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Miravitlles M, Bhutani M, Hurst JR, Franssen FME, van Boven JFM, Khoo EM, Zhang J, Brunton S, Stolz D, Winders T, Asai K, Scullion JE. Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations. Adv Ther 2023; 40:4236-4263. [PMID: 37537515 PMCID: PMC10499689 DOI: 10.1007/s12325-023-02609-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Frits M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- International Primary Care Respiratory Group, Leicester, UK
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tonya Winders
- Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka Metropolitan University, Osaka, Japan
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Hunt V, Anderson D, Lowrie R, Montgomery Sardar C, Ballantyne S, Bryson G, Kyle J, Hanlon P. A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD. NPJ Prim Care Respir Med 2018; 28:38. [PMID: 30305634 PMCID: PMC6180130 DOI: 10.1038/s41533-018-0105-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/13/2018] [Accepted: 08/07/2018] [Indexed: 01/12/2023] Open
Abstract
UK, home-based patients with COPD receive specialist care from respiratory physicians, nurses, and general practitioners (GPs), but increasing complexity of therapeutic options and a GP/Nurse workforce crisis suggests merit in testing the role of home visits by a clinical pharmacist. We conducted a non-randomised intervention study with a contemporaneous comparator group, in Glasgow (Scotland). A clinical pharmacist (working closely with a consultant respiratory physician) visited patients with COPD living at home, assessing respiratory and other co-morbid conditions, and medicines then, with patient approval, agreed treatment modifications with a consultant physician. Comparator group-patients were drawn from another hospital out-patient clinic. Main outcomes were exacerbations during 4-months of follow-up and respiratory hospitalisations (number and duration) after 1 year. In the intervention group, 86 patients received a median of three home visits; 87 received usual care (UC). At baseline, patients in the intervention group were similar to those in UC in terms of respiratory hospitalisations although slightly younger, more likely to receive specific maintenance antibiotics/Prednisolone and to have had exacerbations. Sixty-two (72.1%) of the intervention group received dose changes; 45 (52.3%) had medicines stopped/started and 21 (24.4%) received an expedited review at the specialist respiratory consultant clinic; 46 (53.5%) were referred to other healthcare services. Over one-third were referred for bone scans and 11% received additional investigations. At follow-up, 54 (63.5%) of intervention group participants had an exacerbation compared with 75 (86.2%) in the UC group (p = 0.001); fewer had respiratory hospitalisations (39 (45.3%) vs. 66 (76.7%); p < 0.001). Hospitalisations were shorter in the intervention group. Pharmacist-consultant care for community dwelling patients with COPD, changed clinical management and improved outcomes. A randomised controlled trial would establish causality. Clinical pharmacists, working in collaboration with respiratory specialists, can help people who live at home with chronic obstructive pulmonary disease (COPD) better manage their medications and symptoms. In a non-randomised pilot study, Richard Lowrie from the NHS Greater Glasgow and Clyde,
UK, and colleagues found that patients with COPD who receive standard at-home care—which includes visits to GP surgeries and hospital-based respiratory out-patient clinics, and visits from respiratory specialist nurses—were more likely to experience exacerbations and need lengthy hospital stays than those who additionally received home visits from a clinical pharmacist. The pharmacist, in consultation with the patient’s respiratory physician, often proposed medication changes and suggested additional testing or referrals that presumably explain the improved health outcomes. The authors conclude that a large, randomised trial is warranted to further evaluate the merits of this collaborative intervention for community dwelling patients with COPD.
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Affiliation(s)
- Vicki Hunt
- East Renfrewshire Health and Social Care Partnership Eastwood Health and Care Centre, Drumby Crescent, Glasgow, Scotland, United Kingdom
| | | | - Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, G3 8SJ, United Kingdom.
