An integrated care intervention including education, coordination among levels of care, and improved accessibility, reduced hospital readmissions in chronic obstructive pulmonary disease (COPD) after 1 year. This study analyses the effectiveness of this intervention in terms of clinical and functional status, quality of life, lifestyle, and self-management, under the hypothesis that changes in these factors could explain the observed reduction in readmissions. A total of 113 exacerbated COPD patients (14% female, mean (SD) age 73 (8) years, FEV1 1.2 (0.5) l) were recruited after hospital discharge in Barcelona, Spain, and randomly assigned (1:2) to integrated care (IC) (n = 44) or usual care (UC) (n = 69). The intervention consisted of an individually tailored care plan at discharge shared with the primary care team and access to a specialized case manager nurse through a web-based call centre. After 1 year of intervention, subjects in the intervention group improved body mass index by 1.34 kg/m2. Additionally, they scored better in self-management items: COPD knowledge 81% versus 44%, exacerbation identification 85% versus 22%, exacerbation early treatment 90% versus 66%, inhaler adherence 71 versus 37%, and inhaler correctness 86 versus 24%. There were no differences in the evolution of dyspnea, lung function, quality of life scores, lifestyle factors, or medical treatment. CONCLUSIONS: This IC trial improved disease knowledge, and treatment adherence, after 1 year of intervention, suggesting that these factors may play a role in the prevention of severe COPD exacerbations triggering hospital admissions.

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