Integrated disease management in outpatient chronic obstructive pulmonary disease

There is an undisputable knowledge-to-care implementation gap in chronic obstructive pulmonary disease (COPD) management. Integrated disease management (IDM), a multidisciplinary approach to prevent and manage chronic diseases, has been identified as one potential solution to address this gap. The purpose of this review is to examine the recent evidence base and discuss the nuances of IDM in COPD care.

IDM in COPD has been implemented in the real world setting in diverse geospatial contexts in the last 5 years. IDM teams are predominantly embedded in primary care clinics and consist of 2-8 multidisciplinary team members. Interventions delivered by IDM COPD teams have been highly variable, making it difficult to definitively conclude 'how many' and 'which intervention' or 'combination of interventions' is needed to achieve positive clinical outcomes. Health service utilization and patient symptom scores are the common outcomes examined, and IDM COPD teams invariably achieved positive outcomes.

IDM represents a promising approach to the gaps in COPD guideline implementation and may help reduce care fragmentation. IDM teams have been shown to improve clinical outcomes, and also improve patient and provider satisfaction. A strong implementation plan that is theoretically grounded and considers all relevant contextual factors is more likely to result in successful implementation of an effective IDM team.