Designing patient-related interventions in COPD care: empirical test of a theoretical model

The Association of Health-Related Factors with Leisure-Time Physical Activity among Adults with COPD: A Cross-Sectional Analysis

This study aimed to examine the association of health attitudes, health appraisals and affective experience to leisure-time physical activity in adults with chronic obstructive pulmonary disease (COPD). Cross-sectional analyses were conducted with a sample of 274 adults with COPD drawn from the second wave of the Midlife in the United States (MIDUS 2) Study. Chi-square analyses and independent t-tests were used to test the differences between physically active and inactive COPD patients (active group versus inactive group) for all study variables. Multiple logistic regression was used to examine the association of each study variable with leisure-time physical activity. The results showed that there were significant differences between the active and inactive groups in terms of age, education, functional limitations, health attitudes, health appraisals and affective experience. After controlling for socio-demographic variables and functional limitations, beliefs about the importance of physical fitness and strength for a good life and comparative health appraisals were significantly related to physical activity. However, neither negative nor positive affect was associated with physical activity status. Modifiable factors, such as health attitudes toward physical fitness and strength, as well as health appraisals, should be considered for developing effective physical activity promotion interventions among COPD patients.

The Exercising Brain: An Overlooked Factor Limiting the Tolerance to Physical Exertion in Major Cardiorespiratory Diseases?

“Exercise starts and ends in the brain”: this was the title of a review article authored by Dr. Bengt Kayser back in 2003. In this piece of work, the author highlights that pioneer studies have primarily focused on the cardiorespiratory-muscle axis to set the human limits to whole-body exercise tolerance. In some circumstances, however, exercise cessation may not be solely attributable to these players: the central nervous system is thought to hold a relevant role as the ultimate site of exercise termination. In fact, there has been a growing interest relative to the “brain” response to exercise in chronic cardiorespiratory diseases, and its potential implication in limiting the tolerance to physical exertion in patients. To reach these overarching goals, non-invasive techniques, such as near-infrared spectroscopy and transcranial magnetic stimulation, have been successfully applied to get insights into the underlying mechanisms of exercise limitation in clinical populations. This review provides an up-to-date outline of the rationale for the “brain” as the organ limiting the tolerance to physical exertion in patients with cardiorespiratory diseases. We first outline some key methodological aspects of neuromuscular function and cerebral hemodynamics assessment in response to different exercise paradigms. We then review the most prominent studies, which explored the influence of major cardiorespiratory diseases on these outcomes. After a balanced summary of existing evidence, we finalize by detailing the rationale for investigating the “brain” contribution to exercise limitation in hitherto unexplored cardiorespiratory diseases, an endeavor that might lead to innovative lines of applied physiological research.

Perspectives of older adults with a chronic condition on functioning, social participation and health: a qualitative study

Background

Problems with mobility, functioning and social participation make living independently difficult for frail older adults. To continue living independently, therapy adherence is a prerequisite. The causes for non-adherence among older adults are multiple and complex, which is why insight into older adults’ perspectives regarding their functioning is an essential factor to increase therapy adherence.

This study investigates the perspectives of older adults on their functioning, social participation and health, and the factors influencing these elements.

Methods

We conducted a qualitative study on the older adult’s perceived functioning, social participation and health. Fourteen home-dwelling older adults suffering from chronic health issues were purposively selected.

Semi-structured interviews were conducted with open-ended questions.

Data were analysed following the Basic Logical Model of Abduction and Creswell’s coding method.

Results

Assistive devices, the older adult’s dwelling and living environment, professional and informal support, and medication are perceived as important determinants for retaining functioning and social participation.

Attitude, social influence and personal effectiveness were found to influence whether a person performs or participates in an activity. A person’s attitude is related to the significance the activity has to that person, the activity’s importance, personal wellbeing, the person’s values, and their desire for autonomy. Peers and children have a social influence on the level of activity of the older person. Traditions, in particular religious activities, along with personal effectiveness are motivating factors determining whether a person performs or participates in an activity. Personal effectiveness is linked to the person’s belief in their personal competencies and to the relationship between effort and result.

Finally, it appears that the type of coping strategy the older adult adopts, has an influence on their behavior. The participating older adults often used remarkable problem-focused strategies, which had a positive effect on their level of autonomy.

