Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease

Experiences of patients with advanced COPD affiliated to a cross-sectorial outgoing lung team: A qualitative study

AIM

To explore experiences of patients affiliated to a cross-sectorial outgoing lung team.

BACKGROUND

The outgoing lung team consisted of respiratory nurses from the hospital and community nurses. The lung team offered 24/7 help to patients with advanced chronic obstructive pulmonary disease (COPD) through visits and/or treatment in the patients' home. Affiliation to the lung team reduced both hospitalizations and length of hospital stay due to acute exacerbation of COPD. However, based on questionnaires on health-related quality of life, no significant differences were found between patients affiliated to the lung team and patients receiving usual care.

DESIGN

A qualitative interview study.

METHODS

In total, 16 patients, aged 61-88 years were interviewed between February 2019 and July 2021. They had been affiliated to the outgoing lung team for 1-3 years. Semi-structured interviews were conducted in the patients' home and audio-recorded after informed consent was obtained. The interviews were transcribed verbatim and analysed, inspired by systematic text condensation by Malterud.

FINDINGS

Four themes emerged from the analysis: (1) feeling safe, (2) improvements in living with COPD, (3) avoiding hospitalization and (4) satisfied with staying at home.

CONCLUSION

Affiliation to the cross-sectorial outgoing lung team gave the patients peace of mind and improved their ability to live with advanced COPD. The patients preferred contacting the lung team because they could stay at home and receive treatment, and thus avoid hospitalization.

IMPACT

The findings from this study support that municipalities should consider implementing an outgoing lung team, as it has the potential to bring several benefits, including improving patient self-management.

REPORTING METHOD

The manuscript adhered to Consolidated criteria for reporting qualitative research (COREQ) guideline.

PATIENT OR PUBLIC CONTRIBUTION

Patients were interviewed. Additionally, no patient or public contributed to the design or conduction of the study, analysis, or interpretation of the data.

Does home and community-based services use reduce hospital utilization and hospital expenditure among disabled elders? Evidence from China

Introduction

In the background of aging in place, home and community-based services (HCBS) have been playing an increasingly important role in long-term care (LTC) security systems. However, it is still uncertain whether and how HCBS use affects hospital utilization and the corresponding expenditures.

Methods

Using data from the China Health and Retirement Longitudinal Survey (CHARLS) and the China City Statistical Yearbook, the instrumental variable (IV) approach is applied to identify the causal effects of HCBS use on hospital utilization and hospital expenditure among disabled elders.

Results

We find that HCBS use significantly reduces the probability of being hospitalized, the times of hospitalization, and the length of inpatient stay, as well as the total, out-of-pocket and reimbursement inpatient expenditures, demonstrating not only the substitution impact of HCBS for hospital care but also the effectiveness of medical expenditure control in LTC security systems. Heterogeneity analysis shows that the impacts of HCBS use on hospital utilization and hospital expenditure concentrate on disabled elders who are younger, male, living in urban areas, or from higher-income households; both healthcare and spiritual consolation services have significant negative effects, while the anticipated effects of daily care service use are not supported. The possible mechanisms are the substitution of HCBS for hospital care and the improvements in both the physical and psychological health of disabled elders. However, the mechanism of adverse events decrease is not verified, which needs to be investigated further with more proxy variables.

Conclusion

This study provides empirical evidence that HCBS use can not only reduce hospital utilization and hospital expenditure among disabled elders but also improve their physical and psychological health. Policy designs should emphasize the orientation of HCBS, ensure the fundamental and central position of HCBS in the formal care service system, pay more attention to the accessibility and affordability of HCBS for fragile groups, and diversify and optimize the development of the health service and the spiritual consolation service.

Enhancing potential impact of hospital discharge interventions for patients with COPD: a qualitative systematic review

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) are frequently readmitted to hospital resulting in avoidable healthcare costs. Many different interventions designed to reduce hospital readmissions are reported with limited evidence for effectiveness. Greater insight into how interventions could be better designed to improve patient outcomes has been recommended.

AIM

To identify areas for optimisation within previously reported interventions provided to reduce COPD rehospitalisation to improve future intervention development.

METHODS

A systematic review was conducted by searching Medline, Embase, CINAHL, PsycINFO, and CENTRAL in June 2022. Inclusion criteria were interventions provided to patients with COPD in the transition from hospital to home or community. Exclusion criteria were lack of empirical qualitative results, reviews, drug trials, and protocols. Study quality was assessed using the Critical Appraisal Skills Programme tool and results were synthesised thematically.

RESULTS

A total of 2,962 studies were screened and nine studies included. Patients with COPD experience difficulties when transitioning from hospital to home. It is therefore important for interventions to facilitate a smooth transition process and give appropriate follow-up post-discharge. Additionally, interventions should be tailored for each patient, especially regarding information provided.

CONCLUSION

Very few studies specifically consider processes underpinning COPD discharge intervention implementation. There is a need to recognise that the transition itself creates problems, which require addressing, before introducing any new intervention. Patients report a preference for interventions to be individually adapted-in particular the provision of patient information. Whilst many intervention aspects were well received, feasibility testing may have enhanced acceptability. Patient and public involvement may address many of these concerns and greater use of process evaluations should enable researchers to learn from each other's experiences.

TRIAL REGISTRATION

The review was registered in PROSPERO with registration number CRD42022339523.

Effects of Transitional Care after Hospital Discharge in Patients with Chronic Obstructive Pulmonary Disease: An Updated Systematic Review and Meta-Analysis

This study aimed to systematically review the effects of transitional care programs on healthcare use and quality of life in patients with chronic obstructive pulmonary disease (COPD). Several databases were searched for randomized controlled trials conducted over the past five years, and their quality was evaluated using the Cochrane Risk of Bias 2.0 tool. For indicators with available statistical information, a meta-analysis was performed using RevMan 5.4, and a narrative review was performed for the rest of the results. In the meta-analysis, no statistically significant difference was observed between the intervention and control groups in the number of readmissions and emergency room visits due to COPD. The relative risk (RR) of readmission for COPD was lower in the intervention group. Respiratory-related quality of life tended to be better in the intervention group, though not significantly. Physical capacity was improved in the intervention group. Considering the characteristics of the complex intervention, the context and factors of cases where the expected results could be obtained and cases where the expected results could not be obtained were reviewed and discussed. Based on the results of the analysis, implications for the development of better protocols were presented.

[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.

Anxiety, Dyspnea Management, and Quality of Life in Palliative Care Patients: A Randomized Controlled Trial

AIM

This study aimed to determine the influence of nursing care grounded on Watson's Human Care Model on anxiety, dyspnea control, and life quality in palliative care patients.

METHOD

A randomized controlled study was designed. It was conducted on 64 participants hospitalized in a training and research hospital and 2 state hospital palliative care services in Turkey. The data were collected face to face using the patient information form, the Beck Anxiety Scale, the Hospital Anxiety and Depression Scale, the Medical Research Council Dyspnea Scale, and the Short Form-36 Quality of Life Scale.

RESULTS

It was detected that there was no statistically considerable difference in the median points of the Beck Anxiety Scale, Hospital Anxiety and Depression Scale, Medical Research Council Dyspnea Scale, and Short Form-36 domains between the two groups in the pretest. However, the posttest median points were remarkably lower and the posttest median points of the Short Form-36 scale were meaningfully higher in the intervention group (p < 0.05).

CONCLUSION

Nursing care grounded on Human Care Model reduced the grade of anxiety and dyspnea in patients and raised their life quality.

