Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial

Educational programmes in COPD management interventions: a systematic review

BACKGROUND

According to practice guidelines, educational programmes for patients with COPD should address several educational topics. Which topics are incorporated in the existing programmes remains unclear.

OBJECTIVES

To delineate educational topics integrated in current COPD management interventions; and to examine strengths, weaknesses, and methods of delivery of the educational programmes.

DATA SOURCES

A systematic literature search was performed using MEDLINE/PubMed, Cochrane Central Registry of Controlled Clinical Trials, and Web of Science. The authors of included studies were contacted for additional information.

STUDY SELECTION

Studies that contained educational programmes incorporated in COPD management interventions were included.

DATA EXTRACTION

Data were extracted using a pre-designed data form. The Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework was used for evaluating the strengths and weaknesses of the programmes.

DATA SYNTHESIS

In total, 81 articles, describing 67 interventions were included. The majority (53.8%) of the studies incorporated 10 or more educational topics. The following topics were frequently addressed: smoking cessation (80.0%); medication (76.9%); exercise (72.3%); breathing strategies (70.8%); exacerbations (69.2%); and stress management (67.7%). Printed material and/or brochure (90.5%) and demonstrations and practice (73.8%), were the predominant tool and method, respectively. Nurses (75.8%), physicians (37.9%) and physiotherapists (34.8%) were the most involved healthcare professionals.

CONCLUSIONS

Heterogeneity and wide variation in the content and the method of delivery of educational interventions were present. Alignment between educational topics incorporated in the existing programmes and those recommended by the COPD guidelines, involvement of various professionals and combined use of methods should be emphasised.

Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies

BACKGROUND

Self-management is proposed as the standard of care in chronic obstructive pulmonary disease (COPD), but details of the process and training required to deliver effective self-management are not widely available. In addition, recent data suggest that patient engagement and motivation are critical ingredients for effective self-management. This article carefully describes a self-management intervention using motivational interviewing skills, aimed to increase engagement and commitment in severe COPD patients.

METHODS

The intervention was developed and pilot tested for fidelity to protocol, for patient and interventionist feedback (qualitative) and effect on quality of life. Engagement between patient and interventionists was measured by the Working Alliance Inventory. The intervention was refined on the basis of the results of the pilot study and delivered in the active arm of a prospective randomized study.

RESULTS

The pilot study suggested improvements in quality of life, fidelity to theory, and patient acceptability. The refined self-management intervention was delivered 540 times in the active arm of a randomized study. We observed a retention rate of 86% (patients missing or not available for only 14% the scheduled encounters).

CONCLUSIONS

A self-management intervention that includes motivational interviewing as the way if guiding patients into behavior change is feasible in severe COPD and may increase patient engagement and commitment to self-management. This provides a very detailed description of the process for the specifics of training and delivering the intervention, which facilitates replicability in other settings and could be translated to cardiac rehabilitation.

Helping COPD patients change health behavior in order to improve their quality of life

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent and debilitating diseases in adults worldwide and is associated with a deleterious effect on the quality of life of affected patients. Although it remains one of the leading causes of global mortality, the prognosis seems to have improved in recent years. Even so, the number of patients with COPD and multiple comorbidities has risen, hindering their management and highlighting the need for futures changes in the model of care. Together with standard medical treatment and therapy adherence--essential to optimizing disease control--several nonpharmacological therapies have proven useful in the management of these patients, improving their health-related quality of life (HRQoL) regardless of lung function parameters. Among these are improved diagnosis and treatment of comorbidities, prevention of COPD exacerbations, and greater attention to physical disability related to hospitalization. Pulmonary rehabilitation reduces symptoms, optimizes functional status, improves activity and daily function, and restores the highest level of independent physical function in these patients, thereby improving HRQoL even more than pharmacological treatment. Greater physical activity is significantly correlated with improvement of dyspnea, HRQoL, and mobility, along with a decrease in the loss of lung function. Nutritional support in malnourished COPD patients improves exercise capacity, while smoking cessation slows disease progression and increases HRQoL. Other treatments such as psychological and behavioral therapies have proven useful in the treatment of depression and anxiety, both of which are frequent in these patients. More recently, telehealthcare has been associated with improved quality of life and a reduction in exacerbations in some patients. A more multidisciplinary approach and individualization of interventions will be essential in the near future.