Conclusions

Older adults have identified barriers and facilitators that influence their level of functioning and social participation. These findings help to create a framework for maintaining and increasing therapy adherence, which may be helpful in facilitating occupational therapists and other healthcare professionals to detect determinants of therapy adherence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02365-w.

Objective Data Reveals Gender Preferences for Patients' Primary Care Physician

BACKGROUND AND OBJECTIVES

Most studies based on self-reported data indicate that female patients more often than males have a same-gender preference for their primary care physician (PCP). Because self-reported preferences may not reflect true preferences, we analyzed objective data to investigate patients' preferences for PCP gender.

METHODS

Analyses were performed on 2192 new patients seen within a university-based healthcare system by 13 PCPs (2 male, 11 female) during 2017. New patients were asked about their PCP gender preference when assigned a PCP. We compared the expected prevalence (proportion of males/females in overall patient population) and observed prevalence (gender distribution of patients for each PCP) by PCP gender. A mixed model with PCP as a random effect examined the odds of male and female patients being assigned a same-gender physician.

RESULTS

The expected prevalence of new patients was 65% female and 35% male. The observed prevalence (95% confidence interval [CI]) of male patients among male and female PCPs was, respectively, 59.7% (49.0%-69.5%) and 28.0% (24.0%-32.4%), with neither CI containing the expected prevalence of male patients (35%). Similarly, the observed prevalence of female patients among male and female PCPs was, respectively, 40.3% (95% CI 30.5%-51.0%) and 72.0% (95% CI 67.6%-76.0%), with neither CI containing the expected prevalence of female patients (65%).

CONCLUSIONS

Both male and female patients often preferred to see a same-gender PCP with this preference more pronounced in males. Future research should seek to clarify the relationships between patients' gender preferences, patient-physician gender concordance/discordance, patient satisfaction, and health outcomes.

Self-efficacy and health-related quality of life in chronic obstructive pulmonary disease: A meta-analysis

OBJECTIVE

To determine the association between self-efficacy and health-related quality of life (HRQoL) in people with Chronic Obstructive Pulmonary Disease (COPD) and the moderating effect of self-efficacy type (exercise task, exercise barrier, COPD symptom, general) and HRQoL type (generic, COPD specific).

METHODS

Databases were searched systematically from inception to January 2019. Methodological quality was assessed, and a meta-analysis was conducted following PRISMA guidelines (PROSPERO protocol: CRD42018114846).

RESULTS

Across 31 coefficients, there was a positive relationship between self-efficacy and HRQoL (r = 0.38, 95 %CI [0.32, 0.45]). Exercise barrier self-efficacy had the strongest relationship to HRQoL (r = 0.42, 95 % CI [0.30, 0.52]), followed by COPD symptoms (r = 0.41, 95 % CI [0.33, 0.49]), exercise tasks (r = 0.40, 95 % CI [0.29, 0.50]), and general self-efficacy (r = 0.21, 95 % CI [0.14, 0.28]). Generic HRQoL had a similar relationship to self-efficacy (r = 0.38, 95 % CI [0.28, 0.47]) as COPD specific HRQoL (r = 0.38, 95 % CI [0.30, 0.46]).

CONCLUSION

There is a moderate positive relationship between self-efficacy and HRQoL in COPD, with the relationship stronger for exercise and COPD symptoms than general self-efficacy.

Locomotor Muscles in COPD: The Rationale for Rehabilitative Exercise Training

Exercise training as part of pulmonary rehabilitation is arguably the most effective intervention to improve tolerance to physical exertion in patients with chronic obstructive pulmonary disease (COPD). Owing to the fact that exercise training has modest effects on exertional ventilation, operating lung volumes and respiratory muscle performance, improving locomotor muscle structure and function are key targets for pulmonary rehabilitation in COPD. In the current concise review, we initially discuss whether patients’ muscles are exposed to deleterious factors. After presenting corroboratory evidence on this regard (e.g., oxidative stress, inflammation, hypoxemia, inactivity, and medications), we outline their effects on muscle macro- and micro-structure and related functional properties. We then finalize by addressing the potential beneficial consequences of different training strategies on these muscle-centered outcomes. This review provides, therefore, an up-to-date outline of the rationale for rehabilitative exercise training approaches focusing on the locomotor muscles in this patient population.

