Effect of a Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Hospitalized Patients With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

The use of antibiotics in the early stage of acute exacerbation of chronic obstructive pulmonary disease in patients without obvious signs of infection: a multicenter, randomized, parallel-controlled study

Introduction

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with high prevalence and mortality. In some acute exacerbations of COPD (AECOPD) in patients with no obvious signs of infection, early antibiotic treatment seems to clinically improve the disease, but more studies are needed to determine the prognostic impact of antibiotic treatment in AECOPD patients with no obvious signs of infection.

Purpose

To clarify the impact of antibiotic treatment on the short-term and long-term prognoses of AECOPD patients without obvious signs of infection.

Methods

The impact of the two treatment methods on the prognosis of patients was compared at 30, 90, 180, and 360 days after discharge. A multicenter, randomized, parallel-controlled clinical trial was conducted in a department of respiratory and critical care medicine in Central China. All patients met the inclusion criteria for AECOPD, and the patients were randomly assigned to the antibiotic group or the nonantibiotic group at a 1:1 ratio. Patients in the antibiotic group were given moxifloxacin 400 mg/day intravenously for 7 days. Patients in the nonantibiotic group were intravenously injected with the same amount of normal saline as the amount of moxifloxacin given to those in the antibiotic group for 7 days.

Results

There were 406 patients in the antibiotic group and 410 patients in the nonantibiotic group. During the short-term and long-term follow-ups, the acute exacerbation frequency, intensive care unit (ICU) treatment rate, mortality, and mMRC and CAT scores were not significantly different between the two groups (p > 0.05). At the 180- and 360-day follow-ups, the forced expiratory volume in 1 s (FEV1%) and peak expiratory flow (PEF) were not significantly different between the two groups (p > 0.05). The 30-day readmission rate was significantly lower in the antibiotic group than in the nonantibiotic group (p < 0.05). The time from discharge to the first acute exacerbation was not significantly different between the two groups (p > 0.05). The length of the first hospital stay after discharge was significantly lower in the antibiotic group (5.84 days) than in the nonantibiotic group (6.75 days) (p < 0.05). At the 30-day follow-up, the acute exacerbation frequency, age, C-reactive protein (CRP) level, and sputum viscosity were significantly greater in the nonantibiotic group than in the antibiotic group (p < 0.05). In addition, according to the receiver operating characteristic (ROC) analysis, the frequency of acute exacerbations at the 30-day follow-up was significantly greater in COPD patients aged >62.5 years, with a CRP level >12.56 mg/L or with a sputum viscosity >III, in the nonantibiotic group than in those in the antibiotic group, suggesting that the short-term prognosis was poor.

Conclusion

Patients who are >62.5 years of age, have a CRP concentration >12.56 mg/L, or have a sputum viscosity >III without obvious signs of infection should be treated with antibiotics to improve their short-term prognosis.

Clinical Trial Registration

(https://www.chictr.org.cn), (ChiCTR1800018921).

Disparities in self-reported healthcare access for airways disease in British Columbia, Canada, during the COVID-19 pandemic. Insights from a survey co-developed with people living with asthma and chronic obstructive pulmonary disease

Patients' perspectives on the impact of the COVID-19 pandemic on their access to asthma and COPD healthcare could inform better, more equitable care delivery. We demonstrate this topic using British Columbia (BC), Canada, where the impact of the pandemic has not been described. We co-designed a cross-sectional survey with patient partners and administered it to a convenience sample of people living with asthma and COPD in BC between September 2020 and March 2021. We aimed to understand how access to healthcare for these conditions was affected during the pandemic. The survey asked respondents to report their characteristics, access to healthcare for asthma and COPD, types of services they found disrupted and telehealth (telephone or video appointment) use during the pandemic. We analysed 433 responses and found that access to healthcare for asthma and COPD was lower during the pandemic than pre-pandemic (p < 0.001). Specialty care services were most frequently reported as disrupted, while primary care, home care and diagnostics were least disrupted. Multivariable logistic regression revealed that access during the pandemic was positively associated with self-assessed financial ability (OR = 22.0, 95% CI: 7.0 - 84.0, p < 0.001, reference is disagreeing with having financial ability) and living in medium-sized urban areas (OR = 2.3, 95% CI: 1.0 - 5.2, p = 0.04, reference is rural areas). These disparities in access should be validated post-pandemic to confirm whether they still persist. They also indicate the continued relevance of exploring approaches for more equitable healthcare.

