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
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].

People with chronic conditions are often cared for by partners or family members. Significant psychological and physical consequences occur in carers of patients with chronic diseases. In populations where the patient’s chronic disease is non-respiratory, there is evidence (Jones 1992) that the psychological health status of carers and patients is linked. One of the most effective means of improving the patient’s functional and psychological state is pulmonary rehabilitation.

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). Although these domains are not specifically addressed in the following sections, they are directly relevant to each.

Disease management approaches in COPD include a number of the Chronic Care Model domains. A systematic review by Peytremann-Bridevaux (Peytremann-Bridevaux 2008) assessed the impact of COPD management programs attended by patients, which they defined as interventions with two or more different components (e.g. physical exercise, self-management, structured follow-up), at least one of which continued for 12 months, were delivered by two or more health care professionals and incorporated patient education. It found such programs improved exercise capacity and Health-related Quality of Life (HRQoL), and reduced hospitalisation [evidence level I]. However, it is unclear from this review which specific components of the disease management programs contribute the most benefit to patients. A Cochrane Review (Kruis 2013) examined 26 trials of integrated disease management programs defined as “a group of coherent interventions designed to prevent or manage one or more chronic conditions using a systematic, multidisciplinary approach and potentially employing multiple treatment modalities.” The review found positive effects on disease-specific QoL measured by the Chronic Respiratory Questionnaire (all domains) and on the impact domain of the St George Respiratory Questionnaire (SGRQ). There were also positive effects on exercise tolerance, hospital admissions and hospital days per person [evidence level I].

A cluster RCT conducted in Canadian primary care of an integrated disease management intervention aimed at patients with frequent and/or severe exacerbations and comprising on-site spirometry, case management, education, and skills training including self-management education by a certified respiratory educator resulted in improved disease-related quality of life, improved disease knowledge and FEV1 and fewer exacerbations and unplanned service use compared to usual care (Ferrone 2019) [evidence level II].  In another large multicentre randomised controlled trial (Rice 2010) involving veterans who received a single education session, an action plan for self-treatment of exacerbations and monthly follow-up calls from a case manager, found that, when compared to usual care, the intervention group had a significant reduction in hospitalisation and ED visits for COPD, mortality and quality of life, measured with the Chronic Respiratory Questionnaire [evidence level II].

An intensive, comprehensive health coaching intervention that included motivational interviewing-based intervention delivered via telephone, a written action plan for exacerbations including the use of antibiotics and oral steroids, and an exercise prescription decreased COPD-related hospitalisations at 1, 3, and 6 months after hospital discharge, but not at one year after discharge. The absolute risk reductions of COPD-related rehospitalisation in the health coaching group were 7.5% (p=0.01), 11.0% (p=0.02), 11.6% (p=0.03), 11.4% (p=0.05), and 5.4% (p=0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire (CRQ) emotional score (emotion and mastery domains) and physical score (dyspnoea and fatigue domains) (p<0.05). There were no differences between groups in measured physical activity at any time point (Benzo 2016). It should be noted that several of these individual components have been shown to be effective in isolation.

An alternative approach of home care outreach nursing was studied in a systematic review by Wong (Wong 2012), in which the intervention included home visits to provide education and social support, identify exacerbations and reinforce correct inhaler technique.  They also found a significant benefit in quality of life, measured by the St George’s Respiratory Questionnaire (SGRQ), but no significant effect on mortality or hospitalisations [evidence level I].  In all these studies, it remains unclear which specific components contribute the most benefit to patients, are the most cost effective or should be combined to provide optimal benefit on the many different outcomes.

Box 9: Comparison of outcomes for COPD management programs
Study/ Outcome Mortality Hospitalisation QOL Exercise
OR = 0.85
(0.54 to 1.36)
Benefit in 7/10
Not reported
WMD = 32.2
(4.1 to 60.3)
#MD = 3.7
(-1.4 to 8.8)
*MD = 0.34
(0.15 to 0.52)
MD = 5.1
(2.5 to 7.6)
Not reported
OR = 0.72
(0.45 to 1.15)
OR = 1.01
(0.71 to 1.44)
WMD = -2.60
(-4.81 to -0.39)
WMD = 5.05
(-15.08 to 25.18)

OR = 1.05

0.63 to 1.75)

OR = 0.46

(0.33 to 0.65)

WMD = -6.57

(-13.62 to 0.48)
Not reported

Outcome presented as OR = odds ratio or (W)MD = (weighted) mean difference, with 95% confidence intervals in brackets.  *Hospitalisation and ED visits. # difference per 100 patient years.

However, it is important to note that not all studies of disease management programs have shown benefit. Kruis et al (Kruis 2014) conducted a cluster RCT in 40 general practices in the Netherlands (1086 patients with COPD by GOLD criteria) of a multifaceted disease management intervention comprising multidisciplinary team of caregivers trained in motivational interviewing, setting up individual care plans, exacerbation management, implementing clinical guidelines and redesigning the care process. The intervention was compared to usual care. There was no difference in HRQoL. The differences in findings between studies may be related to variation in implementation of interventions. One of the differences between studies was the extent of emphasis on and uptake of physical activity/exercise training interventions.