D: Develop a plan of care

D: Develop a plan of care

Evidence level

Strength of recommendation*

Good chronic disease care anticipates the wide range of needs in patients with COPD.IStrong
Clinical support teams working with the primary healthcare team can help enhance quality of life and reduce disability for patients with COPD.III-2Weak
Patients may benefit from self-management support.IStrong
Patients may benefit from support groups and other community services.III-2Weak
COPD exacerbation action plans reduce emergency department visits and hospital admissions.IStrong
Good chronic disease care anticipates the wide range of needs in patients with COPD [evidence level I, strong recommendation]

IN THE EARLY STAGES OF DISEASE, patients with COPD will often ignore mild symptoms, and this contributes to delay in diagnosis. As the disease progresses, impairment and disability increase. As a health state, severe COPD has the third-highest perceived “severity” rating, on a par with paraplegia and first-stage AIDS (Mathers 1999). Depression, anxiety, panic disorder, and social isolation add to the burden of disease as complications and comorbidities accu­mulate. Patients with severe COPD often have neuropsychological deficits suggestive of cerebral dysfunction. The deficits are with verbal (Incalzi 1997) and visual short-term memory (Crews 2001), simple motor skills (Roehrs 1995), visuomotor speed and abstract thought processing (Grant 1982). Severe COPD is also associated with lower cognitive performance over time (Hung 2009) [evidence level III-2]. One of the most effective means of improving the patient’s functional and psychological state is pulmonary rehabilitation.

The 2023 GOLD guideline update proposed amending the existing “ABCD” disease severity stratification, to instead combine the highest risk groups “C” and “D” into a new single category GOLD E (for Exacerbation) (GOLD 2023). According to the findings of a 12-month cohort study of 690 participants using a COPD self-management mobile app, this proposed change risks over-combining groups with different disease trajectories, which could lead to a loss of clarity and over-treatment in clinical practice (Duckworth 2023) [evidence level III-1].

People with chronic conditions are often cared for by partners or family members. There is evidence that family carers of people with COPD experience significant psychological and physical burdens (Strang 2018).

Health systems around the world are reorienting health care delivery in ways that continue to provide services for people with acute and episodic care needs while at the same time meeting the proactive and anticipatory care needs of people with chronic diseases and multiple morbidities. Wagner and colleagues have articulated domains for system reform in their Chronic Care Model (Wagner 1996). These include Delivery System Design (e.g. multi-professional teams, clear division of labour, acute versus planned care); Self Management Support (e.g. systematic support for patients / families to acquire skills and confidence to manage their condition); Decision Support (e.g. evidence-based guidelines, continuing professional development programs) and Clinical Information Systems (e.g. recall reminder systems and registries for planning care) (Adams 2007). Many of these domains are addressed in the following sections.