'Investing' in care for old age? An examination of long-term care expenditure dynamics and its spillovers

We study the dynamic drivers of expenditure on long-term care (LTC) programmes, and more specifically, the effects of labour market participation of traditional unpaid caregivers (women aged 40 and older) on LTC spending, alongside the spillover effects of a rise in LTC expenditure on health care expenditures (HCE) and the economy (per capita GDP). Our estimates draw from a panel of more than a decade worth of expenditure data from a sample of OECD countries. We use a panel vector auto-regressive (panel-VAR) system that considers the dynamics between the dependent variables. We find that LTC expenditure increases with the rise of the labour market participation of the traditional unpaid caregiver (women over 40 years of age), and that such expenditures rise exerts large spillover effects on health spending and the economy. We find that a 1% increase in female labour participation gives rise to a 1.48% increase in LTC expenditure and a 0.88% reduction in HCE. The effect of LTC spending over HCE is mainly driven by a reduction in inpatient and medicine expenditures, exhibiting large country heterogeneity. Finally, we document significant spillover effects of LTC expenditures on per capita GDP.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s00181-022-02246-0.

Home-Based Respiratory Care for COPD Patients

Despite significant advances in pharmacological treatment over the last few decades, COPD remains a heavy burden on the health systems around the world, affecting approximately 210 million people, with elevated morbimortality and socioeconomic impact. Barriers to healthcare access were even more evident during the coronavirus disease 19 (COVID-19) pandemic and increased patients’ vulnerability to physical deconditioning, depression, and social isolation. Home-based respiratory care in patients with COPD provides a valuable contribution to effective disease management, with potential advantages for monitoring, treatment adherence, and cost reduction. Technological innovation allows clinical markers of interest, such as respiratory frequency, pulmonary function, and oxygen saturation, to be tracked remotely from the patients’ homes, providing a better understanding of their real needs. Home-based telerehabilitation can also be a viable alternative to hospital-based programs. Here, we highlight the full extent of health benefits of HRC in COPD, particularly for patients with a higher risk of exacerbations, multiple comorbidities, and limited access to health services.

Comparison of Mortality and Hospital Readmissions Among Patients Receiving Virtual Ward Transitional Care vs Usual Postdischarge Care: A Systematic Review and Meta-analysis

IMPORTANCE

Virtual wards (VWs) include patient assessment in their homes by health care personnel and offer ongoing assessment and case management via home, telephone, and/or clinic visits. The association between VWs and patient outcomes during the transition from the hospital to home are unclear; earlier reviews on this topic have often conflated telemonitoring programs with VW models.

OBJECTIVE

To evaluate the use of VW transition systems for community-dwelling individuals after medical discharge.

DATA SOURCES

English-language articles indexed in PubMed or Cochrane and published between January 1, 2000, and June 15, 2021.

STUDY SELECTION

Randomized clinical trials comparing VW care with usual postdischarge care. Studies were stratified by diagnosis.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently identified studies and extracted data. DerSimonian-Laird inverse variance weighted random-effects models were used to compute relative risks (RRs) for dichotomous outcomes and mean differences for continuous outcomes.

MAIN OUTCOMES AND MEASURES

All-cause mortality, hospital readmissions, emergency department visits, health care costs, readmission length of stay, quality of life, and functional status.

RESULTS

Twenty-four randomized clinical trials (11 in patients with heart failure, 3 in patients with chronic obstructive pulmonary disease, 4 in patients at high-risk for readmission, and 6 in mixed patient populations) with 10 876 patients were included (20 more trials than earlier reviews). In patients with heart failure, VWs were associated with fewer deaths (RR, 0.86; 95% CI, 0.76-0.97) and fewer readmissions (RR, 0.84; 95% CI, 0.74-0.96). However, similar associations were not seen in randomized clinical trials enrolling patients with other diagnoses (RR, 0.93; 95% CI, 0.83-1.04 for mortality and RR, 0.96; 95% CI, 0.88-1.05 for readmissions). Across all studies, VWs were associated with fewer emergency department visits (RR, 0.83; 95% CI, 0.70-0.98) and shorter readmission lengths of stay (mean difference, -1.94 days; 95% CI, -3.28 to -0.60 days). Three of 7 studies that evaluated health care expenses reported statistically significant lower costs with VW transition systems.

CONCLUSIONS AND RELEVANCE

Although postdischarge VW interventions appear to be associated with fewer subsequent emergency department visits, shorter readmission lengths of stay, and lower health care costs, fewer deaths and readmissions were seen only in trials enrolling patients with heart failure.

Community-Based Pulmonary Rehabilitation Programs in Individuals With COPD

BACKGROUND

Community-based pulmonary rehabilitation (PR) programs can be offered to patients with COPD, but the literature on its effects is still not well summarized. Our purpose was to investigate the health-, physical-, and respiratory-related effects of community-based PR in individuals with COPD as compared to control groups.

METHODS

The PubMed and Embase databases were searched up to May 17, 2021. We included randomized control trials that compared the effects of community-based PR as compared to control groups in individuals with COPD. The risk of bias was judged using the Cochrane Risk of Bias 2 (RoB2). Meta-analysis was performed using a random-effects model to estimate the standardized mean difference (SMD) with 95% CI of the mean changes from baseline between groups. The Grading of Recommendations Assessment, Development, and Evaluation was used to interpret certainty of results.

RESULTS

We included 10 randomized control studies comprising a total of 9,350 participants with weighted mean age of 62.3 ± 2.38 y. The community-based interventions were based on exercise programs (resistance and/or endurance). All studies were judged as high risk and/or some concerns in one or more domains the risk of bias. All meta-analyses displayed very low certainty of evidence. The community-based PR interventions were significantly superior to control interventions in improving the St. George Respiratory Questionnaire Activity subscore (-0.40 [95% CI -0.72 to -0.08]; k = 5, n = 382) and total score (-0.73 [95% CI -1.29 to -0.18]; k = 4, n = 268) and the Chronic Respiratory Disease Questionnaire dyspnea subscore (0.36 [95% CI 0.03-0.69]; k = 6, n = 550). The mean changes from baseline were not different between the groups for all other outcomes.

CONCLUSIONS

Community-based PR tended to result in superior health-related quality of life and symptoms than control interventions, but the findings were inconsistent across outcomes and with very low certainty of evidence. Further studies are warranted for stronger conclusions.

Does affiliation to a cross-sectorial lung team impact well-being, health-related quality of life, symptoms of anxiety and depression and patient involvement in patients with COPD? A randomised controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease causing limitations in daily life. A cross-sectorial lung team was established for COPD patients at risk of hospitalisation due to exacerbation of COPD.

AIMS

To investigate the impact of affiliation to a cross-sectorial lung team on well-being, health-related quality of life, symptoms of anxiety and depression and patient involvement in patients with severe COPD.

METHODS

A randomised controlled trial was conducted from September 2017 to March 2020. In total, 109 patients were included for analysis in the study: 53 patients were affiliated to a cross-sectorial lung team and 56 patients received usual care. The patients were included for 1 year. Data were collected at baseline and at follow-up after 1 year. Data were collected using COPD Assessment Test (CAT), Hospital Anxiety and Depression Scale (HADS), EuroQol 5-Dimensions (EQ-5D) and Patient Assessment of Chronic Illness Care (PACIC).

RESULTS

The questionnaire response rate was between 84% and 96%. No statistically significant differences were detected between patients affiliated to the cross-sectorial lung team and patients receiving usual care, in either patient's well-being, health-related quality of life, symptoms of anxiety and depression, or patient involvement. However, CAT-total score decreased with -0.21(95%CI: -1.63; 1.20) for patients affiliated to the cross-sectorial lung team and increased with 1.44(95%CI; -0.11; 3.00) for patients receiving usual care.

