Optimizing nonpharmacological management following an acute exacerbation of chronic obstructive pulmonary disease

Exploring Factors Contributing to Chronic Obstructive Pulmonary Disease (COPD) Guideline Non-Adherence and Potential Solutions in the Emergency Department: Interdisciplinary Staff Perspective

Purpose

Acute exacerbations of chronic obstructive pulmonary disease (COPD) have a significant and prolonged impact on health-related quality of life, patient outcomes, and escalation of pulmonary function decline. COPD-X guidelines published in 2003 subsist to facilitate a shift from the emphasis on pharmacological treatment to a more holistic multi-disciplinary interventions approach. Despite the existing comprehensive recommendations, readmission rates have increased in the last decade. Evidence to date has reported sub-optimal COPD guidelines adherence in emergency departments. This qualitative study explored contributing factors to interdisciplinary staff non-adherence and utilisation of COPD-X guidelines in a major Southern Queensland Emergency Department.

Methods

Semi-structured qualitative interviews with interdisciplinary staff were conducted in an emergency department. A purposive sample of doctors, nurses, physiotherapists, pharmacist and a social worker were recruited. Interviews were digitally recorded, de-identified and transcribed verbatim. Data analysis followed a coding process against the Theoretical Domains Framework (TDF) to examine implementation barriers and potential solutions. Identified factors affecting non-adherence and underutilisation of guidelines were then mapped to the capability, opportunity, motivation, behaviour model (COM-B) and behaviour change wheel (BCW) to inform future implementation recommendations.

Results

Prominent barriers influencing the clinical uptake of COPD guidelines were identified using TDF analysis and included knowledge, professional role clarity, clinical behaviour regulation, memory, attention, and decision process, beliefs about departmental capabilities, environmental context and resources. Potential interventions included education, training, staffing, funding and time-efficient digitalised referrals and systems management reminders to prevent COPD readmissions, remissions and improve patient health-related quality of life.

Conclusion

Implementation strategies such as electronic interdisciplinary COPD proforma that facilitates a multimodal approach with appropriate patient/staff resources and referrals prior to discharge from an ED require further exploration. Greater clarity around which components of the COPD X guidelines must be applied in ED settings needs to stem from future research.

Advanced nursing practice in COPD exacerbations: the solution for a gap in Switzerland?

AIM

This study aimed to address the need for adaptation of the current model of chronic obstructive pulmonary disease (COPD) care in Switzerland, particularly in regard to acute exacerbations, and how far an integrated approach involving advanced nursing practice can meet those needs.

METHODS

A state analysis guided by the PEPPA framework was initiated by the Pulmonology Clinic of University Hospital Zürich. Literature describing the current provision of COPD care regarding exacerbations in Switzerland and international qualitative studies describing the patient perspective were systematically searched and summarised. The health providers' perspective was investigated in three focus-group interviews.

RESULTS

A lack of systematic and state-of-the-art support for patient self-management in Switzerland was described in literature and confirmed by the health providers interviewed. While care was assessed as being comprehensive and of good quality in each individual sector, such as inpatient, outpatient, rehabilitation and home settings, it was identified as being highly fragmented across sectors. The interview participants described day-to-day examples in which a lack of support in COPD self-management and fragmentation of care negatively affected the patients' disease management.

CONCLUSION

The necessity of coordinating the transition between healthcare sectors and self-management support and that these organisational boundaries should be addressed by a multi-professional team were identified. Initial evaluation indicates that advanced practice nurses potentially have the skill set to coordinate the team and address patients' self-management needs in complex patient situations. However, the legal foundation and a reimbursement system to ensure long-term implementation is not yet available.

Effects of the health belief model following acute exacerbation of chronic obstructive pulmonary disease in a hospital in China

Background

This study aims to investigate the effects of education with health belief model (HBM) on anxiety and fatigue among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

Patients with AECOPD admitted into Taizhou People's Hospital, Jiangsu, China between December 2012 and October 2013 were randomly selected for the present study according to random number table. A total of 99 cases with anxiety were included. These patients were divided into two groups: experimental group educated by HBM (n=47), and control group educated by conventional method (n=52). The scores for anxiety and fatigue were evaluated using the self-rating anxiety scale (SAS) and multidimensional fatigue inventory (MFI-20).

