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

Technology-supported shared decision-making in chronic conditions: A systematic review of randomized controlled trials

OBJECTIVES

To describe the role of patients with a chronic disease, healthcare professionals (HCPs) and technology in shared decision making (SDM) and the use of clinical decision support systems (CDSSs), and to evaluate the effectiveness of SDM and CDSSs interventions.

METHODS

Randomized controlled studies published between 2011 and 2021 were identified and screened independently by two reviewers, followed by data extraction and analysis. SDM elements and interactive styles were identified to shape the roles of patients, HCPs and technology.

RESULTS

Forty-three articles were identified and reported on 21 SDM-studies, 15 CDSS-studies, 2 studies containing both an SDM-tool and a CDSS, and 5 studies with other decision support components. SDM elements were mostly identified in SDM-tools and interactions styles were least common in the other decision support components.

CONCLUSIONS

Patients within the included RCTs mainly received information from SDM-tools and occasionally CDSSs when it concerns treatment strategies. HCPs provide and clarify information using SDM-tools and CDSSs. Technology provides interactions, which can support more active SDM. SDM-tools mostly showed evidence for positive effects on SDM outcomes, while CDSSs mostly demonstrated positive effects on clinical outcomes.

PRACTICE IMPLICATIONS

Technology-supported SDM has potential to optimize SDM when patients, HCPs and technology collaborate well together.

The effects of telerehabilitation on physiological function and disease symptom for patients with chronic respiratory disease: a systematic review and meta-analysis

OBJECTIVE

To compare the impact of telerehabilitation versus conventional rehabilitation on the recovery outcomes of patients with chronic respiratory disease (CRD).

METHODS

The Cochrane Library, MEDLINE, Web of Science and Embase were searched to collect randomized controlled trials (RCTs) on telerehabilitation for the rehabilitation of patients with chronic respiratory system diseases since the establishment of the database to November 14, 2023. Two researchers independently screened the literature and extracted valid data according to the inclusion criteria. The quality assessment of included studies was conducted individually by using the RoB 2(Risk of Bias 2) tool, followed by meta-analysis using RevMan5.3 software.

RESULTS

Based on inclusion and exclusion criteria, 21 RCTs were included, comprising 3030 participants, with 1509 in the telerehabilitation group and 1521 in the conventional rehabilitation group. Meta-analysis results indicated that compared to conventional rehabilitation, video conference-based telerehabilitation demonstrated significant improvements in short-term (≤ 6 months) outcomes, including 6-min walk distance (6MWD) (MD = 7.52, 95% CI: 2.09, 12.94), modified Medical Research Council Dyspnea Scale (mMRC) (MD = -0.29, 95% CI: -0.41, -0.18), COPD assessment test (CAT) (MD = -1.77, 95% CI: -3.52, -0.02), HADS (MD = -0.44, 95% CI: -0.86, -0.03), and St. George's Respiratory Questionnaire (SGRQ's) activity, impact, and symptom scores. In the long term (> 6 months), although improvements persisted in 6WMD [MD = 12.89, 95% CI (-0.37, 26.14)], mMRC [MD = -0.38, 95% CI (-0.56, -0.21)], CAT [MD = -1.39, 95% CI (-3.83, 1.05)], Hospital anxiety and depression scale (HADS) [MD = -0.34, 95% CI (-0.66, -0.03)], and SGRQ's Activity, Impact, and Symptom scores between intervention and control groups, statistically significant differences were observed only for mMRC and HADS. Without considering time factors, the intervention group exhibited some improvement in FEV1% predicted and the forced expiratory volume in the first one second (FEV1)/ forced vital capacity (FVC) (%) without statistical significance compared to the control group.

CONCLUSION

Telerehabilitation therapy demonstrates short-term benefits in enhancing patients' daily activity capacity, improving respiratory function, and enhancing mental health status, thereby improving patients' quality of life. However, further high-quality, large-sample RCTs are required to ascertain its long-term effectiveness conclusively.

TRIAL REGISTRATION

This study protocol was approved and registered in PROSPERO: CRD 42024509154.

Combined Lifestyle Interventions in the Prevention and Management of Asthma and COPD: A Systematic Review

(1) Background: A healthy lifestyle has a protective role against the onset and management of asthma and chronic obstructive pulmonary disease (COPD). Therefore, combined lifestyle interventions (CLIs) are a potentially valuable prevention approach. This review aims to provide an overview of existing CLIs for the prevention and management of asthma or COPD. (2) Methods: A systematic literature search was conducted using PubMed, EMBASE, and PsycInfo. Studies were included if CLIs targeted at least two lifestyle factors. (3) Results: Among the 56 included studies, 9 addressed asthma and 47 addressed COPD management, with no studies focusing on prevention. For both conditions, the most prevalent combination of lifestyle targets was diet and physical activity (PA), often combined with smoking cessation in COPD. The studied CLIs led to improvements in quality of life, respiratory symptoms, body mass index/weight, and exercise capacity. Behavioural changes were only measured in a limited number of studies and mainly showed improvements in dietary intake and PA level. (4) Conclusions: CLIs are effective within asthma and COPD management. Next to optimising the content and implementation of CLIs, these positive results warrant paying more attention to CLIs for persons with an increased risk profile for these chronic respiratory diseases.

Effect of self-management intervention on patients with chronic obstructive pulmonary diseases, Chitwan, Nepal

BACKGROUND

Self-management skills are important for patients with Chronic Obstructive Pulmonary Disease (COPD) who are responsible for their day to day care. Poor self-management behaviours have a significant influence on symptoms, functional impairments and quality of life. Evidence has shown that self-management interventions support patients to respond to changing symptoms and thereby make appropriate decisions regarding their self-management.

OBJECTIVE

This study aimed to find out the effect of self-management interventions in patients with COPD in terms of self-management practice, inhaler practice, COPD symptoms burden, functional ability, self-perceived dyspnoea and emotional symptoms.

METHODS

Quasi-experimental pre-test post-test design was carried out among patients with COPD attending respiratory units of Chitwan Medical College Teaching Hospital (CMC-TH), Nepal. Convenience sampling technique was used to select the 70 patients with COPD for the study. Baseline data was collected from the participants using (i) Semi-structured interview schedule for socio-demographic and clinical variables, (ii) COPD Self-Management Practice Questionnaire, (iii) Borg Dyspnoea Scale, and (iv) Six Minute Walking Distance (6MWD) Test (v) Pulmonary Function Test (PFT) and (vi) Observation Checklist. Self-management Intervention given was 2 ½ hour sessions per week for 6 weeks along with information booklets distribution. Participants were re-evaluated after 3 months of intervention using same tools. Data analysis was performed using IBMSPSS version 20.0 for window. Wilcoxon signed-rank test was performed to find the effectiveness of the self-management interventions on outcome parameters.

RESULTS

Self-management interventions (2 ½ hour session per week for 6 weeks) elicited a statistically significant change on self-management practice (z = -7.215, p<0.001), inhaler practice (DPI practice z = -6.731, p<0.001, MDI practice, z = -1.816, p = 0.005), functional ability (z = -4.243, p<0.001), self-perceived dyspnoea (z = -4.443, p<0.001), COPD symptom burden (z = -7.009, p<0.001) and emotional symptoms (depression, z = -6.856, p<0.001, anxiety, z = -6.675, p<0.001) of patients with COPD.

CONCLUSIONS

Self-management intervention acts as powerful equipment to improve self-management practice, COPD symptoms burden, functional ability, self-perceived dyspnoea and emotional symptoms of patients with COPD. Hence, clinician and policy maker need to plan and intervene the rehabilitation program for the patients with COPD to enhance the effectiveness of therapy, self-management practice and general longevity.

