Table 2

Regional selection of disease management interventions in the programmes

Setting	Bottlenecks^*	Disease management interventions
Programme A ▶ 14 general practitioners ▶ 8 practice nurses ▶ 7 general practices ▶ 1 hospital ▶ 1 home care organisation ▶ Rural area ▶ Social-economic status: average	Patient involvement 1. Smoking cessation is difficult. 2. Smoking cessation programmes and medication gain too little results. 4. Underestimation of COPD symptoms by patients. 6. Patients are not convinced of/do not experience advantages of complying with therapy and lifestyle instructions.	Patient-related intervention: Structured patient education ▶ Education on smoking behaviour, medication usage, nutrition and physical activity by a practice nurse: frequency: every 3 months; duration: first contact 10 min, follow-up meetings at least 15 min. ▶ Provision of purpose developed information booklet.
	Diagnostics and treatment 9. No clear guidelines for care plans.	Professional-directed intervention: Regional diagnostic and treatment protocol supported by Information and Communications Technology ▶ Implementation of clinical practice guidelines supported by an electronic registry system based on national standards. ▶ Educational meetings general practitioners and practice nurses on COPD management according to guidelines and application of spirometry: Frequency: general practitioner—three times a year; practice nurse—6 days at the start; duration: general practitioner—2 h; practice nurse—8 h (each session). ▶ Audit and feedback by pulmonologist/peers. To confirm diagnosis, every spirometry was assessed by the pulmonologist. In follow-up spirometry tests could be sent to the pulmonologist when necessary. Peer feedback by benchmark report.
	Multidisciplinary collaboration 5. Care provider has insufficient time or means for instruction and education. 7. Division between primary and secondary care.	Organisational intervention: regional arrangements for referral and task delegation ▶ Revision of professional roles: delegation of care from general practitioner to practice nurse, from pulmonologist to general practitioner. ▶ Arrangements for structural follow-up with practice nurse: frequency: 3, 6 and 12 months. ▶ Multidisciplinary collaboration between general practitioner, practice nurse and a pulmonologist. Care coordination by the practice nurse in collaboration with the general practitioner.
Programme B ▶ 17 general practitioners ▶ 10 practice nurses ▶ 10 general practices ▶ 1 hospital ▶ 1 home care organisation ▶ Rural area ▶ Financial support of healthcare insurer ▶ Socio-economic status: average	Patient involvement 2. Smoking cessation is difficult. 4. No clear agreements on responsibilities for instruction and information.	Patient-related intervention: Patient education and information ▶ Education on smoking behaviour, medication usage, nutrition and physical activity by a practice nurse according to a regional protocol: frequency: at least twice a year; duration: 15 to 20 min. ▶ Provision of information brochures and patient diary. ▶ Referral to smoking cessation sessions (group or nurse).
	Diagnostics and treatment 7. Spirometry is not standard performed with all COPD patients. 8. Organisation of practice (no standard COPD follow-up system). 9. No clear guidelines for care plans. 10. Care provider has insufficient time or means for instruction and education.	Professional-directed intervention: Regional diagnostic and treatment protocol ▶ Educational meetings general practitioners and practice nurses on: COPD management according to guidelines and application of spirometry: frequency: general practitioner—once a year; practice nurse—at least three times at the start; duration: general practitioner—2 h; practice nurse—4 h (each session). ▶ Active distribution of clinical practice guidelines: a regionally developed guideline-based care protocol. ▶ Audit and feedback by pulmonologist/peers: spirometry tests could be sent to the pulmonologist when necessary.
	Multidisciplinary collaboration 1. No multidisciplinary approach to COPD care. 4. No clear agreements on responsibilities for instruction and information. 5. Little/no attention for multidisciplinary COPD approach. 6. No multidisciplinary follow-up of COPD (particularly physiotherapy and dietetics). 8. Organisation of practice (no standard COPD follow-up system).	Organisational intervention: protocol for collaboration between primary and secondary care. ▶ Arrangements for structural follow-up with practice nurse: frequency: 1, 6 and 12 months. ▶ Multidisciplinary collaboration between general practitioner, practice nurse and a pulmonologist: multidisciplinary care teams, including physiotherapist. ▶ Revision of professional roles: delegation of care from general practitioner to practice nurse, from pulmonologist to general practitioner. Care coordination by the practice nurse in collaboration with the general practitioner.
Programme C ▶ 8 general practitioners ▶ 2 practice nurses ▶ 2 practice assistants ▶ 2 physiotherapists ▶ 4 general practices 2 hospitals ▶ 1 physiotherapy practice ▶ Rural/urban area ▶ Socio-economic status: average	Patient involvement 3. Underestimation of COPD symptoms by patients. 4. No clear agreements on responsibilities for instruction and information. 9. Patients are not convinced of/do not experience advantages of complying with therapy and lifestyle instructions. 10. Smoking cessation is difficult.	Patient-related intervention: a quit-smoking programme and education by practice nurse ▶ Education on smoking behaviour, medication usage, nutrition and physical activity by a practice nurse: frequency: four times a year; duration: at least 15 min. ▶ Referral to smoking cessation group sessions. ▶ Provision of information brochures. ▶ Reactivation or advice by physiotherapist.
	Diagnostics and treatment 4. No clear agreements on responsibilities for instruction and information. 8. Organisation of practice (no standard COPD follow-up system). 7. Care provider has insufficient time or means for instruction and education.	Professional-directed intervention: regional diagnostic and treatment protocol ▶ Educational meetings general practitioners and practice nurses on: COPD management according to guidelines and application of spirometry: frequency: general practitioner—ones a year; practice nurse—at least three times at the start; duration: general practitioner—2 h; practice nurse—4 h (each session). ▶ Active distribution of clinical practice guidelines: A regionally developed guideline-based care protocol. ▶ Audit and feedback by pulmonologist/peers: Spirometry tests could be sent to the pulmonologist when necessary.
	Multidisciplinary collaboration 1. Little/no attention for multidisciplinary COPD approach. 2. No multidisciplinary follow-up of COPD (particularly physiotherapy and dietetics). 4. No clear agreements on responsibilities for instruction and information. 8. Organisation of practice (no standard COPD follow-up system).	Organisational intervention: regional arrangements for referral and task delegation ▶ Multidisciplinary collaboration between general practitioner, practice nurse, physiotherapist and a pulmonologist. Care coordination by the practice nurse in collaboration with the general practitioner. ▶ Arrangements for structural follow-up with practice nurse: frequency: 3, 6 and 12 months. ▶ Revision of professional roles: delegation of care from general practitioner to practice nurse, from pulmonologist to general practitioner. Care coordination by the practice nurse in collaboration with the general practitioner.

↵* Number of bottleneck corresponds to bottleneck top-10.
COPD, chronic obstructive pulmonary disease.