1
|
van Dijk SHB, Brusse-Keizer MGJ, Effing T, van der Valk PDLPM, Ploumen EH, van der Palen J, Doggen CJM, Lenferink A. Exploring Patterns of COPD Exacerbations and Comorbid Flare-Ups. Int J Chron Obstruct Pulmon Dis 2023; 18:2633-2644. [PMID: 38022827 PMCID: PMC10657781 DOI: 10.2147/copd.s428960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Comorbidities are known to complicate disease management in patients with Chronic Obstructive Pulmonary Disease (COPD). This is partly due to lack of insight into the interplay of acute exacerbations of COPD (AECOPD) and comorbid flare-ups. This study aimed to explore patterns of AECOPDs and comorbid flare-ups. Methods Data of increased symptoms were extracted from a 12-month daily symptom follow-up database including patients with COPD and comorbidities (chronic heart failure (CHF), anxiety, depression) and transformed to visualizations of AECOPDs and comorbid flare-up patterns over time. Patterns were subsequently categorized using an inductive approach, based on both predominance (ie, which occurs most often) of AECOPDs or comorbid flare-ups, and their simultaneous (ie, simultaneous start in ≥ 50%) occurrence. Results We included 48 COPD patients (68 ± 9 years; comorbid CHF: 52%, anxiety: 40%, depression: 38%). In 25 patients with AECOPDs and CHF flare-ups, the following patterns were identified: AECOPDs predominant (n = 14), CHF flare-ups predominant (n = 5), AECOPDs nor CHF flare-ups predominant (n = 6). Of the 24 patients with AECOPDs and anxiety and/or depression flare-ups, anxiety and depression flare-ups occurred simultaneously in 15 patients. In 9 of these 24 patients, anxiety or depression flare-ups were observed independently from each other. In 31 of the included 48 patients, AECOPDs and comorbid flare-ups occurred mostly simultaneously. Conclusion Patients with COPD and common comorbidities show a variety of patterns of AECOPDs and comorbid flare-ups. Some patients, however, show repetitive patterns that could potentially be used to improve personalized disease management, if recognized.
Collapse
Affiliation(s)
- Sanne H B van Dijk
- Health Technology & Services Research, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marjolein G J Brusse-Keizer
- Health Technology & Services Research, TechMed Centre, University of Twente, Enschede, the Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Tanja Effing
- College of Medicine and Public Health, School of Medicine, Flinders University, Adelaide, Australia
- School of Psychology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | | | - Eline H Ploumen
- Health Technology & Services Research, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
- Cognition, Data & Education, BMS Faculty, University of Twente, Enschede, the Netherlands
| | - Carine J M Doggen
- Health Technology & Services Research, TechMed Centre, University of Twente, Enschede, the Netherlands
- Clinical Research Centre, Rijnstate Hospital, Arnhem, the Netherlands
| | - Anke Lenferink
- Health Technology & Services Research, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
- Clinical Research Centre, Rijnstate Hospital, Arnhem, the Netherlands
| |
Collapse
|
2
|
Lenferink A, van der Palen J, van der Valk PDLPM, Burt MG, Frith PA, Brusse-Keizer MGJ, Effing TW. It is time to further expand research in tailoring self-management of COPD exacerbations! Eur Respir J 2020; 55:55/1/1902225. [PMID: 31974121 DOI: 10.1183/13993003.02225-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/24/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Anke Lenferink
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands .,Dept of Health Technology and Services Research, Faculty of Behavioural, Management and Social sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Job van der Palen
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands.,Dept of Research Methodology, Measurement, and Data-Analysis, Faculty of Behavioural, Management and Social sciences, University of Twente, Enschede, The Netherlands
| | | | - Morton G Burt
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
| | - Peter A Frith
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Tanja W Effing
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| |
Collapse
|
3
|
Lenferink A, van der Palen J, van der Valk PDLPM, Cafarella P, van Veen A, Quinn S, Groothuis-Oudshoorn CGM, Burt MG, Young M, Frith PA, Effing TW. Exacerbation action plans for patients with COPD and comorbidities: a randomised controlled trial. Eur Respir J 2019; 54:13993003.02134-2018. [PMID: 31413163 DOI: 10.1183/13993003.02134-2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/22/2019] [Indexed: 11/05/2022]
Abstract