Impact of telephone follow-up on COPD outcomes in pulmonary rehabilitation patients: A randomized clinical trial

Background

The educational component is a comprehensive part of Pulmonary Rehabilitation (PR), and telephone follow-up (TFU) is an alternative to reinforce face-to-face education. The objective was to determine the effect of telephone follow-up on educational needs, dyspnea, quality of life and functional capacity in Chronic Obstructive Pulmonary Disease (COPD) patients undergoing PR.

Methods

Double-blind randomized controlled clinical trial in patients with COPD in a PR program in Cali-Colombia, allocation by randomization tables. All patients received 24 sessions of PR, which included face-to-face education sessions. In addition, the experimental group received telephone calls twice a week to reinforce the face-to-face educational content. The Lung Information Needs Questionnaire (LINQ) was used to measure disease knowledge, the Saint George's Respiratory Questionnaire to measure quality of life, the modified Medical Research Council (mMRC) scale to measure dyspnea, and the 6-minute walking test (6MWT) to measure functional capacity.

Results

Thirty-four patients were randomized and 31 were analyzed. PR group with conventional education (PRTE) n=15 and PR group with education plus telephone follow-up (PRTETFU) n=16. Significant improvement from baseline to endpoint in both groups: LINQ (PRTE 4±1.1, p=0.003, PRTETFU 5.8±10.6, p=0.000), mMRC (PRTE 1.6±0.3, p=0.000, PRTETFU 0.6±0.3, p=0.036) and functional capacity (PM6M: PRTE 45.9m±16.1, p=0.013, PRTETFU 62.8m±21.4, p=0.010). Analysis showed differences between groups for changes in LINQ knowledge domain after intervention, with greater improvement for PRTETFU (p=0.018).

Discussion

The TFU is an alternative to reinforce the education. This study demonstrated greater positive effects for the autonomous management of the pathology.

Conclusion

Adding educational reinforcement through phone calls to patients with COPD during PR leads to improved knowledge and skills for managing the disease.

Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions

BACKGROUND

Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults.

METHODS

Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT.

ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care).

INFORMATION SOURCES

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020.

OUTCOME MEASURES

Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate.

DATA SYNTHESIS

We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data.

RESULTS

We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%).

CONCLUSIONS

KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084810.

Phone contacts and treatment discontinuation predict survival cancer patients in a subsidized drug access program

Aim: Survival of patients with Hodgkin's lymphoma is lower in in low- and middle-income countries, but factors leading to these outcomes are poorly understood. The objective of this study was to identify predictive factors associated with overall survival among cancer patients undergoing therapy in seven low- and middle-income countries. Materials & methods: A multicenter cohort was conducted in Egypt, Malaysia, Mexico, Peru, Philippines, Thailand and Ukraine. Results. A total of 460 patients were included. Phone-based support during patient follow-up and number of patients seen by the physician provided a positive impact, while the number of adverse events remains a predictor of death and physician decision to stop treatment. Conclusion: Furthers research on the potential benefit of phone-based programs to support patients with chronic diseases treatments should be explored in less developed countries.

Systematic review of shared decision-making interventions for people living with chronic respiratory diseases

OBJECTIVE

Shared decision-making (SDM) supports patients to make informed and value-based decisions about their care. We are developing an intervention to enable healthcare professionals to support patients' pulmonary rehabilitation (PR) decision-making. To identify intervention components we needed to evaluate others carried out in chronic respiratory diseases (CRDs). We aimed to evaluate the impact of SDM interventions on patient decision-making (primary outcome) and downstream health-related outcomes (secondary outcome).

DESIGN

We conducted a systematic review using the risk of bias (Cochrane ROB2, ROBINS-I) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) tools.

DATA SOURCES

MEDLINE, EMBASE, PSYCHINFO, CINAHL, PEDRO, Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform Search Portal, ClinicalTrials.gov, PROSPERO, ISRCTN were search through to 11th April 2023.

ELIGIBILITY CRITERIA

Trials evaluating SDM interventions in patients living with CRD using quantitative or mixed methods were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, assessed risk of bias and certainty of evidence. A narrative synthesis, with reference to The Making Informed Decisions Individually and Together (MIND-IT) model, was undertaken.

RESULTS

Eight studies (n=1596 (of 17 466 citations identified)) fulfilled the inclusion criteria.Five studies included components targeting the patient, healthcare professionals and consultation process (demonstrating adherence to the MIND-IT model). All studies reported their interventions improved patient decision-making and health-related outcomes. No outcome was reported consistently across studies. Four studies had high risk of bias, three had low quality of evidence. Intervention fidelity was reported in two studies.

CONCLUSIONS

These findings suggest developing an SDM intervention including a patient decision aid, healthcare professional training, and a consultation prompt could support patient PR decisions, and health-related outcomes. Using a complex intervention development and evaluation research framework will likely lead to more robust research, and a greater understanding of service needs when integrating the intervention within practice.

PROSPERO REGISTRATION NUMBER

CRD42020169897.

Non-pharmacological and non-invasive interventions for chronic pain in people with chronic obstructive pulmonary disease: A systematic review without meta-analysis

OBJECTIVES

Chronic Obstructive Pulmonary Disease (COPD) is complicated by chronic pain. People with COPD report higher pain prevalence than the general population. Despite this, chronic pain management is not reflected in current COPD clinical guidelines and pharmacological treatments are often ineffective. We conducted a systematic review that aimed to establish the efficacy of existing non-pharmacological and non-invasive interventions on pain and identify behaviour change techniques (BCTs) associated with effective pain management.

METHODS

A systematic review was conducted with reference to Preferred Reporting Items for Systematic Review (PRISMA) [1], Systematic review without Meta analysis (SWIM) standards [2] and Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines [3]. We searched 14 electronic databases for controlled trials of non-pharmacological and non-invasive interventions where the outcome measure assessed pain or contained a pain subscale.

RESULTS

Twenty-nine studies were identified involving 3,228 participants. Seven interventions reported a minimally important clinical difference in pain outcomes, although only two of these reached statistical significance (p < 0.05). A third study reported statistically significant outcomes, but this was not clinically significant (p = 0.0273). Issues with intervention reporting prevented identification of active intervention ingredients (i.e., BCTs).

CONCLUSIONS

Pain appears to be a meaningful issue for many individuals with COPD. However, intervention heterogeneity and issues with methodological quality limit certainty about the effectiveness of currently available non-pharmacological interventions. An improvement in reporting is required to enable identification of active intervention ingredients associated with effective pain management.

Preferences for an eHealth tool to support physical activity and exercise training in COPD: a qualitative study from the viewpoint of prospective users

BACKGROUND

Despite well-known positive effects of pulmonary rehabilitation, access is limited. New strategies to improve access are advocated, including the use of eHealth tools.

OBJECTIVES

The aim of this study was to explore prospective users' preferences for an eHealth tool to support the self-management of physical activity and exercise training in COPD.

METHODS

A qualitative research design was applied. Data was collected in six, audio recorded, digital co-creation workshops, which were guided by a participatory and appreciative action and reflection approach. A total of 17 prospective users took part in the process, including people with COPD (n = 10), relatives (n = 2), health care givers (n = 4) and a patient organization representative (n = 1). During the workshops, pre-selected relevant topics to exploring end-users' preferences for eHealth support in self-management in COPD were discussed. The workshops were recorded and transcribed. Data was analysed using inductive qualitative content analysis.

RESULTS

The overarching theme "fusing with, rather than replacing existing support structures" was uncovered when the two-sided relationship between positive expectations towards digital solutions and the fear of losing access to established rehabilitation systems, emerged in the discussions. Three categories were identified, focused on wishes for an evidence-based support platform of information about COPD, a well-designed eHealth tool including functionalities to motivate in the self-management of physical activity and exercise training, and requirements of various forms of support. Co-creators believed that there were clear benefits in combining the best of digital and existing support systems.

CONCLUSIONS

Co-creators viewed an eHealth tool including support for physical activity and exercise training as a valuable digital complement to the now existing rehabilitation services. A future eHealth tool needs to focus on user-friendliness and prospective users's requests.

