Vicki Johnson-Warrington

A self-management programme for COPD: a randomised controlled trial

Studies of programmes of self-management support for chronic obstructive pulmonary disease (COPD) have been inconclusive. The Self-Management Programme of Activity, Coping and Education (SPACE) FOR COPD is a 6-week self-management intervention for COPD, and this study aimed to evaluate the effectiveness of this intervention in primary care. A single-blind randomised controlled trial recruited people with COPD from primary care and randomised participants to receive usual care or SPACE FOR COPD. Outcome measures were performed at baseline, 6 weeks and 6 months. The primary outcome was symptom burden, measured by the self-reported Chronic Respiratory Questionnaire (CRQ-SR) dyspnoea domain. Secondary outcomes included other domains of the CRQ-SR, shuttle walking tests, disease knowledge, anxiety, depression, self-efficacy, smoking status and healthcare utilisation. 184 people with COPD were recruited and randomised. At 6 weeks, there were significant differences between groups in CRQ-SR dyspnoea, fatigue and emotion scores, exercise performance, anxiety, and disease knowledge. At 6 months, there was no between-group difference in change in CRQ-SR dyspnoea. Exercise performance, anxiety and smoking status were significantly different between groups at 6 months, in favour of the intervention. This brief self-management intervention did not improve dyspnoea over and above usual care at 6 months; however, there were gains in anxiety, exercise performance, and disease knowledge. A brief self-management programme for COPD improves some patient outcomes; however, more support may be required http://ow.ly/AbCpm

Important, misunderstood, and challenging: a qualitative study of nurses’ and allied health professionals’ perceptions of implementing self-management for patients with COPD

Background In light of the growing burden of COPD, there is increasing focus on the role of self-management for this population. Currently, self-management varies widely. Little is known either about nurses’ and allied health professionals’ (AHPs’) understanding and provision of self-management in clinical practice. This study explores nurses’ and AHPs’ understanding and implementation of supported COPD self-management within routine clinical practice. Materials and methods Nurses and AHPs participated in face-to-face semistructured interviews to explore their understanding and provision of COPD self-management, as well as their perceptions of the challenges to providing such care. Purposive sampling was used to select participants from a range of professions working within primary, community, and secondary care settings. Three researchers independently analyzed each transcript using a thematic approach. Results A total of 14 participants were interviewed. Nurses and AHPs viewed self-management as an important aspect of COPD care, but often misunderstood what it involved, leading to variation in practice. A number of challenges to supporting self-management were identified, which related to lack of time, lack of insight regarding training needs, and assumptions regarding patients’ perceived self-management abilities. Conclusion Nurses and AHPs delivering self-management require clear guidance, training in the use of effective self-management skills, and education that challenges their preconceptions regarding patients. The design of health care services also needs to consider the practical barriers to COPD self-management support for the implementation of such interventions to be successful.

Pulmonary rehabilitation and interstitial lung disease: aiding the referral decision.

BACKGROUND: Limited evidence exists regarding the effectiveness of pulmonary rehabilitation (PR) within interstitial lung disease (ILD). Oxygen is frequently prescribed for these patients but has not been explored in the context of PR. The aim of this study was to compare short-term outcomes of PR and 2-year mortality in patients with ILD, who use home oxygen against those without oxygen. METHODS: Using an observational cohort design and principles of comparative effectiveness research, data were collected from patients with ILD referred for a 7-week outpatient PR program. Hospital notes were reviewed, oxygen use was documented, and survival status was recorded at 2 years. Exercise capacity and quality of life were measured at baseline and discharge from PR. RESULTS: One hundred fifteen patients were identified (96 with idiopathic pulmonary fibrosis); 43 used oxygen and 72 were nonoxygen users. Nonoxygen users improved their Incremental Shuttle Walk Test more than oxygen users (P < .05). Significant improvements were found after PR for nonoxygen users (Incremental Shuttle Walk Test 39.0 ± 54.3 m, Endurance Shuttle Walk Test 319 ± 359 seconds, Chronic Respiratory Questionnaire (CRQ)-Dyspnea 0.74 ± 0.94, CRQ-Fatigue 0.73 ± 1.15, CRQ-Emotion 0.61 ± 0.98, CRQ-Mastery 0.55 ± 1.01), whereas only Endurance Shuttle Walk Test (197 ± 287 seconds) improved for oxygen users (P < .05). Significant differences were found in survival rates between the 2 groups, 2 years after initial PR assessment (hazard ratio, oxygen users vs nonoxygen users: 2.7 [95% CI = 1.41 − 4.98], P = .002). CONCLUSIONS: Oxygen users gain less from PR and have a higher mortality rate than nonoxygen users. These results should be used to aid discussion between patients and clinicians regarding referral to PR and the anticipated benefits.

