References
- Roberto RR, Klaus FR, Jørgen V, Claus V, Alvar A. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 20th Anniversary: a brief history of time. European Respiratory Journal. 2017;50(1):
1700671 . DOI: 10.1183/13993003.00671-2017 - Vestbo J, Hurd SS, Agustí AG, Jones PW, Vogelmeier C, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine. 2013;187(4):347–65. DOI: 10.1164/rccm.201204-0596PP
- Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J. 2023;61(4). DOI: 10.1183/13993003.00239-2023
- Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of Respiratory and Critical Care Medicine. 2007;176(6):532–55. DOI: 10.1164/rccm.200703-456SO
- Sillen MJH, Franssen FME, Delbressine JML, Uszko-Lencer NHMK, Vanfleteren LEGW, Rutten EPA, et al. Heterogeneity in clinical characteristics and co-morbidities in dyspneic individuals with COPD GOLD D: Findings of the DICES trial. Respiratory Medicine. 2013;107(8):1186–94. DOI: 10.1016/j.rmed.2013.04.020
- Augustin IML, Spruit MA, Houben-Wilke S, Franssen FME, Vanfleteren LEGW, Gaffron S, et al. The respiratory physiome: Clustering based on a comprehensive lung function assessment in patients with COPD. PLoS One. 2018;13(9):
e0201593 . DOI: 10.1371/journal.pone.0201593 - van ‘t Hul AJ, Koolen EH, Antons JC, de Man M, Djamin RS, In ‘t Veen J, et al. Treatable traits qualifying for nonpharmacological interventions in COPD patients upon first referral to a pulmonologist: the COPD sTRAITosphere. Erj Open Research. 2020;6(4). DOI: 10.1183/23120541.00438-2020
- Agustí A, Bel E, Thomas M, Vogelmeier C, Brusselle G, Holgate S, et al. Treatable traits: toward precision medicine of chronic airway diseases. European Respiratory Journal. 2016;47(2):
410 . DOI: 10.1183/13993003.01359-2015 - Agustí A, Mona B, Richard B, Elisabeth HB, Rosa F, Peter GG, et al. Precision medicine in airway diseases: moving to clinical practice. European Respiratory Journal. 2017;50(4):
1701655 . DOI: 10.1183/13993003.01655-2017 - McDonald VM, Fingleton J, Agusti A, Hiles SA, Clark VL, Holland AE, et al. Treatable traits: a new paradigm for 21st century management of chronic airway diseases: Treatable Traits Down Under International Workshop report. European Respiratory Journal. 2019;53(5). DOI: 10.1183/13993003.02058-2018
- van den Akker EFMM, van’t Hul AJ, Birnie E, Chavannes NH, Rutten-van Molken MPMH, In’t Veen JCCM. Comprehensive Diagnostic Assessment of Health Status of Patients with Asthma or COPD: A Delphi Panel Study among Dutch Experts. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2017;14(2):190–9. DOI: 10.1080/15412555.2016.1264378
- Koolen EH, van den Borst B, de Man M, Antons JC, Robberts B, Dekhuijzen PNR, et al. The clinical effectiveness of the COPDnet integrated care model. Respiratory Medicine. 2020;172:
106152 . DOI: 10.1016/j.rmed.2020.106152 - Koolen EH, van der Wees PJ, Westert GP, Dekhuijzen R, Heijdra YF, van ‘t Hul AJ. The COPDnet integrated care model. International Journal of Chronic Obstructive Pulmonary Disease. 2018;13:2225–35. DOI: 10.2147/COPD.S150820
- Spruit MA, Wouters EFM. Organizational aspects of pulmonary rehabilitation in chronic respiratory diseases. Respirology. 2019;24(9):838–43. DOI: 10.1111/resp.13512
- Brauwers B, Machado FVC, Beijers RJHCG, Spruit MA, Franssen FME. Combined Exercise Training and Nutritional Interventions or Pharmacological Treatments to Improve Exercise Capacity and Body Composition in Chronic Obstructive Pulmonary Disease: A Narrative Review. Nutrients. 2023;15(24). DOI: 10.3390/nu15245136
- Zaalen van Y, Deckers S, Schuman H. Handboek interprofessioneel samenwerken in zorg en welzijn. bussum: Coutinho; 2018 . p.
