Chronic obstructive pulmonary disease and comorbidities through the eyes of the patient

Self-Efficacy Intervention Programs in Patients with Chronic Obstructive Pulmonary Disease: Narrative Review

Chronic obstructive pulmonary disease (COPD) is a common chronic disease whose development is irreversible, which leads to more than six million deaths each year. There is no treatment confirmed effective for the improvement of impaired lung function, but the combination of drug therapy with non-drug therapy such as pulmonary rehabilitation training has demonstrated a great potential in reducing the occurrence of complications and delaying the progression of COPD. Self-efficacy is the core of cognitive theory, which is crucial for chronic disease management. It has been proposed as an important component of disease management to help people develop skills to manage diseases more effectively. This study reviewed the development of self-efficacy and its application in patients with COPD, with the purpose of providing a better clinical reference for the treatments of COPD.

Social network participation towards enactment of self-care in people with chronic obstructive pulmonary disease: A qualitative meta-ethnography

BACKGROUND

How people with chronic obstructive pulmonary disease (COPD) engage with supportive social networks to enhance self-care is not understood. The personal rationales for participation in socially directed support have not been addressed in the literature. To determine how people with COPD identify, engage and participate in socially supportive self-care practices, we conducted a systematic review and meta-ethnography of qualitative studies.

METHODS

A systematic literature search was conducted between June 2010 and June 2021. Of 3536 articles, 8 fulfilled the inclusion criteria. Using a meta-ethnography approach to the qualitative synthesis, new concepts were derived from the data to identify aligning themes and develop a conceptual model.

FINDINGS

Interpretations from the papers yielded concepts of (1) accountability and personal responsibility in self-care, (2) valued positive relationships with clinicians, (3) understanding of illness through shared and personal experiences and (4) acknowledging social networks in fostering self-care engagement in people with COPD. The independence-experience (Index) model of synthesized (third order) interpretations highlighted the processes of social networks and self-care practices: (a) fear or avoidance of dependency, (b) learning from experiences of adaptive self-care behaviours and (c) including valued practices in self-care. Self-care strategies are formed through illness experiences and relatable social encounters.

CONCLUSION

The model derived from the third-order interpretations is a framework to describe socially supported self-care and can be used to direct future self-care strategies and target interventions for people with COPD.

PATIENT OR PUBLIC CONTRIBUTION

The findings and model were presented to the long-term conditions patient and public involvement group. The manuscript is coauthored by a public representative.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

OBJECTIVES

To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

SEARCH METHODS

We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

MAIN RESULTS

Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

AUTHORS' CONCLUSIONS

Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

Disease self-management in patients with moderate COPD: a thematic analysis

BACKGROUND

Treatment of patients with moderate chronic obstructive pulmonary disease (COPD) is challenged by the low priority of the disease by patients and general practitioners (GPs) affecting the extent of self-management. The aim of this study was to explore (i) attitudes to COPD self-management in patients with moderate COPD, (ii) perceptions of GP commitment to pulmonary rehabilitation in patients with moderate COPD, and (iii) COPD knowledge in patients with moderate COPD.

METHODS

The study had a qualitative design using semi-structured interviews to explore the views of 14 patients diagnosed with moderate COPD. We applied strategic sampling to obtain maximum variation and conducted a thematic analysis of the data.

RESULTS

Our main findings were that the degree of COPD self-management was linked to the resources of the informants. Further, the patients experienced that GPs only availed themselves of selected parts of the recommendations for COPD treatment by focusing on medical treatment and smoking cessation rather than physical activity and diet. Many patients lacked knowledge regarding the tolerated level of physical activity and therefore avoided activity increasing their heart rate. Finally, many patients were reluctant to accept the diagnosis because the disease is known to be self-inflicted.

CONCLUSION

Our study suggests that patients with moderate COPD need more information, especially regarding the positive effects of physical activity. GPs might need to devote more time to the three main elements of COPD treatment, smoking cessation, medical treatment, and physical activity, to promote self-management and a healthier lifestyle in patients with COPD.