A quasi-experimental study of the effect of a comprehensive blended health educational program on self-management practices among patients with chronic obstructive pulmonary disease

BACKGROUND

The prevalence and illness burden of chronic obstructive pulmonary disease (COPD) are both high. Currently, limited guidance is available to support the establishment of effective health programs to increase self-management practices in patients with COPD.

OBJECTIVES

To explore the effect of a comprehensive blended health education program on self-management practices in patients with mild-to-moderate COPD in Jeddah City, Saudi Arabia.

METHODS

A quasi-experimental research study was carried out with a convenience sample of 60 discharged or stable patients with COPD following treatment. Participants were divided into an intervention group (n = 30) that received usual hospital care and blended health education program, and a control group (n = 30) that obtained the usual hospital care without involvement in the health education program from May 2021- to August 2021. Data were collected before and three months after the intervention using the COPD Self-Management Scale and patient socio-demographic and clinical information surveys.

RESULTS

Statistically significant differences were found between the control and intervention groups after three months of the intervention based on total COPD Self-Management Scale scores. There were no statistically significant relationships between the participants' mean COPD Self-Management Scale scores in both groups with their socio-demographic and clinical characteristics before and after the intervention.

CONCLUSIONS

A nurse-led, comprehensive blended health education program was found to be an effective method for improving COPD patients' self-management practices. COPD nurses and nurse researchers must collaborate to identify the most common interventions with the best cost/benefit ratios and greater positive effects on early COPD patients' self-management practices and general well-being.

Effectiveness of patient activation interventions on chronic obstructive pulmonary disease self-management outcomes: A systematic review

BACKGROUND

Chronic obstructive pulmonary disease is the third leading cause of death worldwide. Although there is currently no cure for chronic obstructive pulmonary disease, the available self-management strategies can result in improving the symptoms, slowing the disease progression, reducing the frequency of acute exacerbations, improving the patients' quality of life and minimising health care utilisation-associated costs. Patient activation is often considered an essential driver of self-management; however, there are contradictory evidence about its impact on chronic obstructive pulmonary disease self-management.

OBJECTIVE

This review aims to fill this gap by collating the available evidence on the effectiveness of patient activation-driven chronic obstructive pulmonary disease self-management interventions.

METHODS

Databases including MEDLINE, Academic Search Complete, CINAHL Plus, Science Citation Index, Social Sciences Citation Index, Scopus, APA PsychInfo, EMBASE and ScienceDirect were searched for randomised controlled trials of patient activation-driven chronic obstructive pulmonary disease self-management interventions between 2004 and July 2020. The search terms included chronic obstructive pulmonary disease, self-management/self-care and patient activation/patient engagement.

FINDINGS

The initial search resulted in 645 articles, and after reviewing, 10 randomised controlled trials met the inclusion and exclusion criteria. Our review found that patient activation level had a positive association with chronic obstructive pulmonary disease self-management and clinical outcomes, and higher patient activation levels led to better outcomes. The interventions also led to moderate improvements in patient activation level. However, improved patient activation levels did not improve hospitalisation rates, quality of life and mental health.

CONCLUSION

Our findings suggest that patient activation can be used as a reliable tool for improving chronic obstructive pulmonary disease self-management and clinical outcomes; however, it should encompass all aspects of patient activation, especially the emotional aspect.

Self-management interventions for people with chronic obstructive pulmonary disease

BACKGROUND

Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable them to control their disease. Since the 2014 update of this review, several studies have been published.

OBJECTIVES

Primary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions. To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation. To evaluate effective characteristics of COPD self-management interventions.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses.

MAIN RESULTS

We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants ; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of 'moderate' to 'very low' quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was 'moderate'.

AUTHORS' CONCLUSIONS

Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.

