Is Internet-based support for dyspnea self-management in patients with chronic obstructive pulmonary disease possible? Results of a pilot study

Development of a Novel Intervention (Mindful Steps) to Promote Long-Term Walking Behavior in Chronic Cardiopulmonary Disease: Protocol for a Randomized Controlled Trial

Background

Despite current rehabilitation programs, long-term engagement in physical activity remains a significant challenge for patients with chronic obstructive pulmonary disease (COPD) and heart failure (HF). Novel strategies to promote physical activity in these populations are greatly needed. Emerging literature on the benefits of both mind–body interventions and web-based interventions provide the rationale for the development of the Mindful Steps intervention for increasing walking behavior.

Objective

This study aims to develop a novel multimodal mind–body exercise intervention through adaptation of an existing web-based physical activity intervention and incorporation of mind–body exercise, and to pilot test the delivery of the new intervention, Mindful Steps, in a randomized controlled feasibility trial in older adults with COPD and/or HF.

Methods

In phase 1, guided by a theoretical conceptual model and review of the literature on facilitators and barriers of physical activity in COPD and HF, we convened an expert panel of researchers, mind–body practitioners, and clinicians to inform development of the novel, multimodal intervention. In phase 2, we are conducting a pilot randomized controlled feasibility trial of the Mindful Steps intervention that includes in-person mind–body exercise classes, an educational website, online mind–body videos, and a pedometer with step-count feedback and goals to increase walking behavior in patients with COPD and/or HF. Outcomes include feasibility measures as well as patient-centered measures.

Results

The study is currently ongoing. Phase 1 intervention development was completed in March 2019, and phase 2 data collection began in April 2019.

Conclusions

Through the integration of components from a web-based physical activity intervention and mind–body exercise, we created a novel, multimodal program to impact long-term physical activity engagement for individuals with COPD and HF. This developmental work and pilot study will provide valuable information needed to design a future clinical trial assessing efficacy of this multimodal approach.

Trial Registration

ClinicalTrials.gov NCT03003780; https://clinicaltrials.gov/ct2/show/NCT03003780

International Registered Report Identifier (IRRID)

DERR1-10.2196/27826

Evaluating the effect of a smartphone app-based self-management program for people with COPD: A randomized controlled trial

AIM

To examine the effect of a 6-month, smartphone app-based self-management program for people with chronic obstructive pulmonary disease (COPD).

BACKGROUND

Technological interventions have been used for chronic disease management, but the effect of a self-management program using a smartphone app has not been evaluated in people with COPD.

METHODS

For this randomized controlled trial, patients with COPD (N = 44) were recruited in pulmonary medicine outpatient clinics at two, metropolitan, tertiary care, academic hospitals. Eligible participants were randomized into two groups and received group education and exercise sessions in the first month of the 6-month intervention. Participants in the experimental group received a smartphone app-based self-management program, which included education, exercises, self-monitoring of symptoms and exercise, and social support. Participants in the control group received one call a month from the research staff. Self-care behavior was measured as a primary outcome. All measures were administered at baseline and at 6 months.

RESULTS

After randomization, the experimental group numbered 22, the control group numbered 20, and 2 participants dropped out. Significant differences between groups were found in change score for self-care behavior, total activity count per wear time, and percent time spent in moderate-to-vigorous physical activity over 6 months.

CONCLUSION

A self-management program, using a smartphone app, can effect behavioral change in people with COPD. This program could be a boon to patients with COPD who have limited access to a health care provider, no opportunities for pulmonary rehabilitation, and frequent exacerbations.

Effect of Physical Activity Coaching on Acute Care and Survival Among Patients With Chronic Obstructive Pulmonary Disease: A Pragmatic Randomized Clinical Trial

IMPORTANCE

While observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD), there are no population-based trials to date testing the effectiveness of physical activity (PA) interventions to reduce acute care use or improve survival.

OBJECTIVE

To evaluate the long-term effectiveness of a community-based PA coaching intervention in patients with COPD.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic randomized clinical trial with preconsent randomization to the 12-month Walk On! (WO) intervention or standard care (SC). Enrollment occurred from July 1, 2015, to July 31, 2017; follow-up ended in July 2018. The setting was Kaiser Permanente Southern California sites. Participants were patients 40 years or older who had any COPD-related acute care use in the previous 12 months; only patients assigned to WO were approached for consent to participate in intervention activities.

INTERVENTIONS

The WO intervention included collaborative monitoring of PA step counts, semiautomated step goal recommendations, individualized reinforcement, and peer/family support. Standard COPD care could include referrals to pulmonary rehabilitation.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite binary measure of all-cause hospitalizations, observation stays, emergency department visits, and death using adjusted logistic regression in the 12 months after randomization. Secondary outcomes included self-reported PA, COPD-related acute care use, symptoms, quality of life, and cardiometabolic markers.

RESULTS

All 2707 eligible patients (baseline mean [SD] age, 72 [10] years; 53.7% female; 74.3% of white race/ethnicity; and baseline mean [SD] percent forced expiratory volume in the first second of expiration predicted, 61.0 [22.5]) were randomly assigned to WO (n = 1358) or SC (n = 1349). The intent-to-treat analysis showed no differences between WO and SC on the primary all-cause composite outcome (odds ratio [OR], 1.09; 95% CI, 0.92-1.28; P = .33) or in the individual outcomes. Prespecified, as-treated analyses compared outcomes between all SC and 321 WO patients who participated in any intervention activities (23.6% [321 of 1358] uptake). The as-treated, propensity score-weighted model showed nonsignificant positive estimates in favor of WO participants compared with SC on all-cause hospitalizations (OR, 0.84; 95% CI, 0.65-1.10; P = .21) and death (OR, 0.62; 95% CI, 0.35-1.11; P = .11). More WO participants reported engaging in PA compared with SC (47.4% [152 of 321] vs 30.7% [414 of 1349]; P < .001) and had improvements in the Patient-Reported Outcomes Measurement Information System 10 physical health domain at 6 months. There were no group differences in other secondary outcomes.

CONCLUSIONS AND RELEVANCE

Participation in a PA coaching program by patients with a history of COPD exacerbations was insufficient to effect improvements in acute care use or survival in the primary analysis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02478359.

Trajectories of change after a health-education program in Japan: decay of impact in anxiety, depression, and patient-physician communication

Background

Health education can benefit people with chronic diseases. However, in previous research those benefits were small, and reinforcement to maintain them was not effective. A possible explanation is that the benefits appeared to be small and reinforcement appeared to be ineffective because those analyses mixed data from two latent groups: one group of people who needed reinforcement and one group of people who did not. The hypothesis is that mixing the data from those two different groups caused the true effects to be “diluted.”

