Integrated care: a new model for COPD management?

T otal healthcare expenditure in countries of the Organisation for Economic Cooperation and Development has risen from an average of 5% of gross domestic product in 1970 to ,10% in 2002 [1]. In 2002, pharmaceutical expenditure ranged from 10% of the total healthcare expenditure in Sweden to 21% in France [1], and a major portion of this expenditure arose through hospital care. Chronic obstructive pulmonary disease (COPD) is one of the most common chronic diseases worldwide [2] and a common cause of hospitalisation. An analysis of the economic cost of COPD in the UK shows that 54% accrues from hospitalisation; a further 32% is equally divided between scheduled care and drug treatment [3]. The Study of Risk Factors of COPD Exacerbation (EFRAM Study) showed that among a wide range of potential risk factors, only previous admissions, lower forced expiratory volume in one second, and the under-prescription of oxygen are independently associated with a higher risk of admission for a COPD exacerbation [4]. Under-prescription of home oxygen is easily modifiable once hypoxia has been diagnosed, but hospital admission rates for COPD remain a challenge for pulmonologists and chest therapists alike. In the current issue of the European Respiratory Journal, there is a new and interesting attempt at management of the severe COPD patient. CASAS et al. [5] advance a model that may have great potential for the cross-cultural modification of hospitalisation rates for COPD. Previous studies have shown that self-management of COPD within the community can reduce hospitalisation [6] and exacerbation severity [6, 7]. The economic efficacy of these models is unknown, but since hospitalisation contributes the greatest proportion of costs for COPD, models targeting patients at risk for hospitalisation may be expected to have the widest appeal to chest physicians and healthcare providers alike. Several attempts have been made at establishing interventions for patients with chronic illnesses, almost all of which include prevention of hospitalisation as an outcome measure and almost always within one cultural environment. A meta-analysis of 102 such studies has shown that commonly used interventions have included patient education, healthcare provider education, and provider feedback. All such studies were associated with improvements in disease control and adherence to practice guidelines, but because of the diversity of outcome measures and structure, little else could be concluded [8]. In COPD, such studies have recruited patients from the community or hospital. The East London COPD study, a long-term cohort study …