Ten simple rules on writing clean and reliable open-source scientific software

Functional, usable, and maintainable open-source software is increasingly essential to scientific research, but there is a large variation in formal training for software development and maintainability. Here, we propose 10 "rules" centered on 2 best practice components: clean code and testing. These 2 areas are relatively straightforward and provide substantial utility relative to the learning investment. Adopting clean code practices helps to standardize and organize software code in order to enhance readability and reduce cognitive load for both the initial developer and subsequent contributors; this allows developers to concentrate on core functionality and reduce errors. Clean coding styles make software code more amenable to testing, including unit tests that work best with modular and consistent software code. Unit tests interrogate specific and isolated coding behavior to reduce coding errors and ensure intended functionality, especially as code increases in complexity; unit tests also implicitly provide example usages of code. Other forms of testing are geared to discover erroneous behavior arising from unexpected inputs or emerging from the interaction of complex codebases. Although conforming to coding styles and designing tests can add time to the software development project in the short term, these foundational tools can help to improve the correctness, quality, usability, and maintainability of open-source scientific software code. They also advance the principal point of scientific research: producing accurate results in a reproducible way. In addition to suggesting several tips for getting started with clean code and testing practices, we recommend numerous tools for the popular open-source scientific software languages Python, R, and Julia.

Perspective on reducing errors in research

Efforts to ensure research integrity has mostly focused on research misconduct. However, the complexity of research operations and processes makes research work also prone to unintentional errors. To safeguard against errors and their consequences, strategies for error reduction, detection, and mitigation can be applied to research work. Nurturing a scientific culture that encourages error disclosure and rectification is essential to reduce the negative consequences of errors. Creating repositories where errors can be reported can enable learning from errors and creation of more robust research processes.

Adherence to care transitions recommendations among high-risk hospitalized older patients

BACKGROUND/OBJECTIVES

Evidence on the effectiveness of inpatient hospital geriatric consultation is scant, and it is unknown whether adherence to specific recommendations will improve care and patient outcomes. This study was conducted to provide insights from a quality improvement project that may help guide further improvements in the effectiveness of these consultations made as a component of a care transitions program (CTP).

DESIGN

Secondary analysis of the implementation of a multicomponent CTP for high-risk hospitalized patients aged 75 and older.

SETTING

A 400-bed community teaching hospital.

PARTICIPANTS

Two hundred and two patients admitted to non-ICU beds who met high-risk criteria.

INTERVENTION

Inpatient comprehensive geriatric consultation including care transition recommendations, telephone and in-person follow-up weekly for 4 weeks after discharge, and collaboration with post-acute organizations and primary care and specialist physicians to implement recommendations.

MEASUREMENTS

Primary outcomes for this analysis was 30-day hospital readmissions and adherence to transition of care recommendations.

RESULTS

The 142 patients with at least one post-discharge visit received 936 care transition recommendations. Overall, 663 (71%) of the 936 care transition recommendations were adhered to (71%). The adherence rate was lower in the 22 patients who were readmitted to the hospital within 30 days (63%) compared to 72% adherence in the 120 patients who were not readmitted. This was not a statistically significant difference, and there were no significant differences in the number and percent adherence in any recommendation category between the two groups.

CONCLUSION

We found adherence to just over two-thirds of care transition recommendations, similar to a small number of other studies. We did not find a relationship between the number of recommendations and adherence to them with 30-day readmissions to the hospital. Future studies of CTPs should consider several strategies may enhance geriatric consultation care transitions recommendations and adherence to them, and improve patient outcomes.

CARE TRANSTION IN HOSPITAL DISCHARGE FOR ADULT PATIENTS: INTEGRATIVE LITERATURE REVIEW

ABSTRACT Objective: to summarize and analyze the scientific production on care transition in the hospital discharge of adult patients. Method: integrative review, conducted from May to July 2020, in four relevant databases in the health area: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus and Virtual Health Library (VHL). The analysis of the results occurred descriptively and was organized into thematic categories that emerged according to the similarity of the contents extracted from the articles. Results: 46 articles from national and international journals, with a predominance of descriptive/non-experimental studies or qualitative studies, met the inclusion criteria. Five categories were identified: discharge and post-discharge process; Continuity of post-discharge care; Benefits of care transition; Role of nurses in care transition and Experiences of patients on care transition. Hospital discharge and care transitions are interconnected processes as transitions qualify the dehospitalization process. Different strategies for continuity of care should be adopted, as they offer greater safety to the patient. Studies have shown that nurses play a fundamental role in transitions and, in Brazil, this activity still needs to gain more space. Reduced hospitalizations, mortality, hospital costs and patient satisfaction are benefits of transitions. Conclusion: care transition is an effective strategy for the care provided to the patient being discharged. It points out the need for integration between the care network and assists services in decision-making about the continuity of care on discharge.