Implementing a palliative care trial in advanced COPD: a feasibility assessment (the COPD IMPACT study)

BACKGROUND

Patients and caregivers living with advanced chronic obstructive pulmonary disease (COPD) have complex care needs and may benefit from palliative care intervention. Little is known about how best to implement and evaluate such initiatives.

OBJECTIVES

To determine the feasibility of: 1) implementing a customized home-based palliative care service for patients and caregivers living with advanced COPD and 2) measuring outcomes of providing such services.

DESIGN

Single-centre cohort longitudinal observational study.

SETTING/SUBJECTS

Patients with advanced COPD and their caregivers were followed in their homes for 6 months.

MEASUREMENTS

Health-related quality of life (HRQoL), caregiver burden, symptom severity, patient/caregiver satisfaction, utilization of acute care services, end-of-life (EOL) outcomes.

RESULTS

30 patients and 18 caregivers were enrolled over 33 months. 25 patients (83%) and 14 caregivers (77%) reached our study endpoint. 13 patients (52%) and 5 caregivers (36%) completed outcome measurements at baseline and endpoint. HRQoL, caregiver burden and symptom severity did not change. Palliative care services were welcomed and valued, yet, despite a stated preference to die at home, 16 patients who died within 18 months of study enrollment died in hospital.

CONCLUSIONS

Providing home-based palliative care services for patients with advanced COPD is feasible but completing repeated questionnaires is impractical. Despite significant palliative supports, managing terminal symptoms exceeded caregivers' capacity to cope and forced hospital admission. Insights into systemic barriers and limitations of current palliative care service models can provide opportunities for local program innovation aimed at improving care for advanced COPD.

Self-management: one size does not fit all

Self-management for people with chronic diseases is now widely recognized as an essential part of treatment. Despite the high expectations and the growing body of evidence in terms of its effectiveness, a wide application of self-management programs is inhibited due to several challenges. Worldwide, a variety of complex and multifactorial interventions have been evaluated in very heterogeneous patient populations leaving healthcare professionals in doubt about what works best and what works in whom. In this letter to the editor the authors systematically reflect on the current evidence of patient-specific determinants of success of self-management and argument the urge for increased scientific efforts to establish tailored self-management in patients with chronic disease.

Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial

OBJECTIVES

To test whether coordination of discharge from hospital reduces hospitalizations in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Randomized controlled clinical trial.

SETTING

Specialized pulmonary hospital.

PARTICIPANTS

Patients hospitalized for an acute exacerbation of COPD.

INTERVENTION

Care as usual included routine patient education, supervised inhaler use, respiratory physiotherapy, and disease-related communication. The discharge coordinator intervention added assessment of patient situation and homecare needs. Patients and caregivers were actively involved and empowered in the discharge planning process, which was communicated with community medical professionals to provide continuity of care at home.

MEASUREMENTS

The primary end-point of the study was the number of patients hospitalized because of worsening COPD. Key secondary end-points were time-to-COPD hospitalization, all-cause mortality, all-cause hospitalization, days alive and out of hospital, and health-related quality of life.

RESULTS

Of 253 eligible patients (71 ± 9 years, 72% men, 87% GOLD III/IV), 118 were assigned to intervention and 135 to usual care. During a follow-up of 180 days, fewer patients receiving intervention were hospitalized for COPD (14% versus 31%, P = .002) or for any cause (31% versus 44%, P = .033). In time-to-event analysis, intervention was associated with lower rates of COPD hospitalizations (P = .001). A Cox model of proportional hazards, adjusted for sex, age, GOLD stage, heart failure, malignant disease, and long-term oxygen treatment, demonstrated that intervention reduced the risk of COPD hospitalization (hazard ratio 0.43, 95% confidence interval 0.24-0.77, P = .002).

CONCLUSION

Among patients hospitalized for acute COPD exacerbation, discharge coordinator intervention reduced both COPD hospitalizations and all-cause hospitalizations.

