Living with chronic obstructive pulmonary disease: a survey of patients' knowledge and attitudes

Patient Engagement in Health Coaching and Self-Management Abilities in Chronic Obstructive Pulmonary Disease

Objective: Health coaching has the potential to improve self-management abilities (SM) in patients with Chronic Obstructive Pulmonary Disease (COPD). Patient engagement with health care providers has a beneficial effect on patient outcomes. We examined the association of patient engagement with the health coach on SM abilities in patients with COPD. Methods: We analyzed the association between the degree of engagement measured by the Working Alliance Inventory (WAI-SR) and the SM measured by the Self-Management-Ability-Scale-30 (SMAS-30) at the end of a COPD health coaching intervention. Results: The cohort included 146 moderate to severe COPD patients. The WAI-SR total score was 85% of the maximum possible scores indicating a high degree of engagement between the health coach and the patients. The WAI-SR Task and Bond domains were positively associated with SM abilities after adjusting for lung function (FEV1 %) and depression symptoms (PHQ-2). Conclusion: The degree of engagement between a health coach and patients is associated with the perception of SM abilities in patients with COPD. Our results may inform self-management intervention and clinical practice.

2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD

Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients.

Knowledge of Vaccination Against Influenza and Pneumococcus in Patients with Chronic Obstructive Pulmonary Disease in an Integrated Care Program

Purpose

To compare the level of knowledge in vaccination against influenza and pneumococcus of patients with chronic obstructive pulmonary disease (COPD) who are managed in an Integrated Care Program (ICP) with those who receive usual care (UC).

Methods

A telephone survey of patients diagnosed with COPD registered in public care networks or private institutions was done. A descriptive and comparative analysis of the characteristics of the ICP and UC groups was carried out. The relationship between belonging to an ICP and the level of knowledge about vaccination was evaluated using Propensity Score Matching (PSM) and multivariate logistic and ordinal regression models.

Results

Of 674 study participants, 27.2% were from the ICP group. ICP patients were older, more frequently men, from a higher socioeconomic stratum and a higher educational level (p<0.05). 75.5% of the patients in the ICP group had a high level of vaccination knowledge compared to 42.7% in the UC group (p<0.001). In the multivariate analysis, adjusting for sociodemographic variables, years of COPD diagnosis, and comorbidities, belonging to the ICP was associated with a higher probability of answering questions about vaccination correctly and having a high level of knowledge (OR 3.397, IC 95% 2.058-5.608, p<0.001).

Conclusion

Patients with COPD managed in an ICP have a higher level of knowledge in vaccination against influenza and pneumococcus, compared to patients in usual care.

Experiences With In-Person and Virtual Health Care Services for People With Chronic Obstructive Pulmonary Disease: Qualitative Study

BACKGROUND

The World Health Organization and the European Commission predict increased use of health technologies in the future care for patients in Europe. Studies have shown that services based on telehealth, which includes components of education, as well as rehabilitation initiatives can support the self-management of individuals living with COPD. This raises an interest in how virtual and in-person interactions and roles can best be organized in a way that suits people living with COPD in relation to their treatment and rehabilitation.

OBJECTIVE

This study aims to investigate how individuals living with COPD experience different combinations of virtual and in-person care, to help us better understand what aspects are valued and how to best combine elements of these services in future care.

METHODS

Two rounds of semistructured interviews were conducted with 13 and 4 informants, respectively. The individuals were all recruited in relation to a research project led by the telehealth initiative Epital Health. The first round of interviews included 11 informants, as 2 dropped out. Of these, 7 received the telemedicine service provided by Epital Health, 3 participated in a 12-week COPD program provided by their respective municipality, and 1 did not receive any supplementary service besides the usual care. In the second round, which included 4 informants, all had at one point received the telemedicine service and participated in a municipality-based rehabilitation program. A content analysis of the interviews was performed based on deductive coding with 4 categories, namely, (1) Self-management, (2) Health-related support, (3) Digital context, and (4) Well-being.

RESULTS

Medical and emotional support from health care professionals is a key aspect of care for individuals with COPD. Acute treatment with at-home medicine, monitoring one's own condition through technology, and having easy access and close contact with health care professionals familiar to them can promote self-management and well-being, as well as provide a feeling of security. Having regular meetings with a network of peers and health care professionals provides education, support, and tools to cope with the condition and improve own health. Furthermore, group-based activity motivates and increases the activity level of the individuals. Continued offers of services are desired as many experience a decrease in achieved benefits after the service ends. More emphasis is placed on the importance of the therapeutic and medical elements of care compared with factors such as technology. The identified barriers related to optimal utilization of the virtual service were related to differentiation in levels of contact depending on disease severity and skills related to the practical use of equipment.

CONCLUSIONS

A combination of virtual and in-person services providing lasting medical and social support is suggested for the future. This should build upon the preferences and needs of individuals living with COPD and support relationships to caregivers and peers.

[Smoking cessation treatment for smokers with COPD: The importance of therapeutic education]

Smoking is a major risk factor for chronic obstructive pulmonary disease (COPD). The diagnosis of tobacco addiction and management of tobacco dependence are part and parcel of COPD treatment, especially in respiratory rehabilitation. Management encompasses psychological support, validated treatments and therapeutic education. The objective of this review is to briefly recall the guiding principles of therapeutic patient education (TPE) as it applies to smokers wishing to quit and, more specifically, to present the tools conducive to shared educational assessment and treatment according to the Prochaska's stages of change model. We are also proposing an action plan and a questionnaire through which TPE sessions can be assessed. Finally, culturally adapted interventions and new communication technologies are taken into consideration insofar as they constructively contribute to TPE.

Online Health Information Seeking Among Patients With Chronic Conditions: Integrating the Health Belief Model and Social Support Theory

BACKGROUND

Chronic diseases are the leading causes of death and disability. With the growing patient population and climbing health care expenditures, researchers and policy makers are seeking new approaches to improve the accessibility of health information on chronic diseases while lowering costs. Online health information sources can play a substantial role in effective patient education and health communication. However, some contradictory evidence suggests that patients with chronic conditions may not necessarily seek online health information.

OBJECTIVE

This study aims to integrate 2 theories (ie, the health belief model and social support theory) and a critical health literacy perspective to understand online health information seeking (OHIS) among patients with chronic conditions.

METHODS

We used the survey method to collect data from online chronic disease communities and groups on social media platforms. Eligible participants were consumers with at least 1 chronic condition and those who have experience with OHIS. A total of 390 valid questionnaires were collected. The partial least squares approach to structural equation modeling was employed to analyze the data.

RESULTS

The results suggested that perceived risk (t=3.989, P<.001) and perceived benefits (t=3.632, P<.001) significantly affected patients' OHIS. Perceived susceptibility (t=7.743, P<.001) and perceived severity (t=8.852, P<.001) were found to influence the perceived risk of chronic diseases significantly. Informational support (t=5.761, P<.001) and emotional support (t=5.748, P<.001) also impacted the perceived benefits of online sources for patients. In addition, moderation analysis showed that critical health literacy significantly moderated the link between perceived risk and OHIS (t=3.097, P=.002) but not the relationship between perceived benefits and OHIS (t=0.288, P=.774).

CONCLUSIONS

This study shows that the health belief model, when combined with social support theory, can predict patients' OHIS. The perceived susceptibility and severity can effectively explain perceived risk, further predicting patients' OHIS. Informational support and emotional support can contribute to perceived benefits, thereby positively affecting patients' OHIS. This study also demonstrated the important negative moderating effects of critical health literacy on the association between perceived risk and OHIS.

COPD disease knowledge, self-awareness and reasons for hospital presentations among a predominately Indigenous Australian cohort: a study to explore preventable hospitalisation

Background

The prevalence of chronic obstructive pulmonary disease (COPD) is higher among Indigenous Australians than that of non-Indigenous Australians. However, no studies have investigated COPD disease awareness and knowledge among Indigenous Australians. In this study, we assessed the COPD disease awareness among Indigenous and non-Indigenous patients in the Top End Health Service region of the Northern Territory of Australia.