304 . - Alma HJ, de Jong C, Jelusic D, Wittmann M, Schuler M, Sanderman R, et al. Thresholds for clinically important deterioration versus improvement in COPD health status: results from a randomised controlled trial in pulmonary rehabilitation and an observational study during routine clinical practice. BMJ Open. 2019;9(6):
e025776 . DOI: 10.1136/bmjopen-2018-025776 - Koff PB, Jones RH, Cashman JM, Voelkel NF, Vandivier RW. Proactive integrated care improves quality of life in patients with COPD. European Respiratory Journal. 2009;33(5):1031–8. DOI: 10.1183/09031936.00063108
- Poot CC, Meijer E, Kruis AL, Smidt N, Chavannes NH, Honkoop PJ. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2021;9(9):
Cd009437 . DOI: 10.1002/14651858.CD009437.pub3 - Kruis AL, Smidt N, Assendelft WJJ, Gussekloo J, Boland MR, Rutten-van Mölken M, et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic reviews. 2013(10):
Cd009437 . DOI: 10.1002/14651858.CD009437.pub2 - Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, et al. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine. 2006;173(12):1390–413. DOI: 10.1164/rccm.200508-1211ST
- Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine. 2013;188(8):e13–64.
- Spruit MA, Pitta F, Garvey C, ZuWallack RL, Roberts CM, Collins EG, et al. Differences in content and organisational aspects of pulmonary rehabilitation programmes. European Respiratory Journal. 2014;43(5):1326–37. DOI: 10.1183/09031936.00145613
- Wadell K, Janaudis Ferreira T, Arne M, Lisspers K, Ställberg B, Emtner M. Hospital-based pulmonary rehabilitation in patients with COPD in Sweden--a national survey. Respiratory medicine. 2013;107(8):1195–200. DOI: 10.1016/j.rmed.2013.04.019
- Nici L, ZuWallack R. An Official American Thoracic Society Workshop Report: The Integrated Care of the COPD Patient. Proceedings of the American Thoracic Society. 2012;9(1):9–18. DOI: 10.1513/pats.201201-014ST
- Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, Puhan MA, et al. An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine. 2015;192(11):1373–86. DOI: 10.1164/rccm.201510-1966ST
- Milner SC, Boruff JT, Beaurepaire C, Ahmed S, Janaudis-Ferreira T. Rate of, and barriers and enablers to, pulmonary rehabilitation referral in COPD: A systematic scoping review. Respiratory Medicine. 2018;137:103–14. DOI: 10.1016/j.rmed.2018.02.021
- Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005;83(3):457–502. DOI: 10.1111/j.1468-0009.2005.00409.x
- Sundh J, Lindgren H, Hasselgren M, Montgomery S, Janson C, Ställberg B, et al. Pulmonary rehabilitation in COPD – available resources and utilization in Swedish primary and secondary care. International journal of chronic obstructive pulmonary disease. 2017;12:1695–704. DOI: 10.2147/COPD.S135111
- de Klein MM, Peters JB, van ‘t Hul AJ, Akkermans RP, In ‘t Veen JC, Vercoulen JH, et al. Comparing health status between patients with COPD in primary, secondary and tertiary care. NPJ primary care respiratory medicine [Internet]. 2020;30:
39 . DOI: 10.1038/s41533-020-00196-7 - Wensing M, Grol R. Implementatie: effectieve verbetering van de patiëntenzorg. Bohn Stafleu van Loghum; 2017. DOI: 10.1007/978-90-368-1732-5
- Arksey H, O’Malley L. Scoping Studies: Towards a Methodological Framework. International Journal of Social Research Methodology – INT J SOC RES METHODOL. 2005;8:19–32. DOI: 10.1080/1364557032000119616
- Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018;169(7):467–73. DOI: 10.7326/M18-0850
- Team TE. Endnote. Philadelphia, PA: Clarivate Analytics; 2013.
- Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Systematic Reviews. 2016;5(1):
210 . DOI: 10.1186/s13643-016-0384-4 - van de Schoot R, de Bruin J, Schram R, Zahedi P, de Boer J, Weijdema F, et al. An open source machine learning framework for efficient and transparent systematic reviews. Nature Machine Intelligence. 2021;3(2):125–33. DOI: 10.1038/s42256-020-00287-7
- Dijk SHBv, Brusse-Keizer MGJ, Bucsán CC, Palen Jvd, Doggen CJM, Lenferink A. Artificial intelligence in systematic reviews: promising when appropriately used. BMJ Open. 2023;13(7):
e072254 . DOI: 10.1136/bmjopen-2023-072254 - Zenodo. ASReview LAB – A tool for AI-assisted systematic reviews. In: developers AL, editor. 2023.
- Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care. 2013;13:
e010 . DOI: 10.5334/ijic.886 - Valentijn PP, Vrijhoef HJ, Ruwaard D, Boesveld I, Arends RY, Bruijnzeels MA. Towards an international taxonomy of integrated primary care: a Delphi consensus approach. BMC family practice. 2015;16:
64 . DOI: 10.1186/s12875-015-0278-x - Valentijn PP. Rainbow of Chaos: A study into the Theory and Practice of Integrated Primary Care. International Journal of Integrated Care. 2016;16(2):1–4.
- Valentijn PP. Het regenboogmodel voor integrale zorg. Essenburgh; 2024. Available from:
https://www.essenburgh.com/nl-regenboogmodel-voor-integrale-zorg/ . - Paciocco S, Kothari A, Licskai CJ, Ferrone M, Sibbald SL. Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study. BMC health services research. 2021;21(1):
717 . DOI: 10.1186/s12913-021-06636-5 - Sibbald SL, Ziegler BR, Maskell R, Schouten K. Implementation of interprofessional team-based care: A cross-case analysis. Journal of interprofessional care. 2021;35(5):654–61. DOI: 10.1080/13561820.2020.1803228
- Overbeck G, Davidsen AS, Kousgaard MB. Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review. Implementation science: IS. 2016;11(1):
165 . DOI: 10.1186/s13012-016-0519-y - Sangaleti C, Schveitzer MC, Peduzzi M, Zoboli E, Soares CB. Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review. Joanna Briggs Institute Database of Systematic Reviews & Implementation Reports. 2017;15(11):2723–88. DOI: 10.11124/JBISRIR-2016-003016
- Supper I, Catala O, Lustman M, Chemla C, Bourgueil Y, Letrilliart L. Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors. Journal of Public Health – Oxford Academic. 2015;37(4):716–27. DOI: 10.1093/pubmed/fdu102
- Wood E, Ohlsen S, Ricketts T. What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review. Journal of Affective Disorders. 2017;214:26–43. DOI: 10.1016/j.jad.2017.02.028
- Mulvale G, Embrett M, Razavi SD. ‘Gearing Up’ to improve interprofessional collaboration in primary care: a systematic review and conceptual framework. BMC family practice. 2016;17:
83 . DOI: 10.1186/s12875-016-0492-1 - Wranik WD, Price S, Haydt SM, Edwards J, Hatfield K, Weir J, et al. Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis. Health Policy. 2019;123(6):550–63. DOI: 10.1016/j.healthpol.2019.03.015
- Muusse JSC, Zuidema R, van Scherpenseel MC, Velde SJT. Influencing factors of interprofessional collaboration in multifactorial fall prevention interventions: a qualitative systematic review. BMC primary care. 2023;24(1):
116 . DOI: 10.1186/s12875-023-02066-w - Tan HQM, Chin YH, Ng CH, Liow Y, Devi MK, Khoo CM, et al. Multidisciplinary team approach to diabetes. An outlook on providers’ and patients’ perspectives. Primary Care Diabetes. 2020;14(5):545–51. DOI: 10.1016/j.pcd.2020.05.012
- Bookey-Bassett S, Markle-Reid M, McKey CA, Akhtar-Danesh N. Understanding interprofessional collaboration in the context of chronic disease management for older adults living in communities: a concept analysis. Journal of Advanced Nursing. 2017;73(1):71–84. DOI: 10.1111/jan.13162