Empowering Self-Efficacy by Using Patient Empowerment among Chronic Obstructive Pulmonary Disease: Pre-Post-Test Study

Patient empowerment is increasingly acknowledged as a milestone of high-quality patient-centered care. This study was conducted using COPD Self-Efficacy Scale to determine the effectiveness of the patient empowerment intervention program among chronic obstructive pulmonary disease patients on self-efficacy. We employed an interventional design with a pre-test and post-test. Sixty COPD patients comprised the final sample of the study. The current study revealed significant improvement in overall self-efficacy factors among most participants. Statistically significant positive correlations were found between the total self-efficacy post-empower intervention model scores concerning age, sex, work, educational level, and marital status. The study's findings revealed that the patient empowerment intervention program positively affected COPD patients' self-efficacy.

Virtual Care Initiatives for Older Adults in Australia: Scoping Review

BACKGROUND

There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia.

OBJECTIVE

We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia.

METHODS

A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework.

RESULTS

Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers.

CONCLUSIONS

Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources.

OBJECTIVES

To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting.

SEARCH METHODS

We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations.

MAIN RESULTS

We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes.

AUTHORS' CONCLUSIONS

The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.

Self-management interventions for people with chronic obstructive pulmonary disease

BACKGROUND

Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable them to control their disease. Since the 2014 update of this review, several studies have been published.

OBJECTIVES

Primary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions. To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation. To evaluate effective characteristics of COPD self-management interventions.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses.

MAIN RESULTS

We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants ; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of 'moderate' to 'very low' quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was 'moderate'.

AUTHORS' CONCLUSIONS

Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.

Integrated disease management interventions for patients with chronic obstructive pulmonary disease

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations.

OBJECTIVES

To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes.

SEARCH METHODS

We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region.

MAIN RESULTS

Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution.

AUTHORS' CONCLUSIONS

This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.

Implementation and Impact of the Pulmonary Specialist Health Coach Consultation Model to Improve Care for Patients with COPD

BACKGROUND

Health coaching has emerged as an important tool for improving patient-centered care in primary care practice but has not specifically been evaluated for patients whose care is shared by a primary care provider (PCP) and specialist.

METHODS

As part of a nine-month randomized controlled trial comparing health coaching to usual care for patients with chronic obstructive pulmonary disease (COPD), the authors developed the Pulmonary Specialist Health Coach Consultation (PuSHCon). In this novel model, health coaches facilitated pulmonary specialist consultations for patients with COPD without the need for an in-person visit. Observational data from the randomized controlled trial were analyzed to study the implementation, adoption, and impact of the PuSHCon model for 70 of 92 patients randomized to the health coaching arm and for 17 of 100 patients in the control arm (who received PuSHCon after the end of the study). Quality of care was measured using the Patient Assessment of Chronic Illness Care (PACIC).

RESULTS

Of 87 patients who participated in PuSHCon, 74 (85.1%) received one or more specialist recommendations, of which 86.8% were implemented. Only 12 patients (13.8%) subsequently required an in-person visit with the PuSHCon specialist. The proportion of PuSHCon participants receiving guideline-concordant care increased from 64.7% to 94.1% (p < 0.001). The mean PACIC item score increased from 3.48 to 3.74 (p = 0.03).

CONCLUSION

The PuSHCon model facilitated consultations that resulted in changes in care, which were implemented for a majority of patients. Guideline-concordant care and patient-reported quality of care increased over nine months. This model could potentially be expanded to help patients with other chronic conditions when PCPs and specialists share patient care.

Telehealth interventions: remote monitoring and consultations for people with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic obstructive pulmonary disease (COPD, including bronchitis and emphysema) is a chronic condition causing shortness of breath, cough, and exacerbations leading to poor health outcomes. Face-to-face visits with health professionals can be hindered by severity of COPD or frailty, and by people living at a distance from their healthcare provider and having limited access to services. Telehealth technologies aimed at providing health care remotely through monitoring and consultations could help to improve health outcomes of people with COPD.

OBJECTIVES

To assess the effectiveness of telehealth interventions that allow remote monitoring and consultation and multi-component interventions for reducing exacerbations and improving quality of life, while reducing dyspnoea symptoms, hospital service utilisation, and death among people with COPD.

SEARCH METHODS

We identified studies from the Cochrane Airways Trials Register. Additional sources searched included the US National Institutes of Health Ongoing Trials Register, the World Health Organization International Clinical Trials Registry Platform, and the IEEEX Xplore Digital Library. The latest search was conducted in April 2020. We used the GRADE approach to judge the certainty of evidence for outcomes.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) included adults with diagnosed COPD. Asthma, cystic fibrosis, bronchiectasis, and other respiratory conditions were excluded. Interventions included remote monitoring or consultation plus usual care, remote monitoring or consultation alone, and mult-component interventions from all care settings. Quality of life scales included St George's Respiratory Questionnaire (SGRQ) and the COPD Assessment Test (CAT). The dyspnoea symptom scale used was the Chronic Respiratory Disease Questionnaire Self-Administered Standardized Scale (CRQ-SAS).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We assessed confidence in the evidence for each primary outcome using the GRADE method. Primary outcomes were exacerbations, quality of life, dyspnoea symptoms, hospital service utilisation, and mortality; a secondary outcome consisted of adverse events.

MAIN RESULTS

We included 29 studies in the review (5654 participants; male proportion 36% to 96%; female proportion 4% to 61%). Most remote monitoring interventions required participants to transfer measurements using a remote device and later health professional review (asynchronous). Only five interventions transferred data and allowed review by health professionals in real time (synchronous). Studies were at high risk of bias due to lack of blinding, and certainty of evidence ranged from moderate to very low. We found no evidence on comparison of remote consultations with or without usual care. Remote monitoring plus usual care (8 studies, 1033 participants) Very uncertain evidence suggests that remote monitoring plus usual care may have little to no effect on the number of people experiencing exacerbations at 26 weeks or 52 weeks. There may be little to no difference in effect on quality of life (SGRQ) at 26 weeks (very low to low certainty) or on hospitalisation (all-cause or COPD-related; very low certainty). COPD-related hospital re-admissions are probably reduced at 26 weeks (hazard ratio 0.42, 95% confidence interval (CI) 0.19 to 0.93; 106 participants; moderate certainty). There may be little to no difference in deaths between intervention and usual care (very low certainty). We found no evidence for dyspnoea symptoms or adverse events. Remote monitoring alone (10 studies, 2456 participants) Very uncertain evidence suggests that remote monitoring may result in little to no effect on the number of people experiencing exacerbations at 41 weeks (odds ratio 1.02, 95% CI 0.67 to 1.55). There may be little to no effect on quality of life (SGRQ total at 17 weeks, or CAT at 38 and 52 weeks; very low certainty). There may be little to no effect on dyspnoea symptoms on the CRQ-SAS at 26 weeks (low certainty). There may be no difference in effects on the number of people admitted to hospital (very low certainty) or on deaths (very low certainty). We found no evidence for adverse events. Multi-component interventions with remote monitoring or consultation component (11 studies, 2165 participants) Very uncertain evidence suggests that multi-component interventions may have little to no effect on the number of people experiencing exacerbations at 52 weeks. Quality of life at 13 weeks may improve as seen in SGRQ total score (mean difference -9.70, 95% CI -18.32 to -1.08; 38 participants; low certainty) but not at 26 or 52 weeks (very low certainty). COPD assessment test (CAT) scores may improve at a mean of 38 weeks, but evidence is very uncertain and interventions are varied. There may be little to no effect on the number of people admitted to hospital at 33 weeks (low certainty). Multi-component interventions are likely to result in fewer people re-admitted to hospital at a mean of 39 weeks (OR 0.50, 95% CI 0.31 to 0.81; 344 participants, 3 studies; moderate certainty). There may be little to no difference in death at a mean of 40 weeks (very low certainty). There may be little to no effect on people experiencing adverse events (very low certainty). We found no evidence for dyspnoea symptoms.