The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: systematic review and meta-analysis

Background

Depression and anxiety are very common in people with chronic obstructive pulmonary disease (COPD) and are associated with excess morbidity and mortality. Patients prefer non-drug treatments and clinical guidelines promote non-pharmacological interventions as first line therapy for depression and anxiety in people with long term conditions. However the comparative effectiveness of psychological and lifestyle interventions among COPD patients is not known. We assessed whether complex psychological and/or lifestyle interventions are effective in reducing symptoms of anxiety and depression in patients with COPD. We then determined what types of psychological and lifestyle interventions are most effective.

Methods and Findings

Systematic review of randomised controlled trials of psychological and/or lifestyle interventions for adults with COPD that measured symptoms of depression and/or anxiety. CENTRAL, Medline, Embase, PsychINFO, CINAHL, ISI Web of Science and Scopus were searched up to April 2012. Meta-analyses using random effects models were undertaken to estimate the average effect of interventions on depression and anxiety. Thirty independent comparisons from 29 randomised controlled trials (n = 2063) were included in the meta-analysis. Overall, psychological and/or lifestyle interventions were associated with small reductions in symptoms of depression (standardised mean difference −0.28, 95% confidence interval −0.41 to −0.14) and anxiety (standardised mean difference −0.23, 95% confidence interval −0.38 to −0.09). Multi-component exercise training was the only intervention subgroup associated with significant treatment effects for depression (standardised mean difference −0.47, 95% confidence interval −0.66 to −0.28), and for anxiety (standardised mean difference −0.45, 95% confidence interval −0.71 to −0.18).

Conclusions

Complex psychological and/or lifestyle interventions that include an exercise component significantly improve symptoms of depression and anxiety in people with COPD. Furthermore, multi-component exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population.

The remediation challenge: theoretical and methodological insights from a systematic review

OBJECTIVES

Remediation is usually offered to medical students and doctors in training who underperform on written or clinical examinations. However, there is uncertainty and conflicting evidence about the effectiveness of remediation. The aim of this systematic review was to synthesise the available evidence to clarify how and why remediation interventions may have worked in order to progress knowledge on this topic.

METHODS

The MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Educational Resources Information Centre), Web of Science and Scopus databases were searched for papers published from 1984 to April 2012, using the search terms 'remedial teaching', 'education', 'medical', 'undergraduate'/or 'clinical clerkship'/or 'internship and residency', 'at risk' and 'struggling'. Only studies that included an intervention, then provided retest data, and reported at least one outcome measure of satisfaction, knowledge, skills or effects on patients were eligible for inclusion. Studies of practising doctors were excluded. Data were abstracted independently in duplicate for all items. Coding differences were resolved through discussion.

RESULTS

Thirty-one of 2113 studies met the review criteria. Most studies were published after 2000 (n=24, of which 12 were published from 2009 onwards), targeted medical students (n=22) and were designed to improve performance on an immediately subsequent examination (n=22). Control or comparison groups, conceptual frameworks, adequate sample sizes and long-term follow-up measures were rare. In studies that included long-term follow-up, improvements were not sustained. Intervention designs tended to be highly complex, but their design or reporting did not enable the identification of the active components of the remedial process.

CONCLUSIONS

Most remediation interventions in medical education focus on improving performance to pass a re-sit of an examination or assessment and provide no insight into what types of extra support work, or how much extra teaching is critical, in terms of developing learning. More recent studies are generally of better quality. Rigorous approaches to developing and evaluating remediation interventions are required.

Integrated care model with self-management in chronic obstructive pulmonary disease

Patient with chronic obstructive pulmonary disease (COPD) has to become a partner and an active participant in his own care, that is, disease self-management. The goal of this article is to present successful and unsuccessful interventions using patient self-management and to propose a model of integrated care more suitable to the needs of COPD patients. This is a narrative review and an opinion article. Many systematic reviews have shown positive outcomes for patients with COPD. These studies have in common a self-management intervention including an action plan in the event of an exacerbation embedded in an integrated health-care system coordinated by a case manager for educational sessions and regular communication. Recently published trials have brought controversy with respect to the effectiveness of self-management programmes, especially in patients with high burden of disease and co-morbidities. It may be more challenging to make the patient with high burden of disease a partner and not without risk of serious adverse events. Finally, our health-care delivery has to be well integrated and more coherent, that is, strategic alliance between primary and secondary care, and supported by interdisciplinary teams for patients with high-risk and complex COPD. Clinical practice has to be structured to address COPD throughout the disease spectrum, that is, secondary versus primary, team work, partnership, self-management and continuity of care.

