Abstract
Background: The high rate of underdiagnosed Chronic Obstructive Pulmonary Disease (COPD) in the Alto Minho region highlighted an urgent need for a comprehensive, community-centered approach to enhance early diagnosis, preventive care, and integrated follow-up for COPD patients. This project aligns with the United Nations Sustainable Development Goals (SDGs) for 2030, specifically SDG 3 (good health and well-being), SDG 10 (reduction of inequalities), and SDG 17 (partnerships for the goals), promoting health and well-being, reducing health disparities, and establishing effective partnerships for sustainable development.
Approach: The Breathing Well, Living Better project, launched in 2014, is a collaborative effort among ULS Alto Minho, Universidade Nova de Lisboa, and Novartis, with the primary goal of strengthening early diagnosis, improving treatment adherence, and enhancing patients’ quality of life through a community-supported model of integrated care.
This approach involves Family Health Units (USF) and Personalized Health Care Units (UCSP), supported by Community Health Units for continuous patient monitoring. The main components include:
•Early diagnosis: Identification and outreach of at-risk patients for spirometry, with subsequent stratification into severity groups (A, B, E).
•Community-based intervention: Promotion of preventive vaccination (influenza and pneumococcus) to reduce respiratory complications, encouragement of treatment adherence, education on the risks of fossil fuel use in home environments, and support for smoking cessation.
•Respiratory physiotherapy: Referral for continued care when indicated, to improve lung function and quality of life for patients with severe COPD.
Results: By the end of 2023, the project had invited 22,007 patients for spirometry, with a 91.92% completion rate. This effort led to the confirmation of 2,187 cases of COPD, reflecting a prevalence rate of 10.8% in the studied population. Among the diagnosed patients, severe cases were referred for specialized follow-up, while others continued care under the USF/UCSP management. The intervention demonstrated improved treatment adherence, increased vaccination rates, and a reduction in the number of exacerbations.
Implications: The Breathing Well, Living Better project demonstrates an effective integrated care model for COPD, aligned with the UN SDGs. Focusing on prevention, therapeutic adherence, and community involvement, and supported by strategic partnerships, this model contributes to improved quality of life and reduced health disparities. Insights from this project highlight the importance of integrated, community-centered approaches for managing chronic respiratory diseases, with strong potential for replication in other regions to promote sustainable, long-term health improvements.