Methods

Of a total convenience sample of 100 adults, 86 patients consented to participate in this study over a 15-month period. A structured interview was conducted to identify participant’s level of knowledge about COPD, medications, self-management, healthcare interaction and utilisations.

Results

Most (69%) participants were Indigenous and men (52%). Indigenous patients were significantly younger (mean 56 vs 68 years p<0.001), with a higher proportion of remote residence and current smoking. COPD knowledge across the cohort was low, with 68% of Indigenous and 19% of non-Indigenous participants reporting they ‘know nothing/had never heard of COPD’. Most patients self-reported use of puffers/inhalers and were able to identify medication used; however, adherence to therapy was observed in only 18%. Shortness of breath was the most common symptom for hospital presentation (83%) and 69% of Indigenous patients reported seeking medical attention during an exacerbation. Self-management and COPD action plans were poorly implemented. A significant proportion (49%) reported ≥2 hospital admissions in the preceding 12 months. During exacerbation, although the majority of Indigenous patients were transferred to a tertiary centre from remote communities, patient’s preference was to be managed in their respective local communities.

Conclusions

Awareness and understanding of COPD are low in this cohort on several domains. Tailored and culturally appropriate initiatives for both patients and health professionals alike are required to improve COPD disease management among Indigenous population. This will not only improve quality of life but also reduce recurrent hospitalisation, healthcare cost and utilisation.

Disease-related knowledge in people with chronic obstructive pulmonary disease and their informal caregivers: A multilevel modelling analysis

AIMS AND OBJECTIVES

To assess the level of chronic obstructive pulmonary disease (COPD)-related knowledge within patient and informal caregiver dyads, and to identify factors influencing the knowledge level considering the interdependence within the dyads.

BACKGROUND

Patients with COPD and their informal caregivers present poor disease knowledge and different characteristics are associated with their level of knowledge. Disease knowledge and related characteristics have been assessed separately in patients and informal caregivers, without considering possible influence within the dyads.

DESIGN

Cross-sectional study.

METHODS

A convenience sample of dyads was recruited in outpatient and inpatient settings in Central and South Italy. The Bristol COPD Knowledge Questionnaire was used to measure disease knowledge. Sociodemographic, clinical and caregiving characteristics, self-efficacy and depression were measured in patients and caregivers. Multilevel modelling was used to analyse COPD knowledge at the level of the dyad to control for interdependency between patients and informal caregivers. The STROBE guidelines for cross-sectional studies were followed for study reporting.

RESULTS

We recruited 133 dyads. The total level of correct knowledge shared by dyads was 32.89%. Dyads presented higher levels of correct knowledge about disease symptoms, smoking cessation and vaccination, and lower about COPD treatment. Younger patients with greater self-efficacy, who attended pulmonary rehabilitation and were cared for by a spouse/partner with low levels of depression, and informal caregivers who were patients' spouse/partner were more likely to have higher levels of disease-related knowledge.

CONCLUSIONS

Our study advances dyadic research in COPD. Future studies should investigate the effects of shared knowledge and incongruent knowledge (where one member knows more than the other) on patient self-care and caregiver contribution to patient self-care.

RELEVANCE TO CLINICAL PRACTICE

Our study shows what knowledge nurses should provide in educational programmes directed at patients and caregivers, and which dyads have greater knowledge deficits, to whom offer targeted educational interventions.

Comparing Self-management Programs with and without Peer Support Among Patients with Chronic Obstructive Pulmonary Disease

RATIONALE

Self-management support (SMS) is an essential component of care for patients who have chronic obstructive pulmonary disease (COPD), but there is little evidence on how to provide SMS most effectively to these patients. Peer support (i.e. support provided by a person with a similar medical condition) has been successfully used to promote self-management among patients with various chronic conditions, yet no randomized studies have focused on testing its effects for patients with COPD.

OBJECTIVES

To assess whether adding peer support to healthcare professional support to help patients with COPD self-management results in better health-related quality of life (HRQOL) and less acute care use.

METHODS

A 2-arm randomized controlled trial (RCT) was performed at one academic and one community hospital, and their affiliate clinics. Study population included patients aged ≥40 years who had been diagnosed with COPD by a physician and were currently receiving daily treatment for it. Two SMS strategies were compared over six-months. One strategy relied on the healthcare professional (HCP) for COPD self-management (HCP Support); the other used a dual approach involving both healthcare professionals and peer supporters (HCP Plus Peer Support). The primary outcome was change in HRQoL measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months (range 0-100, lower is better; 4-point meaningful difference). Secondary outcomes included the COPD-related and all-cause hospitalizations and ED visits. Analysis was conducted under intention to treat.

RESULTS

The number of enrolled participants was 292. Mean age was 67.7 (SD 9.4) years; 70.9% white and 61.3% female . SGRQ scores were not significantly different between the study arms. HCP Plus Peer arm participants had fewer COPD-related acute care events at 3 months ( incidence rate ratio (IRR) 0.68 ; 95% CI 0.50 - 0.93), and 6 months ( IRR 0.84 ; 95% CI 0.71 - 0.99).

CONCLUSIONS

Adding peer support to HCP support to help patients self-manage COPD, did not further improve HRQoL in this study. However, it did result in fewer COPD-related acute care events during the 6-month intervention period. Clinical trial registered with ClinicalTrials.gov (NCT02891200).

Level of Knowledge About COPD Among Patients and Caregivers

Chronic obstructive pulmonary disease (COPD) represents a major health burden worldwide. COPD-specific education may positively affect the emotional distress associated with the disease and may contribute to the patients' poor health-related quality of life. Studies have shown that education regarding COPD is lacking among disease sufferers. The aim of our study was to evaluate the knowledge of COPD among patients and caregivers. We used the Bristol COPD Knowledge Questionnaire in hospitalized and nonhospitalized patients with COPD and other pulmonary diseases, their caregivers, and healthy volunteers. Mean total knowledge score of patients with COPD was 24.27 ± 8.44, of patients with other respiratory diseases 25.53 ± 7.93, of caregivers of patients with COPD 21.80 ± 5.32, of caregivers of patients with other pulmonary diseases 23.50 ± 8.79, and of healthy subjects 25.85 ± 9.27 (p = 0.071). Our data further indicate the lack of knowledge of COPD among patients and their carers and emphasize the need of education programs.

Effectiveness of Peri-Discharge Complex Interventions for Reducing 30-Day Readmissions among COPD Patients: Overview of Systematic Reviews and Network Meta-Analysis

BACKGROUND

An overview of systematic reviews(SRs) and network meta-analysis(NMA) were conducted to evaluate the comparative effectiveness of peri-discharge complex interventions for reducing 30-day readmissions among chronic obstructive pulmonary disease(COPD) patients.

METHODS

Five databases were searched for SRs of randomized controlled trials(RCTs). An additional search was conducted for updated RCTs from database inception until Jun 2020. Pooled effect of peri-discharge complex interventions was assessed using random-effect pairwise meta-analyses. Comparative effectiveness across different peri-discharge complex interventions was evaluated using NMA.

RESULTS

Nine SRs and 11 eligible RCTs(n = 1,422) assessing eight different peri-discharge complex interventions were included. For reducing 30-day all-cause readmissions, pairwise meta-analysis showed no significant difference between peri-discharge complex interventions and usual care, while NMA indicated no significant differences among different peri-discharge complex interventions as well as usual care. For reducing 30-day COPD-related readmissions, peri-discharge complex interventions were significantly more effective than usual care (pooled RR = 0.45, 95% CI:0.24-0.84).

CONCLUSIONS

Peri-discharge complex interventions may not differ from usual care in reducing 30-day all-cause readmissions among COPD patients but some are more effective for lowering 30-day COPD-related readmission. Thus, complex intervention comprising core components of patient education, self-management, patient-centred discharge instructions, and telephone follow up may be considered for implementation, but further evaluation is warranted.

Short-Video Apps as a Health Information Source for Chronic Obstructive Pulmonary Disease: Information Quality Assessment of TikTok Videos

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has become one of the most critical public health problems worldwide. Because many COPD patients are using video-based social media to search for health information, there is an urgent need to assess the information quality of COPD videos on social media. Recently, the short-video app TikTok has demonstrated huge potential in disseminating health information and there are currently many COPD videos available on TikTok; however, the information quality of these videos remains unknown.