Methods

To test that hypothesis we used data from the Chronic Disease Self-Management Program in Japan, focusing on anxiety, depression, and patient-physician communication. To identify latent trajectories of change after the program, we used growth-mixture modeling. Then, to find out which baseline factors were associated with trajectory-group membership, we used logistic regression.

Results

Growth-mixture modeling revealed two trajectories—two groups that were defined by distinct patterns of change after the program. One of those patterns was improvement followed by backsliding: decay of impact. On anxiety and depression the decay of impact was large enough to be clinically important, and its prevalence was as high as 50%. Next, logistic regression analysis revealed that being in the decay-of-impact group could be predicted from multimorbidity, low self-efficacy, and high scores on anxiety or depression at baseline. In addition, one unexpected finding was an association between multimorbidity and better patient-physician communication.

Conclusions

These results support the hypothesis that previous findings (i.e., apparently small effect sizes and apparently ineffective reinforcement) actually reflect “dilution” of large effects, which was caused by mixing of data from distinct groups. Specifically, there was one group with decay of impact and one without. Thus, evaluations of health education should include analyses of trajectory-defined groups. These results show how the group of people who are most likely to need reinforcement can be identified even before the educational program begins. Extra attention and reinforcement can then be tailored. They can be focused specifically to benefit the people with the greatest need.

Web-based Health Information Seeking and eHealth Literacy among Patients Living with Chronic Obstructive Pulmonary Disease (COPD)

Many people living with Chronic Obstructive Pulmonary Disease (COPD) have low general health literacy; however, there is little information available on these patients' eHealth literacy, or their ability to seek, find, understand, and appraise online health information and apply this knowledge to address or solve disease-related health concerns. A nationally representative sample of patients registered in the COPD Foundation's National Research Registry (N = 1,270) was invited to complete a web-based survey to assess socio-demographic (age, gender, marital status, education), health status (generic and lung-specific health-related quality of life), and socio-cognitive (social support, self-efficacy, COPD knowledge) predictors of eHealth literacy, measured using the 8-item eHealth literacy scale (eHEALS). Over 50% of the respondents (n = 176) were female (n = 89), with a mean age of 66.19 (SD = 9.47). Overall, participants reported moderate levels of eHealth literacy, with more than 70% feeling confident in their ability to find helpful health resources on the Internet. However, respondents were much less confident in their ability to distinguish between high- and low-quality sources of web-based health information. Very severe versus less severe COPD (β = 4.15), lower lung-specific health-related quality of life (β = -0.19), and greater COPD knowledge (β = 0.62) were significantly associated with higher eHealth literacy. Higher COPD knowledge was also significantly associated with greater knowledge (ρ = 0.24, p = .001) and use (ρ = 0.24, p = .001) of web-based health resources. Findings emphasize the importance of integrating skill-building activities into comprehensive patient education programs that enable patients with severe cases of COPD to identify high-quality sources of web-based health information. Additional research is needed to understand how new social technologies can be used to help medically underserved COPD patients benefit from web-based self-management support resources.

Computer and mobile technology interventions for self-management in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction due to an abnormal inflammatory response of the lungs to noxious particles or gases, for example, cigarette smoke. The pattern of care for people with moderate to very severe COPD often involves regular lengthy hospital admissions, which result in high healthcare costs and an undesirable effect on quality of life. Research over the past decade has focused on innovative methods for developing enabling and assistive technologies that facilitate patient self-management.

OBJECTIVES

To evaluate the effectiveness of interventions delivered by computer and by mobile technology versus face-to-face or hard copy/digital documentary-delivered interventions, or both, in facilitating, supporting, and sustaining self-management among people with COPD.

SEARCH METHODS

In November 2016, we searched the Cochrane Airways Group Specialised Register (CAGR), which contains trial reports identified through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, and PsycINFO, and we handsearched respiratory journals and meeting abstracts.

SELECTION CRITERIA

We included randomised controlled trials that measured effects of remote and Web 2.0-based interventions defined as technologies including personal computers (PCs) and applications (apps) for mobile technology, such as iPad, Android tablets, smart phones, and Skype, on behavioural change towards self-management of COPD. Comparator interventions included face-to-face and/or hard copy/digital documentary educational/self-management support.

DATA COLLECTION AND ANALYSIS

Two review authors (CMcC and MMcC) independently screened titles, abstracts, and full-text study reports for inclusion. Two review authors (CMcC and AMB) independently assessed study quality and extracted data. We expressed continuous data as mean differences (MDs) and standardised mean differences (SMDs) for studies using different outcome measurement scales.

MAIN RESULTS

We included in our review three studies (Moy 2015; Tabak 2013; Voncken-Brewster 2015) with a total of 1580 randomised participants. From Voncken-Brewster 2015, we included the subgroup of individuals with a diagnosis of COPD (284 participants) and excluded those at risk of COPD who had not received a diagnosis (1023 participants). As a result, the total population available for analysis included 557 participants; 319 received smart technology to support self-management and 238 received face-to-face verbal/written or digital information and education about self-management. The average age of participants was 64 years. We included more men than women because the sample from one of the studies consisted of war veterans, most of whom were men. These studies measured five of our nine defined outcomes. None of these studies included outcomes such as self-efficacy, cost-effectiveness, functional capacity, lung function, or anxiety and depression.All three studies included our primary outcome - health-related quality of life (HRQoL) as measured by the Clinical COPD Questionnaire (CCQ) or St George's Respiratory Questionnaire (SGRQ). One study reported our other primary outcomes - hospital admissions and acute exacerbations. Two studies included our secondary outcome of physical activity as measured by daily step counts. One study addressed smoking by providing a narrative analysis. Only one study reported adverse events and noted significant differences between groups, with 43 events noted in the intervention group and eight events in the control group (P = 0.001). For studies that measured outcomes at week four, month four, and month six, the effect of smart technology on self-management and subsequent HRQoL in terms of symptoms and health status was significantly better than when participants received face-to-face/digital and/or written support for self-management of COPD (SMD -0.22, 95% confidence interval (CI) -0.40 to -0.03; P = 0.02). The single study that reported HRQoL at 12 months described no significant between-group differences (MD 1.1, 95% CI -2.2 to 4.5; P = 0.50). Also, hospitalisations (logistic regression odds ratio (OR) 1.6, 95% CI 0.8 to 3.2; P = 0.19) and exacerbations (logistic regression OR 1.4, 95% CI 0.7 to 2.8; P = 0.33) did not differ between groups in the single study that reported these outcomes at 12 months. The activity level of people with COPD at week four, month four, and month six was significantly higher when smart technology was used than when face-to-face/digital and/or written support was provided (MD 864.06 daily steps between groups, 95% CI 369.66 to 1358.46; P = 0.0006). The only study that measured activity levels at 12 months reported no significant differences between groups (mean -108, 95% CI -720 to 505; P = 0.73). Participant engagement in this study was not sustained between four and 12 months. The only study that included smoking cessation found no significant treatment effect (OR 1.06, 95%CI 0.43 to 2.66; P = 0.895). Meta-analyses showed no significant heterogeneity between studies (Chi² = 0.39, P = 0.82; I² = 0% and Chi² = 0.01, P = 0.91; I² = 0%, respectively).