Effects of Aloe vera in adults with mucocutaneous problems: A systematic review and meta-analysis

AIMS

To analyse the different types of Aloe vera (AV) effects on various mucocutaneous problems among adults.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

An exhaustive scanning of PubMed, Medline, ScienceDirect, and Google Scholar databases was conducted from January 2000-December 2019.

REVIEW METHODS

Randomized controlled trials (RCTs) publishing reports on the effects of AV in various mucocutaneous problems, psoriasis, burn, wound-healing were included. The standardized mean differences (SMD) with 95% confidence Intervals (CIs) were determined for the main outcomes, heterogeneity was analysed using the I² test and the risk of bias in the studies was reviewed by the Cochrane risk of bias assessment tool.

RESULTS

The study included 23 trials with a total of 4,023 participants. Six trials were included in the meta-analysis. The results indicated no significant differences in pain scores as assessed by the Visual Analog Scale (VAS) (SMD = 0.11, 95% CI: -0.37 to 0.59). The Psoriasis Area Severity Index (PASI) scores were significantly lower following AV gel application in two of the studies (SMD = -1.32 95% CI: -1.86 to -0.78). Considering results in a systematic manner, AV accelerated tissue epithelialization and wound-healing process (N = 3), reduced oral mucositis (N = 3), and improved quality of life (N = 1).

CONCLUSION

AV might have beneficial effects in reducing pain scores and the severity of mucocutaneous problems compared with placebo, especially with limited mild to moderate adverse effects.

IMPACT

AV may be used as an alternative and integrative approach to reducing symptom severity in mucocutaneous problems and the wound-healing process. High quality and well-designed RCTs are still needed to elucidate the effects of AV in a variety of dosages and forms among adults with mucocutaneous problems.

Development of a Transitional Care Model Program for Patients with Pneumonia, Asthma, and Chronic Obstructive Pulmonary Disease: In-depth Interviews with Readmitted Patients

Community-based health management policies are needed considering societal aging. We aimed to develop a transitional care model (TCM) program for patients with pneumonia, asthma, and chronic obstructive pulmonary disease. First, we conducted in-depth interviews with patients who were hospitalized, released, and readmitted for those three conditions to identify issues with the current hospitalization/discharge system and post-discharge processes. Next, we developed a new TCM program suited to the realities of the current medical environment. Interviews revealed problems including inadequate awareness of disease and health management; insufficient information exchange between patients, caregivers, and primary medical institutions; and absence/low usage of community-based care services. The investigation applying the new TCM program to patients and following up on readmission rates and life satisfaction after discharge is ongoing. Reviewing these results and conducting further studies in the future will allow improvements to the model.

The effects of nurse-driven self-management programs on chronic obstructive pulmonary disease: A systematic review and meta-analysis

AIMS

To analyse the effects of nurse-driven self-management (SM) programs on physical and psychosocial health variables in people with chronic obstructive pulmonary disease (COPD).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

An exhaustive scanning of PubMed, Cochrane Controlled Register of Trials, CINAHL, ScienceDirect and Medline databases between January 2010-December 2019 was conducted for this meta-analysis.

REVIEW METHODS

Randomized controlled trials (RCTs) related to nurse-driven SM programs in COPD population were included. The standardized mean differences with 95% confidence intervals were determined for the main variables and heterogeneity was analysed using the I² test. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used.

RESULTS

Twelve studies were included. The results indicated that significant difference in physical health scores based on COPD Assessment Tool (CAT) and walking distance according to the 6-min walk distance (6MWD) test in the intervention groups compared with the control groups. About psychosocial health findings, the quality of life increased and the Hospital Anxiety and Depression Scale (HADS) scores decreased following SM programs. All of the studies had good quality (varying from 5-8 points) according to The Modified Jadad Scale.