CONCLUSION

Affiliation to the cross-sectorial lung team seems safe as it did not deteriorate the patients' well-being, symptoms of anxiety and depression, health-related quality of life or patient involvement. Further research is needed and interviewing patients to obtain more knowledge on their experiences might be preferable.

Impfen gegen Influenza – Internationale Bestandsaufnahme und Perspektiven für Deutschland

Hintergrund

Die aktuelle SARS-CoV-2-Pandemie erfordert hohe Durchimpfungsraten von chronisch Kranken gegen Influenza, um das Gesundheitssystem nicht zusätzlich zu belasten. Trotz klarer Evidenz für Sicherheit und Wirksamkeit der Influenza-Impfung sind die Impfquoten in den vergangenen Jahren international auf insuffizientem Niveau verblieben. Der Hausarzt hat eine zentrale Bedeutung für die Versorgung dieser Population. Ziel dieser systematischen Übersichtsarbeit war daher die Evaluation verschiedener Maßnahmen in der Allgemeinmedizin zur Steigerung der saisonalen Influenza-Impfquoten bei chronisch Kranken unter Berücksichtigung verschiedener internationaler Gesundheitssysteme.

Methoden

Eine systematische Literaturrecherche wurde in MEDLINE, CENTRAL, EMBASE und ERIC sowie manuell in Studienregistern und Literaturlisten durchgeführt. Dabei wurden ausschließlich randomisierte kontrollierte Studien berücksichtigt. Die Methodik wurde im Vorfeld in einem Studienprotokoll festgelegt (PROSPERO CRD42018114163).

Ergebnisse

Insgesamt wurden 14 Studien im Rahmen eines nationalen Gesundheitsdienstes (Großbritannien), einer staatlichen (Australien) und sozialen (Schweiz) Krankenversicherung und eines privaten Gesundheitssystems (USA) in unsere Übersichtsarbeit eingeschlossen. Analoge Patientenerinnerungen und automatisierte Arzterinnerungen sowie Veränderungen der beruflichen Rollen führten ausschließlich im privaten Gesundheitssystem zu einem deutlichen Anstieg der Influenzaimpfquoten. Im nationalen Gesundheitsdienst konnte keine der analysierten Interventionen einen signifikanten Anstieg der Impfquoten erreichen, wobei im nationalen Gesundheitsdienst Großbritanniens verhältnismäßig gute Basisimpfraten gegen Influenza bereits vor Durchführung der Studien interventionsunabhängig vorlagen. Fortbildungsveranstaltungen für Praxisteams und Erinnerungs-SMS zeigten in den sozialen und staatlichen Krankenversicherungssystemen der Schweiz und in Australien gute Resultate.

Schlussfolgerungen

In Deutschland könnten vor allem Fortbildungsveranstaltungen für medizinische Teams und sowie zentral organisierte Einladungs- und Monitoringsysteme zur Verbesserung der Impfquoten bei chronisch Kranken geeignet sein. Eine staatliche Kostenübernahme der Impfkosten scheint in verschiedenen Gesundheitssystemen für eine gute Basisimpfquote gegen Influenza bei Indikationspatienten zu sorgen.

Clinical Outcome of a Cross-Sectorial Lung Team Treating Patients with COPD at High Risk of Exacerbation: A Randomized Controlled Trial

In addition to the financial burden, acute exacerbation of chronic obstructive pulmonary disease (AECOPD) also has a negative impact on health status and disease progression for patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the effect of affiliation to a cross-sectorial lung team (CLT) on hospitalization and length of hospital stay for patients with COPD and ≥ one severe or two moderate AECOPD events within a year. We conducted a randomized clinical trial between 2017 and 2020. Participants were randomly assigned 1:1 for one year to CLT or usual care (UC). The CLT was available for telephone calls and home visits day and night on the request from patients, and the CLT could initiate home treatment. In total, 56 patients were affiliated to the CLT (Mean: age 71.6 years, FEV1 37.1%) and 57 patients received UC (Mean: age 71.5 years, FEV1; 33.6%). Patients affiliated to the CLT had on average fewer hospitalizations due to AECOPD than patients receiving UC (CLT: 0.59 (95% CI: 0.35; 0.83 - UC: 1.86 (95% CI: 1.12; 2.20; p = 0.002). Patients affiliated to the CLT also had shorter hospital stay on average due to AECOPD (CLT: 3.27(95% CI: 2.39; 4.15 - UC: 4.47 (95% CI: 3.70; 5.24; (p = 0.045). No significant difference in number of severe adverse events, including death, was observed between groups. Affiliation to the CLT seemed safe and reduced both hospitalizations and length of hospital stay related to AECOPD compared to UC.

The impact on severe exacerbations of establishing a cross-sectorial lung team for patients with COPD at high risk of exacerbating: a pilot study

Background: Exacerbation in Chronic obstructive pulmonary disease (COPD) becomes more frequent with advancing disease severity and often the patients end up being hospitalized.

Objective: To evaluate the impact on exacerbations of establishing a cross-sectorial lung team (CLT) for patients with COPD at high risk of exacerbating.

Methods: In total, 49 patients with severe COPD were affiliated to a CLT for 6 months. On request from the participants, the CLT was available for telephone calls and home visits day and night to initiate treatment and give advice. Data regarding hospitalizations were collected 3 years prior to the intervention year to predict future numbers of admissions and length of stay. These predictions were compared with the observed data. COPD assessment test (CAT) was conducted before and after intervention.

Results: Observed risk of hospitalization (0.54 (95% CI 0.32; 0.90), p = 0.0192)) and length of hospital stay due to COPD (0.41 (95% CI 0.22; 0.76), p = 0.0046)) were significantly lower during the intervention period than predicted. A numerical but non-significant improvement in the total CAT score of 1.10 (95%CI: –0.71;2.91), p = 0.226)) was observed.

Conclusion: Affiliation to a CLT seemed to lower the burden of COPD exacerbations in a high-risk population.

Transitions of care interventions to improve quality of life among patients hospitalized with acute conditions: a systematic literature review

BACKGROUND

Although transitional care interventions can improve health among patients hospitalized with acute conditions, few interventions use patient quality of life (QOL) as the primary outcome. Existing interventions use a variety of intervention components, are not effective for patients of all races and ethnicities, do not address age-related patient needs, and do not incorporate the needs of families. The purpose of this study was to systematically review characteristics of transitional care intervention studies that aimed to improve QOL for younger adult patients of all race and ethnicities who were hospitalized with acute conditions.

METHODS

A systematic review was conducted of empirical literature available in PubMed, Embase, CINAHL, and PsycINFO by November 19, 2019 to identify studies of hospital to home care transitions with QOL as the primary outcome. Data extraction on study design and intervention components was limited to studies of patients aged 18-64.

RESULTS

Nineteen articles comprising 17 studies met inclusion criteria. There were a total of 3,122 patients across all studies (range: 28-536). Populations of focus included cardiovascular disease, chronic obstructive pulmonary disease, stroke, breast cancer, and kidney disease. Seven QOL instruments were identified. All interventions were multi-component with a total of 31 different strategies used. Most interventions were facilitated by a registered nurse. Seven studies discussed intervention facilitator training and eight discussed intervention materials utilized. No studies specified cultural tailoring of interventions or analyzed findings by racial/ethnic subgroup.

CONCLUSIONS

Future research is needed to determine which intervention components, either in isolation or in combination, are effective in improving QOL. Future studies should also elaborate on the background and training of intervention facilitators and on materials utilized and may also consider incorporating differences in culture, race and ethnicity into all phases of the research process in an effort to address and reduce any health disparities.