OBJECTIVE

The aim of this study was to investigate the information quality of COPD videos on TikTok.

METHODS

In December 2020, we retrieved and screened 300 videos from TikTok and collected a sample of 199 COPD-related videos in Chinese for data extraction. We extracted the basic video information, coded the content, and identified the video sources. Two independent raters assessed the information quality of each video using the DISCERN instrument.

RESULTS

COPD videos on TikTok came mainly from two types of sources: individual users (n=168) and organizational users (n=31). The individual users included health professionals, individual science communicators, and general TikTok users, whereas the organizational users consisted of for-profit organizations, nonprofit organizations, and news agencies. For the 199 videos, the mean scores of the DISCERN items ranged from 3.42 to 4.46, with a total mean score of 3.75. Publication reliability (P=.04) and overall quality (P=.02) showed significant differences across the six types of sources, whereas the quality of treatment choices showed only a marginally significant difference (P=.053) across the different sources.

CONCLUSIONS

The overall information quality of COPD videos on TikTok is satisfactory, although the quality varies across different sources and according to specific quality dimensions. Patients should be selective and cautious when watching COPD videos on TikTok.

Efficacy of Web-Based Supportive Interventions in Quality of Life in COPD Patients, a Systematic Review and Meta-Analysis

Background: Adults living with Chronic Obstructive Pulmonary Disease (COPD) often have difficulties when trying to access health care services. Interactive communication technologies are a valuable tool to enable patients to access supportive interventions to cope with their disease. The aim of this revision and meta-analysis is to analyze the content and efficacy of web-based supportive interventions in quality of life in COPD. Methods: Medline (via PubMed), Web of Science, and Scopus were the databases used to select the studies for this systematic review. A screening, analysis, and assessment of the methodological quality was carried out by two independent researchers. A meta-analysis of the extracted data was performed. Results: A total of 9 of the 3089 studies reviewed met the inclusion criteria. Most repeated web content elements were educational and involved communication with healthcare professional content. Finally, seven of the nine studies were included in a quantitative analysis. Web-based supportive interventions significantly improved quality of life when added to usual care (SMD = −1.26, 95% CI = −1.65, −0.86; p < 0.001) but no significant differences were found when compared with an autonomous pedometer walking intervention (p = 0.64) or a face-to-face treatment (p = 0.82). Conclusion: This systematic review and meta-analysis suggests that web-based supportive interventions may complement or accompany treatments in COPD patients due to the advantages of online interventions. The results obtained should be treated with caution due to the limited number of studies in this area and methodological weaknesses.

Patient's awareness on COPD is the strongest predictor of persistence and adherence in treatment-naïve patients in real life: a prospective cohort study

BACKGROUND

There is little evidence about the factors that predict persistence/adherence in treatment-naïve patients with COPD in clinical practice. The aim of this study was to evaluate persistence and adherence levels among treatment-naïve patients diagnosed with COPD who had a prescribed inhaled medication, using data from real-world clinical practice.

METHODS

Multicentric study with a 6 month-followed-up period. Patients were considered persistent if they collected all their inhaler refills. In a random sample of patients, we evaluated adherence using the Test of Adherence to Inhalers (TAI). We assessed Health Related Quality of Life (HRQL) with St George's Respiratory Questionnaire (SGRQ).

RESULTS

Of the 114 patients included, 46 (40.4%) were defined as persistent. Patients who had awareness about COPD (adjusted RR 2.672, 95% CI 1.125-6.349) were more likely to be persistent; patients with multidose DPI were less likely to be persistent that those with single dose DPI (adjusted RR 0.341, 95% CI 0.133-0.877). Higher levels of SGRQ total were associated with a lower probability of persistence (adjusted RR 0.945, 95%CI 0.894-0.998). Patients who had had an appointment with their GP in the previous six months were more likely to be persistent (adjusted RR 3.107, 95% CI 1.022-9.466). Patients who had awareness about COPD and those with lower symptom SGQR score were more likely to be adherent (24/25, 96.0% vs 16/22, 72.7%, p = 0.025, and mean 29.1, sd 19.4 vs mean 41.4, sd 15.9, respectively, p = 0.026, respectively).

CONCLUSIONS

Less than 50% of patients were defined as persistent. Patients' awareness of their disease and levels of HRQL were associated with high rate of persistence and adherence. In addition, frequent visits to general practitioner, increases the rate of persistence to treatment.

Impact of patients' perception of COPD and treatment on adherence and health-related quality of life in real-world: Study in 53 community pharmacies

BACKGROUND

Patient adherence to treatment in chronic obstructive pulmonary disease (COPD) is essential to optimize disease management. We aimed to assess the impact of patients' perception of their treatment and disease on adherence and Health-Related Quality of Life (HRQL) in patients attending a community pharmacy, where usually subjects have a better condition than those in clinical settings.

METHODS

We performed a cross-sectional study of 318 patients with COPD in treatment with inhalers in the last 3 months from 53 community pharmacies. We assessed HRQL with St George's Respiratory Questionnaire (SGRQ). Persistence was assessed from the three previous refills and adherence through the Test of Adherence to Inhalers test.

RESULTS

Persistence was achieved by 78.6% of the patients and 58.5% had good adherence. Patients having a multidose DPI and those with MDI showed a 2.8-fold and 4.1-fold increased association, respectively, with intermediate/poor adherence in comparison with those having a single dose DPI. Those patients who did not have knowledge about COPD (aOR 2.106, p = 0.006) and those who thought that the inhaler effectiveness was fair/poor (aOR 2.361, p = 0.006) were more likely to have intermediate/poor adherence. Overall SGRQ score was significantly worse in patients with intermediate/poor adherence (p = 0.036) and in those who thought the inhaler's effectiveness was fair/poor (p < 0.001).

CONCLUSIONS

The type of inhaler and patients' knowledge and perceptions of their disease and treatment were associated with good adherence and higher HRQL. Clinicians should promote shared-decision making in the choice of inhaler depending on patients' individual abilities and beliefs.

Assessment of the effectiveness of a pharmacist approach for improving disease-specific knowledge and treatment in patients with chronic obstructive pulmonary disease

OBJECTIVE

Adequate knowledge is essential for the appropriate management of chronic conditions such as chronic obstructive pulmonary disease (COPD). However, some patients may not be able either to comprehend or obtain adequate information. This study aims to assess the effectiveness of the clinical pharmacist approach to refining disease-specific knowledge in patients with COPD treated in a tertiary care hospital.

METHODS

A prospective observational longitudinal study was carried out in adult COPD patients for 9 months in the tertiary care hospital of Pune. At the time of enrolment, disease-specific knowledge of patients with COPD was assessed using the Bristol COPD Knowledge Questionnaire (BCKQ). After the assessment, patients were educated, counselled verbally and provided with a validated COPD information leaflet. The patients' knowledge was reassessed 1 month and 3 months after enrolment. Pre and post scores of BCKQ were compared by ANOVA followed by Tukey's post hoc test. The difference in the proportions was calculated using the χ² test.

RESULTS

Of 75 patients, the majority were men (53.33%), aged >60 years (72%), employed (62.67%) and had obtained secondary education (37.33%). The mean baseline BCKQ overall score of the patients was 25.87, which increased after education to 42.43 on the first visit (1 month) and to 45.62 on the second visit (3 months) (p<0.0001). At baseline, the topics 'vaccination', 'inhaled steroids' and 'antibiotics' returned the lowest mean scores of 0.37, 0.38 and 0.60, which were increased to 2.30, 2.70 and 2.72, respectively, after follow-up.

CONCLUSION

The knowledge of patients with COPD about the disease and its treatment was poor at the time of enrolment. Proper counselling and education provided by the clinical pharmacist helped to improve the patients' knowledge about COPD and its treatment.