This international randomised controlled trial evaluated whether COPD patients with comorbidities, trained in using patient-tailored multidisease exacerbation action plans, had fewer COPD exacerbation days than usual care (UC).COPD patients (Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification II-IV) with ≥1 comorbidity (ischaemic heart disease, heart failure, diabetes, anxiety, depression) were randomised to a patient-tailored self-management intervention (n=102) or UC (n=99). Daily symptom diaries were completed for 12 months. The primary outcome "COPD exacerbation days per patient per year" was assessed using intention-to-treat analyses.No significant difference was observed in the number of COPD exacerbation days per patient per year (self-management: median 9.6 (interquartile range (IQR) 0.7-31.1); UC: median 15.6 (IQR 3.0-40.3); incidence rate ratio (IRR) 0.87 (95% CI 0.54; 1.39); p=0.546). There was a significantly shorter duration per COPD exacerbation for self-management (self-management: median 8.1 (IQR 4.8-10.1) days; UC: median 9.5 (IQR 7.0-15.1) days; p=0.021), with no between-group differences in the total number of respiratory hospitalisations (IRR 0.76 (95% CI 0.42; 1.35); p=0.348), but a lower probability of ≥1 for respiratory-related hospitalisation compared to UC (relative risk 0.55 (95% CI 0.35; 0.87); p=0.008). No between-group differences were observed in all-cause hospitalisations (IRR 1.07 (95% CI 0.66; 1.72)) or mortality (self-management: n=4 (3.9%); UC: n=7 (7.1%); relative risk 0.55 (95% CI 0.17; 1.84)).Patient-tailored exacerbation action plans for COPD patients with comorbidities did not significantly reduce exacerbation days, but reduced the duration per COPD exacerbation and the risk of having at least one respiratory-related hospitalisation during follow-up, without excess all-cause mortality.
Collapse
Affiliation(s)
- Anke Lenferink
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands .,Dept of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Job van der Palen
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands.,Dept of Research Methodology, Measurement, and Data-Analysis, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | | | - Paul Cafarella
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Dept of Respiratory Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Anneke van Veen
- Dept of Pulmonary Medicine, Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Stephen Quinn
- Dept of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia
| | - Catharina G M Groothuis-Oudshoorn
- Dept of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Morton G Burt
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
| | - Mary Young
- Dept of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Frith
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Tanja W Effing
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Dept of Respiratory Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| |
Collapse
|
4
|
Effing TW, Lenferink A, Buckman J, Spicer D, Cafarella PA, Burt MG, Bassett KL, van Ommeren C, Anesbury S, van der Valk PDLPM, Frith PA, van der Palen J. Development of a self-treatment approach for patients with COPD and comorbidities: an ongoing learning process. J Thorac Dis 2014; 6:1597-605. [PMID: 25478200 DOI: 10.3978/j.issn.2072-1439.2014.11.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 10/21/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Patient-initiated action plans are an important component of COPD self-management (SM) interventions. When integrated into SM interventions, these action plans have proven to be effective in reducing exacerbation severity, hospitalisations, and costs and in improving health status in patients with COPD without severe comorbidities. Because of overlap in symptoms, a self-treatment (ST) approach that focuses solely on traditional symptoms of COPD is inadequate for patients with COPD and comorbidities. The COPE-III SM intervention combines (I) patient-initiated action plans that are tailored to the individual's co-morbid disease(s), and (II) ongoing nurse support. In this paper we provide information regarding the integration of information from two previous COPD SM studies (COPE I and II) in the development of the current COPE-III ST approach. MATERIALS AND METHODS COPE-III ST materials include daily symptom diaries and action plans that take patient's common comorbidities [chronic heart failure (CHF), anxiety, depression, ischaemic heart disease (IHD), and diabetes] into account. The comorbid diary and action plans components were developed in collaboration with multiple disease-experts. RESULTS Previous SM studies have highlighted some essential topics that need to be considered when developing a SM or ST approach: 'when to initiate ST', 'how to optimize materials and safety', and 'how to achieve behavioural change'. In the COPE-III study, ST is initiated after a significant change in symptoms. This is consistent with the COPE-II approach and was implemented because disease symptoms are often present even when patients are stable. We have tried to ensure patient safety by providing an easily accessible case-manager to patients throughout their involvement in the study. Furthermore, a psychologist has ensured the use of behavioural change techniques throughout the intervention. CONCLUSIONS We should continue to learn from our experiences with SM interventions to further optimize future SM and ST interventions. The use of materials that are suitable for different levels of patient literacy and the training of health care providers are other points of improvement.
