Living in negotiation: patients' experiences of being in the diagnostic process of COPD

Primary care patients with mild or stable chronic obstructive pulmonary disease need more support in disease management: a secondary analysis of a cluster randomized controlled trial

OBJECTIVE

Patient education based on the patient's individual needs and circumstances is known to be associated with positive changes in clinical outcomes in chronic obstructive pulmonary disease (COPD). We aimed to assess the levels of patients' subjective needs for information about COPD before and after their general practitioners had taken part in a COPD education.

DESIGN

A secondary analysis of a cluster randomized controlled trial.

SETTING

22 PHCCs in Stockholm, Sweden.

SUBJECTS

Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 293).

OUTCOME MEASURES

Scores in the Lung Information Needs Questionnaire (LINQ) at baseline and 18 months, spirometry results, and self-reported, descriptive patient data.

RESULTS

GPs' improved skills in COPD did not affect patients' self-management skills over time. In general, patients' information needs remained great in issues concerning diet, exercise and self-management. However, 43% of the patients reported reduced and 57% increased or unchanged information needs, over time. Reduced information needs were mainly associated with a high level of information needs at baseline (OR = 3.17 [95% CI 1.93-5.23], p < .01) and establishing contact with a physiotherapist (OR = 2.26 [95% CI 1.05-4.86], p = .038). Patients in a mild or stable phase of COPD with no recent exacerbations reported greater needs than those with unstable, deteriorated COPD.

CONCLUSION

Patients' information needs are substantial in most areas of self-management of COPD, and seem to covary with the patient's current clinical status. Care providers should thus continuously be vigilant about offering all patients with COPD support and education.

TRIAL REGISTRATION

Clinicaltrials.gov, 10 August 2014, Identifier NCT02213809.

Underdiagnosis and misclassification of COPD in Sweden - A Nordic Epilung study

INTRODUCTION

The prevalence of COPD tends to level off in populations with decreasing prevalence of smoking but the extent of underdiagnosis in such populations needs further investigation.

AIM

To investigate underdiagnosis and misclassification of COPD with a focus on socio-economy, lifestyle determinants and healthcare utilization.

METHOD

The 1839 participants were selected from two ongoing large-scale epidemiological research programs: The Obstructive Lung Disease in Northern Sweden Studies and the West Sweden Asthma Study. COPDGOLD was defined according to the fixed post-bronchodilator spirometric criteria FEV1/FVC<0.70 in combination with respiratory symptoms.

RESULTS

Among the 128 participants who fulfilled the criteria for COPDGOLD, the underdiagnosis was 83.6% (n = 107) of which 57.9% were men. The undiagnosed participants were younger, had higher FEV1% of predicted and less frequently a family history of bronchitis. One in four of the undiagnosed had utilized healthcare and had more frequently utilized healthcare due to a burden of respiratory symptoms than the general population without COPD. Underdiagnosis was not related to educational level. Misclassification of COPD was characterized by being a woman with low education, ever smoker, having respiratory symptoms and having a previous asthma diagnosis.

CONCLUSION

In the high income country Sweden, the underdiagnosis of COPD was highly prevalent. Reduced underdiagnosis can contribute to risk factor modification, medical treatment and self-management strategies in early stages of the disease, which may prevent disease progression and improve the quality of life among those affected. Therefore, there is a need to increase the use of spirometry in primary care to improve the diagnostic accuracy.

The impact of smoking status on anticipated stigma and experience of care among smokers and ex-smokers with chronic illness in general practice

OBJECTIVES

To compare self-reported levels of 'anticipated' stigma and experience of care in general practice between current and ex-smokers living with COPD, other chronic illnesses, or those with no chronic conditions.

METHODS

Participants completed an online survey, advertised through social media, about their experience of care from general practitioners (GPs) in the past 12 months. Respondents self-reported doctor-diagnosed chronic illnesses. Experience of care and anticipated stigma was assessed using validated questions. Multi-nominal regressions were used to determine independent effect of smoking status on anticipated stigma and other indicators of patient experience in primary care.

RESULTS

Patients with COPD (n = 161) reported significantly higher anticipated stigma scores compared to those with other chronic conditions (n = 225) and this was strongly related to delayed or avoidance in seeking help from a GP when needed. This relationship remained irrespective of current smoking status. There was no difference between groups for relational components of experience of care.