Results

After educational intervention by HBM, patients achieved a significant decrease in anxiety and fatigue scores, when compared to patients in the control group, who were educated by the conventional method at the time of admission, discharge, and 6 weeks after discharge (P<0.05).

Conclusions

HBM program effectively may alleviate anxiety and fatigue, providing necessary information for symptom management among patients with AECOPD.

Improving acceptance and uptake of pulmonary rehabilitation after acute exacerbation of COPD: Acceptability, feasibility, and safety of a PR "taster" session delivered before hospital discharge

The objectives of this study were to (1) assess the acceptability, feasibility, and safety of delivering a pulmonary rehabilitation (PR) "taster" session to patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease; (2) evaluate the changes in patient knowledge and readiness to commence PR; and (3) make recommendations for future intervention iterations. Acceptability was measured by the proportion of patients that accepted to participate. Feasibility was measured by the proportion of eligible participants. Knowledge was evaluated using the modified versions of the Understanding COPD (UCOPD) and Bristol COPD Knowledge (BCKQ) questionnaires. Readiness to commence PR was measured by a modified version of the Readiness to Change Exercise Questionnaire. All measures were delivered pre- and post-intervention. Thirty-one of 34 eligible individuals were able to be approached. Prospective acceptability was low, with 24 individuals declining the intervention, 1 being discharged without making a decision, and only 6 participating. Positive median change was recorded in the modified UCOPD questionnaire (+8), but not the BCKQ (0). Three of the patients were already in the action phase pre-intervention, with all but one in that phase post-intervention. The delivery of a PR "taster" session was not prospectively acceptable to a large portion of patients and only feasible with modifications to the original protocol.

Effects of Integrated Case Payment on Medical Expenditure and Readmission of Inpatients with Chronic Obstructive Pulmonary Disease: A Nonrandomized, Comparative Study in Xi County, China

In the past few decades, Chinese government attempted to reduce the economic burden of chronic diseases and lower family financial risk of patients by establishing a nationwide coverage of Social Health Insurance system. However, the payment mode of Social Health Insurance varies across Chinese healthcare settings, and the effectiveness of each mode differs. This study aimed to evaluate the effects of integrated case payment on medical expenditure and readmission of inpatients with chronic obstructive pulmonary disease (COPD), a complex, multicomponent, chronic condition. A nonrandomized, comparative method was used in this study. Inpatients with COPD before (n=1569) and after the integrated case payment reform (n=4764) were selected from the inpatient information database of the New Cooperative Medical Scheme Agency of Xi County. The integrated case payment comprises the case payment (including price-cap case payment and fixed-reimbursement case payment) and clinical pathway (including clinical pathway A, clinical pathway B and clinical pathway C). Effects of integrated case payment were evaluated with indicators of per capita total medical expense and readmission within 30 days. A multivariate linear regression and a binary logistic regression were used to conduct statistical analysis. The results showed that case payment, comprising price-cap case payment β=2382.988, P<0.001) and fixed-reimbursement case payment β=2613.564, P<0.001), and clinical pathway C β=1996.467, P<0.001) were risk factors of per capita total medical expenses. Clinical pathway A β=1443.409, P<0.001) and clinical pathway B β=1583.791, P<0.001) were protective factors. The interactive effects of case payment with hospital level β=0.710, P<0.001) lowered the readmission rate within 30 days. Meanwhile, clinical pathways A β=18.949, P<0.001), B (β=19.152, PO.OOl) and C β=1.882, P<0.001) were associated with the rate increase. The findings revealed that integrated case payment ensured the quality of care for inpatients with COPD to some extent. However, this payment mode increased the per capita total medical expense. Further, policy-makers should set reasonable reimbursement standards of case payment, unify the type of case payment, and strengthen the supervision of the reform to enhance its function on medical cost control.

Acute exacerbation of COPD during pulmonary rehabilitation: outcomes and risk prediction

Purpose

This study was performed to examine acute exacerbation of COPD (AECOPD) during pulmonary rehabilitation (PR) and the usefulness of multidimensional indices (MIs) to predict AECOPD at enrolment in PR.