Home-Based Educational Programs for Management of Dyspnea: A Systematic Literature Review

Dyspnea or breathlessness is a symptom of a plethora of diseases; despite that its management poses a challenge, it leads to frequent hospitalizations and a poor quality of life. In lung cancer, dyspnea may appear at any time of the disease but mainly during the end-of-life period. This article aims to explore the effectiveness of home-based educational programs for the management of dyspnea. This is a systematic review. The inclusion criteria were studies published between 2000 and 2018, and structured nurse-led home educational programs for the management of dyspnea due to cancer. The search via PUBMED, COCHRANE, EBSCO, and Google Scholar was worldwide for English- and Greek-language articles. The keywords included “education, program, intervention, patient, dyspnea, breathlessness, cancer, home, nurse.” The review was expanded to dyspnea being due to any chronic disease as it gave only one research article for lung cancer. The review identified seven research articles evaluating the effectiveness of various home-based educational programs for dyspnea management due to chronic obstructive pulmonary disease, heart failure, and lung cancer. They showed that a structured home-based educational program is of benefit for the patients by improving their dyspnea levels and their quality of life. There is the need to evaluate the benefits of home-based educational programs for cancer patients with dyspnea at home either as part of a symptom alone support program or as part of the general support given to cancer patients at home.

Developing and Assessing the Effectiveness of a Nurse-Led Home-Based Educational Programme for Managing Breathlessness in Lung Cancer Patients. A Feasibility Study

Introduction: Breathlessness is the most common and refractory symptom in lung cancer patients. Even though various educational programmes have been developed, only a few were intended for implementation in the home setting for its management.

Aim: Feasibility of a study for implementing a nurse-led educational programme for breathlessness management of lung cancer patients at home.

Method: A randomized feasibility study was undertaken between February 2017 and October 2018. Patients were recruited through referral from oncologists from two oncology centers in Cyprus under certain inclusion and exclusion criteria. Patients were randomized in the intervention or control group via a computer programme, and their named family caregivers (f.c.) were allocated in the same group. Participants were not blinded to group assignment. The intervention consisted of a PowerPoint presentation and implementation of three non-pharmacological interventions. The control group received usual care. Patients were assessed for breathlessness, anxiety, and depression levels, whereas f.c. were assessed for anxiety, depression, and burden levels. F.c. also assessed patients' dyspnea level. The duration of the study process for both the intervention and control group was over a period of 4 weeks.

Results: Twenty-four patients and their f.c. (n = 24) were allocated equally in the intervention and control group. Five patients withdrew, and the final sample entered analysis was 19 patients and 19 family caregivers. In the intervention group n = 11 + 11, and in the control group n = 8 + 8. In the intervention group patients' breathlessness and anxiety levels showed improvement and their f.c.s in the anxiety and burden levels. Major consideration was the sample size and the recruitment of the patients by the referring oncologists. Attrition was minor during the study process. No harm was recorded by the participants of the study.

Conclusions: The study provided evidence of the feasibility of the implementation of the educational programme. For the future definitive study major consideration should be patients' recruitment method in order to achieve adequate sample size. Moreover, qualitative data should be collected in relation to the intervention and the involvement of f.c. The feasibility study was registered to the Cyprus Bioethics Committee with the registration number 2016/16. There was no funding of the study.

Effect of inhaler drug education on fatigue, dyspnea severity, and respiratory function tests in patients with COPD

OBJECTIVE

This study was conducted to examine the effect of inhaler drug education on fatigue, dyspnea severity, and respiratory function tests in patients with chronic obstructive pulmonary disease (COPD).

METHODS

This randomized controlled study was conducted with a total of 85 patients treated at the chest diseases clinic and outpatient clinic of a state hospital. The data were collected using questionnaires, respiratory function tests, and the COPD and Asthma Fatigue Scale (CAFS) and Visual Analogue Scale (VAS-for dyspnea severity).

RESULTS

It was determined that after 4 weeks of inhaler drug education, the CAFS mean score decreased to 35.32 ± 14.36, the dyspnea severity mean score decreased to 4.76 ± 2.50, and the respiratory function tests mean scores increased to forced expiratory volume in 1 s (FEV₁) = 58.83 ± 25.48, forced vital capacity (FVC) = 59.04 ± 19.19, and FEV₁/FVC = 88.39 ± 21.59 in the intervention group (p < 0.05). No change was observed in the patients in the control group except for FEV₁ and FVC mean scores (p > 0.05).

CONCLUSION

These results demonstrate that inhaler drug education can improve fatigue, dyspnea severity, and respiratory function tests of patients with COPD.

PRACTICE IMPLICATIONS

The training by nurses of every patient hospitalized in the clinic regarding inhaler drug therapy, and the regular checking of patients' way of using the inhaled drugs, will contribute to COPD management.

Klug S, Gensichen J. Increasing Influenza Vaccination Rates in People With Chronic Illness

BACKGROUND

The safety and efficacy of influenza vaccination for the chronically ill are clearly supported by the evidence, yet vaccination rates in this vulnerable popu- lation remain low. This leads to many avoidable hospitalizations and deaths in Germany every year. The goal of this systematic review is to identify measures in primary care medicine that can be used to increase influenza vaccination rates among the chronically ill.

METHODS

This review was carried out as recommended in the PRISMA statement. A systematic literature search was performed. Only randomized, controlled trials were included in the analysis. Details can be found in the study protocol (PROSPERO, CRD42018114163).

RESULTS

15 trials were included in the analysis. Training sessions for medical practice teams focusing on a particular disease raised the vaccination rates by as much as 22%. A financial incentive had the greatest effect (relative risk [RR]: 2.79; 95% confidence interval: [1.18; 6.62]). Reminders via text message yielded a maximum 3.8% absolute increase in vaccination rates. Complex interventions were not found to be of any greater benefit than simple ones.

CONCLUSION

A variety of approaches can be effective. Focusing training sessions for medical practice teams on certain diseases may be of greater benefit than vacci- nation-centered training sessions. Reminder systems for doctors should be more reliably implemented. Simple strategies are perhaps the most suitable ones in the heterogeneous population of chronically ill persons. The limitations of this system- atic review include the heterogeneity of the studies that we examined and the small number of studies in each category.

Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis

BACKGROUND

Hospital readmission after discharge is a frequent, burdensome and costly event, particularly frequent in older people with multiple chronic conditions. Few literature reviews have analysed studies of continuity of care interventions to reduce readmissions of older inpatients discharged home over the short and long term.

OBJECTIVE

To evaluate the effectiveness of continuity of care interventions in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge.

DESIGN

Meta-analysis of randomized controlled trials.

DATA SOURCES

A comprehensive literature search on the databases PubMed, Medline, CINAHL and EMBASE was performed on 27 January 2019 with no language and time limits.

REVIEW METHODS

RCTs on continuity of care interventions on older people discharged from hospital having hospital readmission as outcome, were included. Two reviewers independently screened the studies and assessed methodological quality using the Cochrane Risk of Bias tool. Selected outcome data were combined and pooled using a Mantel-Haenszel random-effects model.

RESULTS

Thirty RCTs, representing 8920 patients were included. Results were stratified by time of readmissions. At 1 month from discharge, the continuity interventions were associated with lower readmission rates in 207/1595 patients in the experimental group (12.9%), versus 264/1645 patients in the control group (16%) (Relative Risk [RR], 0.84 [95% CI, 0.71-0.99]). From 1 to 3 months, readmission rates were lower in 325/1480 patients in the experimental group (21.9%), versus 455/1523 patients in the control group (29.8%) (RR 0.74 [95% CI, 0.65-0.84]). A subgroup analysis showed that this positive effect was stronger when the interventions addressed all of the continuity dimensions. After 3 months this impact became inconclusive with moderate/high statistical heterogeneity.