| | - Colette Montgomery Sardar
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, G3 8SJ, United Kingdom
| | - Susan Ballantyne
- Prescribing Support Pharmacy Team, North East Glasgow HSCP, Glasgow, United Kingdom
| | - Graeme Bryson
- Glasgow City Health and Social Care Partnership, Glasgow, United Kingdom
| | - John Kyle
- General Practice and Primary Care Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Peter Hanlon
- General Practice and Primary Care Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Henoch I, Löfdahl CG, Ekberg-Jansson A. Influences of patient education on exacerbations and hospital admissions in patients with COPD - a longitudinal national register study. Eur Clin Respir J 2018; 5:1500073. [PMID: 30083305 PMCID: PMC6070991 DOI: 10.1080/20018525.2018.1500073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/05/2018] [Indexed: 01/05/2023] Open
Abstract
Introduction: Chronic obstructive pulmonary disease (COPD) contributes to impaired health-related quality of life (HRQoL). Patient education and smoking cessation programs are recommended to reduce the number of exacerbations and hospitalizations, but the effects of such programs have yet to be explored in larger samples. Objective: The aim was to explore the longitudinal effects of patient education and smoking cessation programs on exacerbations and hospital admissions in patients with COPD. Design: This is a register study where data from the Swedish National Airway Register, including 20,666 patients with COPD, were used. Baseline measures of demographic, disease-related, and patient-reported variables were compared with a follow-up, 10-30 months after baseline. Descriptive statistics and changes between baseline and follow-up were calculated. Results: Comparing those not participating in education programs to those who did, HRQoL deteriorated significantly between baseline and follow-up in non-participants; there was no change in either exacerbations or hospitalizations in either group; there was a significant difference in baseline HRQoL between the two, and, when controlling for this, there was no significant change (p = 0.73). Patients who participated in smoking cessation programs were younger than the non-participants; mean 66.0 (standard deviations (SD) 7.8) vs. mean 68.1 (SD 8.8), p = 0.006. Among participants in smoking cessation programs, the proportion with continued smoking decreased significantly, from 76% to 66%, p < 0.001. Exacerbations at follow-up were predicted by FEV1% of predicted value and exacerbations at baseline. Hospital admissions at follow-up were predicted by baseline FEV1% of predicted value and exacerbations at baseline. Conclusions: To prevent exacerbations and hospital admissions, treatment and prevention must be prioritized in COPD care. Patient education and smoking cessation programs are beneficial, but there is a need to combine them with other interventions.
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Affiliation(s)
- Ingela Henoch
- Research and Development Department, Angered Hospital, Gothenburg, Sweden
- The Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Claes-Göran Löfdahl
- Research and Development Department, Angered Hospital, Gothenburg, Sweden
- Department of Respiratory Medicine and Allergology, Clinical Sciences, University of Lund, Lund, Sweden
| | - Ann Ekberg-Jansson
- Department of Research and Development, Region Halland, Sweden
- The Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Yang IA, Brown JL, George J, Jenkins S, McDonald CF, McDonald VM, Phillips K, Smith BJ, Zwar NA, Dabscheck E. COPD‐X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update. Med J Aust 2017; 207:436-442. [DOI: 10.5694/mja17.00686] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/07/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Ian A Yang
- University of Queensland, Brisbane, QLD
- Prince Charles Hospital, Brisbane, QLD
| | - Juliet L Brown
- COPD National Program, Lung Foundation Australia, Brisbane, QLD
| | - Johnson George
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
| | - Sue Jenkins
- Curtin University, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
| | | | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW
- John Hunter Hospital, Newcastle, NSW
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Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, Chan T, Chew-Graham C, Davies L, de Lusignan S, Dickens C, Drinkwater J, Dunn G, Hunter C, Joy M, Kapur N, Langer S, Lovell K, Macklin J, Mackway-Jones K, Ntais D, Salmon P, Tomenson B, Watson J. CHOICE: Choosing Health Options In Chronic Care Emergencies. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Greater Manchester Academic Health Science Network (GM AHSN), Manchester, UK
| | - Claire Blakeley
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Amy Blakemore
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel Byford
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Elizabeth Camacho
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Tom Chan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, UK
| | - Linda Davies
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Simon de Lusignan
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Chris Dickens
- Institute of Health Research, Medical School, University of Exeter, Exeter, UK
- Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Exeter, UK
| | | | - Graham Dunn
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Joy
- Faculty of Science, Engineering and Computing, Kingston University, London, UK
| | - Navneet Kapur
- Manchester Academic Health Science Centre, Manchester, UK
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Susanne Langer
- Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Karina Lovell
- Manchester Academic Health Science Centre, Manchester, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Kevin Mackway-Jones
- Manchester Academic Health Science Centre, Manchester, UK
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dionysios Ntais