Patients' experiences of coping with multiple chronic conditions: A meta-ethnography of qualitative work

Multiple chronic conditions (MCCs) pose a major and growing burden on the individuals' health. The ways in which people cope with their stresses related to their chronic conditions are significant to their health outcomes. This review sought to understand lived experiences of coping with MCCs by a meta-ethnography of qualitative studies. Twenty-six studies were identified in four electronic databases including PubMed, PsycINFO, EMBASE, and CINAHL that were searched from 1966 to 2017. A seven-step analytic method was used after a quality evaluation based on Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). The findings illustrated that experiences of coping with MCCs were interacted with (i) appraisals of MCCs, (ii) strategies to maintain a normal life, (iii) strategies to keep the spirits up, and (iv) coping in the social context. To sum up, this review provided a collection of narratives on coping with MCCs. The findings would help to recognize the high complexity experienced by these patients, also potentially offered a foundation for the design of a feasible intervention to more optimally highlight the demands of managing MCCs.

Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals

Self-management interventions for chronic obstructive pulmonary disease (COPD) can improve quality of life, reduce hospital admissions, and improve symptoms. However, many factors impede engagement for patients and practitioners. Qualitative research, with its focus on subjective experience, can provide invaluable insights into such factors. Therefore, a systematic review and synthesis of qualitative evidence on COPD self-management from the perspective of patients, carers, and practitioners was conducted. Following a systematic search and screening, 31 studies were appraised and data extracted for analysis. This review found that patients can adapt to COPD; however, learning to self-manage is often a protracted process. Emotional needs are considerable; frustration, depression, and anxiety are common. In addition, patients can face an assortment of losses and limitations on their lifestyle and social interaction. Over time, COPD can consume their existence, reducing motivation. Support from family can prove vital, yet tinged with ambivalence and burden. Practitioners may not have sufficient time, resources, or appropriate skills or confidence to provide effective self-management support, particularly in regard to patients' psychosocial needs. This can compound patients' capability to engage in self-management. For COPD self-management to be effective, patients' psychosocial needs must be prioritised alongside medication and exacerbation management. In addition, patients' personal beliefs regarding COPD and its management should be reviewed periodically to avoid problematic behaviours and enhance positive adaptions to the disease. Patients with COPD are not a homogenous group and no one intervention will prove effective for all. Finally, practitioners require greater education, training, and support to successfully assist patients.

How do patients conceptualize chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a leading cause of death in the United States, yet even at risk or diagnosed patients misunderstand COPD and its consequences for their quality of life and mortality. This study explored how patients conceptualize the causes, symptoms, consequences, treatment, and risk for developing COPD. The study consisted of six focus groups: 39 participants who were adults > 40 and current smoker or have COPD symptoms, family history, or exposures. Although many participants had some familiarity with the breathing, lung function, physical, emotional, and social consequences of COPD, confusion and misunderstanding prevailed. Few knew that COPD, chronic bronchitis, and emphysema are synonymous. Some participants claimed that they "only" had bronchitis and/or emphysema and not COPD. Some participants described behavioral adaptations to decrease symptom impact and others expressed strong interest in learning how to increase daily functioning. Insufficient knowledge and persisting misconceptions about COPD can prevent patients from accessing life-enhancing strategies. Patients can benefit from (1) providers clarifying COPD's connection to chronic bronchitis and emphysema to aid them in recognizing the need for mitigating action; (2) encouraging smoking cessation, specifically to stem worsening of disease; and (3) explaining lifestyle adaptations for easing daily life despite decreased lung function.

General practitioners' perceptions of COPD treatment: thematic analysis of qualitative interviews

BACKGROUND

In Denmark, the treatment of COPD is mainly managed by general practitioners (GPs). Pulmonary rehabilitation (PR) is available to patients with COPD in the local community by GP referral, but in practice, many patients do not participate in rehabilitation. The aim of our study was to explore 1) GPs' perceptions of their role and responsibility in the rehabilitation of patients with COPD, and 2) GPs' perceptions of how patients manage their COPD.