CONCLUSIONS

Continuity of care interventions prevent short term hospital readmission in older people with chronic diseases. However, there is inconclusive evidence about the effectiveness of continuity interventions aiming to reduce long term readmission, and it is suggested that stronger focus on it is needed.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Does long-term care subsidization reduce hospital admissions and utilization?

We use quasi-experimental evidence on the expansion of the public subsidization of long-term care to examine the causal effect of a change in caregiving affordability on the delivery of hospital care. More specifically, we examine a reform that both introduced a new caregiving allowance and expanded the availability of publicly funded home care services, on both hospital admissions (both on the internal and external margin) and length of stay. We find robust evidence of a reduction in both hospital admissions and utilization among both those receiving a caregiving allowance and, albeit less intensely, among beneficiaries of publicly funded home care, which amounts to 11% of total healthcare costs. These effects were stronger when regions had an operative regional health and social care coordination plan in place. Consistently, a subsequent reduction in the subsidy, five years after its implementation, is found to significantly attenuate such effects. We investigate a number of potential mechanisms, and show a number of falsification and robustness checks.

The Effect of Progressive Relaxation Exercises on Fatigue and Sleep Quality in Individuals With COPD

This randomized controlled experimental study was conducted to investigate the effect of progressive muscle relaxation exercises on dyspnea, fatigue, and sleep quality in individuals with chronic obstructive pulmonary disease. A Descriptive Questionnaire and the Chronic Obstructive Pulmonary Disease and Asthma Fatigue Scale, Chronic Obstructive Pulmonary Disease and Asthma Sleep Scale and Medical Research Council Dyspnea Scale were used for data collection. The decrease in the mean dyspnea, fatigue, and sleep scores in the intervention group was statistically significantly more pronounced than the patients in the control group (P < .05). Progressive relaxation exercises can be implemented to decrease the dyspnea, fatigue, and sleep problems seen in patients with moderate and advanced chronic obstructive pulmonary disease by nurses working in the clinic.

Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) self-management interventions should be structured but personalised and often multi-component, with goals of motivating, engaging and supporting the patients to positively adapt their behaviour(s) and develop skills to better manage disease. Exacerbation action plans are considered to be a key component of COPD self-management interventions. Studies assessing these interventions show contradictory results. In this Cochrane Review, we compared the effectiveness of COPD self-management interventions that include action plans for acute exacerbations of COPD (AECOPD) with usual care.

OBJECTIVES

To evaluate the efficacy of COPD-specific self-management interventions that include an action plan for exacerbations of COPD compared with usual care in terms of health-related quality of life, respiratory-related hospital admissions and other health outcomes.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials, trials registries, and the reference lists of included studies to May 2016.

SELECTION CRITERIA

We included randomised controlled trials evaluating a self-management intervention for people with COPD published since 1995. To be eligible for inclusion, the self-management intervention included a written action plan for AECOPD and an iterative process between participant and healthcare provider(s) in which feedback was provided. We excluded disease management programmes classified as pulmonary rehabilitation or exercise classes offered in a hospital, at a rehabilitation centre, or in a community-based setting to avoid overlap with pulmonary rehabilitation as much as possible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. Study authors were contacted to obtain additional information and missing outcome data where possible. When appropriate, study results were pooled using a random-effects modelling meta-analysis. The primary outcomes of the review were health-related quality of life (HRQoL) and number of respiratory-related hospital admissions.

MAIN RESULTS

We included 22 studies that involved 3,854 participants with COPD. The studies compared the effectiveness of COPD self-management interventions that included an action plan for AECOPD with usual care. The follow-up time ranged from two to 24 months and the content of the interventions was diverse.Over 12 months, there was a statistically significant beneficial effect of self-management interventions with action plans on HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score, where a lower score represents better HRQoL. We found a mean difference from usual care of -2.69 points (95% CI -4.49 to -0.90; 1,582 participants; 10 studies; high-quality evidence). Intervention participants were at a statistically significant lower risk for at least one respiratory-related hospital admission compared with participants who received usual care (OR 0.69, 95% CI 0.51 to 0.94; 3,157 participants; 14 studies; moderate-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over one year was 12 (95% CI 7 to 69) for participants with high baseline risk and 17 (95% CI 11 to 93) for participants with low baseline risk (based on the seven studies with the highest and lowest baseline risk respectively).There was no statistically significant difference in the probability of at least one all-cause hospital admission in the self-management intervention group compared to the usual care group (OR 0.74, 95% CI 0.54 to 1.03; 2467 participants; 14 studies; moderate-quality evidence). Furthermore, we observed no statistically significant difference in the number of all-cause hospitalisation days, emergency department visits, General Practitioner visits, and dyspnoea scores as measured by the (modified) Medical Research Council questionnaire for self-management intervention participants compared to usual care participants. There was no statistically significant effect observed from self-management on the number of COPD exacerbations and no difference in all-cause mortality observed (RD 0.0019, 95% CI -0.0225 to 0.0263; 3296 participants; 16 studies; moderate-quality evidence). Exploratory analysis showed a very small, but significantly higher respiratory-related mortality rate in the self-management intervention group compared to the usual care group (RD 0.028, 95% CI 0.0049 to 0.0511; 1219 participants; 7 studies; very low-quality evidence).Subgroup analyses showed significant improvements in HRQoL in self-management interventions with a smoking cessation programme (MD -4.98, 95% CI -7.17 to -2.78) compared to studies without a smoking cessation programme (MD -1.33, 95% CI -2.94 to 0.27, test for subgroup differences: Chi² = 6.89, df = 1, P = 0.009, I² = 85.5%). The number of behavioural change techniques clusters integrated in the self-management intervention, the duration of the intervention and adaptation of maintenance medication as part of the action plan did not affect HRQoL. Subgroup analyses did not detect any potential variables to explain differences in respiratory-related hospital admissions among studies.

AUTHORS' CONCLUSIONS

Self-management interventions that include a COPD exacerbation action plan are associated with improvements in HRQoL, as measured with the SGRQ, and lower probability of respiratory-related hospital admissions. No excess all-cause mortality risk was observed, but exploratory analysis showed a small, but significantly higher respiratory-related mortality rate for self-management compared to usual care.For future studies, we would like to urge only using action plans together with self-management interventions that meet the requirements of the most recent COPD self-management intervention definition. To increase transparency, future study authors should provide more detailed information regarding interventions provided. This would help inform further subgroup analyses and increase the ability to provide stronger recommendations regarding effective self-management interventions that include action plans for AECOPD. For safety reasons, COPD self-management action plans should take into account comorbidities when used in the wider population of people with COPD who have comorbidities. Although we were unable to evaluate this strategy in this review, it can be expected to further increase the safety of self-management interventions. We also advise to involve Data and Safety Monitoring Boards for future COPD self-management studies.

Effectiveness of disease-specific self-management education on health outcomes in patients with chronic obstructive pulmonary disease: An updated systematic review and meta-analysis

OBJECTIVES

To update a previously published systematic review on the effectiveness of self-management education (SME) for patients with chronic obstructive pulmonary disease (COPD).

METHODS

Electronic databases were accessed (from inception to July 2016) to find relevant randomized controlled trials. Studies that compared SME with routine methods of care in COPD patients were retrieved. Both data synthesis and descriptive analysis were used for outcome assessment (e.g. quality of life and healthcare utilization).

RESULTS

Twenty-four studies were included. Data synthesis showed better quality of life among COPD patients receiving SME. Significant reductions in COPD-related hospital admissions and emergency department visits were identified in the SME group. SME may positively affect the reduction of COPD patients' emotional distress. No significant reduction in smoking rate and mortality rate was observed between groups. No clear evidence supports the improvement of pulmonary functions, dyspnea, and nutritional status in COPD patients with the use of SME.