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Barbara Tomenson
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Murphy LA, Harrington P, Taylor SJ, Teljeur C, Smith SM, Pinnock H, Ryan M. Clinical-effectiveness of self-management interventions in chronic obstructive pulmonary disease: An overview of reviews. Chron Respir Dis 2017; 14:276-288. [PMID: 28774200 PMCID: PMC5720233 DOI: 10.1177/1479972316687208] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Self-management (SM) is defined as the provision of interventions to increase patients’ skills and confidence, empowering the individual to take an active part in their disease management. There is uncertainty regarding the optimal format and the short- and long-term benefits of chronic obstructive pulmonary disease (COPD) SM interventions in adults. Therefore, a high-quality overview of reviews was updated to examine their clinical effectiveness. Sixteen reviews were identified, interventions were broadly classified as education or action plans, complex interventions with an SM focus, pulmonary rehabilitation (PR), telehealth and outreach nursing. Systematic review and meta-analysis quality and the risk of bias of underlying primary studies were assessed. Strong evidence was found that PR is associated with significant improvements in health-related quality of life (HRQoL). Limited to moderate evidence for complex interventions (SM focus) with limited evidence for education, action plans, telehealth interventions and outreach nursing for HRQoL was found. There was strong evidence that education is associated with a significant reduction in COPD-related hospital admissions, moderate to strong evidence that telehealth interventions and moderate evidence that complex interventions (SM focus) are associated with reduced health care utilization. These findings from a large body of evidence suggesting that SM, through education or as a component of PR, confers significant health gains in people with COPD in terms of HRQoL. SM supported by telehealth confers significant reductions in healthcare utilization, including hospitalization and emergency department visits.
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Affiliation(s)
- Linda A Murphy
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Patricia Harrington
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Stephanie Jc Taylor
- 2 Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Conor Teljeur
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Susan M Smith
- 3 RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Hilary Pinnock
- 4 Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Scotland, Edinburgh, UK
| | - Máirín Ryan
- 1 Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
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Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open 2016; 6:e011952. [PMID: 27872113 PMCID: PMC5129137 DOI: 10.1136/bmjopen-2016-011952] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 08/08/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity. DESIGN Umbrella review of systematic reviews and meta-analyses. SETTING Interventions must have delivered care crossing the boundary between at least two health and/or social care settings. PARTICIPANTS Adult patients with one or more chronic diseases. DATA SOURCES MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references. OUTCOME MEASURES Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs. RESULTS 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15-50%); 11/24 showed significant reductions in all-cause (10-30%) or condition-specific (15-50%) readmissions; 9/16 reported LoS reductions of 1-7 days and 4/9 showed significantly lower A&E use (30-40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with postdischarge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients' homes. CONCLUSIONS Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity. TRIAL REGISTRATION NUMBER CRD42015016458.
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Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Sarah Flanagan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Gill Combes
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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Roche N, Bourbeau J. Health Coaching: Another Component of Personalized Medicine for Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2016; 194:647-9. [DOI: 10.1164/rccm.201604-0696ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Patel N, Jones P, Adamson V, Spiteri M, Kinmond K. Chronic Obstructive Pulmonary Disease Patients' Experiences of an Enhanced Self-Management Model of Care. QUALITATIVE HEALTH RESEARCH 2016; 26:568-577. [PMID: 25711841 DOI: 10.1177/1049732315573013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is debilitating and costly. Self-management is championed to empower individuals to better manage their condition and also to efficiently utilize health resources. As a multi-disciplinary team, we conducted focus group research with individuals living with COPD who were participating in a longitudinal study to use an electronic "diary" to monitor, record, and transmit their own health status, plus receiving regular nurse visits. The main aims of the focus groups were to investigate how far individuals embraced the electronic diary and experienced it as an aid to the self-management of their condition. We also looked at the importance of the nurse visits to the process. Thematic analysis revealed that patients responded positively to the use of technology (the electronic diary), including psychological benefits of perceived support offered by the remote symptom surveillance. Findings also showed patients' increased awareness and monitoring of personal symptoms together with an improved understanding of disease self-management. Nurse support emerged as an important "human" factor in the process. In addition, a reduction in hospital admission was observed, thus reducing costs to the health service.
