A model for integrated primary COPD and/or asthma management was evaluated in this study. The model proved to have a positive effect on planned care and periodic lung function measurement. A positive effect on patient outcomes was also found. The percentage of patients who used their inhalers correctly rose, but the gain in preventing deterioration was even greater, as seen in the control group where the inhalation technique was not checked periodically (we hypothesized that if you assess inhalation technique at a random moment in a cross-sectional population, you also include people who have recently started on medication and have received instructions on how to use the inhaler and have a good technique. If you follow that same population, few people appear to retain the good technique.) The data on patients in our study correspond to those of another Dutch study GPs (70% with a dyspnoea score
. At baseline we found fewer patients with a correct inhalation technique than in a comparable study among a Dutch population (45% vs. 72% with the correct technique). The high score there may have been due to extra attention to inhalation technique in a previous study by the same researchers, as they suggest themselves 
. The difference between the intervention and control group in our study may be substantial but still half of all users do not handle their inhalers correctly, meaning it is unclear whether they inhale the correct dose of medication. Further studies are thus needed to find out whether this can be improved by shortening the intervals between inhaler checks – for example, a check at every prescription renewal, because research shows that mistakes occur shortly after the instructions are given, arguing in favour of short cyclic check 
. The treatment of acute COPD exacerbations is shifting to general practitioners 
. Patient recognition of exacerbations and prompt treatment improves exacerbation recovery, reduces risks of hospitalization, and is associated with a better health-related quality of life 
. From this perspective, the question is whether we should have expected less or maybe even more emergency drug use as positive effect of the care model. The decrease we found is not significantly different from the control group, but we believe it is a positive effect because we also saw a decrease in self-reported exacerbations.
The number of patients willing to take part in the study was relatively low (intervention: 68%, control group: 65%) and the dropout rate was very high. This can be considered a weakness of the study (for data collection patients had to visit a laboratory twice to check the inhalation technique and fill in the questionnaire) but not a weakness of the care model. In fact 88% of all patients being treated by the GP were included in the care model 
Although the number of patients with both measurements was lower than the calculated number needed in the power analyses, we do not think that our study is under-powered. In the repeated measurement analysis (PROC MIXED, SAS) all patients are included. This means that data on patients with only one measurement were also analysed. We did not study the cost-effectiveness of the model, but we would like to make a few points here. A great deal of the efforts (and thus also the costs) in the intervention group were put into surveying the target group. These efforts will always be needed if the GP is going to provide planned care for patients with asthma or COPD, and therefore should not be accounted to this specific model. The same applies to setting up the call-up system. On the other hand, paper consultations by chest physicians are model-specific. Consultation in this way is cheap, has proved to be valid 
, and increases the number of patients who can be treated in primary care.
We conclude that this study has shown that combining various disciplines in an integrated model as described here improves care processes and patient outcomes in primary care for COPD and/or asthma. The care model is especially interesting in those settings in which chronic disease management is general practice based.