What matters to people with COPD: outputs from Working Together for Change

A systems approach to developing user requirements for increased pulmonary rehabilitation uptake by COPD patients

Chronic Obstructive Pulmonary Disease is a progressive lung disease associated with anxiety, depression, and reduced health-related quality of life. Pulmonary rehabilitation (PR) is a cost-effective and transformative treatment, but 31% of referred patients do not take up their PR appointment. The study aimed to develop user requirements for an intervention to increase PR uptake. A systems approach, the Engineering Better Care framework, was used to develop a system map of the PR pathway, translate evidence-based user needs into user requirements, and validate the user requirements in a stakeholder workshop. Eight user requirements addressed patient and health care practitioner needs to understand what PR entails, understand the benefits of PR and have positive conversations about PR to address patient concerns. The solution-independent user requirements can be applied to the development of any intervention sharing similar goals. The study demonstrates potential in taking a systems approach to more challenges within respiratory medicine.

A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation

Background

People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease.

Aim

Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation.

Design

We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity.

Setting

Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant's own home or at a local NHS facility, and by telephone.

Participants

Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate.

Intervention

The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral.

Main outcome measures

Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use.

Results

We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference £770.24, 95% confidence interval -£27.91 to £1568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants' lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants.

Conclusions

The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients.

Trial registration

This trial is registered as ISRCTN59537391.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.

Identifying the Relationship Between Economic Prosperity and Quality of Life in Chronic Obstructive Pulmonary Disease Patients

Background Chronic obstructive pulmonary disease (COPD) places a significant economic burden on national healthcare systems, and the economic effects of diseases have long been known. The study aimed to evaluate the association of parental family financial wealth with current economic prosperity and the combined effect of both on health-related quality of life (HRQOL) in a sample of patients with COPD. The moderating effect of birth order is further investigated. Methods The results of the study are based on a purposive sample of 105 COPD patients at the Larisa University Hospital pulmonology clinic (94 males and 11 females), with an average age of 68.9 (SD = 9.2). The data collection was carried out in the spring and summer of 2020. Participants completed the 36-item Short Form Survey (SF-36) and a sociodemographic questionnaire with self-reported parental and current wealth items. A mediation model with the moderation of the indirect effect of parental wealth on current wealth and the direct effect of parental wealth on HRQOL was applied to test the research hypotheses among the variables studied. Results Parental wealth was found to affect current wealth significantly, and both were involved considerably in HRQOL. Birth order had a significant moderating effect on the relationship between parental wealth and HRQOL. Among parental families with lower financial status, patients who grew up as third or later children had significantly lower HRQOL than the first or second children of these families. Neither age nor COPD duration was related to current wealth or HRQOL. Conclusions An intergenerational transmission of poverty was found in our sample. In addition, a birth order effect can provide further insight into the harsher environment that the later children of a low-income family are exposed to and the long-term implications for their HRQOL.

Features and characteristics of publicly available mHealth apps for self-management in chronic obstructive pulmonary disease

Mobile health applications (mHealth apps) may be able to support people living with chronic obstructive pulmonary disease (COPD) to develop the appropriate skills and routines for adequate self-management. Given the wide variety of publicly available mHealth apps, it is important to be aware of their characteristics to optimize their use and mitigate potential harms.

Objective

To report the characteristics and features of publicly available apps for COPD self-management.

Methods

MHealth apps designed for patients' COPD self-management were searched in the Google Play and Apple app stores. Two reviewers trialed and assessed the eligible apps using the MHealth Index and Navigation Database framework to describe the characteristics, qualities, and features of mHealth apps across five domains.

Results

From the Google Play and Apple stores, thirteen apps were identified and eligible for further evaluation. All thirteen apps were available for Android devices, but only seven were available for Apple devices. Most apps were developed by for-profit organizations (8/13), non-profit organizations (2/13), and unknown developers (3/13). Many apps had privacy policies (9/13), but only three apps described their security systems and two mentioned compliance with local health information and data usage laws. Education was the common app feature; additional features were medication reminders, symptom tracking, journaling, and action planning. None provided clinical evidence to support their use.

Conclusions

Publicly available COPD apps vary in their designs, features, and overall quality. These apps lack evidence to support their clinical use and cannot be recommended at this time.

Relationship between serum Th1/Th2 imbalance and depression in elderly patients with COPD and its clinical implications

BACKGROUND

Chronic obstructive pulmonary disease (COPD) causes organic damage as well as anxiety, depression, fear, and other psychological disorders, which seriously affect the quality of life and prognosis of patients and cause a huge economic burden to the family and society.