AUTHORS' CONCLUSIONS

Although our review suggests that interventions aimed at facilitating, supporting, and sustaining self-managment in people with COPD and delivered via smart technology significantly improved HRQoL and levels of activity up to six months compared with interventions given through face-to-face/digital and/or written support, no firm conclusions can be drawn. This improvement may not be sustained over a long duration. The only included study that measured outcomes up to 12 months highlighted the need to ensure sustained engagement with the technology over time. Limited evidence suggests that using computer and mobile technology for self-management for people with COPD is not harmful and may be more beneficial for some people than for others, for example, those with an interest in using technology may derive greater benefit.The evidence, provided by three studies at high risk of bias, is of poor quality and is insufficient for advising healthcare professionals, service providers, and members of the public with COPD about the health benefits of using smart technology as an effective means of supporting, encouraging, and sustaining self-management. Further research that focuses on outcomes relevant to different stages of COPD is needed. Researchers should provide clear information on how self-management is assessed and should include longitudinal measures that allow comment on behavioural change.

A Mobile Phone App to Stimulate Daily Physical Activity in Patients with Chronic Obstructive Pulmonary Disease: Development, Feasibility, and Pilot Studies

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) demonstrate reduced levels of daily physical activity (DPA) compared to healthy controls. This results in a higher risk of hospital admission and shorter survival. Performing regular DPA reduces these risks.

OBJECTIVE

To develop an eHealth intervention that will support patients with COPD to improve or maintain their DPA after pulmonary rehabilitation.

METHODS

The design process consisted of literature research and the iterative developing and piloting phases of the Medical Research Council (MRC) model for complex clinical interventions and the involvement of end users. Participants were healthy adults and persons with COPD.

RESULTS

The mobile phone interface met all the set requirements. Participants found that the app was stimulating and that reaching their DPA goals was rewarding. The mean (SD) scores on a 7-point scale for usability, ease of use, ease of learning, and contentment were 3.8 (1.8), 5.1 (1.1), 6.0 (1.6), and 4.8 (1.3), respectively. The mean (SD) correlation between the mobile phone and a validated accelerometer was 0.88 (0.12) in the final test. The idea of providing their health care professional with their DPA data caused no privacy issues in the participants. Battery life lasted for an entire day with the final version, and readability and comprehensibility of text and colors were favorable.

CONCLUSIONS

By employing a user-centered design approach, a mobile phone was found to be an adequate and feasible interface for an eHealth intervention. The mobile phone and app are easy to learn and use by patients with COPD. In the final test, the accuracy of the DPA measurement was good. The final version of the eHealth intervention is presently being tested by our group for efficacy in a randomized controlled trial in COPD patients.

Patterns of technology use in patients attending a cardiopulmonary outpatient clinic: a self-report survey

Background

Self-management education for cardiopulmonary diseases is primarily provided through time-limited, face-to-face programs, with access limited to a small percentage of patients. Telecommunication tools will increasingly be an important component of future health care delivery.

Objective

The purpose of this study was to describe the patterns of technology use in patients attending a cardiopulmonary clinic in an academic medical center.

Methods

A prevalence survey was developed to collect data on participant demographics (age in years, sex, and socioeconomic status); access to computers, Internet, and mobile phones; and use of current online health support sites or programs. Surveys were offered by reception staff to all patients attending the outpatient clinic.

Results

A total of 123 surveys were collected between March and April 2014. Technological devices were a pervasive part of everyday life with respondents engaged in regular computer (102/123, 82.9%), mobile telephone (115/117, 98.3%), and Internet (104/121, 86.0%) use. Emailing (101/121, 83.4%), researching and reading news articles (93/121, 76.9%), social media (71/121, 58.7%), and day-to-day activities (65/121, 53.7%) were the most common telecommunication activities. The majority of respondents reported that access to health support programs and assistance through the Internet (82/111, 73.9%) would be of use, with benefits reported as better understanding of health information (16/111, 22.5%), avoidance of difficult travel requirements and time-consuming face-to-face appointments (13/111, 18.3%), convenient and easily accessible help and information (12/111, 16.9%), and access to peer support and sharing (9/111, 12.7%). The majority of patients did not have concerns over participating in the online environment (87/111, 78.4%); the few concerns noted related to privacy and security (10/15), information accuracy (2/15), and computer literacy and access (2/15).

Conclusions

Chronic disease burden and long-term self-management tasks provide a compelling argument for accessible and convenient avenues to obtaining ongoing treatment and peer support. Online access to health support programs and assistance was reported as useful and perceived as providing convenient, timely, and easily accessible health support and information. Distance from the health care facility and a lack of information provision through traditional health sources were both barriers and enablers to telehealth. This is particularly important in the context of a cardiopulmonary clinic that attracts patients from a large geographical area, and in patients who are most likely to have high health care utilization needs in the future. Telecommunication interfaces will be an increasingly important adjunct to traditional forms of health care delivery.

Are improvements maintained after in-home pulmonary telerehabilitation for patients with chronic obstructive pulmonary disease?

This study investigated if improvements can be maintained over 24 weeks when in-home pulmonary telerehabilitation is combined with asynchronous self-management education for Chronic Obstructive Pulmonary Disease (COPD). Twenty-three community-living elders with moderate to very severe COPD participated in a pre/post-intervention study. Over 8 weeks, they had access to self-learning capsules on self-management, received 15 in-home teletreatment sessions and were encouraged to gradually engage in unsupervised sessions. Participants were assessed before the intervention (T1), immediately after the intervention (T2), and 6 months later (T3). Outcome measures were (1) exercise tolerance (6-minute walk test [6MWT]), Cycle Endurance Test [CET]), and (2) quality of life (Chronic Respiratory Questionnaire [CRQ]). Although there were significant improvements after 8 weeks of pulmonary telerehabilitation on the 6MWT, CET and three of four CRQ domains, none of these improvements were maintained after 6 months and scores returned to their baseline values (all p values > 0.05 when comparing T3 with T1). While pulmonary telerehabilitation is possible and has a positive impact on patients with moderate to very severe COPD, improvements were not maintained in the long-term even when physical therapy was accompanied by self-management education.

Engaging community stakeholders to evaluate the design, usability, and acceptability of a chronic obstructive pulmonary disease social media resource center

Background

Patients with chronic obstructive pulmonary disease (COPD) often report inadequate access to comprehensive patient education resources.