Collapse
Affiliation(s)
- Tanja W Effing
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Anke Lenferink
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Julie Buckman
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Deborah Spicer
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Paul A Cafarella
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Morton G Burt
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Katherine L Bassett
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Clara van Ommeren
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Sally Anesbury
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Paul D L P M van der Valk
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Peter A Frith
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| | - Job van der Palen
- 1 Department of Respiratory Medicine, Southern Adelaide Local Health Network, South Australia, Australia ; 2 Flinders University, School of Medicine, Adelaide, South Australia, Australia ; 3 Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands ; 4 Southern Adelaide Local Health Network, South Australia, Australia ; 5 Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, South Australia, Australia ; 6 Department of Research Methodology, University of Twente, Measurement and Data Analysis, Enschede, the Netherlands
| |
Collapse
|
7
|
Effing TW, Kerstjens HAM, Monninkhof EM, van der Valk PDLPM, Wouters EFM, Postma DS, Zielhuis GA, van der Palen J. Definitions of exacerbations: does it really matter in clinical trials on COPD? Chest 2009; 136:918-923. [PMID: 19736196 DOI: 10.1378/chest.08-1680] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Many definitions of COPD exacerbations are reported. The choice for a definition determines the number of exacerbations observed. However, the effect of different definitions on the effect sizes of randomized controlled trials is unclear. This article provides an overview of the large variation of definitions of COPD exacerbations from the literature. Furthermore, the effect of using different definitions on effect sizes (relative risk and hazard ratio) was investigated in a randomized controlled discontinuation trial of inhaled corticosteroids. The following definitions were applied: (1) unscheduled medical attention, (2) a course of oral corticosteroids/antibiotics, (3) deterioration in two major or one major and one minor symptom according to Anthonisen (referenced later), (4) a change in one or more symptoms, (5) a change in two or more symptoms, and (6) a combination of numbers 2 and 4. Relative risks for the exacerbation rate ranged from 1.19 to 1.49, and hazard ratios for time to first exacerbation ranged from 1.36 to 1.84 for the various definitions, varying from nonsignificant to significant. Because the definition of a COPD exacerbation has an impact on the effect size of interventions, there is an urgent need for concerted attempts to reach agreement on a definition of an exacerbation. Also, the exact definition to be used in a study should be specified in the protocol.
Collapse
Affiliation(s)
- Tanja W Effing
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Huib A M Kerstjens
- University Medical Center Groningen and the Department of Pulmonology, University of Groningen, Groningen, the Netherlands
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Emiel F M Wouters
- Department of Respiratory Medicine, University Hospital Maastricht, Maastricht, the Netherlands
| | - Dirkje S Postma
- University Medical Center Groningen and the Department of Pulmonology, University of Groningen, Groningen, the Netherlands
| | - Gerhard A Zielhuis
- Department of Epidemiology, Biostatistics, and HTA, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - Job van der Palen
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, the Netherlands; Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, the Netherlands
| |
Collapse
|