CONCLUSION

SME can be a useful strategy to improve quality of life and disease-specific knowledge in patients with COPD. It also reduces respiratory-related hospital admissions and emergency department visits in COPD patients.

PRACTICE IMPLICATIONS

Inclusion of SME as one of the key components for the comprehensive management of COPD is encouraged.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 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.

Objectives

The 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).

Design

A 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.

Setting

Primary care. Manchester and London.

Participants

People 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.

Results

Evidence 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.

Limitations

The 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.

Conclusions

Prior 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 work

The 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.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Impact of Integrated Care Model (ICM) on Direct Medical Costs in Management of Advanced Chronic Obstructive Pulmonary Disease (COPD)

BACKGROUND Chronic obstructive pulmonary disease (COPD) is a commonly diagnosed condition in people older than 50 years of age. In advanced stage of this disease, integrated care (IC) is recommended as an optimal approach. IC allows for holistic and patient-focused care carried out at the patient's home. The aim of this study was to analyze the impact of IC on costs of care and on demand for medical services among patients included in IC. MATERIAL AND METHODS The study included 154 patients diagnosed with advanced COPD. Costs of care (general, COPD, and exacerbations-related) were evaluated for 1 year, including 6-months before and after implementing IC. The analysis included assessment of the number of medical procedures of various types before and after entering IC and changes in medical services providers. RESULTS Direct medical costs of standard care in advanced COPD were 886.78 EUR per 6 months. Costs of care of all types decreased after introducing IC. Changes in COPD and exacerbation-related costs were statistically significant (p=0.012492 and p=0.017023, respectively). Patients less frequently used medical services for respiratory system and cardiovascular diseases. Similarly, the number of hospitalizations and visits to emergency medicine departments decreased (by 40.24% and 8.5%, respectively). The number of GP visits increased after introducing IC (by 7.14%). CONCLUSIONS The high costs of care in advanced COPD indicate the need for new forms of effective care. IC caused a decrease in costs and in the number of hospitalization, with a simultaneous increase in the number of GP visits.

Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits: a systematic review and meta-analysis

BACKGROUND

Self-management interventions (SMIs) are recommended for individuals with COPD to help monitor symptoms and optimize health-related quality of life (HRQOL). However, SMIs vary widely in content, delivery, and intensity, making it unclear which methods and techniques are associated with improved outcomes. This systematic review aimed to summarize the current evidence base surrounding the effectiveness of SMIs for improving HRQOL in people with COPD.

METHODS

Systematic reviews that focused upon SMIs were eligible for inclusion. Intervention descriptions were coded for behavior change techniques (BCTs) that targeted self-management behaviors to address 1) symptoms, 2) physical activity, and 3) mental health. Meta-analyses and meta-regression were used to explore the association between health behaviors targeted by SMIs, the BCTs used, patient illness severity, and modes of delivery, with the impact on HRQOL and emergency department (ED) visits.

RESULTS

Data related to SMI content were extracted from 26 randomized controlled trials identified from 11 systematic reviews. Patients receiving SMIs reported improved HRQOL (standardized mean difference =-0.16; 95% confidence interval [CI] =-0.25, -0.07; P=0.001) and made fewer ED visits (standardized mean difference =-0.13; 95% CI =-0.23, -0.03; P=0.02) compared to patients who received usual care. Patients receiving SMIs targeting mental health alongside symptom management had greater improvement of HRQOL (Q=4.37; P=0.04) and fewer ED visits (Q=5.95; P=0.02) than patients receiving SMIs focused on symptom management alone. Within-group analyses showed that HRQOL was significantly improved in 1) studies with COPD patients with severe symptoms, 2) single-practitioner based SMIs but not SMIs delivered by a multidisciplinary team, 3) SMIs with multiple sessions but not single session SMIs, and 4) both individual- and group-based SMIs.

CONCLUSION

SMIs can be effective at improving HRQOL and reducing ED visits, with those targeting mental health being significantly more effective than those targeting symptom management alone.

A qualitative study of women's experiences of living with COPD

Aim

To explore women's experiences of living with chronic obstructive pulmonary disease (COPD) at home.

Design

An explorative and descriptive qualitative design.

Methods

A consecutive sample of nine women with COPD living at home. Data were collected in 2014 using semi‐structured interviews and analysed using a qualitative content analysis.

Results

Three main themes were identified: having a good life with COPD despite limitations; predictability and confidence in getting help; and the struggle to achieve a balance between insight and compliance with management of COPD. These women experienced limitations related to the traditional female role and felt unable to fulfil their own expectations. They experienced a good life despite limitations arising from adaptation and coping strategies. To feel safe, they needed to feel confident that they would receive the necessary help in case of exacerbation of their disease. To enhance compliance with COPD management, the women wanted education that provided specific suggestions.

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.

Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: a cluster randomized trial

BACKGROUND

Early detection and intervention for chronic obstructive pulmonary disease (COPD) could potentially slow disease progress and minimize harm.

OBJECTIVES

To assess the effectiveness of early intervention by a practice nurse-GP team on quality of life (QoL) and process of care in patients with newly diagnosed COPD, compared with usual care. Nurses and GPs in intervention practices were educated to develop and implement disease management plans for COPD.

METHODS

A 12-month, multicentre, pragmatic randomized controlled trial with blinded outcome assessment was conducted. Participants were current and former smokers aged 40 to 85 years newly identified as having COPD on post-bronchodilator spirometry. The primary outcome was health-related QoL, assessed with the St George's Respiratory Questionnaire (SGRQ). Secondary outcome measures were other QoL measures, lung function, disease knowledge, smoking and immunization status, inhaler technique and health service use.

RESULTS

Of the 10 234 patients from 36 practices in Sydney invited to a case-finding appointment, 1641 (16%) attended and 287 (18%) were diagnosed with COPD. Nineteen practices (144 patients) were randomized to the intervention group and 17 practices (110 patients) to the control group. Only 15.3% (n = 22) patients in the intervention group saw the nurse for COPD care following case finding. There was no between-group difference in SGRQ score at follow-up (mean difference -0.21; P = 0.86). Influenza vaccination was higher in the intervention group (OR 2.31: P = 0.035), but there were no other significant between-group differences in outcomes.

CONCLUSION

Intervention uptake was low and had no additional beneficial effect, over usual care, on participants' health-related QoL.

The evaluation of a remote support program on quality of life and evolution of disease in COPD patients with frequent exacerbations

Background

Chronic obstructive pulmonary disease (COPD) patients often present considerable individual medical burden in their symptoms, limitations, and well-being that complicate medical treatment. To improve their overall health status, while reducing the number of exacerbations, a multidisciplinary approach including different elements of care is needed. The aim of this study was to evaluate the effects of a remote support program on COPD patients at high risk of experiencing worsening of their disease and other health-related outcomes.

Methods

An observational, multicenter, prospective study aimed at evaluating the impact of a 7-month remote support program on COPD patients in exacerbations control and changes in health status measured with the COPD assessment test (CAT). Factors associated with a clinically relevant decrease in CAT were assessed using a logistic regression analysis.