CONCLUSION

Nurse-driven SM programs may contribute to prognosis in patients with COPD. Due to methodological weaknesses in the included trials, high-quality RCTs are needed to better determine the effects of nurse-driven SM programs in the management of COPD. Nurse-driven SM programs may be employed as a useful strategy to improve health status and QOL and psychosocial health in the COPD population, as well.

IMPACT

Current evidence shows that nurse-driven SM programs could be safely integrated into the clinical practice for patients with COPD. Future studies are warranted that evaluating the effects of nurse-driven SM programs on other frequently observed COPD symptoms such as dyspnoea, fatigue and sleep disturbance.

JM, Mertens A, Hubbard AE, Arnold BF. Internal replication of computational workflows in scientific research

Failures to reproduce research findings across scientific disciplines from psychology to physics have garnered increasing attention in recent years. External replication of published findings by outside investigators has emerged as a method to detect errors and bias in the published literature. However, some studies influence policy and practice before external replication efforts can confirm or challenge the original contributions. Uncovering and resolving errors before publication would increase the efficiency of the scientific process by increasing the accuracy of published evidence. Here we summarize the rationale and best practices for internal replication, a process in which multiple independent data analysts replicate an analysis and correct errors prior to publication. We explain how internal replication should reduce errors and bias that arise during data analyses and argue that it will be most effective when coupled with pre-specified hypotheses and analysis plans and performed with data analysts masked to experimental group assignments. By improving the reproducibility of published evidence, internal replication should contribute to more rapid scientific advances.

Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Objective

Hospital-outreach pulmonary rehabilitation (PR) can improve health status and reduce health-care utilization by patients with chronic obstructive pulmonary disease (COPD). However, its long-term effects and costs versus benefits are still not clear. This study was conducted to develop, deliver, and evaluate the effects and monetary savings of a hospital-outreach PR program for patients with COPD.

Methods

A randomized controlled trial was conducted. Patients with COPD (n=208) were randomly assigned to the hospital-outreach PR program (treatment) or treatment as usual (control). The treatment group received a 3-month intensive intervention, including supervised physical exercise, smoking cessation, self-management education, and psychosocial support, followed by long-term access to a nurse through telephone follow-up and home visits up to 24 months. The control group received routine care, including discharge education and a self-management education brochure. Main outcomes were collected at 3, 6, 12, and 24 -months postrandomization. Primary outcomes included health-care utilization (ie, readmission rates, times, and days, and emergency department visits) and medical costs. Secondary outcomes included lung function (ie, FEV1, FEV1% predicted, FVC), dyspnea (mMCR), exercise capacity (6MWD), impact on quality of life (CAT), and self-management (CSMS).

Results

At the end of 24 months, 85 (81.7%) in the treatment group and 89 (85.6%) in the control group had completed the whole program. Compared with the control group, patients in the treatment group had lower readmission rates, times, and days at 6 and 12 months and during 12-24 months. Regarding costs during the 2 years, the program achieved CN¥3,655.94 medical  savings per patient per year, and every ¥1 spent on the program led to ¥3.29 insavings. Patients in the treatment group achieved improvements in FEV1, FEV1% predicted, exercise capacity, and self-management. It also achieved relief of dyspnea symptoms and improvement in COPD's impact on quality of life.

Conclusion

The hospital-outreach PR program for patients with COPD achieved reductions in health-care utilization, monetary savings, and improvements in patient health outcomes. The effects of the program were sustained for at least 2 years.

Trial Registration

This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-TRC-14005108).