Chronic obstructive pulmonary disease and comorbidities through the eyes of the patient

Patient's attitudes and illness beliefs have shown to be of great importance in chronic obstructive pulmonary disease (COPD). As former qualitative research has mainly focused on patients with end-stage COPD, who are recruited within hospital or pulmonary rehabilitation settings, and excluding patients with disabling comorbidities, this study specifically aims to explore the perspectives of patients with COPD and comorbidities in primary care. This study was designed as a qualitative, explorative study using open patient interviews. The study was conducted at three primary care practices, East Flanders, Belgium. A total number of seven patients, diagnosed with COPD and given a minimum score of 2 on the Charlson Comorbidity Index were included. In-depth interviews were recorded and transcribed verbatim. Thematic analysis was deductive using NVivo software. Researchers' triangulation was performed. Participants show high adaptation capabilities and report quite positively about their functional status, with an emphasis on social participation and partnership. Knowledge of the causes and consequences of COPD appears rather limited, and participants predominantly show an external locus of control in relation to the reported factors influencing the disease and strategies for self-management. Patients with COPD with comorbidity integrate their illness and symptoms into their lives. However, a lack of knowledge and education may leave them more anxious and more dependent on health care than necessary. Our results indicate that health care workers should adopt a positive approach toward patient's functioning and empower and inform their patients. We believe that chronic care for patients with COPD should provide personalized rehabilitation taking into account individual patient characteristics and self-management and coping attitudes. We believe that there is a generic core to be identified, which can tackle both COPD and comorbidities. Further research is mandatory to develop these generic programs focusing on patients with complicated needs. Primary care can provide the setting for exploration.

Comprehensive self management and routine monitoring in chronic obstructive pulmonary disease patients in general practice: randomised controlled trial

OBJECTIVE

To assess the long term effects of two different modes of disease management (comprehensive self management and routine monitoring) on quality of life (primary objective), frequency and patients' management of exacerbations, and self efficacy (secondary objectives) in patients with chronic obstructive pulmonary disease (COPD) in general practice.

DESIGN

24 month, multicentre, investigator blinded, three arm, pragmatic, randomised controlled trial.

SETTING

15 general practices in the eastern part of the Netherlands.

PARTICIPANTS

Patients with COPD confirmed by spirometry and treated in general practice. Patients with very severe COPD or treated by a respiratory physician were excluded.

INTERVENTIONS

A comprehensive self management programme as an adjunct to usual care, consisting of four tailored sessions with ongoing telephone support by a practice nurse; routine monitoring as an adjunct to usual care, consisting of 2-4 structured consultations a year with a practice nurse; or usual care alone (contacts with the general practitioner at the patients' own initiative).

OUTCOME MEASURES

The primary outcome was the change in COPD specific quality of life at 24 months as measured with the chronic respiratory questionnaire total score. Secondary outcomes were chronic respiratory questionnaire domain scores, frequency and patients' management of exacerbations measured with the Nijmegen telephonic exacerbation assessment system, and self efficacy measured with the COPD self-efficacy scale.

RESULTS

165 patients were allocated to self management (n=55), routine monitoring (n=55), or usual care alone (n=55). At 24 months, adjusted treatment differences between the three groups in mean chronic respiratory questionnaire total score were not significant. Secondary outcomes did not differ, except for exacerbation management. Compared with usual care, more exacerbations in the self management group were managed with bronchodilators (odds ratio 2.81, 95% confidence interval 1.16 to 6.82) and with prednisolone, antibiotics, or both (3.98, 1.10 to 15.58).

CONCLUSIONS

Comprehensive self management or routine monitoring did not show long term benefits in terms of quality of life or self efficacy over usual care alone in COPD patients in general practice. Patients in the self management group seemed to be more capable of appropriately managing exacerbations than did those in the usual care group.

TRIAL REGISTRATION

Clinical trials NCT00128765.