Results

A total of 114 subjects started the program. The majority of the study population were males (81.6 %), retired (70.2 %), without academic qualifications or with a low level of education (68.4 %), and ex-smokers (79.8 %). The mean ± SD age was 69.6 ± 9.1 years and the BMI was 27.8 ± 5.5 Kg/m². Overall, 41.9 % (95 % CI 31.9–52.0) patients, significantly improved health status (CAT decrease ≥ 2 points). Univariate analysis showed that significant improvement in CAT was associated with baseline CAT scores [high CAT score 19.2 (±7.5) vs. low CAT score 12.4 (±6.4); OR = 1.15, 95 % CI: 1.07–1.24; p < 0.001] and with being non-compliant [62.5 % (15/24) of non-compliant vs 34.7 % (24/69) of compliant patients significantly improved CAT scores; OR = 3.13, 95 % CI: 1.19–8.19; p = 0.021). After controlling for the effect of all variables in a multivariable logistic regression model, the only factor that remained significant was baseline CAT score. The proportion of smokers in the total population remained constant during the study. There was a significant reduction in the number of exacerbations after entering this remote support program with median -1 (IQR: -2, 0), (p < 0.001). The Morisky-Green questionnaire showed an increase of treatment compliance, namely at baseline, 25.8 % (24/93) of patients were noncompliant while in the end 66.7 % (16/24) of them became compliant) (p = 0.053).

Conclusions

A remote support program for high-risk COPD patients results in an improvement of the patients’ health status, particularly in those with initially poor health status, and it helps to reduce COPD exacerbations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0304-3) contains supplementary material, which is available to authorized users.

How home hospice care facilitates patient and family engagement

Little is known about how patient and family engagement manifests in home hospice care. This qualitative study included interviews and observation of home hospice care with 18 patients, 11 caregivers, and 26 hospice workers in the United States. Structural factors (e.g., home setting, ample time, personal relationships), hospice worker strategies (e.g., patient education and presenting choices), and family member support facilitated engagement. Barriers to engagement included difficult relationships and unavailable or unwilling family members. Home hospice care demonstrates potential strategies for continuous, informed, and holistic engagement. These engagement strategies may translate to other arenas of health care.

Effectiveness of the Assessment of Burden of COPD (ABC) tool on health-related quality of life in patients with COPD: a cluster randomised controlled trial in primary and hospital care

OBJECTIVE

Assessing the effectiveness of the Assessment of Burden of COPD (ABC) tool on disease-specific quality of life in patients with chronic obstructive pulmonary disease (COPD) measured with the St. George's Respiratory Questionnaire (SGRQ), compared with usual care.

METHODS

A pragmatic cluster randomised controlled trial, in 39 Dutch primary care practices and 17 hospitals, with 357 patients with COPD (postbronchodilator FEV1/FVC ratio <0.7) aged ≥40 years, who could understand and read the Dutch language. Healthcare providers were randomly assigned to the intervention or control group. The intervention group applied the ABC tool, which consists of a short validated questionnaire assessing the experienced burden of COPD, objective COPD parameter (eg, lung function) and a treatment algorithm including a visual display and treatment advice. The control group provided usual care. Researchers were blinded to group allocation during analyses. Primary outcome was the number of patients with a clinically relevant improvement in SGRQ score between baseline and 18-month follow-up. Secondary outcomes were the COPD Assessment Test (CAT) and the Patient Assessment of Chronic Illness Care (PACIC; a measurement of perceived quality of care).

RESULTS

At 18-month follow-up, 34% of the 146 patients from 27 healthcare providers in the intervention group showed a clinically relevant improvement in the SGRQ, compared with 22% of the 148 patients from 29 healthcare providers in the control group (OR 1.85, 95% CI 1.08 to 3.16). No difference was found on the CAT (-0.26 points (scores ranging from 0 to 40); 95% CI -1.52 to 0.99). The PACIC showed a higher improvement in the intervention group (0.32 points (scores ranging from 1 to 5); 95% CI 0.14 to 0.50).

CONCLUSIONS

This study showed that use of the ABC tool may increase quality of life and perceived quality of care.

TRIAL REGISTRATION NUMBER

NTR3788; Results.

Preventing Hospitalizations From Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive lung disease is among the leading causes of adult hospital admissions and readmissions in the United States. Preventing acute exacerbations is the primary approach in therapy. Combinations of smoking cessation, pulmonary rehabilitation, vaccinations and inhaled and oral medications may all reduce the overall risk of acute exacerbations. When prevention is unsuccessful, treatment of exacerbations often does not require hospitalization but can be safely executed in the outpatient setting. In the patient who does not require mechanical ventilation or who manifests respiratory acidosis, oxygen supplementation, frequent short-acting inhaled bronchodilators, oral corticosteroids and often antibiotics can abort the decompensation and sometimes return the patient to his or her pre-attack baseline lung function. Several models exist for delivering this care in the ambulatory setting. Follow-up care after an exacerbation has resolved is important, though there are few hard data suggesting which approach is best in this setting.

Effects of a Problem-Based Learning Rehabilitation Programme on Quality of Life in Patients with Coronary Artery Disease

Background: The aim of cardiac rehabilitation (CR) is not only physical improvement but also increased quality of life (QoL). A CR programme based upon problem based learning (PBL) philosophy was developed, to achieve and apply new knowledge related to coronary artery disease (CAD). The aim of this paper was to evaluate the impact of the PBL programme on QoL.

Methods: 207 consecutive patients < 70 years of age with a recent event of CAD were randomised to a PBL group ( n = 104) or a control group ( n = 103). In addition to standard treatment, the PBL patients participated in 13 group sessions during 1 year, where individual learning needs and behavioural changes were focused upon. QoL was measured by the Ladder of Life, Self-Rated Health (SRH), SF 36, and Cardiac Health Profile (CHP).

Results: Significant differences between the groups, favouring the PBL patients, were found by global instruments: more optimistic expectations of the future QoL and a better general condition. No differences were found by SRH, SF 36 or subscales of CHP, but QoL increased in both groups during the year.

Conclusions: The main outcome was that QoL improved in both groups with some effects favouring the PBL programme.

Mortality in a cohort of complex patients with chronic illnesses and multimorbidity: a descriptive longitudinal study

Background

Certain advanced chronic conditions (heart failure, chronic lung disease) are associated with high mortality. Nevertheless, most of the time, patients with these conditions are not given the same level of attention or palliative care as those with cancer.

The objective of this study was to assess mortality and its association with other variables in a cohort of complex multimorbid patients with heart failure and/or lung disease from two consecutive telemonitoring studies.

Methods

This multicentre longitudinal study was conducted between 2010 and 2015. We included 83 patients (27 without telemonitoring) with heart failure and/or lung disease with > 1 hospital admission in the previous year and great difficulties leaving home or were housebound. The following variables were indicators of their complex clinical condition: old age (mean: 81 years), comorbidity (Charlson Comorbidity Index score ≥ 2: 86.2 %), both conditions concurrently (54.2 %) and home oxygen therapy (52 %).

We assessed mortality (rate, cause and place of death) and its association with: age, sex, telemonitoring, functional status (Barthel score), quality of life (EQ-5D visual analogue scale), number of medications, and all-cause and condition-specific (due to conditions prompting inclusion) admissions during the previous year. Uni- and bivariate analysis and logistic regression were performed, considering p < 0.05 significant.

Results

A total of 61 patients died within 5 years, representing 31.2 %/year (95 % CI: 23–40.1 %), considering the overall follow-up (sum of individual follow-up days). Of these, 81 % of deaths (95 % CI: 69.1–89–1 %) were due to the condition prompting inclusion, and 83.3 % (95 % CI: 72–90.7 %) died in hospital (median: 8.5 days).

Mortality was lower among those under telemonitoring (p = 0.027), and with fewer condition-specific admissions the previous year (p = 0.006); the latter also showed the strongest association in the multivariate analysis (Exp(B) = 6.115).

Conclusions

Complex patients with multimorbidity had a high mortality rate, generally dying due to the condition for which they had been included, and in hospital (83.3 %). New approaches for managing such patients should be considered, introducing palliative care as required, and using more comprehensive predictors of mortality (functional status and quality of life), together with those related to the illness itself (previous admissions, progression and symptoms).