OBJECTIVE

The aim of this study was to investigate the correlation between an imbalance of serum Th1/Th2 indicators and psychiatric depression in elderly patients with COPD and analyze its implications for clinical management.

METHODS

From January 2018 to May 2022, 120 elderly patients with COPD treated at our hospital were categorized into two groups based on the self-rating depression scale (SDS): COPD with depression (SDS score ⩾ 50) and COPD alone (SDS score < 50). Blood gas analysis, pulmonary function, and serum Th1/Th2 index were determined. Receiver operating characteristic (ROC) curves were analyzed to explore the diagnostic value of serum Th1/Th2 ratios for COPD complicated by depression.

RESULTS

Compared with the group without depression, the partial pressure of carbon dioxide and COPD assessment test scores were significantly higher, and the oxygenation index, forced expiratory volume in one second (FEV1), and percent predicted FEV1 were significantly lower in the COPD with depression group (P< 0.05). Interleukin (IL)-1β, IL-2, IL-6, IL-8, IL-10, and tumor necrosis factor-α (TNF-α) were significantly higher in the COPD with depression group than in the group without depression (P< 0.05). Logistic regression analysis indicated that the imbalance of serum IL-1β, IL-2, IL-6, IL-8, IL-10, and TNF-α was a risk factor for mental depression in elderly patients with COPD. When comparing prognostic indices, the interval before the first onset of clinically noticeable deterioration (CID-C) in the COPD with depression group was noticeably shorter than that in the COPD without depression group; the incidence of CID-C within 6 months was noticeably higher in the COPD with depression group than in the group without depression.

CONCLUSION

Elderly patients with COPD and depression had reduced pulmonary function and higher serum Th1/Th2 levels, and an imbalance in serum Th1/Th2 indicators was a potential risk factor for depression. Moreover, elderly patients with COPD and depression were at a higher risk of disease progression and had a worse prognosis. Thus, an imbalance in serum Th1/Th2 indicators is a potential prognostic factor for evaluating depression in patients with COPD.

Shared decision-making in general practice from a patient perspective. A cross-sectional survey

OBJECTIVES

We aimed to assess patient involvement in terms of shared decision-making in general practice from the perspectives of patients with chronic obstructive pulmonary disease (COPD) or type 2 diabetes (T2DM) (or both).

DESIGN

A cross-sectional survey using the 9-item Shared Decision-Making Questionnaire (SDM-Q-9) ranging from 0 to 5 (best).

SETTING AND SUBJECTS

Patients diagnosed with either T2DM and/or COPD were asked to focus on their most recent consultation in general practice concerning their T2DM or lung disease. Responders were approached through the Danish Diabetes Association and Danish Lung Association.

RESULTS

The sample included 468 responders. Mean scores for the total sample were between 3.3 and 4.2. The overall mean score for all items was 3.7. The highest overall mean score was for patients with T2DM, whereas the lowest overall mean score was for patients having both T2DM and COPD. Furthermore, we observed a slightly lower overall mean score for women compared to men and for those younger than 65 years compared to those aged 65 years or older.

CONCLUSION

Overall, patients are involved in shared decision-making in general practice Minor nuances were found because patients with COPD were less involved in shared decision-making compared to patients with T2DM. Similarly, younger patients and women were less involved than older patients and men.

Self-management in chronic lung disease: what is missing?

Self-management, as a strategy to support those living with chronic respiratory conditions such as asthma and COPD, has been widely advocated in guidelines and adopted in practice. However, there can be a disconnect between the goals of patients and healthcare professionals. Goals and barriers to self-management are often compounded by the complex social, emotional and medical needs of patients. People living with chronic respiratory conditions also often have symptoms of anxiety and depression, which can impact on self-management. Self-management therefore requires patients and healthcare professionals to work together and it is essential to involve patients when designing, implementing and evaluating self-management interventions.

Patient preferences are clearly important and goal setting needs an individual, flexible and responsive approach from healthcare professionals, which aligns to a more personalised approach to management of treatable traits and the burden of disease. To achieve these goals, healthcare professionals need education to support patients in self-management and behaviour change. This approach should lead to shared decision-making and partnership working that puts the patient right at the centre of their care.

Self-management is often effective in chronic respiratory disease and can improve symptoms and reduce healthcare burden. Yet patients rarely feature in the design or implementation of interventions; are patients as active partners the missing ingredient?https://bit.ly/3LiqhVg