Soins intégrés BPCO (Broncho-pneumopathie Chronique Obstructive) en Valais - Mieux Vivre Avec ma BPCO (COPD Integrated Care Program Valais - Living Well With COPD)

Background: Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by acute exacerbations that contribute to physical impairment and increased healthcare use and costs. Given the increasing burden of this disease in terms of morbidity, disability, mortality and costs, innovative care models centered on patients and aiming at improving quality and comprehensiveness of care are needed. Effective implementation and evaluation of chronic disease management - integrated care(CDM-IC) programs, in the real world context is of great importance. Aim of the pilot study: To conduct a pilot study assessing the acceptability, feasibility and effectiveness of a community-based CDM-IC program for COPD patients residing in the canton of Valais. Design: The evaluation plan of this study will combine both quantitative (controlled before-after study design) and qualitative methods (focus groups with COPD patients and practicing healthcare professionals). Setting: French-speaking part of the canton of Valais. Patients: 50 adult (\>35 years) COPD patients GOLD stage I (symptomatic) - IV of the disease, non-institutionalized and residing in the canton of Valais. The control group of patients will be constituted of age and gender-matched COPD patients from the Swiss COPD cohort study. Measures: Quantitative part: Primary outcomes: Generic and disease-specific health-related quality-of-life and all-cause hospitalizations (past 12 months) Other outcomes: 1. Processes of care 2. Patients' assessment of how care is congruent with the Chronic Care Model (PACIC instrument) 3. Measure of self-efficacy (intermediary outcome) 4. 6-minutes walking test, nb of COPD exacerbations, % of current smokers 5. Healthcare utilization: unscheduled ambulatory care visits 6. Care satisfaction 7. Measures of the process of implementation of the intervention Qualitative part: At 12 months: conduct of two focus groups of participating COPD patients, and of two f