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

Changes in quality of life and health status in patients with extracorporeal life support: A prospective longitudinal study

Background

Extracorporeal life support (ECLS) provides emergency pulmonary and cardiac assistance for patients in respiratory or cardiac failure. Most studies evaluate the success of ECLS based on patients’ survival rate. However, the trajectory of health status and quality of life (QOL) should also be important considerations. The study’s aim was to explore changes in health status and QOL in adult patients weaned from ECLS who survived to hospital discharge over a one-year period.

Study design

A prospective longitudinal study was conducted from April 2012 to September 2014. A convenience sample of patients who had undergone ECLS was followed for one-year after hospital discharge. Heath status was measured with a physical activity scale, the Centre for Epidemiologic Studies Depression scale, and a social support scale; we assessed quality of life with the physical and mental component summary scales of the Short-Form 36 Health Survey. Changes in depression, social support, physical activity and QOL were analysed with generalized estimating equations at 3-month intervals; participants’ QOL at 12 months after discharge was compared with the general population.

Results

A total of 231 patients received ECLS during the study period. Sixty-five patients survived to hospital discharge (28% survival rate); 32 participants completed the study. Data showed scores for physical activity increased significantly over time (p < .001), while depression and social support significantly decreased (p < .05 and p < .001, respectively). Participants with veno-venous ECLS had higher scores for depression than participants with veno-arterial ECLS (p < .05). PCS scores significantly increased at 9, and 12 months after discharge (p < .05 and p < .001, respectively). There was no significant change in MCS scores.

Conclusions

This was a preliminary study of patients with ECLS following hospital discharge over a one-year period. One year following hospital discharge survivors of ECLS continued to experience physical complications and some continued to have depressive symptoms; the level of social support was significantly lower after hospital discharge. Healthcare professionals should understand the trajectory of health status and QOL after discharge, which can help developing evidence-based interventions and improve QOL for survivors of ECLS.

Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether patient- and family-centered care interventions in the ICU improve outcomes.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.

STUDY SELECTION

We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.

DATA EXTRACTION

We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.

DATA SYNTHESIS

There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.

CONCLUSIONS

Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

Development of a Conceptual Model of Disease Progression for Use in Economic Modeling of Chronic Obstructive Pulmonary Disease

BACKGROUND

To develop and validate a new conceptual model (CM) of chronic obstructive pulmonary disease (COPD) for use in disease progression and economic modeling. The CM identifies and describes qualitative associations between disease attributes, progression and outcomes.

METHODS

A literature review was performed to identify any published CMs or literature reporting the impact and association of COPD disease attributes with outcomes. After critical analysis of the literature, a Steering Group of experts from the disciplines of health economics, epidemiology and clinical medicine was convened to develop a draft CM, which was refined using a Delphi process. The refined CM was validated by testing for associations between attributes using data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE).

RESULTS

Disease progression attributes included in the final CM were history and occurrence of exacerbations, lung function, exercise capacity, signs and symptoms (cough, sputum, dyspnea), cardiovascular disease comorbidities, 'other' comorbidities (including depression), body composition (body mass index), fibrinogen as a biomarker, smoking and demographic characteristics (age, gender). Mortality and health-related quality of life were determined to be the most relevant final outcome measures for this model, intended to be the foundation of an economic model of COPD.

CONCLUSION

The CM is being used as the foundation for developing a new COPD model of disease progression and to provide a framework for the analysis of patient-level data. The CM is available as a reference for the implementation of further disease progression and economic models.

Quality of life and its association with direct medical costs for COPD in urban China

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide. Few studies have focused on the quality of life (QoL) associated medical costs for COPD in China.

Methods

A cross-sectional survey of 678 COPD patients was conducted in four major cities (Beijing, Shanghai, Guangzhou and Chengdu), China, in 2011. Data on socio-demographic information, health conditions and medical costs were collected through a face-to-face interview combined with medical record searching. The EuroQol (EQ-5D) health questionnaire was applied to assess the QoL of COPD patients.

Results

Among 678 patients with COPD, nearly 40% had difficulties in mobility, usual activities and pain/discomfort, one third had various degrees of anxiety/depression, and one fifth had difficulties in self-care. The COPD patients had a median utility score of 0.768 and a median visual analog scale score of 70. The degree of difficulties in any dimensions significantly increased, and utility and health scores decreased with severity of the disease. Age, gender and disease severity were significantly associated with the quality of life after taking other covariates into consideration. Poorer QoL was a significant indicator of higher direct medical costs for COPD patients.

