Optimizing COPD care in primary care: going for Silver or for Gold?

Smoking cessation is the cornerstone the treatment of COPD since it reduces the
deterioration of pulmonary function. Apart from smoking cessation, physical
activity and proper use of medication lead to better quality of life and
functional status. However, these interventions are barely implemented in
everyday practice, most importantly due to lack of motivation of patients as
well as general practitioners. To obtain maximum profit out of COPD care,
motivated patients should be offered *result oriented* care instead of the
current *care oriented* care. Result oriented behavioural interventions with
treatment goals signed up in a doctor-patient contract are already applied
successfully in cardiac and lung rehabilitation programmes, treatment of
psychiatric diseases and in addiction care. With these interventions,
improvement of patients* adherence to treatment and self-management due to
shared decision making and patient empowerment is perceived. The use of a
doctor-patient contract targeting on smoking cessation and improvement of
quality of life and functional status of COPD patients has never been
investigated in primary care.

To evaluate a result oriented smoking cessation program in which treatment
goals are signed up in a doctor-patient contract.

This is a two arm cluster randomised controlled trail, with general practice as
the unit of randomisation.

All patients in the *result oriented* group will be asked, when motivated to
initiate a quit attempt, to compose treatment goals in a contract and attend an
intense smoking-cessation program.
After 6, 12 and 24 months the goals will be evaluated. Noncompliant patients
will again receive *care oriented care* for at least three months. During this
period they can again get motivated to participate once more in the
smoking-cessation program. When patients are not motivated to quit smoking they
will continuously receive *care oriented care* and are repeatedly point out the
advantages of *result oriented care*.

The burden and risks associated with participation: The participating patients
fill in questionnaires, undergo pulmonary function tests and 6 minutes walk
tests and their urinary cotinine level will be measured. The patients will
repeatedly consult the doctor (*care oriented care: 4 times in 2 year; *result
oriented* care(voluntarily):22 times in 2 year). All included patients will be
treated according to the Dutch College of General Practitioners guidelines
*COPD* and *smoking cessation*. There are no risks associated with
participation of this trial.