Reducing COPD Readmissions: Strategies for the Pulmonologist to Improve Outcomes

Hospitalizations for patients with acute exacerbations of COPD are associated with several adverse patient outcomes as well as with significant health-care costs. Despite many interventions targeted at reducing readmissions following an initial hospitalization, there are few strategies that have been consistently associated with reductions in this outcome. Despite the lack of consensus as to the best strategies to deploy to reduce readmissions related to acute exacerbations of COPD, efforts must continue to focus on determining the best approaches for this population. These tactics will need to be cost-effective for payers while not being cost-prohibitive for providers. In addition, these interventions will need to be relatively easy to institute while not being overbearing for patients or providers. Larger systems with their greater financial resources will likely find success with technology and data-driven comprehensive programs; independent hospitals and practices are more likely to succeed with less resource-intensive interventions such as early postdischarge follow-up, coaching, action plans, self-management education, and pulmonary rehabilitation. Choosing the right interventions that will utilize financial and human resources in a cost-effective manner, while tailoring the approaches to meet the needs of a specific patient group, will be of key importance.

Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies.

OBJECTIVES

Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP.

MAIN OUTCOMES AND MEASURES

We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients.

RESULTS

Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions.

CONCLUSION

Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.

JM, Mertens A, Hubbard AE, Arnold BF. Internal replication of computational workflows in scientific research

Failures to reproduce research findings across scientific disciplines from psychology to physics have garnered increasing attention in recent years. External replication of published findings by outside investigators has emerged as a method to detect errors and bias in the published literature. However, some studies influence policy and practice before external replication efforts can confirm or challenge the original contributions. Uncovering and resolving errors before publication would increase the efficiency of the scientific process by increasing the accuracy of published evidence. Here we summarize the rationale and best practices for internal replication, a process in which multiple independent data analysts replicate an analysis and correct errors prior to publication. We explain how internal replication should reduce errors and bias that arise during data analyses and argue that it will be most effective when coupled with pre-specified hypotheses and analysis plans and performed with data analysts masked to experimental group assignments. By improving the reproducibility of published evidence, internal replication should contribute to more rapid scientific advances.

Telemonitoring Interventions in COPD Patients: Overview of Systematic Reviews

OBJECTIVE

The role of telemonitoring interventions (TIs) for chronic obstructive pulmonary disease (COPD) has been studied in many systematic reviews (SRs) and meta-analyses (MAs), but robust conclusions have not been reached due to wide variations in scopes, qualities, and outcomes. The aim of this overview was to determine the effectiveness of TIs on COPD patients.

METHODS

PubMed, EMBASE, Web of Science, and Cochrane Library were searched for all reviews on the topic of TI in treating COPD from inception to July 8, 2019, without restrictions on language. According to the inclusion and exclusion criteria, the retrieved literature studies were screened to select SRs and MAs of randomized control trials (RCTs) that evaluated the effects of TIs in COPD patients. The methodological quality of SRs and MAs was assessed with the AMSTAR-2 tool, and the strength of evidence was assessed with the grades of recommendations, assessment, development, and evaluation (GRADE) system for concerned outcomes in terms of mortality, quality of life (SGRQ total scores), exercise capacity (6MWD), and exacerbation-related outcomes (hospitalizations, exacerbation rate, and emergency room visits).

RESULTS

Our overview included eight SRs and MAs published in 2011 to 2019, from 95 RCTs involving 10632 participants. After strict evaluation by the AMSTAR-2 tool, 75% of the SRs and MAs in this overview had either low or critically low methodological quality. The effects of TIs for COPD on mortality, quality of life, exercise capacity, and exacerbation-related outcomes are limited, and all of these outcomes scored either low or very low quality of evidence on the GRADE system.

CONCLUSIONS

There might be insufficient evidence to support the effectiveness of TIs for COPD currently, but the results of this overview should be interpreted dialectically and prudently, and the role of TIs in COPD needs further exploration.

Review of the British Thoracic Society Winter Meeting 2018, 5-7 December 2018, London, UK

INTRODUCTION

The Winter Meeting of the British Thoracic Society (BTS) is a platform for the latest clinical and scientific research in respiratory medicine. This review summarises some key symposia and presentations from the BTS Winter Meeting 2018.

METHODS

Key symposia and research presentations from the BTS Winter Meeting 2018 were attended and reviewed by the authors.

RESULTS

The seminal messages from the latest clinical and scientific research covering a range of respiratory diseases, including asthma, interstitial lung disease, infection, cystic fibrosis, pulmonary vascular disease, pleural disease and occupational lung disease were summarised in this review.