Conclusion

Impaired quality of life was significantly linked to increased medical costs for COPD patients and could be an important measure for policy- and decision-making in COPD care.

Patient perceptions of patient-centred care: empirical test of a theoretical model

AIM

Patient perception measures are gaining increasing interest among scholars and practitioners. The aim of this study was to empirically examine a conceptual model of patient-centred care using patient perception survey data.

BACKGROUND

Patient-centred care is one of the Institute of Medicine's objectives for improving health care in the 21st century. Patient interviews conducted by the Picker Institute/Commonwealth Fund in the 1980s resulted in a theoretical model and survey questions with dimensions and attributes patients defined as patient-centered.

METHOD

The present study used survey data from patients with overnight visits at 142 U.S. hospitals.

RESULTS

Regression analysis found significant support for the theoretical model. Perceptions of emotional support had the strongest relationship with overall care ratings. Coordination of care, and physical comfort were strongly related as well.

CONCLUSION

Understanding how patients experience their care can help improve understanding of what patients believe is patient-centred, and of how care processes relate to important patient outcomes.

Therapeutic paralysis in veterans with COPD

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a common disorder of Veterans that causes significant morbidity and mortality. To measure Veterans' perceptions about COPD, the effect of COPD on their lives and health, and their needs for improved health, we performed a postal survey.

METHODS

3263 Veterans with a diagnosis of COPD who received care at the Cincinnati Veterans Affairs Medical Center in 2008 were stratified into quintiles by Veterans Health Administration-associated COPD healthcare cost and uniformly sampled.

RESULTS

493 of 1000 surveys (49%) were completed and returned. COPD had different effects on respondents in top and bottom quintiles (highest and lowest COPD-related cost) for: knowledge of COPD diagnosis (89% vs. 73%, p = 0.03); activities affected by breathing, including work (69% vs. 45%), recreation (85% vs. 62%), change in living arrangements (36% vs 16%), and increased need for help (54% vs. 25%) (p < 0.05 for all comparisons); emotional effect of respiratory symptoms, including depression (53% vs. 30%), fear (41% vs. 15%), and helplessness (49% vs. 24%) (p < 0.05 for all comparisons). 91% of Veterans were prescribed inhalers and one-quarter had difficulties using them. 25% of Veterans did nothing when they had symptoms of an exacerbation.

CONCLUSIONS

COPD has profound effects on Veterans' breathing related activities and generates many negative emotions. Primary care providers are critical in conveying the diagnosis of COPD and providing information about the disease and its management. Veterans with COPD adhere poorly to their medications, and report little instruction about COPD or its management.

Functional and psychological variables both affect daily physical activity in COPD: a structural equations model

BACKGROUND

Daily physical activity (DPA) level is reduced in patients with COPD. The aim of this study was to investigate the association of DPA with functional and psychological variables in these patients.

METHODS

155 COPD patients (102 males, median (IQR) age 62 years (54-69 years), predicted FEV1 60% (40-75%) were included. We assessed DPA (DigiWalker SW-200), functional capacity and psychological factors.

RESULTS

DPA level was significantly associated with all functional capacity variables and two psychological variables (Perceived Physical Ability Subscale, depression subscale of the Hospital Anxiety and Depression Scale). The six-minute walking distance and St. George Respiratory Questionnaire activity score explained 37% of the variance of DPA in a regression analysis. A structural equations model revealed that psychological variables indirectly explained DPA through functional capacity variables. DPA was stronger associated with functional capacity variables and weaker with psychological variables in patients with lower functional status than in patients with higher functional status.

CONCLUSIONS

Higher levels of DPA are associated with better functional capacity, but interestingly, DPA is also affected by psychological factors, though only indirectly, via functional capacity. The effect of specific treatment addressing psychological factors on DPA level and exercise tolerance needs further investigation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00614796.