Treatment of acute lung inflammation by pulmonary delivery of anti-TNF-α siRNA with PAMAM dendrimers in a murine model

To improve the efficacy of nucleic acid-based therapeutics, e.g., small interfering RNA (siRNA), transfection agents are needed for efficient delivery into cells. Several classes of dendrimers have been found useful as transfection agents for the delivery of siRNA because their surface can readily be functionalized, and the size of the dendriplexes they form with siRNA is within the range of conventional nanomedicine. In this study, commercially available generation 3 poly(amidoamine) (PAMAM) dendrimer was investigated for pulmonary delivery of siRNA directed against tumor necrosis factor (TNF) α for the treatment of acute lung inflammation. Delivery efficiency was assessed in vitro in the RAW264.7 macrophage cell line activated with lipopolysaccharide (LPS), and efficacy was evaluated in vivo in a murine model of LPS-induced lung inflammation upon pre-treatment with TNF-α siRNA. The PAMAM dendrimer-siRNA complexes (dendriplexes) displayed strong siRNA condensation and high cellular uptake in macrophages compared with non-complexed siRNA. Q-PCR analyses showed that the dendriplexes mediated efficient and specific TNF-α silencing in vitro, as compared to non-complexed siRNA and dendriplexes with negative control siRNA. Also in vivo, the PAMAM dendriplexes induced efficacious TNF-α siRNA inhibition, as compared to non-complexed siRNA, upon pulmonary administration to mice with LPS-induced lung inflammation. Hence, these data suggest that PAMAM dendrimers are promising for the local delivery of TNF-α siRNA in the treatment of lung inflammation via pulmonary administration.

Methodology and baseline characteristics of a randomized controlled trial testing a health care professional and peer-support program for patients with chronic obstructive pulmonary disease: The BREATHE2 study

BACKGROUND

Self-management support (SMS) for patients with COPD can improve health-related quality of life (HRQOL). However, it remains unclear what SMS strategies are most effective. Using peer support to advance self-management is promising, as peer supporters possess credibility and can serve as role models.

METHODS

We conducted a single-blinded RCT comparing the effectiveness of two strategies to support patients with COPD. The strategies were 'Health Care Professional (HCP)' and 'HCP Plus Peer' support. Peer support was provided by patients with COPD who have stopped smoking, completed an acute pulmonary rehabilitation program, and met the requirements for becoming a peer supporter. We enrolled patients receiving treatment at inpatient and outpatient settings. Patients were encouraged to invite one family-caregiver to enroll with them. The primary outcome measure was the change in HRQOL at 6 months post enrollment. Secondary outcomes included COPD-related and all-cause hospitalizations and ED visits. Caregiver outcomes included preparedness for caregiving, caregiver stress, and coping.

RESULTS

A total of 292 patients as well as 50 family-caregivers were enrolled. The average patient age was 67.3 yrs. (SD 9.4), 61% were female and 26% were African-Americans. The majority of caregivers were females (68%) and were a spouse/partner (58%).

DISCUSSION

This study tested a dual strategy for providing support to patients with COPD that incorporates peer and health care professional support. The study had minimal exclusion criteria. If shown effective, the study offers a program of peer support that can be readily implemented in health care settings.

Assessment of COPD-Related Knowledge Among Internal Medicine Nurses: A Cross-Sectional Study

Background

Since most internal medicine nurses work with chronic obstructive pulmonary disease (COPD) patients daily, their ability to meet the needs of COPD patients is an important issue. Our study aimed to assess COPD-related knowledge in internal medicine nurses.

Methods

A descriptive cross-sectional study including 175 participants was conducted to investigate COPD-related knowledge levels among internal medicine nurses in a large top-ranked tertiary hospital in China. The Bristol COPD Knowledge Questionnaire (BCKQ) was used to test COPD-related knowledge levels in the participants.

Results

Overall BCKQ score for all nurses in this study was 35.76 ± 5.49. In comparison with non-respiratory nurses, the overall score among respiratory nurses was significantly higher (39.01 ± 3.95 vs 33.32 ± 5.23, p < 0.001). The mean scores for four topics (epidemiology, breathlessness, oral steroids, and inhaled steroids) were less than 3 among both respiratory and non-respiratory nurses. Subgroup analysis of specialist respiratory wards showed that nurses in the chronic airway disease ward had the highest overall knowledge score (40.47 ± 4.03). Linear regression analysis demonstrated that the overall BCKQ score was significantly related to the population of nurses (β coefficient = 3.016, 95% confidence interval [CI]: 0.953-5.079, p < 0.01), education (β coefficient = 4.710, 95% CI: 1.979-7.440, p < 0.01) and previous rotation in respiratory wards (β coefficient = 3.871, 95% CI: 1.776-5.967, p < 0.001).

Conclusion

Internal medicine nurses at this tertiary hospital showed deficits in COPD-related knowledge. Appropriate and systematic education about COPD knowledge and strengthening rotation among different wards are necessary for improving COPD-related knowledge levels among internal medicine nurses.

Association Between Health Literacy, Electronic Health Literacy, Disease-Specific Knowledge, and Health-Related Quality of Life Among Adults With Chronic Obstructive Pulmonary Disease: Cross-Sectional Study

Background

Despite the relatively high prevalence of low health literacy among individuals living with chronic obstructive pulmonary disease (COPD), limited empirical attention has been paid to the cognitive and health literacy–related skills that can uniquely influence patients’ health-related quality of life (HRQoL) outcomes.

Objective

The aim of this study was to examine how health literacy, electronic health (eHealth) literacy, and COPD knowledge are associated with both generic and lung-specific HRQoL in people living with COPD.

Methods

Adults from the COPD Foundation’s National Research Registry (n=174) completed a cross-sectional Web-based survey that assessed sociodemographic characteristics, comorbidity status, COPD knowledge, health literacy, eHealth literacy, and generic/lung-specific HRQoL. Hierarchical linear regression models were tested to examine the roles of health literacy and eHealth literacy on generic (model 1) and lung-specific (model 2) HRQoL, after accounting for socioeconomic and comorbidity covariates. Spearman rank correlations examined associations between ordinal HRQoL items and statistically significant hierarchical predictor variables.

Results

After adjusting for confounding factors, health literacy, eHealth literacy, and COPD knowledge accounted for an additional 9% of variance in generic HRQoL (total adjusted R²=21%; F_9,164=6.09, P<.001). Health literacy (b=.08, SE 0.02, 95% CI 0.04-0.12) was the only predictor positively associated with generic HRQoL (P<.001). Adding health literacy, eHealth literacy, and COPD knowledge as predictors explained an additional 7.40% of variance in lung-specific HRQoL (total adjusted R²=26.4%; F_8,161=8.59, P<.001). Following adjustment for covariates, both health literacy (b=2.63, SE 0.84, 95% CI 0.96-4.29, P<.001) and eHealth literacy (b=1.41, SE 0.67, 95% CI 0.09-2.73, P<.001) were positively associated with lung-specific HRQoL. Health literacy was positively associated with most lung-specific HRQoL indicators (ie, cough frequency, chest tightness, activity limitation at home, confidence leaving home, sleep quality, and energy level), whereas eHealth literacy was positively associated with 5 of 8 (60%) lung-specific HRQoL indicators. Upon controlling for confounders, COPD knowledge (b=−.56, SE 0.29, 95% CI −1.22 to −0.004, P<.05) was inversely associated with lung-specific HRQoL.

Conclusions

Health literacy, but not eHealth literacy, was positively associated with generic HRQoL. However, both health literacy and eHealth literacy were positively associated with lung-specific HRQoL, with higher COPD knowledge indicative of lower lung-specific HRQoL. These results confirm the importance of considering health and eHealth literacy levels when designing patient education programs for people living with COPD. Future research should explore the impact of delivering interventions aimed at improving eHealth and health literacy among patients with COPD, particularly when disease self-management goals are to enhance HRQoL.

[Factors associated with poor acceptance of illness in patients with COPD]

INTRODUCTION

In patients suffering from chronic obstructive pulmonary disease (COPD), the acceptance of the illness is probably a major factor in the improvement of quality of life. The aim of this study is to identify the criteria associated with a good or bad acceptance of the disease and to identify means of improving it.

