Integrated Primary Care Effective for Patients With Severe COPD With No Increase in Costs

An integrated primary care service may improve the health status of patients with severe chronic obstructive pulmonary disease (COPD) without increasing health care costs, according to a recent study.

A recent study published in the European Journal of General Practice found that patients with severe chronic obstructive pulmonary disease (COPD) experienced improved health statuses and no increase in health care costs after a year of treatment in an integrated primary care service.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system was used in order to determine COPD severity. Patients are placed in groups A-D based on forced expiratory volume in 1 second (FEV1), number of admissions or exacerbations, and questionnaire scores assessing symptomology.

Researchers aimed to evaluate outcomes and costs of health care for patients classified as GOLD group D—the most severe level—treated in an integrated primary care asthma/COPD (AC) service in the northern Netherlands. Changes in health status and health care costs were assessed by measuring these variables at baseline and after 12 months of care.

Integrated multidisciplinary care is integral for the treatment of COPD. More than a quarter of newly diagnosed COPD patients in primary care are classified as GOLD group D. Therefore, integrated care is needed in primary care settings in order to improve the health statuses of patients with severe COPD, the researchers note. The AC service forms an integrated care system as pulmonologists support general practitioners in diagnosing and caring for patients with COPD.

This 1-year prospective cohort study included 49 patients, aged 40 or above, who were classified as GOLD group D. The mean age was 66.4 years, and 28 (57%) patients were male.

Researchers used to the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT) to assess the health status of each patient. On the CCQ, patients report the duration of COPD-related complaints they experienced over the past week across 3 domains: symptoms, functional state, and emotional state. The CAT quantifies the patients’ perceived impact of COPD on their health status. A clinically important change in scores on the CCQ and CAT are 0.4 points or above and 2 points or above, respectfully.

Researchers also measured the number of self-reported exacerbations in COPD symptoms, quality-adjusted life years (QALY), and both direct and indirect health care-related costs.

At baseline, the median CCQ score was 1.7 and the mean CAT score was 15.9. Scores improved by 0.5 on the CCQ and 2.7 on the CAT after 6 months. After 12 months, scores improved by 0.4 on the CCQ and 2.3 on the CAT.

From baseline to 12 months of care, 3 patients changed to GOLD group C, 25 to GOLD group B, 2 to GOLD group A, and 14 remained in GOLD group D.

After 12 months, the percentage of patients with 2 or more exacerbations in COPD symptoms decreased from baseline. Throughout the 12 months, the median number of QALYs was 0.9, meaning that patients regarded 0.9 years out of the 12-month follow-up period as lived in perfect health.

Changes in mean quarterly costs at baseline to 12 months were small, and they declined for cost of health care visits and cost of respiratory medication.

There were some limitations of this study. First, the observational design does not include a comparison group. Additionally, more recent studies suggest that 3 points should be considered the minimal clinically important change in CAT scores, which is larger than the average CAT score changes found in the present study. Finally, the relatively small sample size questions the reliability of these data. Many patients were deemed unfit to participate in the present study, meaning that the 49 patients analyzed may be in better health than the average GOLD group D patient.

Results from this study showed that by having pulmonologists support general practitioners to form an integrated primary care setting, patients with newly diagnosed GOLD group D COPD experienced improvement in their symptoms and functionality without increasing their health care costs. Randomized controlled studies to compare integrated primary care to care as usual are needed to support these study findings, the researchers conclude.


de Jong C, van Boven JFM, de Boer MR, Kocks JWH, Berger MY, van der Molen T. Improved health status of severe COPD patients after being included in an integrated primary care service: a prospective cohort study. Eur J Gen Pract. 2022;28(1):66-74. doi:10.1080/13814788.2022.2059070

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