The minimal important difference of the pulmonary functional status and dyspnea questionnaire in patients with severe chronic obstructive pulmonary disease

Background

The modified version of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M) is used in patients with COPD to obtain information about their functional status. It consists of 3 components (change in activities, dyspnea and fatigue) ranging from 0 to 100 and has been shown to be responsive following pulmonary rehabilitation (PR). The interpretation of changes in PFSDQ-M score after an intervention is difficult in the absence of the minimal important difference (MID) of the PFSDQ-M. This study aims at investigating the MID of the PFSDQ-M.

Methods

We enrolled 301 patients with COPD (FEV₁ 42 ± 15%pred) that completed the PFSDQ-M before and after a 3-month PR program (∆Chronic Respiratory Disease Questionnaire (CRDQ) +16 ± 12 points, ∆Six-minute walking distance (6MWD) +47 ± 89 m, both p < 0.001). An anchor-based approach consisted of calculating the correlation between the ∆PFSDQ-M and anchors with an established MID (∆CRDQ and ∆6MWD). Linear regression analyses were performed to predict the MID from these anchors. Secondly several distribution-based approaches (Cohen’s effect size, empirical rule effect size and standard error of measurement method) were used.

Results

Anchor-based estimates for the different PFSDQ-M-components were between −3 and −5 points based on CRDQ score and −6 (only calculated for change in activities) based on 6MWD. Using the distribution-based methods, the estimates of MID ranged from −3 to −5 points for the different components.

Conclusions

We concluded that the estimate of MID of the PFSDQ-M after pulmonary rehabilitation corresponds to a change of 5 points (range - 3 to −6) in each component in patients with severe COPD.

Patient reported determinants of health: a qualitative analysis of veterans with chronic obstructive pulmonary disease

Although COPD is a common disorder of veterans who receive care from the Veterans Healthcare Administration (VHA), the perceptions of veterans with COPD about their disease, its effects on their lives, and their interactions with the VHA have not been determined. Utilizing qualitative methodology, we conducted focus groups of veterans with COPD at the Cincinnati VA Medical Center. Participants were selected by systematic sampling from the top quintile of veterans stratified by the cost of healthcare utilization related to a primary diagnosis of COPD and grouped by age and use of supplemental oxygen. All 42 participants were male and had a mean age of 65 years. Analysis of the focus group transcripts demonstrated five major themes: 1) Physical and Functional Limitations: work and employment constraints, recreation restrictions, limits on activities of daily living, reduced sexuality, concerns about housing and finances, and physical symptoms; 2) Restricted Social Interactions/Altered Social Networks: altered relationships with friends and family and reliance upon family and care givers; 3) Emotional Effects: reduced self-worth, vulnerability, depression, perseverance and adaptation, hopelessness, fear, pride, and lack of control; 4) Limitations in the Understanding of COPD: unawareness of diagnosis, triggers and reaction to disease manifestations, COPD management; and 5) Complex Healthcare Interactions. COPD pervasively and extensively affects all aspects of veterans' lives and causes significant consequences for their care and management.

Patient-Centered Care and Outcomes

Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. Three databases were searched for all years through September 2012. We retained 40 articles for the analysis. Results found mixed relationships between PCC and clinical outcomes, that is, some studies found significant relationships between specific elements of PCC and outcomes but others found no relationship. There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC–outcomes relationship.

Differences between community professional and patient perceptions of chronic obstructive pulmonary disease treatment outcomes: a qualitative study

AIMS AND OBJECTIVES

This study aims to define, compare and order 'assessed needs and defined outcomes' of professional providers of chronic obstructive pulmonary disease services with patients' 'prioritised needs and defined outcomes' and relate these to service provision.

BACKGROUND

Long-term morbidity and death rates from respiratory diseases in the UK are increasing. Few studies report patient views and perceptions of needs or priorities for respiratory conditions in primary care. None compare patient's and health professional's perceptions of patient needs, which may identify specific changes for service delivery.

DESIGN

A qualitative study using focus group discussion and nominal group technique to define, compare and order professional's and patient's groups' statements to prioritise perceptions.

METHOD

Specialist professionals and patients with chronic obstructive pulmonary disease were recruited to focus groups using systematic purposive sampling. Nominal group ordering of agreed statements occurred after the discussions followed by presentation of results to groups for validation.

RESULTS

Four key perceptions ordered and compared show both professionals and patients agreed that access to equitably provided services included more respiratory rehabilitation; other priorities indicate key differences between professional's and patient's perceptions of financial support, the communication of health education and the need for better provision of palliative care at end of life.

