David Coultas

Self-management programmes for COPD: moving forward

Self-management is of increasing importance in chronic obstructive pulmonary disease (COPD) management. However, there is confusion over what processes are involved, how the value of self-management should be determined, and about the research priorities. To gain more insight into and agreement about the content of programmes, outcomes, and future directions of COPD self-management, a group of interested researchers and physicians, all of whom had previously published on this subject and who had previously collaborated on other projects, convened a workshop. This article summarises their initial findings. Self-management programmes aim at structural behaviour change to sustain treatment effects after programmes have been completed. The programmes should include techniques aimed at behavioural change, be tailored individually, take the patient’s perspective into account, and may vary with the course of the patient’s disease and co-morbidities. Assessment should include process variables. This report is a step towards greater conformity in the field of self-management. To enhance clarity regarding effectiveness, future studies should clearly describe their intervention, be properly designed and powered, and include outcomes that focus more on the acquisition and practice of new skills. In this way more evidence and a better comprehension on self-management programmes will be obtained, and more specific formulation of guidelines on self-management made possible.

Predictors of Depressive Symptoms in Patients with COPD and Health Impact

While depression is a common co-morbid condition among patients with COPD, little is known about predictors or health impact of depression among these patients. To address these gaps in knowledge we conducted a cross-sectional survey of 207 patients with COPD cared for in a network of primary care clinics affiliated with an urban academic health center. A standardized questionnaire was used to measure demographic characteristics, smoking status, co-morbid medical conditions, current medications, self-efficacy, social support, illness intrusiveness, and self-reported health care utilization during the previous 6 months. Depressive symptoms were assessed using the Centers for Epidemiologic Studies-Depression scale. Overall, the prevalence of moderate to high levels of depressive symptoms was 60.4%. In a multivariate analysis independent predictors of depressive symptoms were being a former smoker (OR = 0.41 (95% CI 0.19–0.89)), higher self-efficacy (OR = 0.42 (0.28–0.64)), higher social support (OR = 0.72 (0.52–0.99)), and higher perceived illness intrusiveness (OR = 1.05 (1.02–1.08)). Depressive symptoms were associated with increased physician visits, emergency room visits, and hospitalizations for lung disease. In conclusion, depressive symptoms are common among patients with COPD and associated with an increase in healthcare utilization. These findings suggest that the identification of risk factors for depressive symptoms (e.g., continued smoking) may increase detection and improve management of depression and health outcomes among patients with COPD.

Definition of a COPD self-management intervention: International Expert Group consensus

There is an urgent need for consensus on what defines a chronic obstructive pulmonary disease (COPD) self-management intervention. We aimed to obtain consensus regarding the conceptual definition of a COPD self-management intervention by engaging an international panel of COPD self-management experts using Delphi technique features and an additional group meeting. In each consensus round the experts were asked to provide feedback on the proposed definition and to score their level of agreement (1=totally disagree; 5=totally agree). The information provided was used to modify the definition for the next consensus round. Thematic analysis was used for free text responses and descriptive statistics were used for agreement scores. In total, 28 experts participated. The consensus round response rate varied randomly over the five rounds (ranging from 48% (n=13) to 85% (n=23)), and mean definition agreement scores increased from 3.8 (round 1) to 4.8 (round 5) with an increasing percentage of experts allocating the highest score of 5 (round 1: 14% (n=3); round 5: 83% (n=19)). In this study we reached consensus regarding a conceptual definition of what should be a COPD self-management intervention, clarifying the requisites for such an intervention. Operationalisation of this conceptual definition in the near future will be an essential next step. Consensus of a conceptual definition of what should be a COPD self-management intervention with its requisites http://ow.ly/Zfr0F

Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis

It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective. Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models. 14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97–0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92–0.99; RR after 12 months follow-up 0.98, 95% CI 0.96–1.00). Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes. Increasing duration of self-management interventions reduces risk of all-cause hospitalisations in patients with COPD http://ow.ly/YVw9E

Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis

Background Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most. Methods Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models. Results Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes. Conclusion Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.

Rural-urban disparities in quality of life among patients with COPD.

PURPOSE Limited evidence in the United States suggests that among patients with chronic obstructive pulmonary disease (COPD), rural residence is associated with higher hospitalization rates and increased mortality. However, little is known about the reasons for these disparities. This studys purpose was to describe the health status of rural versus urban residence among patients with COPD and to examine factors associated with differences between these 2 locations. METHODS This was a cross-sectional study of baseline data from a representative sample of patients with COPD enrolled in a clinical trial. Rural-urban residence was determined from ZIP code. Health status was measured using the SF-12 and health care utilization. Independent sample t-tests, chi-square tests, and multiple linear and logistic regressions were performed to examine differences between rural and urban patients. FINDINGS Rural residence was associated with poorer health status and higher health care utilization. Among rural patients unadjusted physical functioning scores were lower on the SF-12 (30.22 vs 33.49; P = .005) that persisted after adjustment for potential confounders (β = -2.35; P = .04). However, after further adjustment for social and psychological factors only the body-mass index, airflow obstruction, dyspnea, and exercise (BODE) index was significantly associated with health status. CONCLUSIONS In this representative sample of patients with COPD rural residence was associated with worse health status, primarily associated with greater impairment as measured by BODE index. While rural patients reported a higher dose of smoking, a number of other unmeasured factors associated with rural residence may contribute to these disparities.

A randomized trial comparing 2 types of in-home rehabilitation for chronic obstructive pulmonary disease: a pilot study.

