Action plans for COPD: strategies to manage exacerbations and improve outcomes

Does adherence to exacerbation action plans matter? Insights from two COPD self-management studies

Introduction

Patients' adherence is essential for COPD self-management, as beneficial effects can only be expected in adherent patients. We explored associations between patients' adherence to COPD exacerbation action plans and health outcomes.

Materials and methods

Pooled COPD self-treatment intervention group data from two RCTs were analysed, only including patients who had ≥1 COPD exacerbation or started ≥1 course of oral corticosteroids over one-year follow-up. Optimal adherence was defined as 'self-treatment initiated ≤1 day before or after exacerbation start', suboptimal adherence as 'self-treatment initiated 2 days before or after exacerbation start or no self-treatment initiated for a short (1-3 days) exacerbation', and significant delay or no treatment as 'self-treatment initiated >2 days after exacerbation start or no self-treatment initiated for a longer (>3 days) exacerbation'. Regression models were built for several health outcomes, with the number of COPD exacerbation days/patient/year being the primary outcome.

Results

Patients with significant delay or no treatment (n = 46) had more exacerbation days/patient/year (33.3 (95 % CI 10.9; 55.6)) than optimal adherent patients (n = 38) (23.7 (95 % CI 1.7; 45.7)). The duration per COPD exacerbation was longer for patients with significant delay or no treatment (15.5 days) compared to optimal adherent patients (7.8 days). No differences in health outcomes were observed between optimal and suboptimal adherent patients.

Conclusions

Being adherent to action plans is associated with better health outcomes than significant delayed treatment or no treatment at all. Interestingly, suboptimal adherence demonstrated health benefits comparable to optimal adherence. COPD self-management interventions should prioritise strategies to optimise patients' adherence to action plans.

Quality Improvement Project to Develop a Pictorial Chronic Obstructive Pulmonary Disease (COPD) Action Plan

Introduction Chronic obstructive pulmonary disease (COPD) is a global health concern and a leading cause of morbidity and mortality worldwide. COPD action plans help patients manage exacerbations by recognizing symptoms early and taking necessary steps. We found our COPD written action plan difficult to understand, potentially affecting the patient's ability to self-manage their COPD. Aims We aim to design a new COPD action plan to increase the knowledge scores of our patients during competency checks by 20%. Methods We employed the quality improvement methodology of needs analysis and root cause analysis and used a Pareto chart to identify the top four contributory factors to an ineffective COPD action plan. These include being too wordy, lacking pictorial illustrations, being only available in a single language (English), and too much medical jargon. Using the prioritization matrix to assess possible solutions, the team decided to implement a pictorial COPD action plan. After two cycles of Plan-Do-Study-Act, the final pictorial COPD plan was compared with the original written action plan. Results Ten English-speaking COPD patients from our outpatient respiratory clinics were surveyed with the original action plan while 11 more were surveyed after the introduction of the pictorial action plan. There was an improvement in mean knowledge scores by 92.8% (t(19) = 6.67, p < 0.01, at 95% CI). Patient satisfaction rates also increased from 44% to 100%. Sixty-three percent (63.6%) of patients surveyed said they referred back to the pictorial action plan 3 months after being introduced to it. Conclusion Pictorially enhanced COPD action plans have been shown to improve our patients' knowledge of COPD self-management.

Implementing Digital Technologies in Clinical Trials: Lessons Learned

Multiple digital health technologies have been evaluated across clinical development programs, including external, wearable, implantable, and ingestible devices and sensors, along with digital mobile health applications (apps) that are accessible via users' personal electronic devices (e.g., smartphones, tablets, and computers). Several of these technologies have been incorporated into our ongoing neurology and respiratory clinical development programs. Based on our experience, one of the greatest potential benefits of digital health technologies is the ability to collect objective and/or biological data continuously or at regular intervals outside of office visits during a patient's normal daily activities to provide additional efficacy and safety information, versus data capture from traditional episodic, time point-based office visits. Many challenges encountered with digital health technologies can be successfully addressed by providing the appropriate training to staff and patients, ensuring availability of appropriate infrastructure support, and conducting pilot studies before scaling up to larger trials. Overall, our experience with digital health technologies demonstrated their potential to increase the amount of objective data collected in clinical trials, expand patient access to trials, and facilitate further improvement of clinical outcomes.