CONCLUSIONS

The study offers new knowledge about what patients in all stages of the disease process consider important for services that will retain their independence. This qualitative study illuminates and compares professional's and patient's priorities for service delivery and their perceptions of chronic obstructive pulmonary disease services.

RELEVANCE TO CLINICAL PRACTICE

Changing respiratory services to support patient's perceived needs enhances their independence.

Self-management abilities, physical health and depressive symptoms among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes

OBJECTIVE

This study aimed to identify the predictive role of direct resources (educational level and marital status) and self-management abilities on physical health and depressive symptoms in patients with cardiovascular diseases (CVD), diabetes, or chronic obstructive pulmonary disease (COPD).

METHODS

Our cross-sectional questionnaire-based study included 1570 CVD patients, 917 COPD patients, and 412 patients with diabetes.

RESULTS

Physical health and depressive symptoms of COPD patients was lower than those of CVD and diabetic patients. Correlation analyses indicated that self-management abilities were strong indicators for physical health and depressive symptoms (all p<0.001). This relationship was strongest for depressive symptoms. Self-management abilities were related to educational level in all groups (all p<0.001). Regression analyses revealed that self-management abilities were strong predictors of physical health and depressive symptoms in all three patient groups (all p<0.001).

CONCLUSION

This research showed that self-management abilities are strong predictors of physical health and depressive symptoms.

PRACTICE IMPLICATIONS

Interventions that improve self-management abilities may counteract a decline in physical health and depressive symptoms. Such interventions may be important tools in the prevention of the loss of self-management abilities, because they may motivate people who are not yet experiencing serious problems.

Factors influencing self-management in chronic obstructive pulmonary disease: an integrative review

BACKGROUND

Chronic obstructive pulmonary disease is a common, chronic and burdensome condition requiring the individual to engage in a range of self-management strategies. The capacity to engage in self-management is dependent on a range of internal (e.g., personal) and external (e.g., health service) factors.

OBJECTIVES

This paper seeks to define self-management, identify the determinants which influence the individual's ability to cope and adjust to living with chronic obstructive pulmonary disease in the community, and identify implications for clinical practice and research.

DESIGN

Integrative review.

DATA SOURCES

Medline, Embase, PubMed, CINAHL, Google Scholar.

REVIEW METHODS

Integrative review using prospective research questions. Papers were included in the review if they were published in peer reviewed journals and written in English between 2000 and 2010. Articles were accepted for inclusion if they discussed the determinants that influenced self-management of chronic obstructive pulmonary disease in the community. Confirmation of results and discussion themes was validated by specialists in chronic obstructive pulmonary disease and complex care.

FINDINGS

Self-management is less well characterised in chronic obstructive pulmonary disease compared with other chronic conditions. Functional limitation and the need to balance disease management with everyday life are the two key elements that patients face in managing their condition. Provider characteristics, socioeconomic status and health literacy are sparsely discussed yet are known to influence chronic obstructive pulmonary disease self-management.

CONCLUSIONS

Chronic obstructive pulmonary disease self-management must be a key focus internationally as the disease incidence increases. Collaborative care is required between patients and health providers in order facilitate patients in confident management of their condition.

Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies

Complete surgical resection is the most effective curative treatment for lung cancer. However, many patients with lung cancer also have severe COPD which increases their risk of postoperative complications and their likelihood of being considered "inoperable." Preoperative pulmonary rehabilitation (PR) has been proposed as an intervention to decrease surgical morbidity but there is no established protocol and no randomized study has been published to date. We tested two preoperative PR interventions in patients undergoing lung cancer resection and with moderate-severe COPD in a randomized single blinded design. Outcomes were length of hospital stay and postoperative complications. The first study tested 4 weeks of guideline-based PR vs. usual care: that study proved to be very difficult to recruit as patients and providers were reluctant to delay surgery. Nine patients were randomized and no differences were found between arms. The second study tested ten preoperative PR sessions using a customized protocol with nonstandard components (exercise prescription based on self efficacy, inspiratory muscle training, and the practice of slow breathing) (n=10) vs. usual care (n=9). The PR arm had shorter length of hospital stay by 3 days (p=0.058), fewer prolonged chest tubes (11% vs. 63%, p=0.03) and fewer days needing a chest tube (8.8 vs. 4.3 days p=0.04) compared to the controlled arm. A ten-session preoperative PR intervention may improve post operative lung reexpansion evidenced by shorter chest tube times and decrease the length of hospital stay, a crude estimator of post operative morbidity and costs. Our results suggest the potential for short term preoperative pulmonary rehabilitation interventions in patients with moderate-severe COPD undergoing curative lung resection. 4 weeks of conventional preoperative PR seems non feasible.