- Montano AR. A concept analysis of interprofessional collaborative practice for community-dwelling older adults. Nursing forum. 2021;56(2):413–20. DOI: 10.1111/nuf.12553
- Song Y, Jung MY, Park S, Hasnain M, Gruss V. Challenges of interprofessional geriatric practice in home care settings: an integrative review. Home Health Care Service Quartely. 2023;42(2):98–123. DOI: 10.1080/01621424.2022.2164541
- Peer Y, Koren A. Facilitators and barriers for implementing the integrated behavioural health care model in the USA: An integrative review. Int J Ment Health Nurs. 2022;31(6):1300–14. DOI: 10.1111/inm.13027
- Michielsen L, Bischoff E, Schermer T, Laurant M. Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review. BMC primary care. 2023;24(1):
98 . DOI: 10.1186/s12875-023-02050-4 - Sørensen M, Stenberg U, Garnweidner-Holme L. A Scoping Review of Facilitators of Multi-Professional Collaboration in Primary Care. International Journal of Integrated Care. 2018;18(3):
13 . DOI: 10.5334/ijic.3959 - Threapleton DE, Chung RY, Wong SYS, Wong E, Chau P, Woo J, et al. Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review. International Journal for Quality in Health Care. 2017;29(3):327–34. DOI: 10.1093/intqhc/mzx041
- McNaughton SM, Flood B, Morgan CJ, Saravanakumar P. Existing models of interprofessional collaborative practice in primary healthcare: a scoping review. Journal of interprofessional care. 2021;35(6):940–52. DOI: 10.1080/13561820.2020.1830048
- O’Reilly P, Lee SH, O’Sullivan M, Cullen W, Kennedy C, MacFarlane A. Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review. PLoS One. 2017;12(5):
e0177026 . DOI: 10.1371/journal.pone.0177026 - Chow AF, Morgan D, Bayly M, Kosteniuk J, Elliot V. Collaborative Approaches to Team-Based Primary Health Care for Individuals with Dementia in Rural/Remote Settings. Canadian Journal of Aging. 2019;38(3):367–83. DOI: 10.1017/S0714980818000727
- Montano AR, Cornell PY, Gravenstein S. Barriers and facilitators to interprofessional collaborative practice for community-dwelling older adults: An integrative review. Journal Of Clinical Nursing. 2023;32(9–10):1534–48. DOI: 10.1111/jocn.15991
- Morgan S, Pullon S, McKinlay E. Observation of interprofessional collaborative practice in primary care teams: An integrative literature review. International Journal of Nursing Studies. 2015;52(7):1217–30. DOI: 10.1016/j.ijnurstu.2015.03.008
- Levis-Peralta M, González MDR, Stalmeijer R, Dolmans D, de Nooijer J. Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review. Frontiers in Endocrinology. 2020;11:
352 . DOI: 10.3389/fendo.2020.00352 - Parker SM, Paine K, Spooner C, Harris M. Barriers and facilitators to the participation and engagement of primary care in shared-care arrangements with community mental health services for preventive care of people with serious mental illness: a scoping review. BMC health services research. 2023;23(1):
977 . DOI: 10.1186/s12913-023-09918-2 - Perron D, Parent K, Gaboury I, Bergeron DA. Characteristics, barriers and facilitators of initiatives to develop interprofessional collaboration in rural and remote primary healthcare facilities: a scoping review. Rural Remote Health. 2022;22(4):
7566 . DOI: 10.22605/RRH7566 - Kozlowska O, Lumb A, Tan GD, Rea R. Barriers and facilitators to integrating primary and specialist healthcare in the United Kingdom: a narrative literature review. Future Healthcare Journal. 2018;5(1):64–80. DOI: 10.7861/futurehosp.5-1-64
- Rawlinson C, Carron T, Cohidon C, Arditi C, Hong QN, Pluye P, et al. An Overview of Reviews on Interprofessional Collaboration in Primary Care: Barriers and Facilitators. International Journal of Integrated Care. 2021;21(2):
32 . DOI: 10.5334/ijic.5589 - Grant JC, Kanji Z. Exploring Interprofessional Relationships Between Dental Hygienists and Health Professionals in Rural Canadian Communities. Journal of Dental hygiene. 2017;91(4):6–11.
