Frode Gallefoss

Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease

abstract Objective To determine whether a nurse led smoking cessation intervention affects smoking cessation rates in patients admitted for coronary heart disease. Design Randomised controlled trial. Setting Cardiac ward of a general hospital, Norway. Participants 240 smokers aged under 76 years admitted for myocardial infarction, unstable angina, or cardiac bypass surgery. 118 were randomly assigned to the intervention and 122 to usual care (control group). Intervention The intervention was based on a booklet and focused on fear arousal and prevention of relapses. The intervention was delivered by cardiac nurses without special training. The intervention was initiated in hospital, and the participants were contacted regularly for at least five months. Main outcome measure Smoking cessation rates at 12 months determined by self report and biochemical verification. Results 12 months after admission to hospital, 57% (n = 57/100)of patients in the intervention group and 37% (n = 44/118) in the control group had quit smoking (absolute risk reduction 20%, 95% confidence interval 6% to 33%). The number needed to treat to get one additional person who would quit was 5 (3 to 16). Assuming all dropouts relapsed at 12 months, the smoking cessation rates were 50% in the intervention group and 37% in the control group (absolute risk reduction 13%, 0% to 26%). Conclusion A smoking cessation programme delivered by cardiac nurses without special training, significantly reduced smoking rates in patients 12 months after admission to hospital for coronary heart disease.

The effects of patient education in COPD in a 1-year follow-up randomised, controlled trial

The aims were to explore the effects and health economic consequences of patient education in patients with COPD in a 12-month follow-up. Sixty-two patients with mild to moderate Chronic Obstructive Pulmonary Disease (COPD) were at our out-patient clinic randomly allocated to an intervention group or a control group. The intervention group participated in a 4h group patient education, followed by one to two individual nurse- and physiotherapist-sessions. Self-management was emphasised following a stepwise treatment plan. Effectiveness was expressed in terms of number of general practitioner (GP) consultations, proportions in need of GP consultations, utilisation of rescue medication and patient satisfaction. Costs related to doctor visits, days off work, dispensed pharmaceuticals, hospital admissions, travel costs, educational and time costs were recorded. Patient education reduced the need for GP visits with 85% (from 3.4 to 0.5, P<0.001) and kept a greater proportion independent of their GP during the 12-month follow-up, compared with no education (73% versus 15%, respectively). Patient education reduced the need for reliever medication from 290 to 125 Defined Daily Dosages (DDD), and improved patient satisfaction with overall handling of their disease at GP. The control and intervention groups induced mean total costs of NOK 19,900 and 10,600 per patient, respectively. For every NOK put into patient education, there was a saving of 4.8. The Number Needed to Educate (NNE) to make one person satisfied with their GP was 4.5 and associated with a concomitant saving of NOK 41,900. Patient education of patients with COPD improved patient outcomes and reduced costs in a 12-month follow-up.

Cost effectiveness of a smoking cessation program in patients admitted for coronary heart disease.

Background Smoking cessation is probably the most important action to reduce mortality after a coronary event. Smoking cessation programs are not widely implemented in patients with coronary heart disease, however, possibly because they are thought not to be worth their costs. Our objectives were to estimate the cost effectiveness of a smoking cessation program, and to compare it with other treatment modalities in cardiovascular medicine. Methods A cost-effectiveness analysis was performed on the basis of a recently conducted randomized smoking cessation intervention trial in patients admitted for coronary heart disease. The cost per life year gained by the smoking cessation program was derived from the resources necessary to implement the program, the number needed to treat to get one additional quitter from the program, and the years of life gained if quitting smoking. The cost effectiveness was estimated in a low-risk group (i.e. patients with stable coronary heart disease) and a high-risk group (i.e. patients after myocardial infarction or unstable angina), using survival data from previously published investigations, and with life-time extrapolation of the survival curves by survival function modeling. Results In a lifetime perspective, the incremental cost per year of life gained by the smoking cessation program was ∊280 and ∊110 in the low and high-risk group, respectively (2000 prices). These costs compare favorably to other treatment modalities in patients with coronary heart disease, being approximately 1/25 the cost of both statins in the low-risk group and angiotensin-converting enzyme inhibitors in the high-risk group. In a sensitivity analysis, the costs remained low in a wide range of assumptions. Conclusions A nurse-led smoking cessation program with several months of intervention is very cost-effective compared with other treatment modalities in patients with coronary heart disease.

Predictors of smoking cessation in patients admitted for acute coronary heart disease.