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Affiliation(s)
- Neil Patel
- University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - Pauline Jones
- University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - Vikki Adamson
- University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - Monica Spiteri
- University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
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10
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Boland MRS, Kruis AL, Tsiachristas A, Assendelft WJJ, Gussekloo J, Blom CMG, Chavannes NH, Rutten-van Mölken MPMH. Cost-effectiveness of integrated COPD care: the RECODE cluster randomised trial. BMJ Open 2015; 5:e007284. [PMID: 26525419 PMCID: PMC4636669 DOI: 10.1136/bmjopen-2014-007284] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 07/06/2015] [Accepted: 08/21/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To investigate the cost-effectiveness of a chronic obstructive pulmonary disease (COPD) disease management (COPD-DM) programme in primary care, called RECODE, compared to usual care. DESIGN A 2-year cluster-randomised controlled trial. SETTING 40 general practices in the western part of the Netherlands. PARTICIPANTS 1086 patients with COPD according to GOLD (Global Initiative for COPD) criteria. Exclusion criteria were terminal illness, cognitive impairment, alcohol or drug misuse and inability to fill in Dutch questionnaires. Practices were included if they were willing to create a multidisciplinary COPD team. INTERVENTIONS A multidisciplinary team of caregivers was trained in motivational interviewing, setting up individual care plans, exacerbation management, implementing clinical guidelines and redesigning the care process. In addition, clinical decision-making was supported by feedback reports provided by an ICT programme. MAIN OUTCOME MEASURES We investigated the impact on health outcomes (quality-adjusted life years (QALYs), Clinical COPD Questionnaire, St. George's Respiratory Questionnaire and exacerbations) and costs (healthcare and societal perspective). RESULTS The intervention costs were €324 per patient. Excluding these costs, the intervention group had €584 (95% CI €86 to €1046) higher healthcare costs than did the usual care group and €645 (95% CI €28 to €1190) higher costs from the societal perspective. Health outcomes were similar in both groups, except for 0.04 (95% CI -0.07 to -0.01) less QALYs in the intervention group. CONCLUSIONS This integrated care programme for patients with COPD that mainly included professionally directed interventions was not cost-effective in primary care. TRIAL REGISTRATION NUMBER Netherlands Trial Register NTR2268.
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Affiliation(s)
- Melinde R S Boland
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Apostolos Tsiachristas
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Coert M G Blom
- Stichting Zorgdraad foundation, Oosterbeek, The Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Maureen P M H Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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11
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Deek H, Noureddine S, Newton PJ, Inglis SC, MacDonald PS, Davidson PM. A family-focused intervention for heart failure self-care: conceptual underpinnings of a culturally appropriate intervention. J Adv Nurs 2015; 72:434-50. [PMID: 26365459 DOI: 10.1111/jan.12768] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2015] [Indexed: 12/22/2022]
Abstract
AIM A discussion of the conceptual elements of an intervention tailored to the needs of Lebanese families. BACKGROUND The role of informal caregiving is strongly recommended for individuals with chronic conditions including heart failure. Although this importance is recognized, conceptual and theoretical underpinnings are not well elucidated nor are methods of intervention implementation. DESIGN Discussion paper on the conceptual underpinning of the FAMILY model. METHODS AND DATA SOURCES This intervention was undertaken using linked methods: (1) Appraisal of theoretical model; (2) review of systematic reviews on educational interventions promoting self-management in chronic conditions in four databases with no year limit; (3) socio-cultural context identification from selected papers; (4) expert consultation using consensus methods; and (5) model development. RESULTS Theories on self-care and behavioural change, eighteen systematic reviews on educational interventions and selected papers identifying sociocultural elements along with expert opinion were used to guide the development of The FAMILY Intervention Heart Failure Model. Theory and practice driven concepts identified include: behavioural change, linkage, partnership and self-regulation. IMPLICATIONS FOR NURSING Heart failure is a common condition often requiring in-hospital and home-based care. Educational interventions targeting the socio-cultural influences of the patients and their family caregivers through a structured and well-designed program can improve outcomes. CONCLUSION As the burden of chronic diseases increases globally, particularly in emerging economies, developing models of intervention that are appropriate to both the individual and the socio-cultural context are necessary.