Objective

The purpose of this study was to incorporate community-engagement principles within a mixed-method research design to evaluate the usability and acceptability of a self-tailored social media resource center for medically underserved patients with COPD.

Methods

A multiphase sequential design (qual → QUANT → quant + QUAL) was incorporated into the current study, whereby a small-scale qualitative (qual) study informed the design of a social media website prototype that was tested with patients during a computer-based usability study (QUANT). To identify usability violations and determine whether or not patients found the website prototype acceptable for use, each patient was asked to complete an 18-item website usability and acceptability questionnaire, as well as a retrospective, in-depth, semistructured interview (quant + QUAL).

Results

The majority of medically underserved patients with COPD (n=8, mean 56 years, SD 7) found the social media website prototype to be easy to navigate and relevant to their self-management information needs. Mean responses on the 18-item website usability and acceptability questionnaire were very high on a scale of 1 (strongly disagree) to 5 (strongly agree) (mean 4.72, SD 0.33). However, the majority of patients identified several usability violations related to the prototype’s information design, interactive capabilities, and navigational structure. Specifically, 6 out of 8 (75%) patients struggled to create a log-in account to access the prototype, and 7 out of 8 patients (88%) experienced difficulty posting and replying to comments on an interactive discussion forum.

Conclusions

Patient perceptions of most social media website prototype features (eg, clickable picture-based screenshots of videos, comment tools) were largely positive. Mixed-method stakeholder feedback was used to make design recommendations, categorize usability violations, and prioritize potential solutions for improving the usability of a social media resource center for COPD patient education.

Internet access and use by COPD patients in the National Emphysema/COPD Association Survey

Background

Technology offers opportunities to improve healthcare, but little is known about Internet use by COPD patients. We tested two hypotheses: Internet access is associated with socio-demographic disparities and frequency of use is related to perceived needs.

Methods

We analyzed data from a 2007–2008 national convenience sample survey of COPD patients to determine the relationship between Internet access and frequency of use with demographics, socio-economic status, COPD severity, and satisfaction with healthcare.

Results

Among survey respondents (response rate 7.2%; n = 914, 59.1% women, mean age 71.2 years), 34.2% reported lack of Internet access, and an additional 49% had access but used the Internet less than weekly. Multivariate models showed association between lack of access and older age (OR 1.10, 95% CI 1.07, 1.13), lower income (income below $30,000 OR 2.47, 95% CI 1.63, 3.73), less education (high school highest attainment OR 2.30, 95% CI 1.54, 3.45), comorbid arthritis or mobility-related disease (OR 1.56, 95% CI 1.05, 2.34). More frequent use (at least weekly) was associated with younger age (OR 0.95, 95% CI 0.93, 0.98), absence of cardiovascular disease (OR 0.48, 95% CI 0.29, 0.78), but with perception of needs insufficiently met by the healthcare system, including diagnostic delay (OR 1.72, 95% CI 1.06, 2.78), feeling treated poorly (OR 2.46, 95% CI 1.15, 5.24), insufficient physician time (OR 2.29, 95% CI 1.02, 5.13), and feeling their physician did not listen (OR 3.14, 95% CI 1.42, 6.95).

Conclusions

An analysis of the characteristics associated with Internet access and use among COPD patients identified two different patient populations. Lack of Internet access was a marker of socioeconomic disparity and mobility-associated diseases, while frequent Internet use was associated with less somatic disease but dissatisfaction with care.

Taking Healthy Steps: rationale, design and baseline characteristics of a randomized trial of a pedometer-based Internet-mediated walking program in veterans with chronic obstructive pulmonary disease

Background

Low levels of physical activity are common in patients with chronic obstructive pulmonary disease (COPD), and a sedentary lifestyle is associated with poor outcomes including increased mortality, frequent hospitalizations, and poor health-related quality of life. Internet-mediated physical activity interventions may increase physical activity and improve health outcomes in persons with COPD.

Methods/Design

This manuscript describes the design and rationale of a randomized controlled trial that tests the effectiveness of Taking Healthy Steps, an Internet-mediated walking program for Veterans with COPD. Taking Healthy Steps includes an uploading pedometer, a website, and an online community. Eligible and consented patients wear a pedometer to obtain one week of baseline data and then are randomized on a 2:1 ratio to Taking Healthy Steps or to a wait list control. The intervention arm receives iterative step-count feedback; individualized step-count goals, motivational and informational messages, and access to an online community. Wait list controls are notified that they are enrolled, but that their intervention will start in one year; however, they keep the pedometer and have access to a static webpage.

Discussion

Participants include 239 Veterans (mean age 66.7 years, 93.7% male) with 155 randomized to Taking Healthy Steps and 84 to the wait list control arm; rural-living (45.2%); ever-smokers (93.3%); and current smokers (25.1%). Baseline mean St. George’s Respiratory Questionnaire Total Score was 46.0; 30.5% reported severe dyspnea; and the average number of comorbid conditions was 4.9. Mean baseline daily step counts was 3497 (+/- 2220).

Veterans with COPD can be recruited to participate in an online walking program. We successfully recruited a cohort of older Veterans with a significant level of disability including Veterans who live in rural areas using a remote national recruitment strategy.

Trial registration

Clinical Trials.gov NCT01102777

Educational benefits of Internet and computer-based programmes for prostate cancer patients: a systematic review

OBJECTIVE

This study aims to review systematically the available literature on Internet and computer-based patient education programmes, assess the quality of these studies and analyze the benefit of these programmes for prostate cancer patients.

METHODS

Complete databases were searched. Studies were included if they concerned patient education of prostate cancer patients, were qualitative or quantitative and examined Internet or interactive CD-ROM use.

RESULTS

Eighteen studies met the inclusion criteria. The majority of the studies reported a significant increase in the knowledge of the disease, satisfaction with treatment options and support for men. The benefit of the programmes was that the patients felt more empowered and obtained a heightened sense of control over their disease.

CONCLUSION

The Internet or computer-based programmes had a positive impact on prostate cancer patient education. Most papers reported that the programmes were beneficial, but few presented data from studies with rigorous research methodologies to support these claims.

PRACTICE IMPLICATIONS

Internet and computer-based programmes can be useful tools in prostate cancer patient education. In order to improve the benefits of the programmes, more Internet and computer-based programmes need to be developed and studied.

How virtual admission affects coping - telemedicine for patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

To describe what characterises chronic obstructive pulmonary disease patients' coping of physical, emotional and social problems before, during and after virtual admission, in interaction with health professionals and relatives.

BACKGROUND

Telemedicine for patients with chronic obstructive pulmonary disease is gaining ground. However, virtual admission using telemedicine in the patients' home as a replacement of hospital admission has received little attention. Furthermore, little is known about how telemedicine affects chronic obstructive pulmonary disease patients' coping.