AUTHORS' CONCLUSIONS

Remote monitoring plus usual care provided asynchronously may not be beneficial overall compared to usual care alone. Some benefit is seen in reduction of COPD-related hospital re-admissions, but moderate-certainty evidence is based on one study. We have not found any evidence for dyspnoea symptoms nor harms, and there is no difference in fatalities when remote monitoring is provided in addition to usual care. Remote monitoring interventions alone are no better than usual care overall for health outcomes. Multi-component interventions with asynchronous remote monitoring are no better than usual care but may provide short-term benefit for quality of life and may result in fewer re-admissions to hospital for any cause. We are uncertain whether remote monitoring is responsible for the positive impact on re-admissions, and we are unable to discern the long-term benefits of receiving remote monitoring as part of patient care. Owing to paucity of evidence, it is unclear which COPD severity subgroups would benefit from telehealth interventions. Given there is no evidence of harm, telehealth interventions may be beneficial as an additional health resource depending on individual needs based on professional assessment. Larger studies can determine long-term effects of these interventions.

Systematic review and meta analysis of differential attrition between active and control arms in randomized controlled trials of lifestyle interventions in chronic disease

BACKGROUND

Attrition is a major obstacle for lifestyle interventions sustained for the medium-to-long term and can have significant consequences on the internal validity of a trial. When the degree of attrition differs between active and control arms this is termed differential attrition and is an important consideration during initial stages of trial planning.

OBJECTIVES

The primary research question of this study was: what is the differential attrition between treatment arms in lifestyle interventions for prevalent chronic diseases?

METHODS

We performed a systematic review and meta-analysis of 23 studies involving a lifestyle intervention component in cohorts with chronic diseases. The search accessed three databases: Scopus, Medline Ovid and Web of Science. Attrition between treatment arms was analysed using a random-effects model and examined the relationship between the relative attrition and potential moderators, such as time to final follow-up, time to first follow-up, type of disease, type of control, type of intervention and length of treatment.

RESULTS

The pooled risk ratio was 1.00 (95% CI 0.97 - 1.03) and only one study fell outside this range. A univariable association was described between the pooled risk ration and length (years) to final follow-up, which did not remain in the multivariable model.

CONCLUSIONS

Ultimately, we found no evidence of differential attrition in medium-to-long term lifestyle intervention studies for chronic disease, increasing confidence in conducting such studies with minimal potential of attrition bias.

TRIAL REGISTRATION

PROSPERO registration number CRD42018084495 .

Cognitive Behavioral Therapy for People with Chronic Obstructive Pulmonary Disease: Rapid Review

Cognitive behavioral therapy (CBT) is increasingly recommended in the management of people living with chronic obstructive pulmonary disease (COPD). This rapid review presents the evidence base for CBT for people with COPD and describes 1) the nature of CBT interventions and comparators in controlled trials (high or low resource intensity); and 2) factors influencing intervention effects on health outcomes (anxiety, depression, breathlessness, quality of life and exercise capacity). Primary studies reporting CBT interventions in adults with COPD were identified with data extracted by a single reviewer (20% of studies checked for data accuracy). Studies were synthesized descriptively with meta-analyses (random effects models) of controlled trials undertaken to report mean standardized effect sizes (95% CI) for health outcomes. Random effects meta-regression models explored whether CBT target, intervention dosage, intensity, facilitator profession, delivery mode, clinically significant anxiety/depression, trial design/quality and sample size predicted effect size. The search identified 33 primary studies published between 1996 and 2019 (controlled trials n=24, single group cohort n=6, case exemplars n=2, phenomenological n=1). Controlled trials frequently compared high-intensity CBT interventions against enhanced/usual care (n=12) or high-intensity CBT interventions against high-intensity comparators (n=11). When all controlled studies were included, small, significant improvements favoring CBT were evident across all health outcomes (SMD ranged from -0.27 to 0.35, p<0.05). When intensity dyads were considered, significant improvements were evident only when high-intensity CBT interventions were compared to enhanced usual care/usual care (SMDs ranged from -0.45 to 0.54, p <0.05). No other variable consistently predicted intervention effect sizes across all health outcomes. Overall, the evidence base supports the use of CBT for a range of health outcomes in people with COPD. Consistent benefits were evident when high-resource-intensive CBT interventions were compared to usual care. Low-resource-intensity CBT warrants further investigation in settings where cost of comprehensive care is prohibitive.

Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far.

OBJECTIVES

In people with COPD, which interventions are effective at improving objectively-assessed physical activity?

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies.

SELECTION CRITERIA

We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data.

MAIN RESULTS

We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta2-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training.

AUTHORS' CONCLUSIONS

A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.

Activating primary care COPD patients with multi-morbidity through tailored self-management support

Given the dearth of COPD self-management interventions that specifically acknowledge multi-morbidity in primary care, we aimed to activate COPD patients through personalised self-management support that recognised the implications of co-morbidities. This single-group experimental study included patients aged 40−84 with a spirometry diagnosis of COPD and at least one co-morbidity. A self-management education programme for COPD in the context of multi-morbidity, based on the Health Belief Model, was tailored and delivered to participants by general practice nurses in face-to-face sessions. At 6 months’ follow-up, there was significant improvement in patient activation (p < 0.001), COPD-related quality of life (p = 0.012), COPD knowledge (p < 0.001) and inhaler device technique (p = 0.001), with no significant change in perception of multi-morbidity (p = 0.822) or COPD-related multi-morbidity (0.084). The programme improved patients’ self-efficacy for their COPD as well as overall health behaviour. The findings form an empirical basis for further testing the programme in a large-scale randomised controlled trial.

Effectiveness of cognitive behavioural therapy for chronic obstructive pulmonary disease patients: A systematic review and meta-analysis

BACKGROUND

and purpose: Cognitive behavioural therapy (CBT) has gained increasing attention for the treatment of psychological disorders. This study aims to establish the effectiveness of CBT on psychological and physical outcomes in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Two waves of electronic searches of the PubMed, Cochrane library, EMBASE, Web of Science and China National Knowledge Infrastructure databases were conducted. Statistical analyses were performed using Revman Manager 5.3 and Stata 12.0 software.

RESULTS

Sixteen randomized controlled trials were eligible. There were significant improvements in anxiety (SMD = -0.23; 95% CI: -0.42 to -0.04; P = 0.02), depression (SMD = -0.29, 95% CI: -0.40 to -0.19, P < 0.01), quality of life (MD = -5.21; 95% CI: -10.25 to -0.17; P = 0.04), and mean visits to emergency departments in the CBT groups. No statistically significant differences were observed in fatigue (SMD = 0.88, 95% CI: -0.58 to 2.35, P = 0.24), exercise capacity (MD = 28.75, 95% CI: -28.30 to 85.80, P = 0.32), self-efficacy (SMD = 0.15, 95% CI: -0.05 to 0.34, P = 0.14), or sleep quality (MD = 1.21, 95% CI: -0.65 to 3.06, P = 0.20).

CONCLUSION

This meta-analysis suggests that CBT can serve as a complementary therapy to improve anxiety, depression, and quality of life in COPD patients and deserves more widespread application in clinical practice.