METHODS

We have undertaken a telephone enquiry among patients with COPD with the aid of a standardized questionnaire established by several health experts.

RESULTS

Of the 1040 patients who have been contacted, 356 (34 %) replied to the questionnaire. Ninety-nine patients reported unacceptance of their disease (28 %). The patients who did not accept their disease were significantly more severe, with more difficulty in performing daily life activities, particularly exercising. These patients had significantly greater difficulty in understanding their disease and also reported more frequently a moralizing attitude among their family.

CONCLUSION

The greater the handicap of the disease, the greater is the difficulty in accepting the disease by the patient. The doctor could have an impact in improving the therapeutic education and involving the family in the patient's care.

Factors contributing to COPD hospitalisations from 2010 to 2015: Variation among rural and metropolitan Australians

INTRODUCTION

Rural and remote populations experience the greatest burden of chronic obstructive pulmonary disease (COPD), the fifth leading cause of death in Australia. Currently there is a need to prioritise health services to improve health outcomes among those at higher risk of COPD.

OBJECTIVES

To investigate the differences in COPD hospitalisation between rural and urban populations and determine predictive factors contributing to COPD hospitalisation.

METHODS

Statewide hospitalisation data from 2010 to 2015 were obtained through the Victorian Admitted Episodes Dataset and other key data sets. The rates of hospitalisation were analysed using hierarchical multiple regression to examine the association between COPD hospitalisations and a number of predictor variables.

RESULTS

The highest COPD incidence occurred in metropolitan males aged 85 years of age and older (35.092 hospitalisations per 1000 population). Among metropolitan residents, smoking, population density and household income had a significant association with COPD hospitalisations for both sexes. Among rural males, smoking rates, household income and rural land use (farming) were significant predictors of COPD hospitalisations. There was an overall stability in statewide COPD hospitalisation over the 5 years to 2015, P = 0.420.

CONCLUSION

This investigation highlights many rural and regional areas have much lower COPD hospitalisation rates than metropolitan areas. Between males and females, there are heterogenetic factors that contribute to the significant variation associated with COPD hospitalisation in metropolitan and rural areas, such as rural land use among rural males. This indicates that risk factor assessments, beyond smoking alone, need to be individualised and prioritised in practice to optimise care.

Disease awareness in patients with COPD: measurement and extent

Background

Patient awareness of COPD refers to knowledge and acceptance of the disease and its treatment. Although it is relevant to management and outcomes, the disease awareness of patients is poorly investigated, and no validated questionnaires are currently available. We aimed to develop the novel Disease Awareness in COPD Questionnaire (DACQ), which was validated in relation to demographic and clinical features, in patients participating in the SATisfaction and Adherence to COPD Treatment (SAT) study.

Methods

DACQ was developed according to a list of items regarding the patient’s knowledge, acceptance, and perception of COPD as well as of treatment needs. The questionnaire was validated by assessing internal structure and consistency, correlations with other patient-reported outcomes, and stability over time. Furthermore, the extent of disease awareness of patients enrolled in the SAT study was assessed by using DACQ, and correlations with demographic and clinical features were evaluated.

Results

DACQ was composed of four domains. Overall reliability and stability over time were adequate; correlations between DACQ and other tools measuring different constructs (ie, treatment satisfaction, illness perception, impact of COPD symptoms on daily life, and dyspnea severity) were, as expected, more limited. In the enrolled patient sample, a suboptimal level of disease awareness (<70%) was detected, especially in terms of disease acceptance and perception. Disease knowledge was positively associated with COPD severity, while the impact of symptoms on daily life was negatively associated with disease acceptance, awareness of treatment needs, and overall awareness.

Conclusion

DACQ proved to be a reliable tool to assess awareness in COPD patients. Awareness of COPD patients need to be improved.

Clinical trial registration

ClinicalTrials.gov ID# NCT02689492.

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

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

[Characteristics of non-pharmacological interventions in the elderly with COPD. Smoking cessation, pulmonary rehabilitation, nutritional management and patient education]

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder responsible for a high mortality and disability. People older than 65 years are more commonly affected than younger people and tend to present with more symptoms and a greater level of disability. Non-pharmacological interventions play an important role in the management of all patients with COPD and this is particularly true in the elderly. Given the improvement in quality of life and risk of hospitalization, smoking cessation should be promoted to patients of all ages. Increased physical activity is associated with reduced respiratory symptoms. Tests such as the "Short Physical Performance Battery" can be useful in frailer older people with COPD, while walking tests such as the 6-minute walk test are used as an assessment before pulmonary rehabilitation. Increased physical activity should be combined with nutritional management. Screening for undernutrition by questionnaire, body mass index and albumin quantification is recommended in the elderly. In case of undernutrition, oral supplementation seems to reduce the risk of re-admission. All these measures must be included in an education program adapted to the elderly comorbidities (hearing loss, isolation…).

Experiences of a health coaching self-management program in patients with COPD: a qualitative content analysis

Purpose

To describe the experiences of patients with COPD participating in a health coaching self-management program.

Patients and methods

Twenty patients who had participated in a 6-month health coaching self-management program intervention were purposefully selected for a qualitative evaluation of the program using semi-structured interviews. The interviews were analyzed using inductive qualitative content analysis.

Results

Four categories and 13 subcategories emerged describing the participants’ experiences of the program. Their experiences were expressed as gaining insight into the importance of knowledge and personal responsibilities in the management of COPD, taking action to maintain a healthy lifestyle, feeling supported by the program, and being hindered by individual and program limitations.

Conclusion

Iterative interactions between patients and health care professionals together with the content of the program are described as important to develop skills to manage COPD. However, in future self-management programs more awareness of individual prerequisites should be considered.

Patterns and management of chronic obstructive pulmonary disease in urban and rural China: a community-based survey of 25 000 adults across 10 regions

Introduction

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, with COPD deaths in China accounting for one-third of all such deaths. However, there is limited available evidence on the management of COPD in China.

Methods

A random sample of 25 011 participants in the China Kadoorie Biobank, aged 38–87 years, from 10 regions in China was surveyed in 2013–2014. Data were collected using interviewer-administered questionnaires on the diagnosis (‘doctor-diagnosed’ or ‘symptoms-based’) and management of COPD (including use of medication and other healthcare resources), awareness of diagnosis and severity of symptoms in COPD cases.

Results

Overall, 6.3% of the study population were identified as COPD cases (doctor-diagnosed cases: 4.8% and symptom-based cases: 2.4%). The proportion having COPD was higher in men than in women (7.9% vs 5.3%) and varied by about threefold (3.7%–10.0%) across the 10 regions. Among those with COPD, 54% sought medical advice during the last 12 months, but <10% reported having received treatment for COPD. The rates of hospitalisation for COPD, use of oxygen therapy at home and influenza or pneumococcal vaccinations in the previous year were 15%, 3% and 4%, respectively. Of those with COPD, half had moderate or severe respiratory symptoms, and over 80% had limited understanding of their disease and need for treatment.

Conclusion

Despite a high prevalence of COPD in China and its substantial impact on activities of daily living, knowledge about COPD and its management were limited.

Self-management behaviour and support among primary care COPD patients: cross-sectional analysis of data from the Birmingham Chronic Obstructive Pulmonary Disease Cohort

Self-management support for chronic obstructive pulmonary disease (COPD) patients is recommended by UK national guidelines, but extent of implementation is unknown. We aimed to describe self-management behaviour and support among COPD patients and explore behaviour associated with having a self-management plan. We undertook cross-sectional analysis of self-reported data from diagnosed COPD patients in the Birmingham COPD Cohort study. Questionnaire items relevant to self-management behaviour, knowledge of COPD, receipt of self-management plans and advice from healthcare professionals were examined. Multiple regression models were used to identify behaviour associated with having a self-management plan. One-thousand seventy-eight participants (676 males, 62.7%, mean age 69.8 (standard deviation 9.0) years) were included. The majority reported taking medications as instructed (940, 94.0%) and receiving annual influenza vaccinations (962, 89.2%). Only 400 (40.4%) participants had self-management plans, 538 (49.9%) reported never having received advice on diet/exercise and 110 (42.7%) current smokers had been offered practical help to stop smoking in the previous year. General knowledge about COPD was moderate (mean total Bristol COPD Knowledge Questionnaire score: 31.5 (standard deviation 10.7); max score 65), corresponding to 48.5% of questions answered correctly. Having a self-management plan was positively associated with self-reported adherence to medication (odds ratio 3.10, 95% confidence interval 1.43 to 6.72), attendance at a training course (odds ratio 2.72, 95% confidence interval 1.81 to 4.12), attendance at a support group (odds ratio 6.28, 95% confidence interval 2.96 to 13.35) and better disease knowledge (mean difference 4.87, 95% confidence interval 3.16 to 6.58). Primary care healthcare professionals should ensure more widespread implementation of individualised self-management plans for all patients and improve the lifestyle advice provided.