DISCUSSION

The BTS Winter Meeting 2018 brought the very best of respiratory research to an audience of scientists, physicians, nurses and allied health professionals. The Winter Meeting continues to be a highlight of the UK respiratory research calendar, and we look forward to the next meeting in December 2019.

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.

A Multidisciplinary Intervention to Improve Care for High-Risk COPD Patients

Chronic obstructive pulmonary disease (COPD) exacerbations contribute to both costs and patient morbidity. The authors designed a quality project to improve care for high-risk COPD patients admitted with an exacerbation. An electronic medical record report was used to target admitted high-risk COPD patients for an intervention that included pulmonary and respiratory therapy consults, post-discharge phone calls from a patient navigator, referrals to palliative services when appropriate, and bedside delivery of medications. The control population was a similar group of patients at a community partner hospital who received usual care. In all, 157 unique patients were enrolled over 16 months; referrals to palliative care services increased and rates of outpatient follow-up improved. There was no difference in readmissions or emergency department visits between the 2 groups. Better coordination of outpatient care and attention to psychosocial burdens were identified as possible targets for future interventions.

The efficacy of a flipping education program on improving self-management in patients with chronic obstructive pulmonary disease: a randomized controlled trial

Purpose: Self-management is widely used among patients with a chronic disease to control their condition. However, the self-management programs are less distinctive for patients with chronic obstructive pulmonary disease (COPD) than those with other chronic diseases. This study examines the efficacy of a flipping education program on improving self-management in patients with COPD.

Patients and methods: A single-blinded, randomized controlled trial was conducted at a medical center in northern Taiwan from January 2015 to May 2016. Sixty participants were randomized to an experimental group and a control group. The self-management program with flipped teaching, customized action plans, and scheduled telephone interviews was implemented in the experimental group for three months. Conventional patient education was implemented in the control group. Disease knowledge, self-efficacy, the patient’s activation level, and the impact of COPD were assessed at baseline, 1 month, and 3 months after the intervention. SPSS 22.0 was used for data analysis.

Results: The results showed that the patients who received the flipping education program of self-management had statistically significant improvements in their disease knowledge (p<0.05), self-efficacy (p<0.01), and activation levels (p<0.01) from baseline to the 1 month and 3 months follow-up compared to the control group.

Conclusion: The findings supported that flipped teaching could be applied to patient education in adults and that a nurse case manager can feasibly use this flipping education program of self-management to motivate and support patients with COPD to acquire self-management skills, carry out their action plans, and help them achieve beneficial behaviors in their daily lives.

Effects of Clinical Pathways for COPD on Patient, Professional, and Systems Outcomes: A Systematic Review

BACKGROUND

COPD has a substantial burden seen in both patient quality of life and health-care costs. One method of minimizing this burden is the implementation of clinical pathways (CPWs). CPWs bring the best available evidence to a range of health-care professionals by adapting guidelines to a local context and detailing essential steps in care.

METHODS

A systematic review was conducted to address the following question: What are the effects of CPWs for COPD on patient-, professional-, and systems-level outcomes? The review used methods outlined by the Cochrane Collaboration. We included all studies that met our operational definition for CPWs and focused on COPD. All studies were evaluated for risk of bias, and all data regarding patient, professional, and systems outcomes were extracted.

RESULTS

The search strategy identified 497 potentially relevant titles. Of these, 13 studies were included in the review. These studies reported a total of 398 outcomes, with sufficient data for meta-analysis of five outcomes: complications, length of stay, mortality, readmissions, and quality of life. Results showed statistically significant reductions in complications, readmissions, and length of stay but did not show changes in mortality or quality of life.

CONCLUSIONS

This systematic review reveals evidence to suggest that CPWs for COPD have the potential to reduce complications, readmissions, and length of stay without negatively influencing mortality or quality of life. However, quality of evidence was generally low. The authors therefore acknowledge that results should be interpreted with caution and note the need for additional research in this area.

Coordinated-Transitional Care for Veterans with Heart Failure and Chronic Lung Disease

OBJECTIVES

Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center.

DESIGN

We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission.

SETTING

The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks.

PARTICIPANTS

Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol.

MEASUREMENTS

A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis.

RESULTS

Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89).

CONCLUSION

The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.