasyon programı; kas zayıflığı, depresif belirtiler, hastalıkla başa çıkmada zayıflık, fiziksel aktivite koordinasyonunda bozulma, beslenme defektleri gibi solunum yolu hastalıklarının, solunumsal olmayan ve değiştirilebilir sonuçlarının tespitini amaçlamaktadır.…”

Integrated care of chronic degenerative non-communicable diseases and rehabilitation: the odd couple?

“…A workshop of the American Thoracic Society defined integrated care as the continuum of patient centered services organized as a care delivery value chain for patients with chronic conditions with the goal of achieving the optimal daily functioning and health status for the individual patient and to achieve and maintain the individual's independence and functioning in the community [3].…”