METHODS

The study was based on a qualitative design with semi-structured key-informant interviews with GPs. Investigator triangulation was applied during data generation, and analysis was done using thematic analysis methodology.

RESULTS

Our main findings were that GPs relied on patients themselves to take the initiative to make clinic appointments and on professionals at health centers to provide the PR including consultations on lifestyle changes. The GPs experienced that patients chose to come to the clinic when they were in distress and that patients either declined or had poor adherence to rehabilitation when offered. The GPs were relieved that the health centers had taken over the responsibility of rehabilitation as GPs lacked the resources to discuss rehabilitation and follow up on individual plans.

CONCLUSION

Our study suggested a potential self-reinforcing problem with the treatment of COPD being mainly focused on medication rather than on PR. Neither GPs nor patients used a proactive approach. Further, GPs were not fully committed to discuss non-pharmacological treatment and perceived the patients as unmotivated for PR. As such, there is a need for optimizing non-pharmacological treatment of COPD and in particular the referral process to PR.

Smoking addiction in chronic obstructive pulmonary disease: Integrating neurobiology and phenomenology through a review of the literature

The aim of this review is to extend professional understanding of the various mechanisms that make smoking cessation difficult for patients with chronic obstructive pulmonary disease (COPD). Smoking in people with COPD is a major challenge for health care today. In spite of significant advances in knowledge about the processes of nicotine addiction, current interventions to support smoking cessation in patients with COPD are less successful than hoped for. A wealth of literature has confirmed that nicotine addiction is a powerful force and that smoking is not simply an unhealthy lifestyle or destructive behavior. However, research based on this realization is still in its infancy. To increase understanding and to develop ways of enhancing smoking cessation in patients with COPD, we review and synthesize knowledge found in neurobiology and phenomenology. We use neurobiology to explain the neurochemical changes that take place in addiction in order to substantiate phenomenological perspectives of smoking in patients with COPD. We relate the smoking experience to the concept of "affordances"-in this context "smoking affordances"-to analyze how smoking affects action possibilities in individuals with COPD. Combining these perspectives helps to illuminate the manifold and unique issues related to smoking addiction in patients with COPD.

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

Background:

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

Aims:

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

Methods:

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

Results:

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

Conclusions:

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

Unmet needs of patients with chronic obstructive pulmonary disease (COPD): a qualitative study on patients and doctors

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease with repeated exacerbations resulting in gradual debilitation. The quality of life has been shown to be poor in patients with COPD despite efforts to improve self-management. However, the evidence on the benefit of self-management in COPD is conflicting. Whether this could be due to other unmet needs of patients have not been investigated. Therefore, we aimed to explore unmet needs of patients from both patients and doctors managing COPD.

METHODS

We conducted a qualitative study with doctors and patients in Malaysia. We used convenience sampling to recruit patients until data saturation. Eighteen patients and eighteen doctors consented and were interviewed using a semi-structured interview guide. The interviews were audio-recorded, transcribed verbatim and checked by the interviewers. Data were analysed using a thematic approach.

RESULTS

The themes were similar for both the patients and doctors. Three main themes emerged: knowledge and awareness of COPD, psychosocial and physical impact of COPD and the utility of self-management. Knowledge about COPD was generally poor. Patients were not familiar with the term chronic obstructive pulmonary disease or COPD. The word 'asthma' was used synonymously with COPD by both patients and doctors. Most patients experienced difficulties in their psychosocial and physical functions such as breathlessness, fear and helplessness. Most patients were not confident in self-managing their illness and prefer a more passive role with doctors directing their care.

CONCLUSIONS

In conclusion, our study showed that knowledge of COPD is generally poor. There was mislabelling of COPD as asthma by both patients and physicians. This could have resulted in the lack of understanding of treatment options, outcomes, and prognosis of COPD. The misconception that cough due to COPD was contagious, and breathlessness that resulted from COPD, had important physical and psychosocial impact, and could lead to social isolation. Most patients and physicians did not favour self-management approaches, suggesting innovations based on self-management may be of limited benefit.