The Effects of a Nurse-Led Education and Counseling Program on Dyspnea, Health Status, and Care Dependency in Patients With Chronic Obstructive Pulmonary Disease: A Feasibility Study

The aim of this feasibility study was to determine the effects of a nurse-led education and counseling program for chronic obstructive pulmonary disease (COPD-ECP) on dyspnea, health status, and care dependency in patients. A quasi-experimental, pre-posttest research design without a control group was performed on 30 COPD patients. The patients received an 8-week COPD-ECP via home visits during the first 4 weeks and via phone interviews in the subsequent 4 weeks. After completion of COPD-ECP and a 4-week break, a final follow-up was conducted at the end of 12th week. The Dyspnea-12, COPD Assessment Test (CAT), and Care Dependency Scale (CDS) scores were calculated during the first interview, and on the 4th, 8th, and 12th week of the study. The patients completed all sessions of COPD-ECP without side effects. There was a significant decrease in the total Dyspnea-12 scores at the end of the study period. Compared to the baseline assessment, CAT total scores significantly decreased in the 4th, 8th, and 12th week ( p < 0.05), and CDS scores showed a significant reduction at the 12th week ( p < 0.05). In conclusion, COPD-ECP is feasible in regular clinical practice and well accepted by patients, and it seems to improve health status and decrease dyspnea, and care dependency. Future randomized controlled studies are warranted to explore the effects of COPD-ECP on fatigue, cough and sleep problems, and the best innovative strategies to improve the efficiency of COPD-ECP.

Technology-Enabled Self-Monitoring of Chronic Obstructive Pulmonary Disease With or Without Asynchronous Remote Monitoring: Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality worldwide. Reducing the number of COPD exacerbations is an important patient outcome and a major cost-saving approach. Both technology-enabled self-monitoring (SM) and remote monitoring (RM) programs have the potential to reduce exacerbations, but they have not been directly compared with each other. As RM is a more resource-intensive strategy, it is important to understand whether it is more effective than SM.

OBJECTIVE

The objective of this study is to evaluate the impact of SM and RM on self-management behaviors, COPD disease knowledge, and respiratory status relative to standard care (SC).

METHODS

This was a 3-arm open-label randomized controlled trial comparing SM, RM, and SC completed in an outpatient COPD clinic in a community hospital. Patients in the SM and RM groups recorded their vital signs (oxygen, blood pressure, temperature, and weight) and symptoms with the Cloud DX platform every day and were provided with a COPD action plan. Patients in the RM group also received access to a respiratory therapist (RT). The RT monitored their vital signs intermittently and contacted them when their vitals varied outside of predetermined thresholds. The RT also contacted patients once a week irrespective of their vital signs or symptoms. All patients were randomized to 1 of the 3 groups and assessed at baseline and 3 and 6 months after program initiation. The primary outcome was the Partners in Health scale, which measures self-management skills. Secondary outcomes included the St. George's Respiratory Questionnaire, Bristol COPD Knowledge Questionnaire, COPD Assessment Test, and modified-Medical Research Council Breathlessness Scale. Patients were also asked to self-report on health system usage.

RESULTS

A total of 122 patients participated in the study, 40 in the SC, 41 in the SM, and 41 in the RM groups. Out of those patients, 7 in the SC, 5 in the SM, and 6 in the RM groups did not complete the study. There were no significant differences in the rates of study completion among the groups (P=.80).

CONCLUSIONS

Both SM and RM have shown promise in reducing acute care utilization and exacerbation frequencies. As far as we are aware, no studies to date have directly compared technology-enabled self-management with RM programs in COPD patients. We believe that this study will be an important contribution to the literature.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03741855; https://clinicaltrials.gov/ct2/show/NCT03741855.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13920.

Characteristics of nursing interventions that improve the quality of life of people with chronic diseases. A systematic review with meta-analysis

PURPOSE

The objective of this systematic review was to determine the characteristics of the interventions conducted by nurses that attempt to improve the health related quality of life (HRQoL) of people over 18 years of age with chronic diseases.

METHODS

This systematic review with meta-analysis summarizes 24 studies, conducted in 10 countries, that evaluated HRQoL through the Short-Form Health Survey (SF). Five databases were accessed to find the available studies from December 31st, 2000 to May 22sd, 2017. Selected studies were coded according to the characteristics of the sample and the intervention. A model of random effects was adopted for the overall estimation and to explain the heterogeneity.

RESULTS

Twenty-four studies were included in the systematic review and meta-analysis providing a sample of 4324 chronic patients aged 63.4 years. Among the 8 subscales and two summary measures that comprise the SF-36, only an overall significant effect size (ES) index was found in the Mental Health Component summary score (ES = 0.14; 95% CI:0.03 - 0.26; I2 = 44.6, p = 0.042) and the Mental Health subscale. This improvement on HRQoL was associated to interventions on "Case Management" and "Treatments and Procedures", which were based on a theory, were of shorter duration, and had a follow-up period.

CONCLUSIONS

Interventions targeting people with chronic diseases resulted in a slight increase in the HRQoL that was not always significant, which suggests that there is a need for their continuous improvement.

Effectiveness of chronic obstructive pulmonary disease self-management interventions in primary care settings: a systematic review

Chronic obstructive pulmonary disease (COPD) is one of the more disabling diseases and the third cause of mortality worldwide. Self-management is considered an effective strategy for controlling and managing COPD. This review aims to summarise the available evidence on the effectiveness of COPD self-management in primary care settings. Social Sciences, Citation Index, MEDLINE, CINAHL, Academic Search Complete and Scopus were searched for randomised controlled trials of COPD self-management in general practice between 2001 and 2018. Ten randomised controlled trials of COPD self-management trials conducted in primary care settings were included in this review. The identified trials have recruited stable patients; a majority having mild to moderate COPD. The trials implemented different types of interventions and measured improvements in knowledge, skills and behaviours of self-management, mental health, self-efficacy and endpoint outcomes such as hospitalisation and quality of life. The findings showed that COPD self-management trials had positive effects on COPD knowledge and improved self-management behaviours such as adherence to medication, physical activities and smoking cessation in some cases; however, the effect of trials on hospitalisation rate, quality of life and healthcare utilisation were not conclusive. There was also not enough evidence to suggest that the trials were efficient in improving self-efficacy, a major driver of self-management behaviours. Primary care COPD self-management trials are efficient in improving surrogate outcomes such as knowledge of and adherence to self-management behaviours; however, such improvements are less likely to be sustainable in the absence of self-efficacy. Future studies should also focus on improving endpoint self-management outcomes like hospitalisation rate and quality of life to benefit both patient and healthcare system.

Does health coaching improve health-related quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? A systematic review and meta-analysis

Purpose

To systematically review the evidence for health coaching as an intervention to improve health‐related quality of life (HRQoL) and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD).

Methods

We systematically searched MEDLINE, EMBASE, PsycINFO, and CINAHL from database inception to August 2018 to identify all randomized controlled trials (RCTs) of health coaching for people with COPD. Eligible health coaching interventions had to include three components: goal setting, motivational interviewing, and COPD‐related health education. Data were extracted on study characteristics and the effects of the intervention on HRQoL, hospital admissions, physical activity, self‐care behaviour, and mood. Study quality was appraised by two authors using the Cochrane tool for assessing the risk of bias in RCTs. Effect sizes (standardized mean differences [SMD] or odds ratios [OR]) with 95% confidence intervals (CIs) were calculated and pooled using random effects meta‐analyses.

Results

Of 1578 articles, 10 RCTs were included. Meta‐analysis showed that health coaching has a significant positive effect on HRQoL (SMD = −0.69, 95% CI: −1.28, −0.09, p = .02, from k = 4) and leads to a significant reduction in COPD‐related hospital admissions (OR = 0.46, 95% CI: 0.31, 0.69, p = .0001, from k = 5), but not in all‐cause hospital admissions (OR = 0.70, 95% CI: 0.41–1.12, p = .20, from k = 3). Three of four studies reported significant improvements to self‐care behaviours such as medication adherence and exercise compliance.

Conclusions

This is the first systematic review to show that health coaching may be a candidate intervention to improve HRQoL and reduce costly hospital admissions in people with COPD.

