Vanfleteren Lowie E G W, van 't Hul Alex J, Kulbacka-Ortiz Katarzyna, Andersson Anders, Ullman Anders, Ingvar Martin
COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden.
Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden.
J Clin Med. 2020 May 2;9(5):1311. doi: 10.3390/jcm9051311.
Chronic Obstructive Pulmonary Disease (COPD) is a complex disease defined by airflow limitation and characterized by a spectrum of treatable and untreatable pulmonary and extra-pulmonary disease characteristics. Nonpharmacological management related to physical activity, physical capacity, body composition, breathing and energy-saving techniques, coping strategies, and self-management is as important as its pharmacological management. Most patients with COPD carry other chronic diagnoses and this poses a key challenge, as it lowers the quality of life, increases mortality, and impacts healthcare consumption. A personalized, multi-, and interprofessional approach is key. Today, healthcare is poorly organized to meet this complexity with the isolation between care levels, logic silos of the different healthcare professions, and lack of continuity of care along the patient's journey with the healthcare system. In order to meet the criteria for integrated, personalized care for COPD, the structural capabilities of healthcare to support a comprehensive approach and continuity of care needs improvement. COPD is preeminently a disease that requires a transition from a reactive single-specialty approach to a proactive interprofessional approach. In this study, we discuss the issues that need to be addressed when moving from current health care practice to a person-centered model where the care processes and information are aligned to the individual personal needs of the patient.
慢性阻塞性肺疾病（COPD）是一种以气流受限为定义的复杂疾病，其特征是一系列可治疗和不可治疗的肺部及肺外疾病特征。与身体活动、身体能力、身体成分、呼吸和节能技术、应对策略以及自我管理相关的非药物管理与其药物管理同样重要。大多数慢性阻塞性肺疾病患者还患有其他慢性疾病诊断，这构成了一项关键挑战，因为它会降低生活质量、增加死亡率并影响医疗保健消费。个性化、多专业和跨专业的方法是关键。如今，医疗保健的组织方式难以应对这种复杂性，存在护理级别之间的隔离、不同医疗专业的逻辑孤岛以及患者在医疗保健系统中的就医过程中缺乏护理连续性等问题。为了满足慢性阻塞性肺疾病综合、个性化护理的标准，医疗保健支持全面方法和护理连续性的结构能力需要改进。慢性阻塞性肺疾病显然是一种需要从被动的单一专科方法转变为主动的跨专业方法的疾病。在本研究中，我们讨论了从当前医疗实践转向以患者为中心的模式时需要解决的问题，在这种模式下，护理过程和信息与患者的个人需求相一致。
