Can Patients With COPD Assimilate Disease-Specific Information During an Acute Exacerbation?

Primary care patients with mild or stable chronic obstructive pulmonary disease need more support in disease management: a secondary analysis of a cluster randomized controlled trial

OBJECTIVE

Patient education based on the patient's individual needs and circumstances is known to be associated with positive changes in clinical outcomes in chronic obstructive pulmonary disease (COPD). We aimed to assess the levels of patients' subjective needs for information about COPD before and after their general practitioners had taken part in a COPD education.

DESIGN

A secondary analysis of a cluster randomized controlled trial.

SETTING

22 PHCCs in Stockholm, Sweden.

SUBJECTS

Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 293).

OUTCOME MEASURES

Scores in the Lung Information Needs Questionnaire (LINQ) at baseline and 18 months, spirometry results, and self-reported, descriptive patient data.

RESULTS

GPs' improved skills in COPD did not affect patients' self-management skills over time. In general, patients' information needs remained great in issues concerning diet, exercise and self-management. However, 43% of the patients reported reduced and 57% increased or unchanged information needs, over time. Reduced information needs were mainly associated with a high level of information needs at baseline (OR = 3.17 [95% CI 1.93-5.23], p < .01) and establishing contact with a physiotherapist (OR = 2.26 [95% CI 1.05-4.86], p = .038). Patients in a mild or stable phase of COPD with no recent exacerbations reported greater needs than those with unstable, deteriorated COPD.

CONCLUSION

Patients' information needs are substantial in most areas of self-management of COPD, and seem to covary with the patient's current clinical status. Care providers should thus continuously be vigilant about offering all patients with COPD support and education.

TRIAL REGISTRATION

Clinicaltrials.gov, 10 August 2014, Identifier NCT02213809.

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.

Information Needs in COPD After an Educational Programme: Influence in Exacerbations and Admissions

Introduction

Improving patients’ information needs (IN) may contribute to better control in COPD. This study analyses IN using Lung Information Needs Questionnaire (LINQ) following an educational intervention, evaluates how clinical characteristics modify IN, and studies high IN as a prognostic factor for COPD exacerbations and hospital admissions.

Methods

Cohort of 143 patients with initial diagnosis of COPD included in a structured educational program. Two months after completing the program, IN was assessed using LINQ. Correlations between IN and clinical variables of COPD and distribution of IN in different clinical groups were analyzed. Univariate and multivariate analysis was performed to determine influence of IN on exacerbations and COPD admissions over the following year.

Results

LINQ scored 6.3±2.9. There were no differences in LINQ scoring between different clinical groups, but LINQ score positively correlated with age (r=0.184, p=0.029). High IN was a predictor of COPD hospitalizations (HR 2.3 [95% CI 1.1–5.1] (p=0.029)) but not of less severe exacerbations (p=0.334).

Conclusion

IN was not associated with any clinical variables, but it correlated with age. High IN proved to be an independent predictor of admissions.

Design of pulmonary rehabilitation programmes during acute exacerbations of COPD: a systematic review and network meta-analysis

This systematic review aimed to systematise the different designs used to deliver pulmonary rehabilitation during acute exacerbations of COPD (AECOPD) and explore which ones are the most effective. PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Randomised controlled trials comparing pulmonary rehabilitation or at least one of its components with usual care or comparing different components of pulmonary rehabilitation were included. Network meta-analysis was conducted in MetaXL 5.3 using a generalised pairwise modelling framework. Pooled effects compared each treatment to usual care. 42 studies were included. Most studies were conducted in an inpatient setting (57%) and started the intervention 24-48 h after hospital admission (24%). Exercise training (71%), education and psychosocial support (57%) and breathing techniques (55%) were the most used components. Studies combining exercise with breathing techniques presented the larger effects on exercise capacity (weighted mean difference (WMD) -41.06, 95% CI -131.70-49.58) and health-related quality of life (WMD 16.07, 95% CI 10.29-21.84), and breathing techniques presented the larger effects on dyspnoea (WMD 1.90, 95% CI 0.53-3.27) and length of hospitalisation (effect size =0.15, 95% CI -0.28-0.57). A few minor adverse events were found.Pulmonary rehabilitation is a safe intervention during AECOPD. Exercise, breathing techniques, and education and psychosocial support seem to be the core components for implementing pulmonary rehabilitation during AECOPD. Studies may now focus on comparisons of optimal timings to start the intervention, total duration of the intervention, duration and frequency of sessions, and intensity for exercise prescription.