Background:Pulmonary rehabilitation has been shown to be effective for improving quality of life and function in patients with chronic obstructive pulmonary disease (COPD) but has not been studied extensively in homebound patients. Furthermore, little is known about the effectiveness of specific types of home-based interventions. Purpose:The purpose of this study was to examine the effectiveness of in-home rehabilitation programs for individuals with COPD considered homebound according to Medicare definition and to compare outcomes of 2 different rehabilitation interventions. Methods:Patients were randomly assigned to 2 home-based interventions including aerobic conditioning (group A) or functional strength training (group B), which were conducted over 8 weeks. In addition, all patients received COPD self-management education. Outcome measures were collected after completion of the intervention and after 16 weeks and included the Chronic Respiratory Questionnaire (CRQ), Geriatric Depression Scale, and 2-minute walk test. Results:Of 41 patients enrolled, 24 completed the 8-week intervention. On average, all CRQ quality-of-life domains improved in both groups, with the largest improvements in the CRQ-dyspnea domain. Overall, at 16 weeks, 80% of group A and 71% of group B patients had clinically significant improvements in the CRQ-dyspnea domain. Furthermore, depression scores improved in both groups. Only group A had a clinically significant improvement in walking distance. Conclusion:The results of this pilot study suggest that both forms of home-based rehabilitation may improve disease-specific quality of life in homebound patients with COPD.

Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial (COPD-SMART): Results of Recruitment and Baseline Patient Characteristics

OBJECTIVE To describe the recruitment methods, study participation rate, and baseline characteristics of a representative sample of outpatients with COPD eligible for pulmonary rehabilitation participating in a trial of a lifestyle behavioral intervention to increase physical activity. SETTING AND DESIGN A patient registry was developed for recruitment using an administrative database from primary care and specialty clinics of an academic medical center in northeast Texas for a parallel group randomized trial. RESULTS The registry was comprised of 5582 patients and over the course of the 30 month recruitment period 325 patients were enrolled for an overall study participation rate of 35.1%. After a 6-week COPD self-management education period provided to all enrolled patients, 305 patients were randomized into either usual care (UC; n=156) or the physical activity self-management intervention (PASM; n=149). There were no clinically significant differences in demographics, clinical characteristics, or health status indicators between the randomized groups. CONCLUSION The results of this recruitment process demonstrate the successful use of a patient registry for enrolling a representative sample of outpatients eligible for pulmonary rehabilitation with COPD from primary and specialty care. Moreover, this approach to patient recruitment provides a model for future studies utilizing administrative databases and electronic health records.

A Lifestyle Physical Activity Intervention for Patients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial

RATIONALE Physical inactivity is associated with poor outcomes among patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine effectiveness of a behavioral intervention intended to increase daily physical activity with the goal of improving health-related quality of life and functional performance. METHODS We conducted a randomized trial among patients with COPD cared for in primary care and pulmonary clinics. The patients were at least 45 years of age and eligible for pulmonary rehabilitation. All patients received self-management education during a 6-week run-in period. Subsequently, patients were randomized to usual care or the intervention delivered over 20 weeks. MEASUREMENTS AND MAIN RESULTS Co-primary outcomes were change from baseline in Chronic Respiratory Questionnaire dyspnea domain score and 6-minute-walk distance measured at 6, 12, and 18 months after randomization. A total of 325 patients were enrolled, with 156 randomized to receive usual care and 149 to receive the intervention. At 18 months, there was no overall statistical or clinically significant change in the dyspnea domain in either group. However, for 6-minute-walk distance, there were statistically significant declines in both groups. In contrast, 6-minute-walk distance remained stable (5.3 m; P = 0.54) among patients in the intervention group with moderate spirometric impairment, but it was associated with clinically and statistically significant declines (-28.7 m; P = 0.0001) among usual care patients with moderate spirometric impairment. Overall, there was no increase in adverse events associated with the intervention, which was associated with a lower prevalence of hospitalization for COPD exacerbations (28.3%) compared with usual care (49.5%). CONCLUSIONS During this 18-month trial among outpatients with COPD, a health coach-based behavioral intervention did not improve scores in the dyspnea domain of the Chronic Respiratory Questionnaire or 6-minute-walk test distance. However, subgroup analyses suggested that there may be differential effects for specific outcomes that vary with severity of COPD. Specifically, benefits of this low-intensity intervention may be limited to 6-minute walk distance among patients with moderate spirometric impairment. Clinical trial registered with www.clinicaltrials.gov (NCT1108991).

Idiopathic pulmonary fibrosis: tracking the true occurrence is challenging

Tracking patterns of disease incidence and mortality is fundamental to disease control. The story of lung cancer is exemplary; the 20th century epidemic of lung cancer was first detected in western countries as mortality rates rose; initially it affected males more than females; and rates were not uniform across regions and between countries [1]. The epidemiological studies, motivated by the changing patterns of lung cancer occurrence, identified smoking, and occupational and environmental agents as causes of this highly fatal malignancy. Lung cancer mortality rates, which are very close to incidence rates because of the high case-fatality rate of lung cancer, and incidence rates, tracked through cancer registries, have now fallen in the USA and much of Europe in response to successful tobacco control and reduction of exposures to occupational and environmental carcinogens. In the example of lung cancer, tracking of occurrence is facilitated by the close correspondence of mortality with incidence, such that mortality is a reasonable index of occurrence, by the long standing surveillance of cancer through population-based cancer registries in many countries of Europe and much of the USA [2], and by improved diagnosis of lung cancer by increasingly accurate diagnostic methods. IPF is not “just” a rare disease: better diagnosis and reporting by clinicians of this fatal disease is needed http://ow.ly/P284a