DISCUSSION

Primary care patients living with COPD reported worse experience of care across several domains and were more likely to anticipate experiencing stigma in the GP setting irrespective of their current smoking status compared to those with other chronic illnesses or no chronic illnesses.

The primary care experience of adults with chronic obstructive pulmonary disease (COPD). An interpretative phenomenological inquiry

BACKGROUND

Studies of the lived experience of chronic obstructive pulmonary disease (COPD) reveal a number of challenges patients face when interacting with healthcare providers that may be exacerbated by unwillingness or inability to quit smoking. However, none have explored, in-depth, primary care experiences among patients with COPD in community healthcare settings.

AIMS/ OBJECTIVE

The study investigated healthcare experiences of patients living independently in the community with COPD who smoked or had recently quit (at most within the last 5 years), seeking care in primary care settings.

METHOD

An Interpretative Phenomenological Analysis (IPA) involving thirteen participants purposively recruited from social media posts in COPD and carer support groups, general community groups, community noticeboards and paid adverts on social media. In-depth interviews were held between February and April 2022 by phone or Zoom™ and explored patient experience of primary care, focusing on how smoking patterns, addiction and stigma impact upon and shape these experiences.

RESULTS

Participants were aged between 45 to 75 years. Nine were female and two thirds were current smokers. Problematic experiences including time-constrained consultations, having to self-advocate for care "…go digging myself and then go and see him and say, can we do this, can we do that type of thing?" and guilt about smoking were common. Positive care experiences described non-judgemental interpersonal interactions with doctors, timely referral, proactive care and trust "I have an actual great trust for my GP… they're awesome, they'll look after you". Participants described how their care experience shifted as primary care adapted care delivery during COVID-19.

CONCLUSIONS

Pro-active, empathetic care from general practitioners is desired from patients living with COPD. Stigma and fear of judgement was an important underlying driver of negative care experiences contributing to delayed help seeking from general practitioners.

Development and preliminary psychometric evaluation of the COPD-related Stigma Scale

BACKGROUND

Stigma experiences contribute to psychological distress and negatively affect healthcare-seeking behavior in people with chronic obstructive pulmonary disease (COPD). Most evidence comes from qualitative research, and no well-established measure of COPD-related stigma exists. Prior research yielded a preliminary measure of COPD-related stigma, but it required item reduction and validation.

OBJECTIVES

The purpose of this study was to revise the preliminary measure, reduce the number of items, identify underlying constructs, and evaluate the reliability and validity of the shortened version.

METHODS

A descriptive, cross-sectional study was conducted. Participants (N = 148; mean = 64 ± 7.27 years) completed the 51-item preliminary COPD-related Stigma Scale (COPDSS). Item-level analysis was conducted before running exploratory factor analysis (EFA). Reliability was assessed using Cronbach's alpha. Convergent validity and known-groups validity were evaluated.

RESULTS

In the item-level analysis, eight items were deleted, leaving 43 items for factor analysis. A four-factor model with 24 items (α = 0.93) was derived from EFA: social stigma (α = 0.95), felt stigma (α = 0.95), anticipated stigma-oxygen (α = 0.80), and smoking-related stigma (α = 0.81). The 24-item COPDSS was significantly correlated with the 8-item Stigma Scale for Chronic Illness (r = 0.83), the Hospital Anxiety and Depression Scale (r = 0.57), and the PROMIS Physical Function (r = -0.48). The 24-item COPDSS discriminated between known groups based on age (p = .03), use of inhalers (p = .002) and use of supplemental oxygen (p < .001), and psychological distress levels (ps < .001).

CONCLUSION

Findings support the reliability and validity of the 24-item COPDSS. This instrument can be used to understand underlying stigma processes in people with COPD.

Healthcare experience of adults with COPD during the COVID-19 pandemic: a rapid review of international literature

BACKGROUND

People living with chronic obstructive pulmonary disease (COPD) are a group who may be particularly vulnerable to COVID-19. This vulnerability has been associated with increased anxiety or fear about exposure to the virus, which may also impact upon experience in healthcare settings.

AIM/OBJECTIVES

The aim of this narrative mixed-methods review was to systematically scope, identify and synthesise findings from peer-reviewed qualitative, quantitative and mixed-methods studies published in academic journals describing the healthcare experiences of adults living with COPD independently in the community, following the emergence of COVID-19 in December 2019-June 2022.