DESIGN

Grounded Theory study using semi-structured interviews.

METHODS

The study was a part of The Virtual Hospital study, exploring virtual admission for patients with acute exacerbation of chronic obstructive pulmonary disease. During virtual admission, patients had access to medical equipment consisting of monitoring devices, medication, nebuliser and a touch screen with built-in videoconference system. Nine participants were interviewed after virtual admission. Open coding, axial coding and selective coding, using constant comparative analysis, were conducted.

RESULTS

A substantive Grounded Theory was developed, containing the core category - struggling to be in control of life with chronic obstructive pulmonary disease - related to four categories: complete powerlessness, dependency, pursuit of regaining autonomy and efforts to remain in control of problems related to chronic obstructive pulmonary disease. Virtual admission supported participants' autonomy. The involvement of health professionals was reduced as participants used the medical equipment to cope with disease-related problems. Participants' coping was closely linked to the presence of the equipment, making it difficult for them to apply their experiences after discharge from virtual admission.

CONCLUSIONS

Virtual admission may support chronic obstructive pulmonary disease patients' coping of physical and emotional problems. However, coping experiences made during virtual admission may not be directly applicable outside a telemedical setting.

RELEVANCE TO CLINICAL PRACTICE

Telemedicine may result in different roles for patients, relatives and health professionals. Clinicians should consider how they can support chronic obstructive pulmonary disease patients' coping during telemedical interventions, focusing on how to ensure a sustained improvement that patients can benefit from outside the telemedical setting.

Web-based interventions in nursing

With recent advances in computer and Internet technologies and high funding priority on technological aspects of nursing research, researchers at the field level began to develop, use, and test various types of Web-based interventions. Despite high potential impacts of Web-based interventions, little is still known about Web-based interventions in nursing. In this article, to identify strengths and weaknesses of Web-based nursing interventions, a literature review was conducted using multiple databases with combined keywords of "online," "Internet" or "Web," "intervention," and "nursing." A total of 95 articles were retrieved through the databases and sorted by research topics. These articles were then analyzed to identify strengths and weaknesses of Web-based interventions in nursing. A strength of the Web-based interventions was their coverage of various content areas. In addition, many of them were theory-driven. They had advantages in their flexibility and comfort. They could provide consistency in interventions and require less cost in the intervention implementation. However, Web-based intervention studies had selected participants. They lacked controllability and had high dropouts. They required technical expertise and high development costs. Based on these findings, directions for future Web-based intervention research were provided.

Internet-based dyspnea self-management support for patients with chronic obstructive pulmonary disease

CONTEXT

People with chronic obstructive pulmonary disease experience dyspnea with activities despite optimal medical management.

OBJECTIVES

The purpose of this study was to test the efficacy of two 12-month dyspnea self-management programs (DSMPs), Internet-based (eDSMP) and face-to-face (fDSMP), compared with a general health education (GHE) control on the primary outcome of dyspnea with activities.

METHODS

Participants with chronic obstructive pulmonary disease were randomized to eDSMP (n=43), fDSMP (n=41), or GHE (n=41). The content of the DSMPs were similar and focused on education, skills training, and coaching on dyspnea self-management strategies, including exercise, and only differed in the delivery mode. Dyspnea with activities was measured with the Chronic Respiratory Questionnaire at three, six, and 12 months. Secondary outcomes included exercise behavior and performance, health-related quality of life, self-efficacy for dyspnea management, and perception of support for exercise. The study was registered at Clinicaltrials.gov (NCT00461162).

RESULTS

There were no differences in dyspnea with activities across groups over 12 months (P=0.48). With the exception of arm endurance (P=0.04), exercise behavior, performance, and health-related quality of life did not differ across groups (P>0.05). Self-efficacy for managing dyspnea improved for the DSMPs compared with GHE (P=0.06). DSMP participants perceived high levels of support for initiating and maintaining an exercise program.

CONCLUSION

The DSMPs did not significantly reduce dyspnea with activities compared with attention control. However, the high participant satisfaction with the DSMPs combined with positive changes in other outcomes, including self-efficacy for managing dyspnea and exercise behavior, highlight the need for additional testing of individually tailored technology-enabled interventions to optimize patient engagement and improve clinically relevant outcomes.

Advocacy of home telehealth care among consumers with chronic conditions

AIMS AND OBJECTIVES

To describe use of home telehealth care as an alternative for chronic disease management from users' perspective.

BACKGROUND

As the population ages, telehealth is increasingly being used to tackle problems related to the fast growing ageing population. Home telehealth care therefore poses challenges and offers opportunities for patients and healthcare providers.

DESIGN

A qualitative approach was adopted with a purposeful sample of 20 patients residing in Taiwan.

METHOD

Patients who had received the service for three months and were willing to share their experiences were recruited. Data were collected by face-to-face interviews with semi-structured interview guideline (n = 8) and a focus group discussion (n = 12) in 2010. A qualitative content analysis was used.

RESULTS

Four key themes were identified: perceived support and security, enhanced disease self-management, concerned with using the devices and worries about the cost by patients. Most users favoured using the service to control their chronic conditions because of its convenience and accessibility, and their condition could be measured daily to enhance their sense of security. Users could determine and understand changes in their condition and improve medical regimen compliance, and they were empowered to revise their lifestyles for better disease self-management. However, users were concerned about the utility of the service, because they were unfamiliar with the operating procedures and doubted its quality. As the service is still in stage of pilot testing, users worried about possible cost and reimbursement policy changes in the future.

CONCLUSION

Most users perceived telehealth care was a convenient and useful model for healthcare-delivery. It increased the availability of health care and improved the self-care ability of patients.

RELEVANCE TO CLINICAL PRACTICE

To advocate for home telehealth care, nurses must play an active role in providing consumers with proper training and support for any problems when adopting the system to foster patients' willingness to use this service.

Decay of impact after self-management education for people with chronic illnesses: changes in anxiety and depression over one year

BACKGROUND

In people with chronic illnesses, self-management education can reduce anxiety and depression. Those benefits, however, decay over time. Efforts have been made to prevent or minimize that "decay of impact", but they have not been based on information about the decay's characteristics, and they have failed. Here we show how the decay's basic characteristics (prevalence, timing, and magnitude) can be quantified. Regarding anxiety and depression, we also report the prevalence, timing, and magnitude of the decay.

METHODS

Adults with various chronic conditions participated in a self-management educational program (n = 369). Data were collected with the Hospital Anxiety and Depression Scale four times over one year. Using within-person effect sizes, we defined decay of impact as a decline of ≥0.5 standard deviations after improvement by at least the same amount. We also interpret the results using previously-set criteria for non-cases, possible cases, and probable cases.

