Frances Early

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

Flicker Masking and Developmental Dyslexia

Recent studies have provided evidence that dyslexic children tend to show longer visual persistence than control children when presented with low-spatial-frequency grating stimuli. The possibility that this phenomenon might reflect an impairment of inhibitory Y-cell activity in the visual system of dyslexics has been investigated. A flicker masking technique was used to mask Y-cell activity selectively in a group of dyslexic boys and a group of age-matched controls. There were no overall differences in reaction times to the offsets of grating patterns of various spatial frequencies between the groups, and no differences between subgroups defined by age, degree of reading impairment, or any other criterion. The results show no evidence of abnormal Y-cell function in developmental dyslexia.

Mindfulness-based cognitive therapy in COPD: a cluster randomised controlled trial

A considerable proportion of patients with chronic obstructive pulmonary disease (COPD) entering pulmonary rehabilitation (PR) report psychological distress, which is often accompanied by poor physical health status. Mindfulness-based cognitive therapy (MBCT) has been shown to improve psychological and physical outcomes in other chronic diseases. We therefore evaluated the efficacy of MBCT as an add-on to a standard PR programme in COPD. COPD patients eligible for PR were cluster randomised to receive either an 8-week, group-based MBCT programme as an add-on to an 8-week PR programme (n=39), or PR alone (n=45). The primary outcomes of psychological distress and physical health status impairment were measured with the Hospital Anxiety and Depression Scale (HADS) and the COPD Assessment Test (CAT) before randomisation (T1), mid- (T2) and post-intervention (T3), and at 3 (T4) and 6 (T5) months’ follow-up . A statistically significant time×arm effect was found for the HADS (Cohens d=0.62, 95% CIs (d)=0.18–1.06, p=0.010). The treatment effect on the CAT failed to reach statistical significance (d=0.42, 95% CIs (d)=−0.06–0.90, p=0.061). MBCT showed a statistically significant and durable effect on psychological distress, indicating that MBCT may be an efficacious add-on to standard PR programmes in COPD. Mindfulness-based cognitive therapy: an efficacious add-on to PR programmes to reduce psychological distress in COPD http://ow.ly/9noC30hnlxr

Patient agenda setting in respiratory outpatients A randomized controlled trial

Soliciting a patient’s agenda (the reason for their visit, concerns and expectations) is fundamental to health care but if not done effectively outcomes can be adversely affected. Forms to help patients consider important issues prior to a consultation have been tested with mixed results. We hypothesized that using an agenda form would impact the extent to which patients felt their doctor discussed the issues that were important to them. Patients were randomized to receive an agenda form to complete whilst waiting or usual care. The primary outcome measure was the proportion of patients agreeing with the statement ‘My doctor discussed the issues that were important to me’ rated on a four-point scale. Secondary outcomes included other experience and satisfaction measures, consultation duration and patient confidence. There was no significant effect of agenda form use on primary or secondary outcomes. Post hoc exploratory analyses suggested possible differential effects for new compared to follow-up patients. There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. There is a need for greater understanding of what works for whom in supporting patients to get the most from their consultation.

P94 Patient Agenda Setting And Clinic Efficiency In Outpatients: An Individual Randomised Controlled Trial

Introduction Most patients have issues to raise in a consultation but may not actually raise them, adversely affecting the consultation outcome. Evidence suggests that methods to help patients consider their information needs before a consultation can increase satisfaction without increasing consultation length but there is a need to assess a wider range of outcome measures and to measure consultation length accurately. We studied the impact of a paper agenda form to prompt question asking in a respiratory outpatient clinic. The primary objective was to identify whether this increased agreement that “My doctor discussed the issues that were important to me”. Secondary endpoints included consultation length and post-consultation confidence to self-manage (0–10 scale). Method Patients were randomised to receive the agenda form or usual care by blocked randomization (block size 6), stratified by consultant. Patients receiving the form had a written brief inviting them to complete it in the waiting room. PROMs were collected post-consultation. Consultations were timed by an observer outside the room. As planned in the protocol, categorical data were analysed using Fisher’s exact test and continuous data were analysed using a t-test. Exploratory analyses to assess the effects of a number of factors used mixed model ANOVA. Abstract P94 Table 1 Analysis of primary and secondary outcomes measures Results Groups were well matched at baseline for age, gender and respiratory diagnosis. There was no significant effect of agenda form use on the primary or secondary endpoints (Table 1). Exploratory analyses identified that in new patients (but not in follow-up patients) the form was associated with shorter consultation length (LS mean=15.2 mins) than usual care (LS mean=21.3 mins) (p = 0.017) and with lower confidence to self-manage (LS mean=6.6) than usual care (LS mean=9.2) (p = 0.001). Conclusion There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. This resonates with reports from other more complex self-management interventions that have found unexpected detrimental effects in some patients. There is a need for greater understanding of what works for whom with regard to self-management support. It cannot be assumed that the impact will be universally beneficial at best or neutral at worst. Reference Trial reference: REC reference: 13/WA/0171

Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review

Pulmonary rehabilitation (PR) reduces the number and duration of hospital admissions and readmissions, and improves health-related quality of life in patients with COPD. Despite clinical guideline recommendations, under-referral and limited uptake to PR contribute to poor treatment access. We reviewed published literature on the effectiveness of interventions to improve referral to and uptake of PR in patients with COPD when compared to standard care, alternative interventions, or no intervention. The review followed recognized methods. Search terms included “pulmonary rehabilitation” AND “referral” OR “uptake” applied to MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BNI, Web of Science, and Cochrane Library up to January 2018. Titles, abstracts, and full papers were reviewed independently and quality appraised. The protocol was registered (PROSPERO # 2016:CRD42016043762). We screened 5,328 references. Fourteen papers met the inclusion criteria. Ten assessed referral and five assessed uptake (46,146 patients, 409 clinicians, 82 hospital departments, 122 general practices). One was a systematic review which assessed uptake. Designs, interventions, and scope of studies were diverse, often part of multifaceted evidence-based management of COPD. Examples included computer-based prompts at practice nurse review, patient information, clinician education, and financial incentives. Four studies reported statistically significant improvements in referral (range 3.5%–36%). Two studies reported statistically significant increases in uptake (range 18%–21.5%). Most studies had methodological and reporting limitations. Meta-analysis was not conducted due to heterogeneity of study designs. This review demonstrates the range of approaches aimed at increasing referral and uptake to PR but identifies limited evidence of effectiveness due to the heterogeneity and limitations of study designs. Research using robust methods with clear descriptions of intervention, setting, and target population is required to optimize access to PR across a range of settings.

Understanding influences on the uptake of pulmonary rehabilitation in the East of England: an Inclusive Design/mixed-methods study protocol

Introduction 1.2 million people in the UK have chronic obstructive pulmonary disease (COPD) that causes breathlessness, difficulty with daily activities, infections and hospitalisation. Pulmonary rehabilitation (PR), a programme of supervised exercise and education, is recommended for patients with COPD. However, only 1 in 10 of those who need it receive PR. Also, the UK National COPD Audit Programme concluded that the COPD treatment might not be accessible to people with disabilities. This paper applies an Inclusive Design approach to community-based PR service provisions. It aims to inform improvements to the PR service by identifying barriers to the uptake of PR in the COPD care journey in relation to patients’ capabilities that can affect their access to PR. Methods and analysis The protocol includes four steps. Step 1 will involve interviews with healthcare professionals and patients to gather insight into their experiences and produce a hierarchical task analysis of the COPD care journeys. Step 2 will estimate the service exclusion: the demand of every task on patients’ capabilities will be rated by predefined scales, and the proportion of the population excluded from the service will be estimated by an exclusion calculator. Step 3 will identify the challenges of the PR service; a framework analysis will guide the data analysis of the interviews and care journey. Step 4 will propose recommendations to help patients manage their COPD care informed by the challenges identified in step 3 and refine recommendations through interviews and focus groups. Ethics and dissemination The Cambridge Central Research Ethics Committee gave the study protocol a positive ethical opinion (17/EE/0136). Study results will be disseminated through peer-reviewed journals, conferences and the British Lung Foundation networks. They will also be fed into a Research for Patient Benefit project on increasing the referral and uptake of PR.

A case series of an off-the-shelf online health resource with integrated nurse coaching to support self-management in COPD

Background COPD has significant psychosocial impact. Self-management support improves quality of life, but programs are not universally available. IT-based self-management interventions can provide home-based support, but have mixed results. We conducted a case series of an off-the-shelf Internet-based health-promotion program, The Preventive Plan (TPP), coupled with nurse-coach support, which aimed to increase patient activation and provide self-management benefits. Materials and methods A total of 19 COPD patients were recruited, and 14 completed 3-month follow-up in two groups: groups 1 and 2 with more and less advanced COPD, respectively. Change in patient activation was determined with paired t-tests and Wilcoxon signed-rank tests. Benefits and user experience were explored in semistructured interviews, analyzed thematically. Results Only group 1 improved significantly in activation, from a lower baseline than group 2; group 1 also improved significantly in mastery and anxiety. Both groups felt significantly more informed about COPD and reported physical functioning improvements. Group 1 reported improvements in mood and confidence. Overall, group 2 reported fewer benefits than group 1. Both groups valued nurse-coach support; for group 1, it was more important than TPP in building confidence to self-manage. The design of TPP and lack of motivation to use IT were barriers to use, but disease severity and poor IT skills were not. Discussion Our findings demonstrate the feasibility of combining nurse-coach support aligned to an Internet-based health resource, TPP, in COPD and provide learning about the challenges of such an approach and the importance of the nurse-coach role.