The Push and Pull of Self-Managing Mild COPD: An Evaluation of Participant Experiences of a Nurse-Led Telephone Health Coaching Intervention

Health coaching is a novel population intervention to support self-management but it is untested in people with mild disease. People with chronic obstructive pulmonary disease with mild dyspnea are a population excluded from supported self-management and whose illness might progress without intervention. We explored participants' experiences about how health coaching motivated behavior change. Interviews were conducted with 21 intervention and 10 control participants at 6 months, and 20 intervention participants at 12 months. Participants were identified from a randomized controlled trial of telephone health coaching. Data were analyzed using the framework method. Participants positively enacted behavior change to become more physically active. Participants took advantage of environmental affordances to pull themselves toward activity targets, or relied on being pushed to be more active by the health coach or significant others. Behavior change was maintained where efforts to be more active were built into the everyday lifeworld of participants.

Patient perceived impact of nurse-led self-management interventions for COPD: A systematic review of qualitative research

BACKGROUND

Self-management interventions are increasingly implemented to manage the health impact and economic burden of the growing prevalence of chronic obstructive pulmonary disease. Nurses are the primary providers of self-management education, yet there have been few attempts to assess their contribution in delivering these programmes. Qualitative evidence that explores patients' perceptions of the benefits of self-management is limited.

OBJECTIVE

To synthesize qualitative evidence on patient perceived benefits of nursing interventions to support self-management.

DESIGN

Systematic review and qualitative synthesis.

METHODS

Data were collected from six electronic databases: British Nursing Index (BNI, Proquest), MEDLINE (Ovid), CINAHL (EBSCO), AMED (Ovid), Embase (Ovid), and PsycINFO (Ovid). Pre-defined keywords were used to identify qualitative or mixed methods English-language studies published in any year. The included studies were selected by screening titles, abstracts and full-texts against inclusion and exclusion criteria that were established a priori. The Critical Appraisal Skills Programme tool was used to undertake a quality review. Data were analysed with a framework approach using categories of self-management outcomes reported in a previous review as a coding structure.

RESULTS

Fourteen articles were included in the review. Four key themes were identified from the original research: Empowerment through new knowledge, Psychological wellbeing, Expanding social worlds and Increased physical activity.

CONCLUSIONS

When provided with adequate knowledge and support, patients gained self-confidence and their coping behaviour increased. Social and psychological support were identified as key aspects of self-management interventions that patients found improved their sense of wellbeing. Group exercise components of self-management programmes were also favourably evaluated due to a perceived sense of increased well-being and enhanced social interaction.

Systematic review of the effectiveness of community-based self-management interventions among primary care COPD patients

COPD self-management reduces hospital admissions and improves health-related quality of life (HRQoL). However, whilst most patients are managed in primary care, the majority of self-management trials have recruited participants with more severe disease from secondary care. We report the findings of a systematic review of the effectiveness of community-based self-management interventions in primary care patients with COPD. We systematically searched eleven electronic databases and identified 12 eligible randomised controlled trials with seven included in meta-analyses for HRQoL, anxiety and depression. We report no difference in HRQoL at final follow-up (St George's Respiratory Questionnaire total score -0.29; 95%CI -2.09, 1.51; I2 0%), nor any difference in anxiety or depression. In conclusion, supported self-management interventions delivered in the community to patients from primary care do not appear to be effective. Further research is recommended to identify effective self-management interventions suitable for primary care populations, particularly those with milder disease.

Effects of a COPD self-management support intervention: a randomized controlled trial

BACKGROUND

This study examines the effects of the COPD-specific health promoting self-management intervention "Better living with COPD" on different self-management-related domains, self-efficacy, and sense of coherence (SOC).

METHODS

In a randomized controlled design, 182 people with COPD were allocated to either an intervention group (offered Better living with COPD in addition to usual care) or a control group (usual care). Self-management-related domains were measured by the Health Education Impact Questionnaire (heiQ) before and after intervention. Self-efficacy was measured by the General Self-Efficacy Scale (GSE) and SOC was measured by the 13-item Sense of Coherence Scale (SOC-13). Effects were assessed by ANCOVA, using intention-to-treat (ITT) analysis and per-protocol analysis (PPA).

RESULTS

The PPA and the ITT analysis showed significant positive changes on Constructive attitudes and approaches (heiQ) (ITT: P=0.0069; PPA: P=0.0021) and Skill and technique acquisition (heiQ) (ITT: P=0.0405; PPA: P=0.0356). Self-monitoring and insight (heiQ) showed significant positive change in the PPA (P=0.0494). No significant changes were found on the other self-management domains (heiQ), self-efficacy (GSE), or SOC (SOC-13).

CONCLUSION

Better living with COPD had a significant positive short-term effect on some self-management-related domains, and could be an intervention contributing to the support of self-management in people with COPD. However, further work is needed to establish the clinical relevance of the findings and to evaluate the long-term effects.

Self management of patients with mild COPD in primary care: randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of telephone health coaching delivered by a nurse to support self management in a primary care population with mild symptoms of chronic obstructive pulmonary disease (COPD).

DESIGN

Multicentre randomised controlled trial.

SETTING

71 general practices in four areas of England.

PARTICIPANTS

577 patients with Medical Research Council dyspnoea scale scores of 1 or 2, recruited from primary care COPD registers with spirometry confirmed diagnosis. Patients were randomised to telephone health coaching (n=289) or usual care (n=288).

INTERVENTIONS

Telephone health coaching intervention delivered by nurses, underpinned by Social Cognitive Theory. The coaching promoted accessing smoking cessation services, increasing physical activity, medication management, and action planning (4 sessions over 11 weeks; postal information at weeks 16 and 24). The nurses received two days of training. The usual care group received a leaflet about COPD.

MAIN OUTCOME MEASURES

The primary outcome was health related quality of life at 12 months using the short version of the St George's Respiratory Questionnaire (SGRQ-C).

RESULTS

The intervention was delivered with good fidelity: 86% of scheduled calls were delivered; 75% of patients received all four calls. 92% of patients were followed-up at six months and 89% at 12 months. There was no difference in SGRQ-C total score at 12 months (mean difference -1.3, 95% confidence interval -3.6 to 0.9, P=0.23). Compared with patients in the usual care group, at six months follow-up, the intervention group reported greater physical activity, more had received a care plan (44% v 30%), rescue packs of antibiotics (37% v 29%), and inhaler use technique check (68% v 55%).

CONCLUSIONS

A new telephone health coaching intervention to promote behaviour change in primary care patients with mild symptoms of dyspnoea did lead to changes in self management activities, but did not improve health related quality of life.

TRIAL REGISTRATION

Current controlled trials ISRCTN 06710391.

Effects of telephone support on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease: a meta-analysis

The aim of this meta-analysis was to evaluate the effects of disease education or pulmonary rehabilitation programs assisted with telephone support on physical capacity and quality of life (QOL) in chronic obstructive pulmonary disease (COPD) patients. A systematic search of PubMed, Embase, Web of Science and The Cochrane Library was conducted until May 2017. Randomized controlled trials (RCTs) examining the effects of telephone-assisted intervention versus a control group on exercise tolerance and QOL in patients with COPD were included. Two independent authors assessed the methodological quality of the trials using the Cochrane risk of bias tool. A meta-analysis was conducted with the Revman5.3 to quantify the effects of telephone-assisted interventions on walking capacity and QOL. In total, 10 studies involving 1037 participants were included. Due to the effect of telephone-assisted interventions, statistically significant results were found on Saint-George's Respiratory Questionnaire (SGRQ) symptom scores [standard mean difference (SMD) -.18, 95% confidence interval (CI) -.33, -.03, p-value .02)], SGRQ impact scores [SMD -.35, 95% CI -.60, -.10, p-value .006)], SGRQ activity scores [SMD -.30, 95% CI -.45, -.15, p-value < .0001)], SGRQ total score [SMD -.36, 95% CI -.51, -.21, p-value < .00001)]. The effects on 6-min walk test (6MWT) and all Chronic Respiratory Questionnaire (CRQ) subscales were not significant (p > .05) based on the insufficient evidence. In conclusion, the role of telephone-assisted interventions in the management of COPD remains equivocal. Some encouraging results were seen with regard to SGRQ symptom, SGRQ impact, SGRQ activity and SGRQ total score. We believe that more methodologically rigorous large-scale randomized controlled trials are necessary to answer this study question.