Patients and methods

A 4-week PR program (PRP) was implemented for 125 consecutive patients with COPD. At baseline and PRP completion, we recorded the FEV₁, 6-minute walk test, peak work rate at cardiopulmonary testing, modified Medical Research Council score, and COPD Assessment Test (CAT) score. The risk of AECOPDs at baseline was assessed using the body mass index, airway obstruction, dyspnea, Exercise capacity (BODE), dyspnea, obstruction, smoking, exacerbation (DOSE), and score to predict short-term risk of COPD exacerbations (SCOPEX) MIs.

Results

Thirty-two episodes of AECOPD occurred. The COPD status was worse in patients with than without AECOPD at baseline (lower FEV₁, 6-minute walk test, and peak work rate; higher modified Medical Research Council and CAT scores). The sensitivities of the BODE, DOSE, and SCOPEX MIs to predict the occurrence of AECOPD during PRP were 78.1%, 21.9%, and 84.4%, and the specificities were 73.6%, 87.1%, and 51.6%, respectively.

Conclusion

The BODE and SCOPEX MIs help to predict the exacerbation risk during PR.

Patient Education Provided by Physiotherapists for Patients with Chronic Obstructive Pulmonary Disease: Results of a Scoping Review

Purpose: Physiotherapists have been acknowledged as playing a vital role in the care of people living with chronic obstructive pulmonary disease (COPD), and this care includes providing patient education (PE). Yet very little is known about the issues critical to providing this PE. The purpose of this scoping review was to identify and map out the current knowledge about the content, processes, and overall effectiveness of the PE provided by physiotherapists for people living with COPD. Method: Using the guidelines developed by Arksey and O'Malley in 2005 and by Levac in 2010, key databases were searched. A total of 447 articles were identified and screened for the following inclusion criteria: adults living with COPD, published in English or French between 1995 and 2015, and describing the PE provided by physiotherapists. Fourteen studies matched these criteria. Results: In the majority of studies, both physiotherapists and nurses provided PE to patients. Common PE topics included energy conservation, exacerbations, and breathlessness. None of the studies included measures for evaluating the effectiveness of the PE. Conclusions: Even though physiotherapists routinely provide PE to people living with COPD, this PE varies substantially. The heterogeneity of the studies and lack of measures of effectiveness prevented them from providing any evidence-based recommendations for physiotherapists.

Dokumentiranje navodil o življenjskem slogu in samoobvladovanju bolezni pri pacientih s kronično obstruktivno pljučno boleznijo

Uvod: Za boljše doseganje kakovosti življenja pacientov s kronično obstruktivno pljučno boleznijo je slednje treba poučiti o značilnostih bolezni ter o ukrepih za njeno učinkovito samoobvladovanje. Namen raziskave je bil ugotoviti pogostost dokumentiranja in vrsto dokumentiranih navodil o življenjskem slogu in samoobvladovanju bolezni v bolnišnični dokumentaciji pacientov s kronično obstruktivno pljučno boleznijo.Metode: Izvedena je bila retrospektivna kvantitativna raziskava, v kateri je bila pregledana celotna bolnišnična dokumentacija (terapevtski listi, liste zdravstvene nege, arhivi zdravstvenovzgojnih šol, odpustna pisma) 253 pacientov s kronično obstruktivno pljučno boleznijo. Za analizo podatkov sta bila poleg osnovne deskriptivne statistike uporabljena tudi hi-kvadrat test in ordinalna logistična regresija.Rezultati: V bolnišnični dokumentaciji so pacienti s kronično obstruktivno pljučno boleznijo imeli dokumentirana v povprečju manj kot 4 navodila o življenjskem slogu in samoobvladovanju bolezni (x = 3,8, s = 5,1). V odpustnem pismu je polovica pacientov (x = 0,5, s = 0,9) imela zabeleženih manj navodil o življenjskem slogu in samoobvladovanju bolezni kot v bolnišnični dokumentaciji (x2 = 33,455, p < 0,001). Diplomirane medicinske sestre so navodila dokumentirale petkrat pogosteje kot zdravniki.Diskusija in zaključek: Raziskava je za bolnišnično dokumentacijo pacientov s kronično obstruktivno pljučno boleznijo ugotovila nizko število dokumentiranih navodil o življenjskem slogu in samoobvladovanju bolezni. Treba bo povečati ozaveščenost o pomenu dokumentiranja zdravstvenovzgojnih navodil in oblikovati orodja za izboljšanje medpoklicne komunikacije.