Interventions to increase referral to and uptake of Pulmonary Rehabilitation programmes for people with Chronic Obstructive Pulmonary Disease (COPD): A systematic review

Introduction and objectives Pulmonary Rehabilitation (PR) reduces the number and duration of hospital admissions, readmissions and improves health-related quality of life, e.g. breathlessness and fatigue, in patients with COPD. Despite evidence, guidelines and quality standards, PR is significantly underutilised with under-referral (15% of normative need) and limited uptake ( We aimed to address the research question: How effective are interventions to improve referral to and uptake of exercise-based pulmonary rehabilitation programmes in patients with COPD when compared to standard care or no intervention? Methods Systematic review following recognised methods, including all published observational, interventional, qualitative and quantitative studies of interventions specifically intended to increase levels of referral and/or uptake of pulmonary rehabilitation in patients with COPD. Exclusion criteria: individual case studies, conference abstracts and opinion pieces. No date or language restrictions. Search terms included: ‘pulmonary rehabilitation’ AND ‘referral’ OR ‘uptake’ applied to MEDLINE, EMBASE, CINAHL, PsychINFO, ASSIA, BNI, Web of Science and Cochrane Library from inception to June 2016 supplemented by review of reference lists and citation search. Titles, abstracts and full papers were reviewed independently, quality appraised (using Cochrane Collaboration’s tool for RCTs and ROBINS-I, AMSTAR) and entered into summary tables. The protocol was registered (PROSPERO) and reported according to PRISMA guidelines. Results We screened 3217 references, from which 7 papers including 6345 patients and 22 clinicians met inclusion criteria. Most studies (n = 5) were UK based. Designs, interventions and scope of studies were diverse with interventions often part of multifaceted evidence based management of COPD. Examples included computer based prompts at practice nurse review, patient information, financial incentives. Most studies (n = 5) reported improvements in referral or uptake of PR (range 0% – 25% increase), however most had methodological limitations with risk of bias. Due to heterogeneity, studies were not considered combinable and meta-analysis was inappropriate. Conclusions There is limited evidence for the efficacy of interventions to increase referral and uptake of PR. Existing studies are diverse and further testing using robust methods in various populations and settings is required to optimise access to PR.

P45 Investigating the feasibility of an on-line health resource integrated with nurse coach support for those with advanced COPD

Background Self-management may improve health status in chronic disease. It is not routinely embedded into COPD care. Pulmonary rehabilitation provides behaviour change opportunities but is not available to all. Aims To test the feasibility of a combined intervention (online health resource ‘The Prevention Plan’ (TPP) with nurse coach support) with a key aim to identify impact on activation for self-management. Secondary outcomes of interest were health-related quality of life, emotional functioning, information needs and exercise capacity. Method 17 patients were recruited (FEV1 < 75% predicted (range 15–74, mean 38.01, SD 17.92). Hardware and internet access were provided. Patients had unlimited access to TPP, home visits, telephone contacts and email with the nurse coach. The nurse coach supported behaviour change through patient-led goal setting and techniques to enhance self-efficacy. Outcomes were followed up at 9–29 weeks (mean = 15) after joining the programme. Measures were patient activation (PAM), health-related quality of life (CRQ), anxiety and depression (HADS), information needs (LINQ) and GAIT test. Semi-structured interviews were conducted. Qualitative analysis is underway and results will be reported separately. Results Mean age was 61.4 years (range 46 to 79), 9 female, 8 male. 14 patients completed follow-up assessments. 1 patient withdrew due to illness and two were unable to complete follow-up. Statistically significant improvement was found for activation (p = 0.0035, t = 3.56, df = 13), CRQ-fatigue (p = 0.0427, t = 2.25, df = 13), anxiety (p = 0.0444, t = 2.22, df = 13), information needs (p = 0.0001, t = 6.09, df = 13). Conclusion The intervention supported patients to become more activated for self-management. Patients showed increased confidence to manage their condition and strengthening of belief that taking an active role in managing their COPD was important. Secondary benefits related to fatigue, anxiety and feeling more informed about COPD. Qualitative analysis will illuminate these findings and explore intervention factors that led to greatest benefit.