METHODS

Databases including Ovid MEDLINE, PsychINFO, Ovid Emcare and CINAHL Plus were searched. Studies were uploaded to Covidence to support selection and appraisal of studies. Studies were appraised for quality using the Mixed Methods Appraisal Tool. A narrative synthesis of these themes was provided, and qualitative and quantitative findings are interpreted together in the discussion.

FINDINGS

The quality and experience of care for patients with COPD was impacted through the COVID-19 pandemic. Innovations and adoption of technologies such as telehealth and telerehabilitation were well received and mitigated the potential implications of severe disruption to care access to some extent. Patients feared feeling forgotten and experienced isolation and anxiety; however, telerehabilitation and exercise through modalities such as Zoom classes help support social connection and physical activity.

IMPLICATIONS

These innovations are likely to be useful to be offered to patients on an ongoing basis, and education and standardised protocols around their use will benefit healthcare providers and patients alike.

PROSPERO REGISTRATION NUMBER

CRD42022341168.

Healthcare experiences of adults with COPD across community care settings: a meta-ethnography

Background

Studies investigating lived experiences of patients with COPD raise important concerns about interactions with healthcare professionals. Patients often describe feelings of guilt and shame associated with their COPD and may experience stigma and poor patient experience of care. The aims and objectives of the present study were to systematically scope and synthesise findings from peer-reviewed qualitative studies describing healthcare experiences of patients living with COPD across community care settings.

Methods

A meta-ethnography was undertaken. Database searches were performed in Ovid MEDLINE, PsychINFO, Ovid Emcare, CINAHL Plus and Sociological Abstracts. Eligible qualitative studies were included. Study screening and data extraction was performed by two independent reviewers. A "line-of-argument" synthesis and deductive and inductive analysis was used to identify key themes, where the deductive element aligned to Wong and Haggerty's six key dimensions of patient experiences.

Results

Data from 23 studies were included. Experiences and their meaning to patients were explored within the context of six domains of patient experience including access, interpersonal communication, continuity and coordination, comprehensiveness and trust. Inductive coding revealed emotion, stigma, identity and vulnerability shaped healthcare experiences of adults with COPD.

Implications

Experiences often fell short of what was expected and needed in community settings. Adopting strategies to improve experiences of care in the community can be expected to improve self-management and contribute to improved health outcomes and quality of life. These strategies should take account of vulnerability, stigma and emotions such as guilt and blame that are potent affective drivers of the experience of care for patients with COPD.

Using a computer-tailored COPD screening assessment to promote advice-seeking behaviors

Background

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality, despite evidence there is a high proportion of underdiagnosis. Online screening assessments are low-cost solutions to identify high-risk adults who may benefit from confirmatory screening (ie, spirometry test). Little evidence exists to support whether high-risk adults seek advice after completing COPD screening assessments and from whom. The purpose of this study is to examine how the perceived quality of an online screening assessment influences high-risk adults to seek advice from a healthcare provider or other online resources.

Methods

Adults without a prior COPD diagnosis (N = 199) completed an online survey that included a computer-tailored assessment programmed with the clinically validated COPD Population Screener (COPD-PS).

Results

An elevated COPD risk score was associated with expectations to talk with a healthcare provider (P < 0.05) or go on the Internet (P < 0.05) to get advice, controlling for statistically significant covariates. Positive perceptions about the quality of the risk score was associated with strengthened expectations to speak with a healthcare provider, but only among high-risk adults (P < 0.01).

Conclusions

Results of this study support the use of computer-tailored screening assessments as a scalable solution to encourage high-risk adults to learn more about COPD. Strengthened perceptions about the quality of an online COPD screening assessment increased the likelihood that high-risk adults will speak with their healthcare provider about the condition. Implications are discussed for leveraging telehealth solutions, such as conversational agents (ie, chatbots), to disseminate COPD screening assessments and alleviate its underdiagnosis.

Trial registration

not applicable

The information needs of people with COPD-The holistic approach with special reference to gender and time since diagnosis

AIMS

The aim of this study was to determine what kinds of unmet information needs people with COPD have and whether there are differences in information needs between genders or based on the time since COPD diagnosis.

DESIGN

A descriptive cross-sectional study.

