Abstract:OBJECTIVE To explore the management effect of integrated COPD management mode with community medical care as the core and multidisciplinary cooperation on COPD compliance, clinical symptom control and acute attack frequency in patients with stable COPD. METHODS From January 2017 to June 2017, 60 patients with stable COPD who signed contracts with family doctors were randomly divided into the general management group and the conventional management group with 30 patients each. The general management group implemented the chronic disease management mode with general practitioners as the core, and 30 patients without chronic disease management mode in the same period were selected as the conventional management group. Compliance, BODE index and acute episodes were investigated after 24 months of different management models. RESULTS Two years after intervention, 30 patients in the comprehensive management group were followed up, and 3 patients in the routine management group were lost to follow-up.Smoking cessation, rational medication and reasonable exercise compliance in the comprehensive management group were all higher than those in the conventional management group(6 MWT and fev1% pre), with statistically significant differences(P<0.05).The BODE index of the two groups was (2.87±1.25) and (3.37±1.88), respectively. The BODE index of the comprehensive management group was lower than that of the conventional management group, and the difference was statistically significant(P<0.05).In the second year of intervention, the average number of acute attacks and length of hospital stay in the comprehensive management group were (2.14±0.22) and (6.51±2.62), respectively, which were lower than that in the conventional management group, and the difference was statistically significant(P<0.05). CONCLUSION Taking community medical care as the core, the multidisciplinary cooperative integrated COPD management model is feasible and worthy of further promotion.