Educational topics and their rationale for inclusion within pulmonary rehabilitation - a systematic review

OBJECTIVE

To identify the scope of educational topics within pulmonary rehabilitation (PR) for people with chronic respiratory diseases and determine their rationale for inclusion.

METHODS

Four electronic databases were searched, with data extracted and assessed for quality by two reviewers using the Downs and Black tool or the Critical Appraisal Skills Programme checklist.

RESULTS

Twenty-one studies of variable quality were included. In chronic obstructive pulmonary disease (COPD), common education topics included disease pathophysiology, medications, psychological support, strategies for breathlessness, role of exercise and recognition of acute exacerbations, while less frequent topics included end-of-life planning, disease impact on sexual relationships and comorbidities. In interstitial lung disease (ILD), topics focused upon disease pathophysiology, approaches to limit disease progression, symptom management and end-of-life care. Evidence of a rationale for including education topics in PR were often lacking, but focused on recommended guidelines and information to improve self-management.

CONCLUSION

A core range of educational topics based broadly upon clinical presentation and management strategies appear to be incorporated into PR for people with COPD. Topics for people with ILD appear to be selected according to patient need.

PRACTICE IMPLICATIONS

The topics identified in this review may help clinicians seeking to develop educational resources for PR.

COPD patients need more information about self-management: a cross-sectional study in Swedish primary care

Objective: In Sweden, patients with chronic conditions, such as chronic obstructive pulmonary disease (COPD), often receive education at specialized nurse-led clinics at primary health care centers (PHCCs). Identifying patients' needs for information about COPD is the key to individualized care. This study aimed to assess self-reported needs for information about COPD in primary care patients with either moderate (GOLD 2) or severe (GOLD 3) COPD and identify patient characteristics and exacerbation patterns associated with the findings.Design: A cross-sectional study.Setting: Twenty-four PHCCs in Stockholm, Sweden.Subjects: Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 542).Main outcome measures: The Lung Information Needs Questionnaire (LINQ) was used to assess perceived information needs. Spirometry results and descriptive, self-reported data on patient factors such as exacerbation history, treatment, smoking, weight/height, comorbidities, health care contacts, education and symptoms were collected.Results: Overall, the greatest reported needs were for information about self-management and diet. GOLD 2 patients (68%) expressed greater needs for information than GOLD 3 patients (32%). We found significant associations between high information needs and patient-related factors such as 'No assigned GP' (OR = 4.32 [95% CI 2.65-7.05]) and 'No contact with COPD nurse in the past 12 months' (OR = 1.83 [95% CI 1.19-2.81]).Conclusion: COPD patients felt they knew too little about self-management of their disease. Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. These associations were strongest in patients with moderate COPD.Key points: As patients with COPD often have multimorbidity, identifying patients' needs for information about COPD is essential to providing individualized patient education and care. In this study of 542 patients from 24 Swedish primary care centers, we found that:Patients with COPD, particularly those with moderate airflow limitation (i.e. GOLD 2) felt they needed more information about COPD than currently provided by health care professionals in primary care.Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. GPs' part in COPD patient education should not be overlooked, as individualized COPD care relies on GPs' expertise in managing patients with multimorbidity.

Improving acceptance and uptake of pulmonary rehabilitation after acute exacerbation of COPD: Acceptability, feasibility, and safety of a PR "taster" session delivered before hospital discharge

The objectives of this study were to (1) assess the acceptability, feasibility, and safety of delivering a pulmonary rehabilitation (PR) "taster" session to patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease; (2) evaluate the changes in patient knowledge and readiness to commence PR; and (3) make recommendations for future intervention iterations. Acceptability was measured by the proportion of patients that accepted to participate. Feasibility was measured by the proportion of eligible participants. Knowledge was evaluated using the modified versions of the Understanding COPD (UCOPD) and Bristol COPD Knowledge (BCKQ) questionnaires. Readiness to commence PR was measured by a modified version of the Readiness to Change Exercise Questionnaire. All measures were delivered pre- and post-intervention. Thirty-one of 34 eligible individuals were able to be approached. Prospective acceptability was low, with 24 individuals declining the intervention, 1 being discharged without making a decision, and only 6 participating. Positive median change was recorded in the modified UCOPD questionnaire (+8), but not the BCKQ (0). Three of the patients were already in the action phase pre-intervention, with all but one in that phase post-intervention. The delivery of a PR "taster" session was not prospectively acceptable to a large portion of patients and only feasible with modifications to the original protocol.