CHRONIC LUNG DISEASE

CALL FOR WIDER IMPLEMENTATION OF SELF-MANAGEMENT PLANS: Health professionals should ensure all patients with chronic lung disease receive individualized self-management plans and lifestyle advice. UK national guidelines state that patients with chronic obstructive pulmonary disease (COPD) should receive personalized self-management plans and comprehensive support to help them manage their disease. Ainee Khan and colleagues at the University of Birmingham analyzed patient questionnaire data gathered during the Birmingham COPD Cohort study to explore self-management behavior, receipt of self-management plans and advice, and patient knowledge of COPD. Of 1,078 participants, only 400 had self-management plans, and less than half reported receiving lifestyle advice or support. Those with plans were more likely to adhere to medication, had greater knowledge about COPD and were more likely to attend support groups and training courses. The authors recommend carefully-planned, wider implementation of COPD self-management plans and associated support.

Factors influencing exacerbation-related self-management in patients with COPD: a qualitative study

BACKGROUND

In patients with COPD, self-management skills are important to reduce the impact of exacerbations. However, both detection and adequate response to exacerbations appear to be difficult for some patients. Little is known about the underlying process of exacerbation-related self-management. Therefore, the objective of this study was to identify and explain the underlying process of exacerbation-related self-management behavior.

METHODS

A qualitative study using semi-structured in-depth interviews was performed according to the grounded theory approach, following a cyclic process in which data collection and data analysis alternated. Fifteen patients (male n=8; age range 59-88 years) with mild to very severe COPD were recruited from primary and secondary care settings in the Netherlands, in 2015.

RESULTS

Several patterns in exacerbation-related self-management behavior were identified, and a conceptual model describing factors influencing exacerbation-related self-management was developed. Acceptance, knowledge, experiences with exacerbations, perceived severity of symptoms and social support were important factors influencing exacerbation-related self-management. Specific factors influencing recognition of exacerbations were heterogeneity of exacerbations and habituation to symptoms. Feelings of fear, perceived influence on exacerbation course, patient beliefs, ambivalence toward treatment, trust in health care providers and self-empowerment were identified as specific factors influencing self-management actions.

CONCLUSION

This study provided insight into factors influencing exacerbation-related self-management behavior in COPD patients. The conceptual model can be used as a framework for health care professionals providing self-management support. In the development of future self-management interventions, factors influencing the process of exacerbation-related self-management should be taken into account.

A study of attitudes, beliefs and organisational barriers related to safe emergency oxygen therapy for patients with COPD (chronic obstructive pulmonary disease) in clinical practice and research

Background

Patients can be harmed by receiving too little or too much oxygen. There is ongoing disagreement about the use of oxygen in medical emergencies.

Methods

This was a mixed methods study (survey, telephone interviews and focus groups) involving patients, the public and healthcare professionals (HCPs).

Results

62 patients with chronic obstructive pulmonary disease (COPD), 65 members of the public, 68 ambulance crew members, 22 doctors, 22 nurses and 10 hospital managers took part. For five factual questions about oxygen therapy, the average score for correct answers was 28% for patients with COPD, 33% for the general public and 75% for HCPs. The HCPs had an average score of 66% for five technical questions. Patients (79%) and members of the public (68%) were more likely than HCPs (36%) to believe that oxygen was beneficial in most medical emergencies and less likely to have concerns that it might harm some people (35%, 25% and 68%). All groups had complex attitudes about research into oxygen use in medical emergencies. Many participants would not wish for themselves or their loved ones to have their oxygen therapy determined by a randomised protocol, especially if informed consent was not possible in an emergency situation.

Conclusions

We have found low levels of factual knowledge about oxygen use among patients with COPD and the general public and many false beliefs about the potential benefits and harms of using oxygen. HCPs had a higher level of factual knowledge. All groups had complex attitudes towards research into emergency oxygen use.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Standard compared with mnemonic counseling for fecal incontinence: a randomized controlled trial

OBJECTIVE

To estimate whether women who underwent mnemonic counseling had better recall of fecal incontinence therapies at 2 months and if mnemonic counseling resulted in greater satisfaction with physician counseling and improvement in quality of life when compared with a group who underwent standard counseling.

METHODS

Counseling-naive women with fecal incontinence were recruited from an academic urogynecology clinic. Women underwent physical examinations, completed the Quality of the Physician-Patient Interaction, recorded fecal incontinence treatment options they recalled, and completed the Fecal Incontinence Severity Index and Manchester Health Questionnaire immediately after counseling and again at 2 months.

RESULTS

Ninety women consented to participate, were randomized, and completed baseline questionnaires. At baseline, women did not differ in age, ethnicity, education, Fecal Incontinence Severity Index, or Manchester Health Questionnaire scores. After counseling, the mnemonic group reported higher satisfaction on Quality of the Physician-Patient Interaction (66.4±6.5 compared with 62.2±10.7, P=.03). Ninety percent (81/90) of women followed up at 2 months. Our primary endpoint, 2-month recall of fecal incontinence treatments, was not different between groups (2.3±1.6 mnemonic counseling compared with 1.8±1.0 standard counseling; P=.08). Secondary endpoints for the mnemonic group reported greater improvement on total Manchester Health Questionnaire (P=.02), emotional (P=.03), sleep (0.045), role limitations (P<.01), and physical limitations (P=.04) when compared with the standard group.

CONCLUSION

Fecal incontinence counseling with a mnemonic aid did not improve recall at 2 months but improved patient satisfaction and quality of life at 2 months.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Patient-reported outcomes and considerations in the management of COPD: focus on aclidinium

Chronic obstructive pulmonary disease (COPD) is a complex heterogeneous disease, in which several factors combine to give the final clinical expression. Both early and more recent studies have shown that forced expiratory volume in one second (FEV1), despite being an extremely important parameter to predict the progression of the disease, is a poor surrogate marker for symptoms perception. Accordingly, patient-reported outcomes (PROs) have gained popularity as a measure of the impact of treatment from the patients' perspective, since they represent the individuals' perception of their health status, beyond any physiological limitations. Several such PROs, therefore, are currently included in multidimensional COPD evaluation. This multidimensional approach helps identify different patient types and individualize, up to a certain point, pharmacological treatment. In this multidimensional approach it is important to highlight the importance of long-acting bronchodilators in COPD treatment strategies. Long-acting bronchodilators are cost-effective and have been shown to achieve the greatest functional and clinical improvements in COPD. As a result, long-acting bronchodilators are now the main pharmacological treatment for COPD at all stages of the disease. Until recently, tiotropium was the leading bronchodilator for the treatment of COPD. The clinical development of this medication, unprecedented in inhaled therapy, involved tens of thousands of patients and yielded consistent outcomes in terms of lung function, symptoms, quality of life, exacerbations, and prognosis. However, new long-acting bronchodilators have recently been developed or are currently under development. In this review, we evaluate the effects of aclidinium bromide, a novel long-acting bronchodilator, on PROs in COPD. Aclidinium is a novel long-acting muscarinic antagonist with a good safety profile for the treatment of COPD, and has proven efficacy in both objective functional measurements and PROs. Comparison studies with tiotropium have shown it to have similar lung function improvement and a similar impact on PROs, including quality of life or symptom perception.

