The family and community nurse-led proactive management of COPD patients: experience of an Italian health district

Abstract

Integrated care management for COPD may reduce healthcare utilisation, improving cost-efficiency. To assess the primary outcomes of a family and community nurse-led proactive management of COPD patients of an Italian health district. Target population comprised men and women >60 years, resident in the municipalities of Collegno and Grugliasco (metropolitan area of Turin). Administrative databases (hospital discharge records, drug prescriptions, legal exemptions) were first used to identify patients with diagnosis of COPD; the cases were validated by the General Practitioners (GPs). The 335 patients were enrolled from July 1, 2015 to November 30, 2016. Family and community nurses were responsible for anamnesis, spirometry, assessment of adherence to therapy, counselling and healthy lifestyles education. GPs were responsible for the clinical staging and revision of therapy. Patients were followed-up to 12 months. Improvements were observed in smoking cessation (prevalence of smokers from 23.9% to 20%), BMI normalization (in 13.4% of patients out of standard), physical activity (from 32.5% to 64.5% of patients), and pneumococcal vaccinations (from 14.9% to 58%). The last two outcomes were statistically significant. Patients showed high levels of satisfaction; 12-months compliance was 62.1%. A family and community nurse-led proactive management of COPD patients in primary care is feasible and effective. Interventions should be structured, personalised and multi-component, oriented at motivating, engaging and supporting the patients. Positive results led to continue and extend the programme.