Clinical and Physiological Effects of Rollators in Individuals With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW

PURPOSE

To determine the effects of using a rollator in people with chronic obstructive pulmonary disease (COPD).

METHODS

Studies were systematically identified from literature searches of MEDLINE, CINAHL, PEDro, PubMed, EMBASE, and the Cochrane Library databases and the reference lists of included studies. Two reviewers independently selected randomized controlled or crossover studies examining the effects of rollator usage compared with no aid in individuals with COPD. Methodologic quality was assessed by 2 reviewers independently using the Cochrane Risk of Bias tool. Two reviewers also used a customized form to extract characteristics of and outcomes for subjects related to exercise capacity, symptoms, health-related quality of life (HRQOL), physiological, and gait parameters. Weighted mean differences (WMD) with 95% CI were calculated using a fixed-effects model.

RESULTS

A total of 7 studies (126 participants) were included. Use of a rollator during a 6-Minute Walk Test (6MWT) improved distance walked (WMD = 13 m; 95% CI, 5-22) and lowered end-6MWT dyspnea rating (WMD = 0.97; 95% CI, 0.63-1.32). Longer-term use did not appear to impact exercise capacity or HRQOL, although this may be related to the frequency of use.

CONCLUSIONS

When used in the short-term, rollators resulted in a small increase in 6MWT and a reduction in dyspnea. Details on patient adherence are required to accurately evaluate the longer-term effects of rollator usage.

Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns

Background

Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established.

Aims

The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year.

Materials and methods

COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care.

Results

Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0–1] vs 1 [0–2.5]; P=0.022) and in days of admission (0 [0–7] vs 7 [0–12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (β coefficient −0.785, P=0.014, and R²=0.219).

Conclusion

A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention.

COPD patients' self-reported adherence, psychosocial factors and mild cognitive impairment in pulmonary rehabilitation

In addition to clinical comorbidities, psychological and neuropsychological problems are frequent in COPD and may affect pulmonary rehabilitation delivery and outcome. The aims of the study were to describe a COPD population in a rehabilitative setting as regards the patients depressive symptoms, anxiety, mild cognitive impairment (MCI) and self-reported adherence and to analyze their relationships; to compare the COPD sample MCI scores with normative data; and to investigate which factors might predict adherence to prescribed physical exercise. This was a multicenter observational cross-sectional study. Of the 117 eligible stable COPD inpatients, 84 were enrolled according to Global initiative for chronic Obstructive Lung Disease (GOLD) criteria (mainly in Stage III-IV). The assessment included Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), anxiety, depression and self-reported pharmacological and nonpharmacological adherence. From the MMSE, 3.6% of patients were found to be impaired, whereas from the MoCA 9.5% had a likely MCI. Patients referred had mild-severe depression (46.7%), anxiety (40.5%), good pharmacological adherence (80.3%) and difficulties in following prescribed diet (24.1%) and exercise (51.8%); they struggled with disease acceptance (30.9%) and disease limitations acceptance (28.6%). Most of them received good family (89%) or social (53%) support. Nonpharmacological adherence, depression, anxiety and MCI showed significant relations with 6-minute walking test, body mass index (BMI) and GOLD. Depression was related to autonomous long-term oxygen therapy modifications, disease perception, family support and MCI. In the multivariate logistic regression analysis, higher BMI, higher depression and lower anxiety predicted lower adherence to exercise prescriptions (P=0.0004, odds ratio =0.796, 95% CI =0.701, 0.903; P=0.009, odds ratio =0.356, 95% CI =0.165, 0.770; and P=0.05, odds ratio =2.361, 95% CI =0.995, 5.627 respectively). In COPD patients, focusing on pharmacological and nonpharmacological adherence enhance the possibility of tailored pulmonary rehabilitation programs.