Exercise Capacity and Physical Activity in Patients With COPD and Healthy Subjects Classified as Medical Research Council Dyspnea Scale Grade 2.

PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) are often classified by Medical Research Council (MRC) dyspnea grade and comparisons thus made to healthy individuals. The MRC grade of a healthy population is assumed to be grade 1, although this may be inaccurate. Physical activity and exercise capacity are not well-defined for those with MRC grade 2. This study was undertaken to establish whether there are differences in physical activity and exercise capacity between individuals with COPD and healthy controls, who have all assessed themselves as MRC grade 2. METHODS: Patients with COPD (n = 83) and 19 healthy controls, with a self-selected MRC grade of 2, completed the Incremental Shuttle Walk Test (ISWT) and wore a SenseWear (BodyMedia, Pittsburgh, PA) activity monitor for 12 hours for 2 weekdays. RESULTS: Adjusting for age, step count and ISWT were significantly reduced for those with COPD, compared with healthy controls (P < .05). Patients with COPD achieved mean (SD) 425.5 (131.3) m on ISWT and took 6022 (3276) steps per day compared with 647.8 (146.3) m and 9462 (4141) steps per day for healthy controls. For subjects achieving 10 000 steps per day, 8 (42.11%) healthy controls achieved this level compared with 7 (8.43%) patients with COPD (P < .01). CONCLUSIONS: Healthy individuals may report functional limitations and categorize themselves as MRC grade 2. However, despite both groups subjectively considering themselves similarly functionally limited, exercise capacity and physical activity were significantly reduced in patients with COPD compared with healthy participants. This highlights the importance of early interventions to increase physical performance and prevent functional decline for patients with COPD.

Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial

Introduction Patients with COPD experience exacerbations that may require hospitalization. Patients do not always feel supported upon discharge and frequently get readmitted. A Self-management Program of Activity, Coping, and Education for COPD (SPACE for COPD), a brief self-management program, may help address this issue. Objective To investigate if SPACE for COPD employed upon hospital discharge would reduce readmission rates at 3 months, compared with usual care. Methods This is a prospective, single-blinded, two-center trial (ISRCTN84599369) with participants admitted for an exacerbation, randomized to usual care or SPACE for COPD. Measures, including health-related quality of life and exercise capacity, were taken at baseline (hospital discharge) and at 3 months. The primary outcome measure was respiratory readmission at 3 months. Results Seventy-eight patients were recruited (n=39 to both groups). No differences were found in readmission rates or mortality at 3 months between the groups. Ten control patients were readmitted within 30 days compared to five patients in the intervention group (P>0.05). Both groups significantly improved their exercise tolerance and Chronic Respiratory Questionnaire (CRQ-SR) results, with between-group differences approaching statistical significance for CRQ-dyspnea and CRQ-emotion, in favor of the intervention. The “Ready for Home” survey revealed that patients receiving the intervention reported feeling better able to arrange their life to cope with COPD, knew when to seek help about feeling unwell, and more often took their medications as prescribed, compared to usual care (P<0.05). Conclusion SPACE for COPD did not reduce readmission rates at 3 months above that of usual care. However, encouraging results were seen in secondary outcomes for those receiving the intervention. Importantly, SPACE for COPD appears to be safe and may help prevent readmission with 30 days.

Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: a randomised non-inferiority trial

Background Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD. Methods A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV1% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units. Results There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: −0.24, 95% CI −0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks. Conclusions The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation. Trial registration number ISRCTN81189044.