COPD Is Associated with Elevated IFN-β Production by Bronchial Epithelial Cells Infected with RSV or hMPV

IFN treatment may be a viable option for treating COPD exacerbations based on evidence of IFN deficiency in COPD. However, in vitro studies have used primarily influenza and rhinoviruses to investigate IFN responses. This study aims to investigate the susceptibility to infection and IFN response of primary bronchial epithelial cells (BECs) from COPD donors to infection with RSV and hMPV. BECs from five COPD and five healthy donors were used to establish both submerged monolayer and well-differentiated (WD) cultures. Two isolates of both RSV and hMPV were used to infect cells. COPD was not associated with elevated susceptibility to infection and there was no evidence of an intrinsic defect in IFN production in either cell model to either virus. Conversely, COPD was associated with significantly elevated IFN-β production in response to both viruses in both cell models. Only in WD-BECs infected with RSV was elevated IFN-β associated with reduced viral shedding. The role of elevated epithelial cell IFN-β production in the pathogenesis of COPD is not clear and warrants further investigation. Viruses vary in the responses that they induce in BECs, and so conclusions regarding antiviral responses associated with disease cannot be made based on single viral infections.

Reducing the Number of Hospitalization Days for COPD: Setting up a Transmural-Care Pathway

Background

Many patients with chronic obstructive pulmonary disease (COPD) experience exacerbations of symptoms, leading to a large burden on patients and the health system and costs to society. To address this burden, a 25% reduction in number of hospitalization days for COPD exacerbations was recently declared a national goal in the Netherlands, to be achieved in 5 years.

Methods

A national care pathway was designed following an established managed clinical pathway setup, which involved prior national surveys and the identification of ten key elements. The concept was discussed, made locally applicable, and finally tested in eight regions containing eleven hospitals and surrounding primary-care groups in a prospective cohort study. All patients were followed for 1 year, starting at hospitalization.

Results

In total, 752 patients gave informed consent and participated (mean age 70 years, 58% female). Of these, 120 (16%) died within a year. The median length of index hospitalization was 5 days, and 43% had at least one rehospitalization within 1 year (range 0–8). There was a 19.4% reduction in number of total hospitalization days, without a decrease in health-related quality of life or perceived quality of care. Elements that contributed significantly to the reduction were contact in the first week after hospitalization, and during the year of follow-up pharmacological and nonpharmacological smoking-cessation guidance, checks on inhalation technique, and discussion of lung-attack plan.

Discussion

With concerted action between patients and health workers in the hospital and in the community, a large reduction in number of hospitalization days can be achieved. The program was quite demanding for both patients and health workers. In our subsequent national implementation plan after this pilot study, we have named the major contributors to success and advocate the stepwise introduction of the elements in light of feasibility.

The impact of a personalised action plan delivered at discharge to patients with COPD on readmissions: a pilot study

Background

Self‐management interventions in COPD, including action plans, have the potential to increase quality of life and to reduce respiratory‐related hospitalisations. However, knowledge is still sparse of the effectiveness of a personally tailored action plan introduced at or right after discharge from hospital.

Aim

This pilot study aimed to test whether a personalised, stepwise action plan supported with a short instruction provided at or postdischarge after an acute exacerbation in chronic obstructive pulmonary disease admission as an addition to usual care reduces readmissions and symptom burden, including anxiety and depression levels at 3‐month follow‐up.

Methods

The study was carried out in a randomised controlled design with follow‐up after 3 months. In all, 75 participants were randomly assigned to either an intervention group that received an action plan, including the COPD Assessment Test (CAT), or to a control group that received usual care. The incidence of COPD‐related readmissions was measured as the primary outcome.

Results

Compared to the control group, the action plan group significantly reduced the incidence of readmissions. The action plan group showed a trend towards a significant decrease in HADS‐depression, but none in HADS‐anxiety. Significant improvements in CAT scores were observed for the participants in the intervention group. Only inferior minor differences were found in use of inhalation therapy.