METHODS

Data on people with COPD (N = 169) were collected from a two-part questionnaire distributed via website. On the first part, information needs concerning the medical aspects of self-management were measured by the Lung Information Needs Questionnaire (LINQ). On the second part, which was developed specifically for this study, a more holistic view of self-management counselling was sought. Statistical methods were used to analyse the data.

RESULTS

The respondents had wide-ranging information needs in many areas of COPD self-management. The most often reported areas of unmet information needs included exacerbations, diet, fatigue, stress and anxiety, palliative care and sexual life. The information needs varied by gender and time since COPD diagnosis.

Micro-phenomenological approach to explore the patient experience during an initial spirometry examination to diagnose COPD in general practice in France

OBJECTIVES

To explore the patient experience of a spirometry test used to confirm chronic obstructive pulmonary disease (COPD) diagnosis in patients with suspected smoking-related COPD.

DESIGN

This is a qualitative study, performed with open interviews in adults following a routine spirometry test to confirm COPD diagnosis. Data were analysed with a phenomenological-inspired micro-phenomenology approach.

PARTICIPANTS

Eligible patients were recruited through their general practitioner, 10 were interviewed.

SETTING

Primary care in Centre-Val-De-Loire area, France, in 2018.

RESULTS

Participants reported the spirometry test experience as being unfamiliar but gave meaning to the symptoms they experience. Participants expressed a desire to perform the test well and a willingness to confront their state of health. After the spirometry had been completed and the results announced, participants moved through stages of grief from their pre-spirometry self and symptom perception to a state of acceptance. Overall, participants expressed a narrative of an evolving cognitive and corporeal awareness during this spirometry experience. The verbatim quotes describe a cognitive rupture with their chronic illness usually considered as a 'way of life'.

CONCLUSIONS

A spirometry test goes beyond a diagnostic value, providing patients with an opportunity to gain awareness of their own state of health, reframe their breathlessness-related limitations and thus begin to accept the disease. These awareness gains may be considered as small steps towards health behavioural change. Spirometry may have educative potential and support lifestyle changes.

Stigma Experiences in People with Chronic Obstructive Pulmonary Disease: An Integrative Review

Background

People with chronic obstructive pulmonary disease (COPD) are stigmatized by smoking history. Although little is known about COPD-related stigma, it can adversely affect self-management and quality of life.

Objective

To synthesize relevant scientific literature exploring stigma experiences and their impacts on people with COPD.

Methods

CINAHL/PsycINFO/PubMed/Scopus were searched for relevant studies. Findings were organized using Major et al’s conceptual model.

Results

Fifteen studies documented COPD-related stigma processes: enacted, felt, internalized, and anticipated. Moderating factors included visibility, origin, and illness perception. Individual-level stigma responses included emotional distress, limited social interactions, and negative effects on medication adherence and help-seeking. Social/community-level stigma experiences included healthcare provider and employer behaviors. Smoking is interwoven throughout all domains of stigma processes and responses to stigma.

Conclusion

Substantial evidence documents processes, moderating factors, and individual and social/community responses to the complex phenomenon of COPD-related stigma; however, prevalence of COPD-related stigma and its health effects are unclear.

Mirror of shame: Patients experiences of late-stage COPD. A qualitative study

AIMS AND OBJECTIVES

This study aims to shed light on patients with late-stage COPD and their experiences of shame.

BACKGROUND

Patients with COPD often experience shame for bringing the disease into their lives due to smoking. Knowledge about patients with COPD and their feelings of shame is crucial, but limited, however.

DESIGN

The study has a qualitative and explorative design. We interviewed twelve patients with late-stage COPD. The data were analysed using Kvale and Brinkmann's three interpretative contexts. The COREQ checklist was used.

RESULTS

Three main themes were defined; the body as a mirror of shame; a sense of being unworthy, invisible and powerless; and that sharing the burden is too difficult. The participants experienced that the disease defined their value as human beings and that made them feel vulnerable, ashamed and more socially isolated.

CONCLUSIONS

The participants experienced feelings of shame, guilt and self-blame due to their own perceptions of themselves. They were in doubt about whether they were worthy to receive care and comfort from both health professionals and, their family and friends. The participants seemed to have internalised the moral norms of contemporary society and the understanding that the disease, and especially a 'self-inflicted' disease, is a personal weakness.

