{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T16:02:50Z","timestamp":1790870570498,"version":"4.1.0"},"reference-count":10,"publisher":"Ordem dos Medicos","issue":"10","license":[{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Acta Med Port"],"abstract":"<jats:p>A doen\u00e7a pulmonar obstrutiva cr\u00f3nica (DPOC) est\u00e1 associada a elevada morbilidade e utiliza\u00e7\u00e3o de servi\u00e7os de sa\u00fade, particularmente na sequ\u00eancia de exacerba\u00e7\u00f5es agudas que levam ao servi\u00e7o de urg\u00eancia (SU) e internamentos hospitalares. Doentes com comorbilidades e vulnerabilidade social apresentam maior risco de reinternamento. Este estudo teve como objetivo avaliar o impacto de uma interven\u00e7\u00e3o precoce com um plano individual e integrado de cuidados (PIC) na redu\u00e7\u00e3o de desloca\u00e7\u00f5es ao SU e internamentos em doentes com DPOC de alto risco. O protocolo Avalia\u00e7\u00e3o Pneumol\u00f3gica Precoce\/Plano Individual de Cuidados (APP\/PIC) foi implementado em fevereiro de 2024. Os doentes com risco elevado foram identificados atrav\u00e9s do c\u00e1lculo do \u00edndice LACE (&gt; 9 pontos ou 5 \u2013 9 na presen\u00e7a de fatores adicionais). A interven\u00e7\u00e3o combinou avalia\u00e7\u00e3o m\u00e9dica, enfermagem e servi\u00e7o social, atrav\u00e9s de um modelo de seguimento h\u00edbrido, presencial e remoto. Os principais dados avaliados foram o n\u00famero de idas ao SU e internamentos hospitalares no ano anterior e posterior \u00e0 institui\u00e7\u00e3o do protocolo. Foi utilizado o teste t de Student emparelhado para a an\u00e1lise. Foram inclu\u00eddos 53 doentes (m\u00e9dia de idade de 67,6 anos; 62% do sexo masculino). A m\u00e9dia do \u00edndice de comorbilidades de Charlson foi de 4,5 pontos e do \u00edndice LACE 13,8 pontos. Um ano depois, o n\u00famero m\u00e9dio de idas ao SU reduziu de 3,09 para 0,067 (p &lt; 0,001), e o n\u00famero de internamentos, de 1,39 para 0,33 (p &lt; 0,001). O seguimento remoto gerou alertas cl\u00ednicos que resultaram em consultas m\u00e9dicas e de enfermagem, tendo apenas dois casos necessitado de encaminhamento ao SU e internamento por insufici\u00eancia respirat\u00f3ria grave. A interven\u00e7\u00e3o social permitiu que a maioria dos doentes mantivesse ou retomasse apoio domicili\u00e1rio. O protocolo APP\/PIC demonstrou efic\u00e1cia na redu\u00e7\u00e3o de idas ao SU e internamentos em doentes com DPOC de alto risco. Este modelo representa uma abordagem promissora e sustent\u00e1vel para a gest\u00e3o integrada de doen\u00e7as respirat\u00f3rias cr\u00f3nicas.<\/jats:p>","DOI":"10.20344\/amp.24695","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T08:33:13Z","timestamp":1790843593000},"page":"630-634","source":"Crossref","is-referenced-by-count":0,"title":["Impacto de um Modelo Integrado de Cuidados em Doentes com DPOC e Risco Elevado de Reinternamento"],"prefix":"10.20344","volume":"39","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8892-7761","authenticated-orcid":false,"given":"Diana","family":"Organista","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4403-2878","authenticated-orcid":false,"given":"Maria F\u00e1tima","family":"Caetano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9702-7573","authenticated-orcid":false,"given":"Jorge","family":"Lopes da Costa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-1772-6809","authenticated-orcid":false,"given":"Andreia","family":"Fernandes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2612-4383","authenticated-orcid":false,"given":"Ana","family":"Almeida","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4708-5311","authenticated-orcid":false,"given":"C\u00e1tia","family":"Br\u00e1s","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-6437-6223","authenticated-orcid":false,"given":"Paula","family":"Ricardo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-1765-9182","authenticated-orcid":false,"given":"Maria Jo\u00e3o","family":"Figueiredo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8187-679X","authenticated-orcid":false,"given":"Alexandra","family":"Ramos Cort\u00eas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-2995-416X","authenticated-orcid":false,"given":"Paula Cristina","family":"Reis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7188-6302","authenticated-orcid":false,"given":"F\u00e1tima","family":"Rodrigues","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"8464","published-online":{"date-parts":[[2026,10,1]]},"reference":[{"key":"13667","unstructured":"Global Initiative for Chronic Obstructive Lung Disease (GOLD). 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