A hybrid care intervention for high-risk patients with chronic obstructive respiratory diseases: bridging the gap between clinical trials and real-world practice

BackgroundCommunity-based management of exacerbations in high-risk patients with chronic obstructive respiratory diagnoses remains a major challenge due to patients heterogeneities, comorbidities and symptoms-based assessment of the episodes. Hybrid care interventions, combining digital tools with in-person, patient-centered care, have demonstrated efficacy in reducing unplanned hospitalizations. However, their effectiveness in real-world settings is less well established. ObjectivesTo conduct a co-design process aiming to: (1) identify target candidates; and (2) adapt the implementation of a hybrid care intervention to routine clinical practice. MethodsIn the Integrated Health District of Barcelona-Esquerra (520 k citizens), four Plan-Do-Study-Act (PDSA) co-design cycles, each lasting six months, were conducted using a mixed-methods approach during the two-year follow-up (2024-2025) of a cohort of 205 high-risk patients with chronic obstructive pulmonary disease (COPD) and co-morbidities or severe asthma. ResultsBy the end of PDSA-3, we profiled the target candidates for the hybrid care intervention and refined its main components: i) health risk assessment, ii) digital support with an adaptive case management approach, and iii) nurse-led in person care. Home-based, patients self-administered Oscillometry was feasible and acceptable for the objective assessment and management of exacerbations. Adapting the implementation of the hybrid care intervention to local clinical workflows was identified as a priority to enable its sustainable adoption. ConclusionsThe adaptive case management approach for personalized hybrid care at community level is suitable and shows acceptability by the different stakeholders. Its sustainable adoption and scalability in the real-world setting still requires implementation tailoring and demonstration of healthcare value generation. Trial registration numberNCT06421402.