RELEVANCE FOR CLINICAL PRACTICE

Findings from this study show that patients struggle with feelings such as shame and misery. The nurses who work bedside are in continuous contact with the patients and have an opportunity to gain knowledge of these feelings in order to meet the patients' needs for comfort and care. They have an obligation to ask patients about their feelings and meet them with empathy and respect. Moreover, it is necessary to have interdisciplinary fora in clinical practice where health professionals reflect, discuss and challenge themselves according to attitudes towards patients with so-called 'self-inflicted' diseases.

Consensus document on the management preferences of patients with ulcerative colitis: points to consider and recommendations

BACKGROUND AND AIMS

Our objective was to define, describe and organize (on the basis of consensus) the patient's preferences in the management of ulcerative colitis (UC), in order to further incorporate them in daily practice and improve patients satisfaction, adherence to the treatment and quality of care.

METHODS

Qualitative study. A narrative literature review in Medline using Mesh and free-text terms was conducted to identify articles on UC patient preferences as well as clinical scenarios that may influence the preferences. The results were presented and discussed in a multidisciplinary nominal group meeting composed of six gastroenterologists, one primary care physician, one nurse practitioner and one expert patient. Key clinical scenarios and patient preferences were then defined, generating a series of points to consider and recommendations. The level of agreement with the final selection of preferences was established following a Delphi process.

RESULTS

The narrative review retrieved 69 articles of qualitative design and moderate quality. The following key clinical scenarios were identified: diagnosis, follow-up, surgery, and special situations/patients profiles such as adolescents or women. Patient preferences were classified into information, treatment (pharmacological and non-pharmacological), follow-up, relations with health professionals, relations with the health system and administration. Finally, 11 recommendations on patient preferences for UC in relation to its management reached the level of agreement established.

CONCLUSION

The consensual description of patient's preferences contribute to identify different areas for improvement in healthcare practice.

COPD patients need more information about self-management: a cross-sectional study in Swedish primary care

Objective: In Sweden, patients with chronic conditions, such as chronic obstructive pulmonary disease (COPD), often receive education at specialized nurse-led clinics at primary health care centers (PHCCs). Identifying patients' needs for information about COPD is the key to individualized care. This study aimed to assess self-reported needs for information about COPD in primary care patients with either moderate (GOLD 2) or severe (GOLD 3) COPD and identify patient characteristics and exacerbation patterns associated with the findings.Design: A cross-sectional study.Setting: Twenty-four PHCCs in Stockholm, Sweden.Subjects: Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 542).Main outcome measures: The Lung Information Needs Questionnaire (LINQ) was used to assess perceived information needs. Spirometry results and descriptive, self-reported data on patient factors such as exacerbation history, treatment, smoking, weight/height, comorbidities, health care contacts, education and symptoms were collected.Results: Overall, the greatest reported needs were for information about self-management and diet. GOLD 2 patients (68%) expressed greater needs for information than GOLD 3 patients (32%). We found significant associations between high information needs and patient-related factors such as 'No assigned GP' (OR = 4.32 [95% CI 2.65-7.05]) and 'No contact with COPD nurse in the past 12 months' (OR = 1.83 [95% CI 1.19-2.81]).Conclusion: COPD patients felt they knew too little about self-management of their disease. Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. These associations were strongest in patients with moderate COPD.Key points: As patients with COPD often have multimorbidity, identifying patients' needs for information about COPD is essential to providing individualized patient education and care. In this study of 542 patients from 24 Swedish primary care centers, we found that:Patients with COPD, particularly those with moderate airflow limitation (i.e. GOLD 2) felt they needed more information about COPD than currently provided by health care professionals in primary care.Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. GPs' part in COPD patient education should not be overlooked, as individualized COPD care relies on GPs' expertise in managing patients with multimorbidity.

Patients and informal caregivers' experiences of burden of treatment in lung cancer and chronic obstructive pulmonary disease (COPD): a systematic review and synthesis of qualitative research

OBJECTIVE

To identify, characterise and explain common and specific features of the experience of treatment burden in relation to patients living with lung cancer or chronic obstructive pulmonary disease (COPD) and their informal caregivers.

DESIGN

Systematic review and interpretative synthesis of primary qualitative studies. Papers were analysed using constant comparison and directed qualitative content analysis.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science searched from January 2006 to December 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary qualitative studies in English where participants were patients with lung cancer or COPD and/or their informal caregivers, aged >18 years that contain descriptions of experiences of interacting with health or social care in Europe, North America and Australia.