RESULTS

Prevalence: On anxiety, decay occurred in 19% of the participants (70/369), and on depression it occurred in 24% (90/369). Timing: In about one third of those with decay, it began 3 months after the baseline measurement (6 weeks after the educational program ended). Magnitude: The median magnitudes of decay on anxiety and on depression were both 4 points, which was about 1 standard deviation. Early in the follow-up year, many participants with decay moved into less severe clinical categories (e.g., becoming non-cases). Later, many of them moved into more severe categories (e.g., becoming probable cases).

CONCLUSIONS

Decay of impact can be identified and quantified from within-person effect sizes. This decay occurs in about one fifth or more of this program's participants. It can start soon after the program ends, and it is large enough to be clinically important. These findings can be used to plan interventions aimed at preventing or minimizing the decay of impact.

Hidden decay of impact after education for self-management of chronic illnesses: hypotheses

People with chronic illnesses can benefit from self-management education. However, those benefits are said to decay over time (there is some evidence that this 'decay of impact' does occur), and the reinforcements used to prevent that decay appear to be ineffective. We hypothesize that the reinforcements appear to be ineffective because decay of impact occurs only in a subgroup of these programs' participants, so any benefits of reinforcements in that subgroup are concealed by whole-group summary statistics. We also hypothesize that reinforcements can benefit those who need them - those who would otherwise have decay. One approach to testing these hypotheses requires analysis of individual-level data, which is uncommon in this field. Some useful data could come from studies that have already been completed, but the strongest evidence will require prospectively designed tests in future trials. If the hypotheses are false, then time and resources spent on reinforcements can be saved or redirected. If the hypotheses are true, then reinforcements can be implemented with less waste and they can be made more effective. These programs can also be improved to better fit their users' needs, and there can be a new basis for evaluating the programs' effectiveness.

Effects of an animated diagram and video-based online breathing program for dyspnea in patients with stable COPD

BACKGROUND

Breathing programs have been reported to have positive effects in alleviating symptoms and optimizing pulmonary function in patients with chronic obstructive pulmonary disease (COPD). However, patients with stable disease may drop out of such programs if they are not modified to the individual's exercise tolerance level, or if they are not easy to perform in the home. Little is known about the effectiveness of web-based home breathing programs for dyspnea. The purpose of this study was to evaluate the effectiveness of an online breathing program which included an animated diagram and video-guided instruction on pulmonary function, exercise capacity, and health-related quality of life in patients with COPD.

METHODS

Sixty patients with stable COPD were randomized 1:1 to an experimental group (n = 30) or a control group (n = 30). Subjects in the experimental group trained for four months using an online program which included an animated diagram and video-guided instruction while the control group received conventional patient education on discharge from hospital. Forced expiratory volume, forced expiratory volume in one second (FEV1)/forced vital capacity (%), peak expiratory volume, six-minute walking distance test, and responses to the St George's Respiratory Questionnaire were assessed before and after the intervention.

RESULTS

Patients in the two groups were well matched for demographic and clinical characteristics at baseline. All outcome measures showed significant improvement in the experimental group but not in the control group.

CONCLUSION

The online training program resulted in improved pulmonary function, exercise capacity, and health status. Therefore, it is strongly recommended that patients with stable COPD be trained with such programs.

Behavioral medicine approaches to chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory disease and associated with considerable individual and socioeconomic burden. Recent research started examining the role of psychosocial factors for course and management of the disease.

PURPOSE

This review provides an overview on recent findings on psychosocial factors and behavioral medicine approaches in COPD.

RESULTS

Research has identified several important psychosocial factors and effective behavioral medicine interventions in COPD. However, there is considerable need for future research in this field.

CONCLUSIONS

Although beneficial effects of some behavioral medicine interventions have been demonstrated in COPD, future research efforts are necessary to study the effects of distinct components of these interventions, to thoroughly examine promising but yet not sufficiently proven interventions, and to develop new creative interventions.

Attitudes of women in midlife to web-based interventions for promoting physical activity

We explored the attitudes of women at midlife to web-based interventions for promoting physical activity. 145 women volunteered to participate in one of four online forums. The forums were for four major racial/ethnic groups. 90 volunteers were recruited for the online forums (29 Whites, 23 Hispanics, 21 African Americans, and 17 Asians). Two sets of topics on attitudes to physical activity and racial/ethnic contexts were used. Each topic had some introductory questions and related prompts, and these were posted on the online forum sites in a serial fashion during the six-month period. We used a thematic analysis. Four major themes emerged: (1) ‘a matter of the source of the information’; (2) ‘I can pace myself’; (3) ‘lack of interpersonal interactions’; and (4) ‘culture-specificity and low cost.’ The women in all ethnic groups thought that the source of the information was much more important than the medium of the information (e.g. web-based, booklet or face-to-face). They liked the self-controllability in web-based interventions. They preferred web-based interventions to other types of interventions because of easy accessibility, but they were concerned about lack of interpersonal interaction. None of the White or African American women indicated the need for culture-specificity in web-based interventions, but Hispanic and Asian women indicated that culture-specific interventions should be provided. Web-based interventions appear to have several advantages over conventional approaches to promoting physical activity.

Real-time telehealth for COPD self-management using Skype™

The utility of real-time interactive voice and video telehealth for teaching pursed-lips breathing (PLB) in chronic obstructive pulmonary disease (COPD) is unknown. This was a pilot study to determine its feasibility and efficacy on the key variables of social support and dyspnea. A randomized control study design with repeated measures (baseline, 4 and 12 weeks) was used. All participants in the control and intervention groups received PLB instruction at baseline, but only the intervention group received one weekly PLB reinforcement session for 4 weeks via home computer and Skype™ software. Outcome measures were Medical Outcomes Study Social Support Survey and dyspnea assessment (visual analogue scales for intensity and distress, modified Borg after six-minute walk distance, and Shortness of Breath Questionnaire for activity-associated dyspnea). A total of 22 participants with COPD (mean FEV(1)% predicted = 56) were randomized; 16 (9 telehealth, 7 control) completed the protocol. Intent-to-treat analysis at week 4, but not week 12, demonstrated significantly improved total social support (P = 0.02) and emotional/informational subscale (P = 0.03) scores. Dyspnea intensity decreased (P = 0.08) for the intervention group with a minimal clinical important difference of 10.4 units. Analysis of only participants who completed the protocol demonstrated a significant decrease in dyspnea intensity (P = < 0.01) for the intervention group at both week 4 and 12. Real-time telehealth is a feasible, innovative approach for PLB instruction in the home with outcomes of improved social support and decreased dyspnea.

A critique of Rasch analysis using the Dyspnoea-12 as an illustrative example

AIM

This paper is a report of a study of the application and critique of Rasch analysis to the development of the Dyspnoea-12 questionnaire; an instrument that measures breathlessness severity.

