A Hybrid Care Intervention for High-Risk Chronic Respiratory Patients Bridging the Gap Between Clinical Trials and Real-World Practice
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Background
Community-based management of exacerbations in high-risk chronic obstructive respiratory patients remains a major challenge due to patients’ heterogeneities, co-morbidities 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.
Objectives
To report the co-design process aiming to (1) characterize target candidates; and (2) adapt the implementation of a hybrid care intervention to routine clinical practice.
Methods
In the Integrated Health District of Barcelona-Esquerra (520 k citizens), three Plan-Do-Study-Act (PDSA) co-design cycles, each lasting six months, were conducted using a mixed-methods approach during a two-year follow-up (2024–2025) of a cohort of 205 patients with chronic obstructive pulmonary disease (COPD) and co-morbidities or severe asthma.
Results
By the end of PDSA cycle 3 (August 2025), profiles of high-risk candidates for the hybrid care intervention were identified. The specificities of the three intertwined components of the intervention: i) health risk assessment, ii) advanced digital support, and iii) nurse-led in person care were defined. Home-based, patient’s self-administered Oscillometry proved useful 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.
Conclusions
A personalized hybrid care intervention appears suitable for the management of heterogeneous high-risk respiratory patients. Ongoing tailored implementation during PDSA cycle 4, until February 2026, will be key for its scale up and sustainable adoption.
Trial registration number
NCT06421402.