RESULTS

We identified 127 articles with 1769 patients and 491 informal caregivers. Patients, informal caregivers and healthcare professionals (HCPs) acknowledged lung cancer's existential threat. Managing treatment workload was a priority in this condition, characterised by a short illness trajectory. Treatment workload was generally well supported by an immediacy of access to healthcare systems and a clear treatment pathway. Conversely, patients, informal caregivers and HCPs typically did not recognise or understand COPD. Treatment workload was balanced with the demands of everyday life throughout a characteristically long illness trajectory. Consequently, treatment workload was complicated by difficulties of access to, and navigation of, healthcare systems, and a fragmented treatment pathway. In both conditions, patients' capacity to manage workload was enhanced by the support of family and friends, peers and HCPs and diminished by illness/smoking-related stigma and social isolation.

CONCLUSION

This interpretative synthesis has affirmed significant differences in treatment workload between lung cancer and COPD. It has demonstrated the importance of the capacity patients have to manage their workload in both conditions. This suggests a workload which exceeds capacity may be a primary driver of treatment burden.

PROSPERO REGISTRATION NUMBER

CRD42016048191.

Expert recommendations on the psychological needs of patients with rheumatoid arthritis

OBJECTIVE

To establish feasible and practical recommendations for the management of the psychological needs of patients with rheumatoid arthritis (RA) from the moment of diagnosis through the course of the disease.

METHODS

A nominal group meeting was held with an RA expert team including rheumatologists and psychologists, at which a guided discussion addressed the most important psychological and emotional needs in RA. Based on the comments collected, and a literature review, a matrix document of recommendations for telematics discussion was prepared, as well as a Delphi survey to test agreement with these recommendations. Agreement was defined if at least 80% of participants voted ≥ 7 (from 1, totally disagree to 10, totally agree). For each recommendation, the level of evidence and grading of recommendations was established following the Oxford criteria, and the degree of agreement through the Delphi.

RESULTS

Thirteen recommendations were established, addressing several key processes: (1) identification of psychological problems and needs in patients with RA, and a guideline for their management in daily practice; (2) communication with patients; (3) referral criteria to mental health professionals.

CONCLUSIONS

These recommendations are intended to help health care professionals openly address the psychological aspects of patients in daily practice to follow and treat them properly.

Support needs of patients with COPD: a systematic literature search and narrative review

Introduction

Understanding the breadth of patients’ support needs is important for the delivery of person-centered care, particularly in progressive long-term conditions such as chronic obstructive pulmonary disease (COPD). Existing reviews identify important aspects of managing life with COPD with which patients may need support (support needs); however, none of these comprehensively outlines the full range of support needs that patients can experience. We therefore sought to systematically determine the full range of support needs for patients with COPD to inform development of an evidence-based tool to enable person-centered care.

Methods

We conducted a systematic search and narrative review of the literature. Medline (Ovid), EMBASE, PsycINFO, Cochrane Library, and CINAHL were systematically searched for papers which included data addressing key aspects of support need, as identified by patients with COPD. Relevant data were extracted, and a narrative analysis was conducted.

Results

Thirty-one papers were included in the review, and the following 13 domains (broad areas) of support need were identified: 1) understanding COPD, 2) managing symptoms and medication, 3) healthy lifestyle, 4) managing feelings and worries, 5) living positively with COPD, 6) thinking about the future, 7) anxiety and depression, 8) practical support, 9) finance work and housing, 10) families and close relationships, 11) social and recreational life, 12) independence, and 13) navigating services. These 13 domains of support need were mapped to three of the four overarching categories of need commonly used in relevant national strategy documents (ie, physical, psychological, and social); however, support needs related to the fourth category (spiritual) were notably absent.

Conclusion

This review systematically identifies the comprehensive set of domains of support need for patients with COPD. The findings provide the evidence base for a tool to help patients identify and express their support needs, which underpins a proposed intervention to enable the delivery of person-centered care: the Support Needs Approach for Patients (SNAP).

Patients and families realising their future with chronic obstructive pulmonary disease-A qualitative study

AIMS AND OBJECTIVES

To gain insight into the lived experience of learning about having chronic obstructive pulmonary disease for patients and their families.

