A Comprehensive Care Programme for Patients With Chronic Obstructive Pulmonary Disease
Condition: Chronic Obstructive Pulmonary Disease
MeSH terms: Lung Diseases; Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive
Study type: Interventional

Summary: 
      Objective: Chronic obstructive pulmonary disease (COPD) is a disease with significant
      morbidity and incurs heavy utilization of healthcare resources. The direct cost of hospital
      admissions related to COPD is the single largest source of expenditure in the public hospital
      system. This study aims to assess whether a comprehensive care programme can decrease the
      rate of hospital admissions for COPD patients.
    

Detailed description: 
      Design: A randomised controlled trial of patients discharged from hospital after an episode
      of acute exacerbation of COPD. Patients will be randomised to the intervention arm or usual
      care group.

      Setting: Tertiary University affiliated Hospital.

      Interventions:

      The Intervention group will receive a comprehensive programme which involves inputs from
      doctors, respiratory nurses and physiotherapists, providing an individualized care plan for
      each subject. The components in the programme will include optimization of medications,
      specialist physician follow up, nursing support in education, and physiotherapist support for
      pulmonary rehabilitation. Patients in the intervention group will also receive monthly
      telephone calls by a respiratory nurse for a period of 1 year to assess their conditions and
      answer their queries. Patients will also be followed up in the respiratory clinic by
      respiratory specialist once every 3 months for 1 year.

      The control group will be managed as the usual care. The discharging physician will determine
      the patients' medication and follow up as in normal practice.

      All patients will be asked to return for assessments (spirometry, 6 minute walk test,
      questionnaires on the severity of dyspnoea and quality of life) at baseline and 12 months

      Main outcome measures: The primary endpoint is the hospital readmission rate and the
      secondary endpoints are the quality of life, mortality, lung function and exercise capacity
      of the patients.
    

Intervention name(s): Comprehensive care programme
Intervention type(s): Other
Intervention description(s): Intervention group:
Patients will be interviewed by a respiratory nurse and given education in 1-2 sessions
Physiotherapist assessment and training (individualized physical training programme to perform at home or a short course out-patient pulmonary rehabilitation)
Respiratory physician assessment and optimization of treatment
Patients will also be taught about a personalized action plan by the physician and respiratory nurse.
Subsequent intervention: Patients will receive monthly telephone calls by a respiratory nurse for a period of 1 year to assess their conditions and also answer their queries.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: COPD; Comprehensive care