BACKGROUND

The development of questionnaires has traditionally involved application of classical test theory. Rasch analysis has gained international momentum as a robust application of 'modern' psychometric testing for the development of new instruments and the refinement of existing ones.

METHOD

A total of 358 patients [mean age 62 (sd = 8); chronic obstructive pulmonary disease = 123, interstitial lung disease = 129, heart failure = 106], responded to an initial list of 81 items (between May 2006 and February 2008). Hierarchical modelling reduced the list to 34 items. Rasch analysis was used to inform decisions about further item removal and fit to the unidimensional model. Rasch analysis included tests of item response appropriateness, item residual, differential item functioning (including gender and diagnosis) and unidimensionality.

RESULTS

Twenty-two items failed to reach the requirements of the Rasch model and were removed. Reasons included high residuals and item bias associated with gender and diagnosis. The 12-items conformed to the Rasch unidimensional parameters (number of statistically significant t-tests 6·7%; confidence interval: 4·4-9·0%).

CONCLUSION

We have presented the steps involved in reducing and refining a large item-set by identifying those items which possessed the most reliable measurement properties. The Dyspnoea-12 is reliable and simple to use and should find utility in both practice and research settings. We recommend that nurses consider Rasch analysis in the development of health-related questionnaires.

Use of pedometer and Internet-mediated walking program in patients with chronic obstructive pulmonary disease

We evaluated an Internet-mediated, pedometer-based program to promote walking in chronic obstructive pulmonary disease (COPD). First, we assessed the accuracy of the Omron HJ-720ITC pedometer (OMRON Healthcare, Inc; Bannockburn, Illinois) in 51 persons with COPD. The Bland-Altman plot showed a median difference of 3 steps (5th and 95th quintiles, -8.0 and 145.0, respectively). We calculated percent difference = ([manual - Omron step counts]/manual step counts) x 100. Variability in percent difference occurred at the lowest usual walking speeds. At speeds <or= 0.94 m/s, the mean +/- standard deviation percent difference was 14 +/- 26%. Nevertheless, the Omron captured >80% of the manual step counts in 20 of the 23 persons with walking speed <or= 0.94 m/s. Second, we examined step counts in 24 persons with COPD who used the Omron and an Internet-mediated, 16-week walking program. At baseline, participants with COPD walked an average of 3429 +/- 1502 steps per day. Sixteen participants completed the program with an average increase in daily step count of 988 +/- 1048 steps (p = 0.002). The Omron is accurate in persons with COPD with usual walking speeds > 0.94 m/s. Accuracy is more variable at lower speeds, but the Omron captures more than 80% of manual step counts in most persons.In this preliminary study, an Internet-mediated walking program using the Omron significantly increased step counts in COPD.

Technologically-assisted behaviour change: a systematic review of studies of novel technologies for the management of chronic illness

A systematic review was conducted to investigate the use of technology in achieving behaviour change in chronic illness. The areas reviewed were: (1) methods employed to adapt traditional therapy from a face-to-face medium to a computer-assisted platform; (2) targets of behaviour change; and (3) level of human (e.g. therapist) involvement. The initial literature search produced 2032 articles. A total of 45 articles reporting 33 separate interventions met the inclusion/exclusion criteria and were reviewed in detail. The majority of interventions reported a theoretical basis, with many arising from a cognitive-behavioural framework. There was a wide range of therapy content. Therapist involvement was reported in 73% of the interventions. A common problem was high participant attrition, which may have been related to reduced levels of human interaction. Instigating successful behaviour change through technological interventions poses many difficulties. However, there are potential benefits of delivering therapy in this way. For people with long-term health conditions, technological self-management systems could provide a practical method of understanding and monitoring their condition, as well as therapeutic guidance to alter maladaptive behaviour.

Prevalence and characteristics of home Internet access in patients with cardiovascular disease from diverse geographical locations

BACKGROUND

Patients living outside of urban centres do not have access to the same level of care as patients in cities. The use of the Internet has been suggested as a possible resolution to this geographic inequity.

OBJECTIVE

To identify the determinants of Internet use in patients with cardiovascular disease and the patterns of use.

METHODS

Cardiac inpatients of an urban tertiary and a northern regional hospital in British Columbia were invited to participate. Patients who could not speak English or who had mental impairment were excluded. Consenting patients were interviewed regarding demographics and home Internet use.

RESULTS

A total of 294 patients participated. The mean (+/- SD) age was 64.0+/-12.7 years. Most participants were men (68%) of European ancestry (77%) with some postsecondary education (57%). All geographical regions of British Columbia were represented. A total of 66% of patients had home Internet access. In rural areas, 47% of patients had access to the Internet (P=0.020 compared with nonrural areas). Eighty-four per cent of patients with Internet access had a high-speed connection, 55% reported using the Internet daily and 23% used it more than once per week. Accessing health information from the Internet was reported by 70% of patients.

CONCLUSION

These data indicate a high prevalence of Internet use among English-speaking cardiac patients and a strong desire to obtain health information using the Internet. Health care organizations can take advantage of the Internet to develop and evaluate the delivery of cardiac services to patients in their homes, particularly to patients in rural and remote communities.

Designing and testing a web-based interface for self-monitoring of exercise and symptoms for older adults with chronic obstructive pulmonary disease

The use of information and communication technologies to support collaborative management of chronic obstructive pulmonary disease and associated symptoms is particularly appealing since most people with chronic obstructive pulmonary disease continue to experience dyspnea despite optimal medical therapy and therefore must engage in the long-term tasks of self-management. Exercise is an effective therapy to reduce dyspnea in patients with chronic obstructive pulmonary disease. The purpose of this article was to describe our process of developing a set of integrated tools to support collaborative symptom and exercise monitoring for patients with chronic obstructive pulmonary disease. This process could be followed by other researchers and clinicians interested in developing collaborative management tools for other chronic conditions. User-centered design principles guided the 4-phase development process of a set of integrated tools for self-symptom management. The usability challenges uncovered during the field testing were mostly minor and were easily corrected. Patients had a strong preference for a calendar-like display of completed exercise coupled with simultaneous goal viewing. Field usability testing showed that the integrated set of tools was relatively easy to learn, efficient to use, and with minimal errors and has a high level of user satisfaction. An iterative, multimodal process is essential to successful development of acceptable Web-based tools for self-management in chronic obstructive pulmonary disease.

Is the Internet a reliable source for dietary recommendations for stone formers?

PURPOSE

Kidney stone formation is influenced by environmental factors, especially diet. Certain dietary modifications, including increased fluid intake, reduced animal protein and sodium consumption, and normal calcium intake, reduce the risk of stone activity. Patients frequently use the Internet for information regarding disease processes. We undertook this study to determine the quality of dietary stone information available in this communication domain.