Conclusions

A personally tailored action plan introduced at or postdischarge combined with follow‐up support is an effective self‐management tool to support recovery and to reduce unnecessary readmissions. In future follow‐up care, the healthcare professional must initiate the action plan at discharge and immediately after having the opportunity to follow the patient at home. This might require healthcare professionals working across healthcare sectors, who support patients until they have the needed confidence and competence in using the plan.

Technology-Enabled Self-Monitoring of Chronic Obstructive Pulmonary Disease With or Without Asynchronous Remote Monitoring: Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality worldwide. Reducing the number of COPD exacerbations is an important patient outcome and a major cost-saving approach. Both technology-enabled self-monitoring (SM) and remote monitoring (RM) programs have the potential to reduce exacerbations, but they have not been directly compared with each other. As RM is a more resource-intensive strategy, it is important to understand whether it is more effective than SM.

OBJECTIVE

The objective of this study is to evaluate the impact of SM and RM on self-management behaviors, COPD disease knowledge, and respiratory status relative to standard care (SC).

METHODS

This was a 3-arm open-label randomized controlled trial comparing SM, RM, and SC completed in an outpatient COPD clinic in a community hospital. Patients in the SM and RM groups recorded their vital signs (oxygen, blood pressure, temperature, and weight) and symptoms with the Cloud DX platform every day and were provided with a COPD action plan. Patients in the RM group also received access to a respiratory therapist (RT). The RT monitored their vital signs intermittently and contacted them when their vitals varied outside of predetermined thresholds. The RT also contacted patients once a week irrespective of their vital signs or symptoms. All patients were randomized to 1 of the 3 groups and assessed at baseline and 3 and 6 months after program initiation. The primary outcome was the Partners in Health scale, which measures self-management skills. Secondary outcomes included the St. George's Respiratory Questionnaire, Bristol COPD Knowledge Questionnaire, COPD Assessment Test, and modified-Medical Research Council Breathlessness Scale. Patients were also asked to self-report on health system usage.

RESULTS

A total of 122 patients participated in the study, 40 in the SC, 41 in the SM, and 41 in the RM groups. Out of those patients, 7 in the SC, 5 in the SM, and 6 in the RM groups did not complete the study. There were no significant differences in the rates of study completion among the groups (P=.80).

CONCLUSIONS

Both SM and RM have shown promise in reducing acute care utilization and exacerbation frequencies. As far as we are aware, no studies to date have directly compared technology-enabled self-management with RM programs in COPD patients. We believe that this study will be an important contribution to the literature.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03741855; https://clinicaltrials.gov/ct2/show/NCT03741855.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13920.

Chronic Obstructive Pulmonary Disease Discharge Education and Quality of Life Evaluation: A Feasibility Study

Background and Purpose:

Discharge instructions provided to hospitalized participants with chronic obstructive pulmonary disease (COPD) are essential to promote improved health outcomes, reduce incidence of hospitalization, and enhance quality of life (QOL). This study evaluated the feasibility of implementing the American Lung Association’s COPD Action Plan and assessment of QOL among participants hospitalized for acute exacerbation of COPD or COPD as a primary or secondary diagnosis.

Methods:

The study was conducted on a cohort of critically ill participants hospitalized on a progressive care unit. The Principal Investigator administered the WHOQOL-BREF Questionnaire to assess QOL before discharge and 30 days after discharge via phone call. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate outcomes from the discharge study.

Results:

Among participants enrolled (n = 50), 13 completed the in-hospital and follow-up phone call. Participants scored (12; 92% answered “yes”) that they learned appropriate COPD self-management skills, such as change in respiratory symptoms and appropriate actions to take. At 30-day follow-up: number of rehospitalizations (12; 99%), no emergency department visits, and (1; 1%) emergency department visit for insulin reaction, not COPD. Most frequent principal admitted diagnosis was acute respiratory failure, and secondary diagnosis was COPD. There was no significant difference in QOL comparing scores at discharge to 30-day follow-up, using the Wilcoxon signed-rank test.

Implications for Practice:

COPD education can increase participant satisfaction in receiving self-management instructions from an action plan near the time of discharge based on a small sample.