P97 Optimising management and improving outcomes in chronic obstructive pulmonary disease by integrating care

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Previous integrated care models for COPD have reduced length of stay slightly1 or improved patient quality of life. In this study a pathfinder consortium of 20 practices and the local acute hospital, implemented a collaborative project with a partner from the pharmaceutical industry to improve COPD outcomes. The aims were to reduce hospital admissions, re-admissions and length of stay by integrating care via a patient focussed pathway.


A care pathway was developed, involving patients, that crossed primary and secondary care boundaries and led to improved access to community respiratory services. In each practice patients with COPD were stratified by risk and reviewed by trained nurses, in a structured format. Practice Nurse educational needs were assessed and a mentorship programme put in place. A Consultant Respiratory Physician from the local hospital visited the practices to discuss COPD management and the care pathway, and now runs on-going education and support. National medicine management guidelines were adhered to and reinforced with all healthcare professionals. The links between primary care and the community respiratory team were enhanced and clear referral guidelines were disseminated. The local patient support group (Breathe Easy) was re-launched.


Patients were satisfied with the structured nurse-led COPD reviews, 463/487 said they were “very satisfied”, and 433/487 said they were “totally aware” of their self-management plan. There was a 21% reduction in COPD hospital bed days and the average length of stay fell from 6.8 days to 5.0 days. At the end of 2010 the 30 day re-admission rate had fallen below the Strategic Health Authority average. Over the 12 months of the project the 90 day re-admission rate fell from 43% to 31%, a 12% reduction not shown previously elsewhere1—see Abstract P97 figure 1.


By engaging with all aspects of COPD care, an integrated multidisciplinary team improved service delivery and patient care, reducing COPD hospital bed days and re-admission rates. If the current proposed NHS reforms offer an opportunity for better integrated healthcare then they may deliver improved outcomes.

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