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.

Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization. A Randomized Study

RATIONALE

Hospital readmission for chronic obstructive pulmonary disease (COPD) has attracted attention owing to the burden to patients and the health care system. There is a knowledge gap on approaches to reducing COPD readmissions.

OBJECTIVES

To determine the effect of comprehensive health coaching on the rate of COPD readmissions.

METHODS

A total of 215 patients hospitalized for a COPD exacerbation were randomized at hospital discharge to receive either (1) motivational interviewing-based health coaching plus a written action plan for exacerbations (the use of antibiotics and oral steroids) and brief exercise advice or (2) usual care.

MEASUREMENTS AND MAIN RESULTS

We evaluated the rate of COPD-related hospitalizations during 1 year of follow-up. The absolute risk reductions of COPD-related rehospitalization in the health coaching group were 7.5% (P = 0.01), 11.0% (P = 0.02), 11.6% (P = 0.03), 11.4% (P = 0.05), and 5.4% (P = 0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. The odds ratios for COPD hospitalization in the intervention arm compared with the control arm were 0.09 (95% confidence interval [CI], 0.01-0.77) at 1 month postdischarge, 0.37 (95% CI, 0.15-0.91) at 3 months postdischarge, 0.43 (95% CI, 0.20-0.94) at 6 months postdischarge, and 0.60 (95% CI, 0.30-1.20) at 1 year postdischarge. The missing value rate for the primary outcome was 0.4% (one patient). Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire emotional score (emotion and mastery domains) and physical score (dyspnea and fatigue domains) (P < 0.05). There were no differences between groups in measured physical activity at any time point.

CONCLUSIONS

Health coaching may represent a feasible and possibly effective intervention designed to reduce COPD readmissions. Clinical trial registered with www.clinicaltrials.gov (NCT01058486).

An integrated method of therapeutic lifestyle change for older adults with dyslipidaemia

OBJECTIVES

To evaluate the effect of therapeutic lifestyle change with a non-pharmacological intervention method in older adults with dyslipidaemia.

STUDY DESIGN

Stratified randomized trial.

METHODS

Participants with dyslipidaemia (n = 214) aged ≥60 years were randomized to the conventional guide group, the educational course (EC) group, the telephone call (PC) group or the PC + EC group for 24 weeks. Total cholesterol, triglyceride, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and the knowledge, attitude and practice score for serum lipids were measured at baseline (T1), mid-intervention (week 12, T2) and post-intervention (week 24, T3).

RESULTS

Except the conventional guide group (n = 62), the PC group (n = 56), the EC group (n = 49) and the PC + EC group (n = 47) showed significant intra-group differences in serum total cholesterol, low-density lipoprotein cholesterol, triglyceride, high-density lipoprotein cholesterol and knowledge, attitude and practice score after the intervention. The improvements were most prominent and sustained over time in the PC + EC group at post-intervention.

CONCLUSIONS

The PC + EC method is more efficient for improving serum lipids and enhancing health awareness than any single programme in older adults with dyslipidaemia. This overlapped therapeutic lifestyle change method may serve as a cost-effective adjunct and ensure the continuity of high-quality health services for patients with dyslipidaemia.

Conceptualising a model to guide nursing and midwifery in the community guided by an evidence review

Background

Successful models of nursing and midwifery in the community delivering healthcare throughout the lifespan and across a health and illness continuum are limited, yet necessary to guide global health services. Primary and community health services are the typical points of access for most people and the location where most care is delivered. The scope of primary healthcare is complex and multifaceted and therefore requires a practice framework with sound conceptual and theoretical underpinnings.

The aim of this paper is to present a conceptual model informed by a scoping evidence review of the literature.

Methods

A scoping evidence review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases included CINAHL, MEDLINE, PsycINFO and SocINDEX using the EBSCO platform and the Cochrane Library using the keywords: model, nursing, midwifery, community, primary care. Grey literature for selected countries was searched using the Google ‘advanced’ search interface. Data extraction and quality appraisal for both empirical and grey literature were conducted independently by two reviewers. From 127 empirical and 24 non-empirical papers, data extraction parameters, in addition to the usual methodological features, included: the nature of nursing and midwifery; the population group; interventions and main outcomes; components of effective nursing and midwifery outcomes.

Results

The evidence was categorised into six broad areas and subsequently synthesised into four themes. These were not mutually exclusive: (1) Integrated and Collaborative Care; (2) Organisation and Delivery of Nursing and Midwifery Care in the Community; (3) Adjuncts to Nursing Care and (4) Overarching Conceptual Model. It is the latter theme that is the focus of this paper. In essence, the model depicts a person/client on a lifespan and preventative-curative trajectory. The health related needs of the client, commensurate with their point position, relative to both trajectories, determines the nurse or midwife intervention. Consequently, it is this need, that determines the discipline or speciality of the nurse or midwife with the most appropriate competencies.

Conclusion

Use of a conceptual model of nursing and midwifery to inform decision-making in primary/community based care ensures clinical outcomes are meaningful and more sustainable. Operationalising this model for nursing and midwifery in the community demands strong leadership and effective clinical governance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-017-0225-3) contains supplementary material, which is available to authorized users.

Effectiveness of Shared Decision-Making Training Program in People With Schizophrenia in South Korea

PURPOSE

This study aimed to investigate the effects of shared decision-making (SDM) training program on self-esteem, problem-solving ability, and quality of life in people with schizophrenia.

DESIGN AND METHODS

A quasi-experiment with a nonequivalent control group pre-posttest design was conducted. The self-esteem scale, the problem-solving ability scale, and the WHOQOL Scale were used.

FINDINGS

The SDM training program was effective in improving their self-esteem, problem-solving ability, and quality of life in people with schizophrenia.

PRACTICE IMPLICATIONS

The SDM training program can be used in various mental health fields such as hospitals, mental health centers, and rehabilitation facilities.

Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis

The expansion of primary care and community-based service delivery systems is intended to meet emerging needs, reduce the costs of hospital-based ambulatory care and prevent avoidable hospital use by the provision of more appropriate care. Great emphasis has been placed on the role of self-management in the complex process of care of patient with long-term conditions. Several studies have determined that nurses, among the health professionals, are more recommended to promote health and deliver preventive programs within the primary care context. The aim of this systematic review and meta-analysis is to assess the efficacy of the nurse-led self-management support versus usual care evaluating patient outcomes in chronic care community programs. Systematic review was carried out in MEDLINE, CINAHL, Scopus and Web of Science including RCTs of nurse-led self-management support interventions performed to improve observer reported outcomes (OROs) and patients reported outcomes (PROs), with any method of communication exchange or education in a community setting on patients >18 years of age with a diagnosis of chronic diseases or multi-morbidity. Of the 7,279 papers initially retrieved, 29 met the inclusion criteria. Meta-analyses on systolic (SBP) and diastolic (DBP) blood pressure reduction (10 studies-3,881 patients) and HbA1c reduction (7 studies-2,669 patients) were carried-out. The pooled MD were: SBP -3.04 (95% CI -5.01--1.06), DBP -1.42 (95% CI -1.42--0.49) and HbA1c -0.15 (95% CI -0.32-0.01) in favor of the experimental groups. Meta-analyses of subgroups showed, among others, a statistically significant effect if the interventions were delivered to patients with diabetes (SBP) or CVD (DBP), if the nurses were specifically trained, if the studies had a sample size higher than 200 patients and if the allocation concealment was not clearly defined. Effects on other OROs and PROs as well as quality of life remain inconclusive.

Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials

Background

Physical inactivity is associated with poor outcomes in COPD, and as a result, interventions to improve physical activity (PA) are a current research focus. However, many trials have been small and inconclusive.

Objective

The aim of this systematic review and meta-analysis was to study the effects of randomized controlled trials (RCTs) targeting PA in COPD.