Effects of pulmonary rehabilitation on quality of life in chronic obstructive pulmonary disease patients

PURPOSE OF REVIEW

Pulmonary rehabilitation plays a key role in the management of chronic obstructive pulmonary disease (COPD). Although the American Thoracic Society recently provided a grade of 1A for evidence of health-related quality of life (HRQoL) benefits related to pulmonary rehabilitation, knowledge about the psychological and behavioral processes explaining the impact of pulmonary rehabilitation on HRQoL in COPD patients remains limited. This review describes the state of knowledge over the past year concerning HRQoL benefits after pulmonary rehabilitation and suggests avenues for future research.

RECENT FINDINGS

HRQoL outcomes related to pulmonary rehabilitation explores five themes: optimizing pulmonary rehabilitation components to improve HRQoL; characterization of a responder phenotype; suitability of pulmonary rehabilitation following acute exacerbations; exploration of psychological and behavioral mechanisms explaining pulmonary rehabilitation benefits; and long-term maintenance of HRQoL benefits after pulmonary rehabilitation.

SUMMARY

Evidence supports the use of pulmonary rehabilitation to improve HRQoL in patients with moderate-to-severe COPD. However, it is unclear how pulmonary rehabilitation improves HRQoL and which characteristics confer the greatest HRQoL benefits. Moreover, most studies failed to provide a compelling theoretical rationale for the intervention employed. Future research should focus on improving the understanding of the psychological mechanisms implicated in the adoption and maintenance of healthy behavior.

Consequences of physical inactivity in chronic obstructive pulmonary disease

The many health benefits of regular physical activity underline the importance of this topic, especially in this period of time when the prevalence of a sedentary lifestyle in the population is increasing. Physical activity levels are especially low in patients with chronic obstructive pulmonary disease (COPD). Regular physical activity and an active lifestyle has shown to be positively associated with outcomes such as exercise capacity and health-related quality of life, and therefore could be beneficial for the individual COPD patient. An adequate level of physical activity needs to be integrated into daily life, and stimulation of physical activity when absent is important. This article aims to discuss in more detail the possible role of regular physical activity for a number of well-known outcome parameters in COPD.

Application of a theoretical model to evaluate COPD disease management

BACKGROUND

Disease management programmes are heterogeneous in nature and often lack a theoretical basis. An evaluation model has been developed in which theoretically driven inquiries link disease management interventions to outcomes. The aim of this study is to methodically evaluate the impact of a disease management programme for patients with chronic obstructive pulmonary disease (COPD) on process, intermediate and final outcomes of care in a general practice setting.

METHODS

A quasi-experimental research was performed with 12-months follow-up of 189 COPD patients in primary care in the Netherlands. The programme included patient education, protocolised assessment and treatment of COPD, structural follow-up and coordination by practice nurses at 3, 6 and 12 months. Data on intermediate outcomes (knowledge, psychosocial mediators, self-efficacy and behaviour) and final outcomes (dyspnoea, quality of life, measured by the CRQ and CCQ, and patient experiences) were obtained from questionnaires and electronic registries.

RESULTS

Implementation of the programme was associated with significant improvements in dyspnoea (p < 0.001) and patient experiences (p < 0.001). No significant improvement was found in mean quality of life scores. Improvements were found in several intermediate outcomes, including investment beliefs (p < 0.05), disease-specific knowledge (p < 0.01; p < 0.001) and medication compliance (p < 0.01). Overall, process improvement was established. The model showed associations between significantly improved intermediate outcomes and improvements in quality of life and dyspnoea.

CONCLUSIONS

The application of a theory-driven model enhances the design and evaluation of disease management programmes aimed at improving health outcomes. This study supports the notion that a theoretical approach strengthens the evaluation designs of complex interventions. Moreover, it provides prudent evidence that the implementation of COPD disease management programmes can positively influence outcomes of care.