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Affiliation(s)
- Hiba Deek
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Australia
| | - Samar Noureddine
- Rafic Hariri School of Nursing, American University of Beirut, Lebanon
| | - Phillip J Newton
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Australia
| | - Sally C Inglis
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Australia
| | - Peter S MacDonald
- Transplantation Research Laboratory at the Victor Chang Institute, St Vincent Hospital, Darlinghurst, Australia
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12
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Liu F, Zou Y, Huang Q, Zheng L, Wang W. Electronic health records and improved nursing management of chronic obstructive pulmonary disease. Patient Prefer Adherence 2015; 9:495-500. [PMID: 25848228 PMCID: PMC4376268 DOI: 10.2147/ppa.s76562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This paper identifies evolving trends in the diagnosis and treatment of chronic obstructive pulmonary disease (COPD), and recommends the integration of nursing strategies in COPD management via widespread implementation of electronic health records. COPD is a complex lung disease with diverse origins, both physical and behavioral, manifested in a wide range of symptoms that further increase the patient's risk for comorbidities. Early diagnosis and effective management of COPD require monitoring of a dizzying array of COPD symptoms over extended periods of time, and nurses are especially well positioned to manage potential progressions of COPD, as frontline health care providers who obtain, record, and organize patient data. Developments in medical technology greatly aid nursing management of COPD, from the deployment of spirometry as a diagnostic tool at the family practice level to newly approved treatment options, including non-nicotine pharmacotherapies that reduce the cravings associated with tobacco withdrawal. Among new medical technologies, electronic health records have proven particularly advantageous in the management of COPD, enabling providers to gather, maintain, and reference more patient data than has ever been possible before. Thus, consistent and widespread implementation of electronic health records facilitates the coordination of diverse treatment strategies, resulting in increased positive health outcomes for patients with COPD.
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Affiliation(s)
- Fengping Liu
- Yancheng Medical College, Yancheng, Jiangsu Province, People’s Republic of China
| | - Yeqing Zou
- Yancheng Medical College, Yancheng, Jiangsu Province, People’s Republic of China
| | - Qingmei Huang
- The First Affiliated College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Li Zheng
- The First Affiliated College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Wei Wang
- The First Affiliated College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China
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13
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Mas MÀ, Santaeugènia S. Hospitalización domiciliaria en el paciente anciano: revisión de la evidencia y oportunidades de la geriatría. Rev Esp Geriatr Gerontol 2015; 50:26-34. [PMID: 24948521 DOI: 10.1016/j.regg.2014.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/25/2014] [Accepted: 04/30/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Miquel Àngel Mas
- Servicio de Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Hospital Municipal de Badalona, CSS El Carme, Badalona, Cataluña, España; Universitat Autònoma de Barcelona, Cataluña, España.
| | - Sebastià Santaeugènia
- Servicio de Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Hospital Municipal de Badalona, CSS El Carme, Badalona, Cataluña, España; Universitat Autònoma de Barcelona, Cataluña, España
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14
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Billington J, Coster S, Murrells T, Norman I. Evaluation of a Nurse-Led Educational Telephone Intervention to Support Self-Management of Patients With Chronic Obstructive Pulmonary Disease: A Randomized Feasibility Study. COPD 2014; 12:395-403. [DOI: 10.3109/15412555.2014.974735] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Blakemore A, Dickens C, Anderson R, Tomenson B, Woodcock A, Guthrie E. Complex interventions reduce use of urgent healthcare in adults with asthma: systematic review with meta-regression. Respir Med 2014; 109:147-56. [PMID: 25433953 DOI: 10.1016/j.rmed.2014.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/15/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Asthma accounts for considerable healthcare expenditure, a large proportion of which is attributable to use of expensive urgent healthcare. This review examines the characteristics of complex interventions that reduce urgent healthcare use in adults with asthma. METHOD Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to January 2013 were conducted. Studies were eligible for inclusion if they: i) included adults with asthma ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up. Data on participants recruited, methods, characteristics of complex interventions and the effects of the intervention on urgent healthcare use were extracted. RESULTS 33 independent studies were identified resulting in 39 comparisons altogether. Pooled effects indicated that interventions were associated with a reduction in urgent healthcare use (OR = 0.79, 95% CI = 0.67, 0.94). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.77, 95% CI = 0.64, 0.91), skills training (OR = 0.64, 95% CI = 0.48, 0.86) and relapse prevention (OR = 0.75, 95% CI = 0.57, 0.98). In multivariate meta-regression analysis, only skills training remained significant. CONCLUSIONS Complex interventions reduced the use of urgent healthcare in adults with asthma by 21%. Those complex interventions including skills training, education and relapse prevention may be particularly effective in reducing the use of urgent healthcare in adults with asthma.
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Affiliation(s)
- Amy Blakemore
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK; National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Chris Dickens
- Institute of Health Research, University of Exeter Medical School and Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Veysey Building, Room 007, Salmon Pool Lane, Exeter, EX2 4SG, UK
| | - Rebecca Anderson
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Barbara Tomenson
- Biostatistics Unit: Institute of Population Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Ashley Woodcock
- Institution of Inflammation and Repair, University of Manchester, 2nd Floor Education and Research Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - Else Guthrie
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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