title: Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial.
abstract: BACKGROUND
  Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level.
  
  
  OBJECTIVE
  The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients.
  
  
  METHODS
  From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV1 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient's empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years.
  
  
  RESULTS
  IC enhanced self-management (P=0.02), reduced anxiety-depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years.
  
  
  CONCLUSIONS
  The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force.
authors: Medical and Nursing Direction, Hospital Clinic de Barcelona. CIBER en Enfermedades Respiratorias (CIBERES), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
authors: Carme
authors: C
authors: Hernández
authors: Information System Department, Hospital Clinic de Barcelona, CIBER en Enfermedades Respiratorias (CIBERES), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
authors: Albert
authors: A
authors: Alonso
authors: Centre for Research in Environmental Epidemiology (CREAL), CIBER Epidemiologia y Salud Pública (CIBERESP), Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
authors: Judith
authors: J
authors: Garcia-Aymerich
authors: Centre for Research in Environmental Epidemiology (CREAL), CIBER Epidemiologia y Salud Pública (CIBERESP), Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
authors: Ignasi
authors: I
authors: Serra
authors: Programa d'Atenció Domiciliaria i Equips de Suport (PADES), Grup MUTUAM, Barcelona, Spain.
authors: Dolors
authors: D
authors: Marti
authors: Medical and Nursing Direction, Hospital Clinic de Barcelona. CIBER en Enfermedades Respiratorias (CIBERES), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
authors: Robert
authors: R
authors: Rodriguez-Roisin
authors: Interprofessional Education, West Virginia University, Morgantown, WV, USA.
authors: Georgia
authors: G
authors: Narsavage
authors: Nursing Direction, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors: Maria
authors: M
authors: Carmen Gomez
authors: Medical and Nursing Direction, Hospital Clinic de Barcelona. CIBER en Enfermedades Respiratorias (CIBERES), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
authors: Josep
authors: J
authors: Roca
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018450:Disease Progression; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D010348:Patient Care Team / Q000458:organization & administration*; D029424:Pulmonary Disease, Chronic Obstructive / Q000401:mortality; D011787:Quality of Health Care; D018570:Risk Assessment