The COPDnet integrated care model

Figures & data

Figure 1 The COPDnet integrated care model.

Abbreviations: DT, diagnostic trajectory; GP, general practitioner; PROMs, Patient-Reported Outcome Measurements.

Table 1 Additional diagnostics

Additional diagnostics	Aim	Indication
Measurement of static lung volumes	To determine the presence of restrictive pulmonary function impairment	– FVC <80% of the predicted value
CO diffusion capacity	To determine whether or not CO diffusion is limited	– Persisting doubts about the diagnosis of asthma or COPD – Suspected ILD – Discrepancy between spirometric values and desaturation during the 6MWD
Histamine provocation test	To determine the presence and severity of bronchial hyperreactivity	– Doubts about the diagnosis of asthma or COPD – To set up or adjust medication in case of asthma
Cardiopulmonary exercise test	To determine maximal exercise capacity and cause of exercise limitation	– Steps per day <5,000 or VMU <0.210 and 6MWD <70% of predicted value and the patient is willing to participate in an exercise training program
CT thorax	Imaging of the thorax	– Doubts about the presence of malignancy or ILD
Referral to cardiologist or ENT specialist	To determine the diagnosis and treatment of relevant comorbidity	– Suspicion of relevant cardiac or ENT comorbidity

Abbreviations: 6MWD, 6-minute walk distance; CO, carbon monoxide; CT, computed tomography; ENT, ear nose throat; FVC, forced vital capacity; ILD, interstitial lung disease; VMU, vector magnitude units.

Table 2 Classification of burden of disease

Mild	Moderate	Severe
– Exacerbations: none in the last year	– Exacerbations: one in the last year	– Exacerbations: ≥2 in the last year or one hospitalization due to exacerbation COPD
– Comorbidities: none or do not contribute to the burden of disease	– Comorbidities: present and contribute moderately to the burden of disease	– Comorbidities: present and contribute markedly to the burden of disease
– MRC =0–1	– MRC =1–2	– MRC =3–5
– BMI >21 or <30	– BMI <21 or 30–35	– BMI <21 or >35
– 6MWD ≥500 m	– 6MWD =400–500 m	– 6MWD <400 m
– PAL ≥1.7	– PAL =1.4–1.7	– PAL <1.4
– CCQ <2.0	– CCQ =2–3	– CCQ >3.0
– NCSI = normal or mildly disturbed	– NCSI = moderately disturbed	– NCSI = severely disturbed
– No or mild disturbance of the social participation (work, family, hobbies, sports, and so on)	– Moderate disturbance of the social participation (work, family, hobbies, sports, and so on)	– Severe disturbance of the social participation (work, family, hobbies, sports, and so on)

Note: PAL was measured with the MoveMonitor.

Abbreviations: 6MWD, 6-minute walk distance; BMI, body mass index; CCQ, Clinical COPD Questionnaire; MRC, Medical Research Council; NCSI, Nijmegen Clinical Screening Instrument; PAL, physical activity level.

Figure 2 Guideline on decision making for nonmedical intervention modules in a primary care setting.

Note: PAL was measured with the MoveMonitor.
Abbreviations: 6MWD, 6-minute walk distance; BIC, blood isotope clearance; BMI, body mass index; CAT, COPD assessment test; CCQ, Clinical COPD Questionnaire; FFMI, Fat-Free Mass Index; IC, inspiratory capacity; MPT, manually paced tachypnea; NCSI, Nijmegen Clinical Screening Instrument; PAL, physical activity level; pCO₂, partial pressure of carbon dioxide.