METHODS

The Google search engine was used to survey 458 consecutive sites related to kidney stones and dietary information. The presence or absence of the four aforementioned dietary recommendations was recorded. The sites were analyzed for correctness, information on all four domains present and correct; inaccuracy, something mentioned about all four areas but > or =1 recommendation error(s); deficiency, information on < or =3 or domains and no recommendation errors; deficiency and inaccuracy, information on < or =3 areas and > or =1 recommendation error(s).

RESULTS

[Table: see text] There were 10 errors regarding calcium intake and 2 pertaining to protein consumption. The quality of information varied with the reporting source.

CONCLUSIONS

Internet-based information regarding four important dietary modifications for kidney stone formers is frequently incomplete. Dietary inaccuracy, while uncommon in this communication domain, is mostly centered on the misconception that calcium restriction is beneficial. The quality of dietary information may depend on the Internet information source.

Home-based telehealth: a review and meta-analysis

We conducted a systematic review to identify studies on the effect of home telehealth on clinical care outcomes. The search was restricted to peer-reviewed publications (published between 2001 and 2007) about studies conducted in home or residential settings. The search yielded 154 potential articles and dissertations. A total of 29 articles met the inclusion criteria and were included in a meta-analysis. The weighted mean effect size for the overall meta-analysis was 0.50, and the z-statistic was 3.0, indicating that telehealth had a moderate, positive and significant effect (P < or = 0.01) on clinical outcomes. Subanalyses also indicated positive significant effects of telehealth for some disease categories (heart disease and psychiatric conditions), but not others (diabetes), patient populations and telehealth interventions. Overall, the meta-analysis indicated that telehealth positively affects clinical outcomes of care, even in different patient populations.

Randomized controlled trial of an internet-based versus face-to-face dyspnea self-management program for patients with chronic obstructive pulmonary disease: pilot study

Background

People with chronic obstructive pulmonary disease (COPD) continue to experience dyspnea with activities of daily living (ADL) despite optimal medical management. Information and communication technologies may facilitate collaborative symptom management and could potentially increase the reach of such interventions to those who are unable to attend face-to-face pulmonary rehabilitation or self-management programs.

Objective

The purpose of this randomized study was to test the efficacy of two 6-month dyspnea self-management programs, Internet-based (eDSMP) and face-to-face (fDSMP), on dyspnea with ADL in people living with COPD.

Methods

We randomly assigned 50 participants with moderate to severe COPD who were current Internet users to either the eDSMP (n = 26) or fDSMP (n = 24) group. The content of the two programs was similar, focusing on education, skills training, and ongoing support for dyspnea self-management, including independent exercise. The only difference was the mode (Internet/personal digital assistant [PDA] or face-to-face) in which the education sessions, reinforcement contacts, and peer interactions took place. Participants returned to one of two academic clinical sites for evaluation at 3 and 6 months. The primary outcome of dyspnea with ADL was measured with the Chronic Respiratory Questionnaire. Secondary outcomes of exercise behavior, exercise performance, COPD exacerbations, and mediators, such as self-efficacy and social support, were also measured. A satisfaction survey was administered and a semistructured exit interview was conducted at the final visit.

Results

The study was stopped early due to multiple technical challenges with the eDSMP, but follow-up was completed on all enrolled participants. Data were available for 39 participants who completed the study (female: 44%; age: 69.5 ± 8.5 years; percent predicted forced expiratory volume in 1 s: 49.6 ± 17.0%). The fDSMP and eDSMP showed similar clinically meaningful changes in dyspnea with ADL from baseline to 3 months (fDSMP: + 3.3 points; eDSMP: + 3.5 points) and sustained these improvements at 6 months (fDSMP: + 4.0 points; eDSMP: + 2.5 points; time effects P < .001; group by time P = .51). Self-reported endurance exercise time (P = .001), physical functioning (P = .04), and self-efficacy for managing dyspnea (P = .02) also showed positive improvements over time in both groups with no significant differences with respect to program modality. Participants who completed the study reported favorable satisfaction with the programs.

Conclusions

Although there were numerous technical challenges with the eDSMP, both dyspnea self-management programs were effective in reducing dyspnea with ADL in the short term. Our findings will need to be confirmed in a larger randomized trial with more mature Web and personal digital assistant tools, use of a control group, and longer follow-up.

Trial registration

clinicaltrials.gov NCT00102401, http://www.webcitation.org/5X8CX4gLC

Utilization of the internet to deliver cardiac rehabilitation at a distance: a pilot study

Less than 25% of eligible patients attend cardiac rehabilitation programs (CRP), with geographical proximity being a predominant barrier. Therefore, we undertook a pilot study to assess the feasibility and safety of using the Internet as a medium for delivery of an interactive "virtual" CRP (vCRP) to patients at a distance. Fifteen patients on the waiting list for a local hospital-based CRP were randomized to either an Internet-based vCRP or observational control. The vCRP consisted of on-line intake forms, one-on-one chat sessions with a nurse, dietitian, and exercise specialist, downloadable exercise heart rate monitoring, education and data monitoring of blood pressure, weight, and glucose. Participants were assessed for exercise capacity, risk factors, and lifestyle behaviors at baseline and at 12 weeks. Those in the vCRP logged onto the Internet-based CRP an average of 4.2 times per week. There were no adverse events in the vCRP participants. The vCRP group significantly improved their HDL-C, triglycerides, total cholesterol:HDL-C ratio, exercise capacity as assessed in metabolic equivalents, weekly physical activity, and exercise specific self-efficacy (p < 0.05). There were no significant improvements in the control group. Improvements in the vCRP group were similar to historical controls in a standard CRP. Feedback from exit interviews of the vCRP participants was unanimously positive. This Internet-based CRP resulted in clinically significant improvements in risk factors and exercise capacity similar to that of a standard CRP. The high user acceptance indicated that this program may have the potential to effectively manage patients who do not have access to traditional hospital-based CRP.

Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases

Dyspnea is an impairing symptom in obstructive pulmonary diseases. Besides multiple physiological pathways contributing to this sensation recent research has demonstrated an important role of psychological factors in the perception of dyspnea. The present review article synthesizes the research literature with regard to psychological aspects of the perception of dyspnea as well as other dyspnea-related issues such as course of disease, neuropsychological correlates and interventions that focus on psychological or behavioural changes. The available data show that inaccurate perception of dyspnea is related to poorer treatment outcome in obstructive pulmonary diseases and is impacted upon by emotional, attentional and learning processes. Neuropsychological deficits might further contribute to this association. Different psychological and behavioural interventions might reduce comorbid psychological disorders and thus improve the perception of dyspnea. However, future research is clearly required to substantiate current findings.