Knowledge about COPD among users of primary health care services

Background

Chronic obstructive pulmonary disease (COPD) is often underdiagnosed, which might be attributable to a lack of knowledge about the disease among the general population. The objective of this study was to evaluate COPD-related knowledge among primary care users in an urban area in Brazil.

Methods

This study was carried out at primary care clinics (PCCs), including 12 general PCCs and 26 family health PCCs, in the city of Goiânia, Brazil. Between May 2013 and February 2014, we interviewed 674 PCC users, applying a questionnaire designed to assess COPD-related knowledge. Satisfactory knowledge of COPD was defined as knowing at least two of its symptoms and that smoking is a risk factor for the disease.

Results

Of the 674 users interviewed, only 9.2% recognized the term “COPD”, 75.1% recognized the term “emphysema”, and 15.7% did not recognize either term. We found that recognizing either term was associated with a higher level of education (P<0.001). The prevalence of satisfactory knowledge of COPD was 16.2%, and having such knowledge was associated with being over 60 years of age. The COPD symptom known by the greatest proportion of users (70.6%) was dyspnea, and most (87.5%) knew that smoking is a risk factor, whereas only a few (4.9%) knew that exposure to wood smoke is also a risk factor. The most frequently cited sources of knowledge were the media (43.1%) and a relative with COPD (36.4%).

Conclusion

Most of the PCC users evaluated did not know the term “COPD” but were familiar with the term “emphysema”. The level of basic knowledge about the disease was low in this population. These results should alert health care administrators to the need for interventions aimed at increasing the diagnosis rate and thus promoting the early treatment of COPD.

Patients' perspectives on the impact of a new COPD diagnosis in the face of multimorbidity: a qualitative study

Background:

Chronic obstructive pulmonary disease (COPD), a major cause of morbidity and mortality worldwide, often occurs in the presence of comorbidities, which may influence experience and management of the disease. No prior research seems to have gained perspectives of newly diagnosed primary care COPD patients in the context of multimorbidity.

Aims:

This qualitative study aimed to explore the impact of a new diagnosis of COPD in the context of multimorbidity and also sought to gain a better understanding of how patients react to the diagnosis and incorporate it into their lives.

Methods:

Participants were identified from a cohort of primary care patients with multimorbidity recently diagnosed with COPD. Data was collected via semi-structured interviews from nine male and eight female participants. Thematic analysis was performed and the data interpreted from a constructivist perspective.

Results:

Five core themes regarding COPD were induced: (i) reaction to diagnosis, (ii) impact on function and health behaviour, (iii) factors influencing self-management capacity, (iv) healthcare utilisation and (v) interplay of comorbidities. Most participants had difficulty recognising the importance of COPD and its long-term implications. For many, the salience of another chronic condition outweighed COPD. Self-management capacity and utilisation of healthcare services were challenged by low prioritisation of COPD among other comorbidities.

Conclusions:

This study provides an insight into how primary care patients feel about being diagnosed with COPD, as well as their prioritisation of the disease in the context of multimorbidity. It highlights the need for tailored education and personalised management incorporating patients’ perspectives in primary care.

Primary and secondary care clinicians' views on self-treatment of COPD exacerbations: a multinational qualitative study

OBJECTIVE

To explore clinicians' views on antibiotic and/or steroid 'rescue packs' used as self-treatment for patients with exacerbations of COPD.

METHODS

21 focus groups conducted in 7 countries--Netherlands, Russia, Norway, China (Hong Kong), Wales, Germany and Poland involving 142 primary care clinicians and pulmonologists.

RESULTS

We found wide variation in reported use of and attitudes to self-treatment among GPs and pulmonologists in the participating countries. Clinicians highlighted the importance of identifying patients who were most likely to benefit (those with more severe disease) and most likely to use the treatment appropriately (demonstrated by previous behaviour), and the importance of adequate patient education and ongoing communication in regard to use of self-treatment packs. Clinicians recognised patient empowerment and facilitating prompt treatment as potential benefits of self-treatment. However, many felt they did not have the time or resources for appropriate patient selection and education.

CONCLUSION

Clinicians do not feel it is appropriate to offer self-treatment rescue packs to all patients routinely without careful consideration of patient understanding of their illness and their capacity for self-management.

PRACTICE IMPLICATIONS

Adequate resources and continuity of patient care are required for clinicians to feel confident in the safe and effective implementation of this strategy.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process

INTRODUCTION

ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission.

METHODS

COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation.

RESULTS

Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation.

CONCLUSIONS

The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.

Awareness in patients with COPD about the disease and pulmonary rehabilitation: A survey

Background and Objective:

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide. It overloads the healthcare system and increase healthcare expenditure. As a patient's awareness enables him/her to acquire better self-management skills, it helps to reduce the severity and frequency of exacerbations, prevents hospitalizations, and improves health-related quality of life. The current study aims to assess the awareness amongst COPD patients about the disease itself and pulmonary rehabilitation.

Materials and Methods:

A cross-sectional survey was carried out in order to evaluate awareness through “a COPD awareness questionnaire”. This was developed and validated for its content. A total of 21 questions were included in this questionnaire. These questions were divided into two domains that included pulmonary disease (1-12) and pulmonary rehabilitation (13-21).

Results:

Three hundred patients were recruited of which 282 were included in the study. The subject group consisted of 177 males and 105 females. The mean age of the subjects was 63.54 ± 10.656. Awareness in the “disease domain” was 47.84% and “pulmonary rehabilitation domain” was 25.14%. Awareness about the causes of COPD was 34.8%, of common symptoms was 83.0%, and of activities of daily living that could increase breathlessness was found to be 73.8%. The need to consult a physiotherapist was reported by only 26.2%. 81.2% of the subjects believed that breathing exercise could cause breathlessness; whereas, only 19.5% were aware of secretion removal techniques.

Conclusion:

The findings of the study suggest an imminent need to educate the public about the disease and the scope of pulmonary rehabilitation and its role in the management of COPD. The education of patients in this regard needs to be incorporated into standard health care practice in order to improve their self-management skills and their quality of life.

Rehabilitation and supportive therapy in elderly patients with Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) very often coexists with cardiovascular, musculoskeletal and metabolic comorbidities. This condition significantly impact on the general health, function, frailty and disability of such patients, and consequently on their prognosis. Indeed, complex and recurrent symptoms of general dysfunction are commonly present and burden on the health status. Symptomatic COPD patients, even with chronic and complex comorbidities or with different degree of severity, may benefit from rehabilitation including exercise and maintenance of physical activity, in order to reducing symptoms and restoring the highest possible level of independent function. This review will focus on the associated and relevant clinical problems of these patients at the onset of disability, methods of assessment and useful non-pharmacological treatments for caring and supporting them.

Patients admitted with an acute exacerbation of chronic obstructive pulmonary disease had positive experiences exercising from the beginning of their hospital stay: a qualitative analysis

The aim of the study is to explore the experiences of inpatients with an acute exacerbation of chronic obstructive pulmonary disease, who participated in a very early exercise programme while acutely unwell. This qualitative study analysed responses from participant interviews as part of a mixed method trial whereby participants were randomly allocated into three groups: low intensity, moderate to high intensity aerobic and resistance exercises or a control group who received routine physiotherapy. Everyone allocated to the exercise groups were invited to participate in the qualitative study. Interviews were within a week post discharge and the results were analysed thematically. A total of 19 participants were interviewed and described their experience as positive and beneficial and reported an increased motivation towards exercising. These findings converged with the high levels of exercise adherence (83%) and within-group improvements in walking capacity observed in both exercise groups. Participants also reported commencement of a home exercise programme after discharge but intention to participate in community pulmonary rehabilitation remained low. Participation in a very early exercise programme while acutely unwell can lead to positive attitude towards exercise. The results converge with the quantitative results that provided preliminary evidence of programme feasibility and within-group improvement in exercise tolerance.