Self-management of health care behaviors for COPD: a systematic review and meta-analysis

Purpose

This systematic review aimed to identify the most effective components of interventions to facilitate self-management of health care behaviors for patients with COPD. PROSPERO registration number CRD42011001588.

Methods

We used standard review methods with a systematic search to May 2012 for randomized controlled trials of self-management interventions reporting hospital admissions or health-related quality of life (HRQoL). Mean differences (MD), hazard ratios, and 95% confidence intervals (CIs) were calculated and pooled using random-effects meta-analyses. Effects among different subgroups of interventions were explored including single/multiple components and multicomponent interventions with/without exercise.

Results

One hundred and seventy-three randomized controlled trials were identified. Self-management interventions had a minimal effect on hospital admission rates. Multicomponent interventions improved HRQoL (studies with follow-up >6 months St George’s Respiratory Questionnaire (MD 2.40, 95% CI 0.75–4.04, I² 57.9). Exercise was an effective individual component (St George’s Respiratory Questionnaire at 3 months MD 4.87, 95% CI 3.96–5.79, I² 0%).

Conclusion

While many self-management interventions increased HRQoL, little effect was seen on hospital admissions. More trials should report admissions and follow-up participants beyond the end of the intervention.

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.

Home nursing care with the self-care model improves self-efficacy of patients with chronic obstructive pulmonary disease

AIM

This study was carried out as an intervention study to determine the effect of nursing care provided at home with the self-care model on the self-efficacy of patients with chronic obstructive pulmonary disease in northern Turkey.

METHODS

The study sample totaled 106 patients with chronic obstructive pulmonary disease divided into two groups. The intervention group and the control group each included 53 patients. To collect data, the patient data sheet, Orem's self-care model-based data collection form, symptom evaluation form, Medical Research Council dyspnea scale, and the chronic obstructive pulmonary disease self-efficacy scale (CSES) were used. The nursing care applied for the intervention group consisted of four visits, two during the first month and two for the next 2 months. An educational guidebook was distributed to the intervention group during the first visit, and at all visits, education, care, and supervision were provided according to the care plan. All data were analyzed with the number, percentage, χ(2) -test, Kruskal-Wallis H test, Wilcoxon rank sum test, and Mann-Whitney U-test.

RESULTS

The dyspnea level measured at the last visit for the control group was high compared with the intervention group (P < 0.05). The chronic obstructive pulmonary disease self-efficacy scale scores for subscale dimensions at the last visit and the general score for the intervention group were high compared with the first visit scores (P < 0.05).

CONCLUSION

According to the study results, home nursing care based on the Orem's self-care model is effective in improving self-efficacy of patients with chronic obstructive pulmonary disease.

Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant?

Hospitalisations for severe exacerbations of chronic obstructive pulmonary disease are associated with significant physical and psychological consequences including an increase in symptom severity, severe reductions in physical activity, a deleterious effect on skeletal muscle, impaired exercise tolerance/ability to self-care, decline in quality of life, and increased anxiety and depression. As these consequences are potentially amenable to exercise training, there is a clear rationale for pulmonary rehabilitation in the peri/post-exacerbation setting. Although a 2011 Cochrane review was overwhelmingly positive, subsequent trials have shown less benefit and real-life observational studies have revealed poor acceptability. Qualitative studies have demonstrated that the patient experience is a determining factor while the presence of comorbidities may influence referral, adherence and response to pulmonary rehabilitation. Systematic reviews of less supervised interventions, such as self-management, have shown limited benefits in the post-exacerbation setting. The recent update of the Cochrane review of peri-exacerbation pulmonary rehabilitation showed that benefits were associated with the "comprehensive" nature of the intervention (the number of sessions received, the intensity of exercise training and education delivered, and the degree of supervision) but implementation is demanding. The challenge is to develop interventions that are deliverable and acceptable around the time of an acute exacerbation but also deliver the desired clinical impact.

Self-management following an acute exacerbation of COPD: a systematic review

BACKGROUND

Self-management (SM) reduces hospital admissions in patients with stable COPD. However, its role immediately post-acute exacerbation (AE) is unclear. The objectives of this review were to describe SM interventions delivered immediately following an AE of COPD (AECOPD) and to conduct a systematic review with meta-analysis of its impact on health-care utilization and health outcomes.

METHODS

Randomized controlled trials reporting on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge were included. Seven articles were identified. Data were extracted and assessed for quality by two researchers.

RESULTS

By definition, all interventions included action plans, education, and at least two SM skills. Nurses were responsible for providing all SM interventions. The delivery and follow-up periods varied widely. At 12 months, there were no significant differences between those who completed the SM intervention and control subjects in the number of patients readmitted to hospital (P = .38), or in health-related quality of life (P = .27). No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health promoting behavior. SM was associated with positive effects on knowledge and management of an AECOPD.

CONCLUSIONS

SM interventions delivered immediately post-AE vary widely and outcome measures are inconsistent, making it difficult to draw strong recommendations regarding its effectiveness. The evaluation of SM interventions, delivered by trained health-care professionals to selected patients and which offer structured follow-up, appears necessary.

Hospital management of acute exacerbations of chronic obstructive pulmonary disease

The course of chronic obstructive pulmonary disease (COPD) is often complicated by episodes of acute worsening of respiratory symptoms, which may lead to escalation of therapy and occasionally emergency department visits and hospitalization. Acute exacerbations of COPD (AECOPD) have a negative impact on quality of life and hasten the decline of lung function. They also significantly contribute to the direct and indirect healthcare costs of this disease. Severe exacerbations (those leading to hospital admission) have been associated with significant poor outcomes including an increased risk of readmissions and mortality. COPD is currently the fourth leading cause of hospital readmission in the United States. In this review, we will provide a broad overview on the etiology, assessment, management, discharge planning, and follow-up care of patients hospitalized with AECOPD.

Supported self-management for patients with COPD who have recently been discharged from hospital: a systematic review and meta-analysis

PURPOSE

Although many hospitals promote self-management to chronic obstructive pulmonary disease (COPD) patients post discharge from hospital, the clinical effectiveness of this is unknown. We undertook a systematic review of the evidence as part of a Health Technology Assessment review.

METHODS

A comprehensive search strategy with no language restrictions was conducted across relevant databases from inception to May 2012. Randomized controlled trials of patients with COPD, recently discharged from hospital after an acute exacerbation and comparing a self-management intervention with control, usual care or other intervention were included. Study selection, data extraction, and risk of bias assessment were undertaken by two reviewers independently.

RESULTS

Of 13,559 citations, 836 full texts were reviewed with nine randomized controlled trials finally included in quantitative syntheses. Interventions were heterogeneous. Five trials assessed highly supported multi-component interventions and four trials were less supported with fewer contacts with health care professionals and mainly home-based interventions. Total sample size was 1,466 (range 33-464 per trial) with length of follow-up 2-12 months. Trials varied in quality; poor patient follow-up and poor reporting was common. No evidence of effect in favor of self-management support was observed for all-cause mortality (pooled hazard ratio =1.07; 95% confidence interval [0.74 to 1.55]; I (2)=0.0%, [n=5 trials]). No clear evidence of effect on all-cause hospital admissions was observed (hazard ratio 0.88 [0.61, 1.27] I (2)=66.0%). Improvements in St George's Respiratory Questionnaire score were seen in favor of self-management interventions (mean difference =3.84 [1.29 to 6.40]; I (2)=14.6%), although patient follow-up rates were low.

CONCLUSION

There is insufficient evidence to support self-management interventions post-discharge. There is a need for good quality primary research to identify effective approaches.

Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline

BACKGROUND

COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations.

METHODS

In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion.

RESULTS

The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD.

CONCLUSIONS

This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.