BACKGROUND

Chronic obstructive pulmonary disease often progresses for years. Adjustment to declining health is gradual, and the disease may have developed considerably when health care is sought and people are diagnosed. Reaching patients at early stages is necessary to delay progression of the disease.

DESIGN

Interpretive phenomenology.

METHODS

Data were collected in four family focus group interviews (N = 37) and a subsample of eight family-dyad interviews. Patients were eight men, and 14 women aged 51-68 years. Majority of the patients (n = 19) were at GOLD grades II and III, with three at grade IV. The family members were eight men, and seven women aged 29-73 years. Data were collected between June-November 2012.

RESULTS

Five, not mutually exclusive themes, revealed a long and arduous process of learning about and becoming diagnosed with chronic obstructive pulmonary disease and how unaware participants were of the imminent threat that the disease imposes on life. The themes were as follows: burden of shame and self-blame, enclosed in addiction, living in parallel worlds, realising the existence of the disease and a cry for empathy.

CONCLUSIONS

Learning about and realising the existence of chronic obstructive pulmonary disease and what it entails at present time and in the future was bleak for the participants. The patients tended to put aside the thought of being a person with chronic obstructive pulmonary disease and defer actions that might halter progression of the disease, particularly to quit smoking.

RELEVANCE TO CLINICAL PRACTICE

Individuals and families need support early in the disease process to realise and accept the existence of chronic obstructive pulmonary disease and particularly to deal with the challenges that nicotine addiction, shame and self-blame present. Increased public awareness about this enormous, but hidden, health problem is necessary.

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.

Exploring self-conscious emotions in individuals with chronic obstructive pulmonary disease

This study aimed to explore the extent to which self-conscious emotions are expressed, to explore any associations with adverse health outcomes, and to compare self-conscious emotions in individuals with chronic obstructive pulmonary disease (COPD) to healthy controls. A two-stage mixed-methods study design was employed. Interviews with 15 individuals with COPD informed the choice of questionnaires to assess self-conscious emotions which were completed by individuals with COPD and healthy controls. Five overarching themes were abstracted: grief, spectrum of blame, concern about the view of others, concealment, and worry about the future. The questionnaires were completed by 70 patients (mean( SD) age 70.8(9.4) years, forced expiratory volume in one second predicted 40.5(18.8), 44% male) and 61 healthy controls (mean( SD) age 62.2(12.9) years, 34% male]. Self-conscious emotions were associated with reduced mastery, heightened emotions, and elevated anxiety and depression (all p < 0.001). Individuals with COPD reported lower self-compassion, higher shame, and less pride than healthy controls (all p ≤ 0.01). There is a need to increase awareness of self-conscious emotions in individuals with COPD. Therapies to target such emotions may improve mastery, emotions, and psychological symptoms.

Identifying cases of undiagnosed, clinically significant COPD in primary care: qualitative insight from patients in the target population

Background:

Many cases of chronic obstructive pulmonary disease (COPD) are diagnosed only after significant loss of lung function or during exacerbations.

Aims:

This study is part of a multi-method approach to develop a new screening instrument for identifying undiagnosed, clinically significant COPD in primary care.

Methods:

Subjects with varied histories of COPD diagnosis, risk factors and history of exacerbations were recruited through five US clinics (four pulmonary, one primary care). Phase I: Eight focus groups and six telephone interviews were conducted to elicit descriptions of risk factors for COPD, recent or historical acute respiratory events, and symptoms to inform the development of candidate items for the new questionnaire. Phase II: A new cohort of subjects participated in cognitive interviews to assess and modify candidate items. Two peak expiratory flow (PEF) devices (electronic, manual) were assessed for use in screening.

Results:

Of 77 subjects, 50 participated in Phase I and 27 in Phase II. Six themes informed item development: exposure (smoking, second-hand smoke); health history (family history of lung problems, recurrent chest infections); recent history of respiratory events (clinic visits, hospitalisations); symptoms (respiratory, non-respiratory); impact (activity limitations); and attribution (age, obesity). PEF devices were rated easy to use; electronic values were significantly higher than manual (P<0.0001). Revisions were made to the draft items on the basis of cognitive interviews.

Conclusions:

Forty-eight candidate items are ready for quantitative testing to select the best, smallest set of questions that, together with PEF, can efficiently identify patients in need of diagnostic evaluation for clinically significant COPD.