- Yutong T, Yan Z, Qingyun C, Lixue M, Mengke G, Shanshan W. Information and Communication Technology Based Integrated Care for Older Adults: A Scoping Review. International Journal of Integrated Care. 2023;23(2):
2 . DOI: 10.5334/ijic.6979 - Vachon B, Giasson G, Gaboury I, Gaid D, Noel De Tilly V, Houle L, et al. Challenges and Strategies for Improving COPD Primary Care Services in Quebec: Results of the Experience of the COMPAS+ Quality Improvement Collaborative. International journal of chronic obstructive pulmonary disease. 2022;17:259–72. DOI: 10.2147/COPD.S341905
- Hojs R, Ekart R, Bevc S, Vodošek Hojs N. Chronic Kidney Disease and Obesity. Nephron. 2023;147(11):660–4. DOI: 10.1159/000531379
- Tazzeo C, Zucchelli A, Vetrano DL, Demurtas J, Smith L, Schoene D, et al. Risk factors for multimorbidity in adulthood: A systematic review. Ageing Research Reviews. 2023;91:
102039 . DOI: 10.1016/j.arr.2023.102039 - Mazza D, Mitchell G. Cancer, ageing, multimorbidity and primary care. European Journal of Cancer Care. 2017;26(3):
e12717 . DOI: 10.1111/ecc.12717 - Dambha-Miller H, Simpson G, Hobson L, Olaniyan D, Hodgson S, Roderick P, et al. Integrating primary care and social services for older adults with multimorbidity: a qualitative study. British Journal of General Practice. 2021;71(711):e753–e61. DOI: 10.3399/BJGP.2020.1100
- Pache B, Vollenweider P, Waeber G, Marques-Vidal P. Prevalence of measured and reported multimorbidity in a representative sample of the Swiss population. BMC Public Health. 2015;15(1):
164 . DOI: 10.1186/s12889-015-1515-x - Licskai C, Hussey A, Rowley V, Ferrone M, Lu Z, Zhang K, et al. Quantifying sustained health system benefits of primary care-based integrated disease management for COPD: a 6-year interrupted time series study. Thorax. 2024;79(8):725–34. DOI: 10.1136/thorax-2023-221211
- Körner M, Bütof S, Müller C, Zimmermann L, Becker S, Bengel J. Interprofessional teamwork and team interventions in chronic care: A systematic review. Journal of Interprofessional Care. 2016;30(1):15–28. DOI: 10.3109/13561820.2015.1051616
- Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11(1):
19 . DOI: 10.1186/1478-4491-11-19 - Doornebosch AJ, Smaling HJA, Achterberg WP. Interprofessional Collaboration in Long-Term Care and Rehabilitation: A Systematic Review. Journal of the American Medical Directors Association. 2022;23(5):764–77.e2. DOI: 10.1016/j.jamda.2021.12.028
- DiazGranados D, Dow AW, Appelbaum N, Mazmanian PE, Retchin SM. Interprofessional practice in different patient care settings: A qualitative exploration. Journal of Interprofessional Care. 2018;32(2):151–9. DOI: 10.1080/13561820.2017.1383886
- Nelson-Brantley H, Buller C, Befort C, Ellerbeck E, Shifter A, Ellis S. Using Implementation Science to Further the Adoption and Implementation of Advance Care Planning in Rural Primary Care. Journal of nursing scholarship: an official publication of Sigma Theta Tau International Honor Society of Nursing. 2020;52(1):55–64. DOI: 10.1111/jnu.12513
- Ferdinands G, Schram R, de Bruin J, Bagheri A, Oberski DL, Tummers L, et al. Performance of active learning models for screening prioritization in systematic reviews: a simulation study into the Average Time to Discover relevant records. Systematic Reviews. 2023;12(1):
100 . DOI: 10.1186/s13643-023-02257-7