How integrated are services for patients with chronic obstructive pulmonary disease? Perceptions of patients and health care providers

Chronic obstructive pulmonary disease (COPD) is a common cause of hospital readmissions worldwide. Outcomes for COPD patients improve if care is more integrated. COPD patients and their health care providers at a district hospital and community health service were interviewed about their perceptions of integration of care. Patients were confused about provider roles, had little understanding of their disease, had difficulty accessing services and did not have COPD action plans. Health care providers espoused integration of COPD care. Care was reasonably well integrated in the hospital. Integration of care was compromised in the community because COPD patients went to the emergency department when symptoms became unmanageable, while only attending their GPs for routine booked appointments. Integration could be improved if health care providers spent more time with patients, promoting understanding of the disease, supporting self-management and liaising with other providers. Patients would benefit from an action plan and additional support. Potentially preventable COPD admissions will continue without action to improve integration of community services and patients’ understanding of their condition.

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Canadian practice assessment in chronic obstructive pulmonary disease: respiratory specialist physician perception versus patient reality

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. Optimal COPD management requires patients to participate in their care and physician knowledge of patients' perceptions of their disease.

METHODS

A prospective study in which respiratory specialist physicians completed a practice assessment questionnaire and patient assessments for 15 to 20 consecutive patients with COPD. Patients also completed a questionnaire regarding their perceptions of COPD and its management.

RESULTS

A total of 58 respiratory specialist physicians from across Canada completed practice assessments and 931 patient assessments. A total of 640 patients with COPD (96% with moderate, severe or very severe disease) completed questionnaires. Symptom burden was high and most patients had experienced a recent exacerbation. Potential COPD care gaps were identified with respect to appropriate medication prescription, lack of an action plan, and access to COPD educators and pulmonary rehabilitation. Perceived knowledge needs and gaps differed between physicians and patients.

CONCLUSIONS

Despite the dissemination of Canadian and international COPD clinical practice guidelines for more than a decade, potential care gaps remain among patients seen by respiratory specialist physicians. Differing perceptions regarding many aspects of COPD among physicians and patients may contribute to these care gaps.

Effects of telephone health mentoring in community-recruited chronic obstructive pulmonary disease on self-management capacity, quality of life and psychological morbidity: a randomised controlled trial

OBJECTIVES

To assess benefits of telephone-delivered health mentoring in community-based chronic obstructive pulmonary disease (COPD).

DESIGN

Cluster randomised controlled trial.

SETTING

Tasmanian general practices: capital city (11), large rural (3), medium rural (1) and small rural (16).

PARTICIPANTS

Patients were invited (1207) from general practitioner (GP) databases with COPD diagnosis and/or tiotropium prescription, response rate 49% (586), refused (176) and excluded (criteria: smoking history or previous study, 68). Spirometry testing (342) confirmed moderate or severe COPD in 182 (53%) patients.

RANDOMISATION

By random numbers code, block stratified on location, allocation by sequentially numbered, opaque and sealed envelopes.

INTERVENTION

Health mentor (HM) group received regular calls to manage illness issues and health behaviours from trained community health nurses using negotiated goal setting: problem solving, decision-making and action planning.

CONTROL

usual care (UC) group received GP care plus non-interventional brief phone calls.

OUTCOMES

Measured at 0, 6 and 12 months, the Short Form 36 (SF-36) and St George's Respiratory Questionnaire (SGRQ, primary); Partners In Health (PIH) Scale for self-management capacity, Hospital Anxiety and Depression Scale (HADS), Center for Epidemiologic Studies-Depression (CES-D) questionnaire, Post-Traumatic Stress Disorder Checklist, Satisfaction with life and hospital admissions (secondary).

RESULTS

182 participants with COPD (age 68±8 years, 62% moderate COPD and 53% men) were randomised (HM=90 and UC=92). Mixed model regression analysis accounting for clustering, adjusting for age, gender, smoking status and airflow limitation assessed efficacy (regression coefficient, β, reported per 6-month visit). There was no difference in quality of life between groups, but self-management capacity increased in the HM group (PIH overall 0.15, 95% CI 0.03 to 0.29; knowledge domain 0.25, 95% CI 0.00 to 0.50). Anxiety decreased in both groups (HADS A 0.35; 95% CI -0.65 to -0.04) and coping capacity improved (PIH coping 0.15; 95% CI 0.04 to 0.26).

CONCLUSIONS

Health mentoring improved self-management capacity but not quality of life compared to regular phone contact, which itself had positive effects where decline is generally expected.

Patient outcomes according to COPD action plan adherence

AIMS AND OBJECTIVES

To identify the level of pulmonary function, number of unplanned hospital visits, knowledge level of chronic obstructive pulmonary disease (COPD), level of anxiety and depression, and level of health-related quality of life (HRQoL) according to COPD action plan (AP) adherence in Korean patients with COPD.

BACKGROUND

Previous studies reported conflicting results about the effect of COPD AP on patient outcomes, with little descriptive information.

DESIGN

A cross-sectional descriptive study design was used.

METHODS

A total of 126 patients with COPD were recruited from Chonnam National University Hospital in Gwangju city from September 2009 to March 2010. COPD action plan adherence and the levels of knowledge of COPD, anxiety and depression, and HRQoL were measured using a short COPD AP developed by the Family Physician Airway Group of Canada executive members, Bristol COPD Knowledge Questionnaire (BCKQ), the hospital anxiety and depression scale (HADS) and the St George's Respiratory Questionnaire (SGRQ), respectively.

RESULTS

The score of COPD AP adherence was positively associated with the level of knowledge of COPD and negatively associated with the number of unplanned hospital visits and the level of anxiety and depression.

CONCLUSION

Good adherence to COPD AP is likely related to better health outcomes in COPD. Healthcare providers may need to enhance COPD AP aspect in various COPD self-management programmes to improve the health status of patients with COPD.

RELEVANCE TO CLINICAL PRACTICE

Chronic obstructive pulmonary disease AP aspect targeting frequent individual education with a written guideline would be helpful to enhance self-management in patients with COPD.

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.

A qualitative study of patients' goals and expectations for self-management of COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an illness that affects patients on multiple levels, both physically and psychologically. While there is a growing body of evidence for the efficacy of self-management among patients with COPD, little evidence is available on the optimal content and methods for delivering self-management support.

AIMS

The purpose of this study was to address gaps in the literature on self-management support by examining patients' responses to questions about goals, needs, and expectations regarding self-management using qualitative methods in a broadly representative sample of patients with moderate to severe COPD. By focusing on patients' perceptions of their needs, we hoped to guide development of cognitive-behavioural interventions for self-management support.

METHODS

Patients >45 years of age with a physician diagnosis of COPD were recruited as part of a larger randomised controlled trial designed to determine the effectiveness of a lifestyle behavioural intervention to increase physical activity. In-depth interviews were conducted at baseline data collection using 10 standardised open-ended questions tailored to examine factors relevant to self-management support including concerns, fears, learning needs, barriers, facilitators, and goals. All interviews were audio recorded and analysed using qualitative methods. Responses were coded by three raters into thematic categories.

RESULTS

A sample of 47 interviews with patients of mean age 68.4 years, 53% male, 87% white were used in the analysis. The distribution of spirometric impairment based on percent predicted forced expiratory volume in 1 second (FEV1) was moderate (57.5%), severe (31.9%), and very severe (10.6%). In response to questions targeting needs and goals for care, three main themes (loss, fear, and desire for improved care) and seven associated sub-themes were identified. Because of breathlessness and fatigue as well as symptoms from conditions other than COPD, patients reported the loss of ability to participate in pleasurable and necessary activities of daily living and the desire to recover at least some of their functioning. They expressed problems with social isolation and uncertainty about their prognosis, as well as the hope to improve. In addition, fearful experiences associated with uncontrolled breathlessness and a wish for greater understanding and knowledge about treatment were major concerns.

CONCLUSIONS

These qualitative results suggest that the content of self-management support for patients with COPD should focus on addressing patients' fears associated with the uncertainty, progression, and suffering of their disease, their expectations about overcoming or replacing losses, their needs for improved health literacy and their desire for improved care. These responses indicate areas where cognitive-behavioural intervention should focus in order to enhance patient self-efficacy, motivation, and behavioural change for improved self-management.