Methods

Databases (Physiotherapy Evidence Database [PEDro], Embase, MEDLINE, CINAHL and the Cochrane Central Register for Controlled Trials) were searched using the following keywords: “COPD”, “intervention” and “physical activity” from inception to May 20, 2016; published RCTs that aimed to increase PA in individuals with COPD were included. The PEDro scale was used to rate study quality. Standardized mean differences (effect sizes, ESs) with 95% confidence intervals (CIs) were determined. Effects of included interventions were also measured according to the minimal important difference (MID) in daily steps for COPD (599 daily steps).

Results

A total of 37 RCTs with 4,314 participants (mean forced expiratory volume in one second (FEV₁) % predicted 50.5 [SD=10.4]) were identified. Interventions including exercise training (ET; n=3 studies, 103 participants) significantly increased PA levels in COPD compared to standard care (ES [95% CI]; 0.84 [0.44–1.25]). The addition of activity counseling to pulmonary rehabilitation (PR; n=4 studies, 140 participants) showed important effects on PA levels compared to PR alone (0.47 [0.02–0.92]), achieving significant increases that exceeded the MID for daily steps in COPD (mean difference [95% CI], 1,452 daily steps [549–2,356]). Reporting of methodological quality was poor in most included RCTs.

Conclusion

Interventions that included ET and PA counseling during PR were effective strategies to improve PA in COPD.

Nurses' perspectives of a new individualized nursing care intervention for COPD patients in primary care settings: A mixed method study

BACKGROUND

The major challenges in Chronic Obstructive Pulmonary Disease (COPD) care are guiding a patient in daily living with the consequences of the disease, reducing the impact of symptoms and improving Health Related Quality of Life (HRQoL). The new nurse-led COPD-Guidance, Research on an Illness Perception (COPD-GRIP) intervention translates the evidence concerning illness perceptions and Health Related Quality of Life (HRQoL) into a practice nurse intervention. The aim is to explore the nurses' experiences with applying the new COPD-GRIP intervention.

METHOD

An explanatory mixed-method study nested in a cluster randomized trial in primary care was conducted. Pre-intervention questionnaires were sent to all participating nurses (N=24) to identify expectations. Post-intervention questionnaires identified experiences after applying the intervention followed by two focus groups to further extend exploration of findings. Questionnaires were analyzed by descriptive analyses. To identify themes the audio-taped and transcribed focus groups were independently coded by two researchers.

RESULTS

The nurses described the intervention as a useful, structured and individualized tool to guide COPD patients in living with the consequences of COPD. Applying the intervention took less time than the nurses initially expected. The intervention enables to provide patient-centered care and to address patient needs. Barriers were encountered, especially in patients with a lower social economic status, in patients with a lower health literacy and in patients with other cultural backgrounds than the Dutch background.

CONCLUSION

Nurses perceived the COPD-GRIP intervention as a feasible, individualized tool. According to the nurses, the intervention is a valuable improvement in the care for COPD patients.

Construct Validity of the Dutch Version of the 12-Item Partners in Health Scale: Measuring Patient Self-Management Behaviour and Knowledge in Patients with Chronic Obstructive Pulmonary Disease

Objective

The 12-item Partners in Health scale (PIH) was developed in Australia to measure self-management behaviour and knowledge in patients with chronic diseases, and has undergone several changes. Our aim was to assess the construct validity and reliability of the latest PIH version in Dutch COPD patients.

Methods

The 12 items of the PIH, scored on a self-rated 9-point Likert scale, are used to calculate total and subscale scores (knowledge; coping; recognition and management of symptoms; and adherence to treatment). We used forward-backward translation of the latest version of the Australian PIH to define a Dutch PIH (PIH(Du)). Mokken Scale Analysis and common Factor Analysis were performed on data from a Dutch COPD sample to investigate the psychometric properties of the Dutch PIH; and to determine whether the four-subscale solution previously found for the original Australian PIH could be replicated for the Dutch PIH.

Results

Two subscales were found for the Dutch PIH data (n = 118); 1) knowledge and coping; 2) recognition and management of symptoms, adherence to treatment. The correlation between the two Dutch subscales was 0.43. The lower-bound of the reliability of the total scale equalled 0.84. Factor analysis indicated that the first two factors explained a larger percentage of common variance (39.4% and 19.9%) than could be expected when using random data (17.5% and 15.1%).

Conclusion

We recommend using two PIH subscale scores when assessing self-management in Dutch COPD patients. Our results did not support the four-subscale structure as previously reported for the original Australian PIH.

A randomized controlled trial of telephone-mentoring with home-based walking preceding rehabilitation in COPD

PURPOSE

With the limited reach of pulmonary rehabilitation (PR) and low levels of daily physical activity in chronic obstructive pulmonary disease (COPD), a need exists to increase daily exercise. This study evaluated telephone health-mentoring targeting home-based walking (tele-rehab) compared to usual waiting time (usual care) followed by group PR.

PATIENTS AND METHODS

People with COPD were randomized to tele-rehab (intervention) or usual care (controls). Tele-rehab delivered by trained nurse health-mentors supported participants' home-based walking over 8-12 weeks. PR, delivered to both groups simultaneously, included 8 weeks of once-weekly education and self-management skills, with separate supervised exercise. Data were collected at three time-points: baseline (TP1), before (TP2), and after (TP3) PR. The primary outcome was change in physical capacity measured by 6-minute walk distance (6MWD) with two tests performed at each time-point. Secondary outcomes included changes in self-reported home-based walking, health-related quality of life, and health behaviors.

RESULTS

Of 65 recruits, 25 withdrew before completing PR. Forty attended a median of 6 (4) education sessions. Seventeen attended supervised exercise (5±2 sessions). Between TP1 and TP2, there was a statistically significant increase in the median 6MWD of 12 (39.1) m in controls, but no change in the tele-rehab group. There were no significant changes in 6MWD between other time-points or groups, or significant change in any secondary outcomes. Participants attending supervised exercise showed a nonsignificant improvement in 6MWD, 12.3 (71) m, while others showed no change, 0 (33) m. The mean 6MWD was significantly greater, but not clinically meaningful, for the second test compared to the first at all time-points.

CONCLUSION

Telephone-mentoring for home-based walking demonstrated no benefit to exercise capacity. Two 6-minute walking tests at each time-point may not be necessary. Supervised exercise seems essential in PR. The challenge of incorporating exercise into daily life in COPD is substantial.

Measuring chronic condition self-management in an Australian community: factor structure of the revised Partners in Health (PIH) scale

PURPOSE

To evaluate the factor structure of the revised Partners in Health (PIH) scale for measuring chronic condition self-management in a representative sample from the Australian community.

METHODS

A series of consultations between clinical groups underpinned the revision of the PIH. The factors in the revised instrument were proposed to be: knowledge of illness and treatment, patient-health professional partnership, recognition and management of symptoms and coping with chronic illness. Participants (N = 904) reporting having a chronic illness completed the revised 12-item scale. Two a priori models, the 4-factor and bi-factor models were then evaluated using Bayesian confirmatory factor analysis (BCFA). Final model selection was established on model complexity, posterior predictive p values and deviance information criterion.

RESULTS

Both 4-factor and bi-factor BCFA models with small informative priors for cross-loadings provided an acceptable fit with the data. The 4-factor model was shown to provide a better and more parsimonious fit with the observed data in terms of substantive theory. McDonald's omega coefficients indicated that the reliability of subscale raw scores was mostly in the acceptable range.

CONCLUSION

The findings showed that the PIH scale is a relevant and structurally valid instrument for measuring chronic condition self-management in an Australian community. The PIH scale may help health professionals to introduce the concept of self-management to their patients and provide assessment of areas of self-management. A limitation is the narrow range of validated PIH measurement properties to date. Further research is needed to evaluate other important properties such as test-retest reliability, responsiveness over time and content validity.