Background Smoking cessation is probably the most important single action after a coronary event. In order to increase the effectiveness of smoking cessation programs, it is important to have knowledge of the predictors of smoking cessation. Further, it is unknown whether smoking cessation programs have impact on these predictors. Methods Data were obtained from a randomized controlled trial of smoking cessation intervention in 240 smokers aged less than 76 years admitted for myocardial infarction, unstable angina, or cardiac bypass surgery. Baseline characteristics were prospectively recorded. Smoking cessation was determined by self report and biochemical verification at 12 months follow-up. Results In multivariate logistic regression analysis, a high level of nicotine addiction, low level of self-confidence in quitting and having previous coronary heart disease were significant negative predictors of smoking cessation at 12 months follow-up. Having previous coronary heart disease and a diagnosis other than acute myocardial infarction as a reason for admission were important negative predictors of abstinence in the usual care group, in contrast to the intervention group, although this did not reach a level of significance in the subgroup interaction analyses. A high level of nicotine addiction was a strong negative predictor in both groups. Conclusion A high level of nicotine addiction is an important negative predictor of smoking cessation, even within an individualized smoking cessation program. Smoking cessation intervention seems to be especially effective in patients with previous coronary heart disease and in patients with unstable angina or coronary artery bypass surgery, compared to usual care.

Does smoking affect the outcome of patient education and self-management in asthmatics?

Information on the potential effect of smoking on the outcome of patient education in asthma is lacking. We randomly allocated 78 asthmatics to either a control or intervention group. Intervention consisted of two 2-h group sessions followed by 1-2 individual sessions each by a nurse and a physiotherapist. Self-management was emphasised following a stepwise treatment plan at exacerbations. Smokers experienced more general practitioner (GP) visits (P=0.001) and absenteeism from work (P=0.02), a greater need for rescue medication (P=0.03), a larger drop in FEV1 (P=0.02) and worse St. Georges respiratory questionnaire (SGRQ) scores (P<0.001) compared to non-smokers during the 1-year follow-up. In multiple linear and logistic regression models smoking was still associated with worse SGRQ scores, a drop in FEV1, higher need for GP visits and rescue medication and higher total costs. We, thus, conclude that smoking was associated with reduced health related quality of life, a drop in FEV1, increased need for rescue medication and GP visits and higher costs after patient education during the 1-year follow-up, compared to no smoking.

Health related quality of life, mood disorders and coping abilities in an unselected sample of patients with primary lung cancer

BACKGROUND Health related quality of life (HRQL), mood disorders and coping abilities have previously not been evaluated in an unselected sample of patients with primary lung cancer. DESIGN A prospective study was performed on all patients diagnosed with primary lung cancer in Southern Norway from 2002 to 2005. HRQL was assessed according to EORTC, anxiety and depression according to HAD and coping ability according to SoC. RESULTS Fatigue and sore mouth were more pronounced in SCLC than in NSCLC. Besides this, there were no difference in EORTC scores between histological groups. Non-responders to EORTC were older and more than twice as many had poor performance status compared to those answering. According to HAD, 17% of patients scored compatible with anxiety and 14% with depression, and one in four consistent with manifest anxiety and/or depression. Mean SoC score was 58.3. A HAD score compatible with anxiety or depression was associated with considerably worse EORTC function scores. A reduced coping ability according to SoC was only weakly associated with anxiety and depression. These scores are poorer than that recorded in selected EORTC databases from chemotherapy and radiotherapy studies. CONCLUSION In this real-life survey on unselected patients with newly diagnosed lung cancer, mean HRQL scores were poorer than reference values from previous, treatment-based studies, documenting a higher burden of illness in lung cancer than previously documented. Anxiety and depression are common in lung cancer and are clearly related to reduced quality of life. From the clinical point of view, an increased focus on information when lung cancer is diagnosed, seems justified, as well as specific attention for patients with lung cancer with accompanying mood disorders.

Does smoking cessation improve Quality of Life in patients with coronary heart disease

Objective. To evaluate whether smoking cessation after a coronary event improves quality of life, and to assess whether quality of life is a predictor of smoking cessation. Design. Health-related quality of life at baseline and at 12 months follow up were measured in a randomised smoking cessation trial of 240 smokers aged under 76 years admitted for myocardial infarction, unstable angina or coronary bypass surgery. At 12 months follow up 101 had managed to give up smoking (quitters), and 117 were smokers (sustained smokers). Results. The quitters and sustained smokers had similar improvements in all quality of life domains from baseline to 12 months follow up. Further, after adjustment for differences in baseline characteristics, the quality of life was not significantly different in the quitters compared to the sustained smokers neither at baseline nor at 12 months follow up. Conclusions. Smoking cessation did not improve quality of life compared to sustained smoking after a coronary event in a 12 month follow up. Quality of life was not a significant predictor of smoking cessation.

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.

HRQoL changes, mood disorders and satisfaction after treatment in an unselected population of patients with lung cancer.

Objectives:  This study intended to explore the impact of the first treatment modality on health‐related quality of life (HRQoL), mood disorders and mastery in an unselected population of patients with primary lung cancer and to judge patient satisfaction with treatment.