An economic evaluation of a self-management programme of activity, coping and education for patients with chronic obstructive pulmonary disease

The aim was to undertake a cost-utility analysis of a self-management programme of activity, coping and education (SPACE) for chronic obstructive pulmonary disease (COPD). The analysis was conducted alongside a six-month randomized controlled trial in 30 primary care settings. The economic analysis used data from 184 patients with confirmed diagnosis of COPD, forced expiratory volume in one second/forced vital capacity ratio <0.7 and with grade 2–5 on the Medical Research Council dyspnoea scale. Participants received either a self-management programme consisting of an education manual (SPACE for COPD) and consultation or usual care. Six-month costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life years (QALYs) were calculated based on patient responses at baseline and six months. The mean difference in costs between usual care and SPACE FOR COPD programme was −£27.18 (95% confidence interval (CI); −£122.59 to £68.25) while mean difference in QALYs was −0.10 (95% CI; −0.17 to −0.02). The results suggest that the intervention is more costly and more effective than usual care. The probability of the intervention being cost-effective was 97% at a threshold of £20,000/QALY gained. We conclude that the SPACE FOR COPD programme is cost-effective compared to usual care.

Do we need a practice incremental shuttle walk test for patients with interstitial lung disease referred for pulmonary rehabilitation

Patients with interstitial lung disease (ILD) are increasingly being referred to pulmonary rehabilitation (PR) where exercise capacity is measured, often by an incremental shuttle walk test (ISWT). These patients are frequently limited by severe dyspnoea and exertional desaturation. Available guidelines suggest two ISWT are needed; however, this is time consuming and it has not been reported whether a practice ISWT is necessary in ILD. We aimed to investigate if a practice ISWT is needed for patients with ILD referred to PR.

Is a practice incremental shuttle walk test needed for patients with chronic obstructive pulmonary disease admitted to hospital for an acute exacerbation

Background: The incremental shuttle walk test (ISWT) assesses exercise capacity in chronic obstructive pulmonary disease (COPD) patients. Guidelines suggest that 2 ISWTs should be performed. However, in inpatients with an acute exacerbation, it is unknown if 2 ISWTs are required. Objective: To investigate if a practice ISWT is needed for inpatients with an acute COPD exacerbation. Methods: Patients admitted to hospital with an acute exacerbation completed 2 ISWTs prior to discharge. Patients provided informed consent and were included if they used the same oxygen and mobility aid (if any) between tests. Results: Thirty-nine inpatients with COPD were included with a mean (SD) forced expiratory volume in 1 s (FEV1) of 1.1 litres (0.5) [42.5% predicted (13.2)] and a median (interquartile range) Medical Research Council dyspnoea grade of 4 (3-5). Participants achieved 88.2 m (96.7) on ISWT1, and there was a statistically significant increase of 14.1 m (28.4) for ISWT2 (p < 0.05). Multiple regression explained 98.8% of the variance (F(8-22) p < 0.001, R2 = 0.988) between ISWTs using age, FEV1/forced vital capacity (FVC)%, FVC, resting oxygen saturation, resting heart rate (HR), ISWT1 distance, ISWT1 post-HR and post-Rated Perceived Exertion (p < 0.05). Using this equation to calculate predicted ISWT2, there was good agreement and no significant difference between this and actual ISWT2 (0.01 m, p > 0.05). Conclusions: There was a small but statistically significant increase between ISWTs, which was below the minimal clinically important difference but would have had consequences for exercise prescription. This exploratory work has shown that we may be able to predict the difference between ISWTs using a multiple regression equation which could substitute the need for a second ISWT; this needs to be confirmed prospectively.

S24 A self-management programme of activity, coping and education (SPACE) for COPD: A randomised non-inferiority trial in a pulmonary rehabilitation population

Introduction Self-managed programmes for patients with COPD offer an alternative to conventional pulmonary rehabilitation (PR). Previously reported self management (SM) programmes either offer short education sessions or action plans or are long intensive programme with a high level of support which are more comprehensive than tradition UK PR programmes. There is limited data reported on self managed approaches to PR which offer minimal support for education, skills acquisition and exercise in comparison to PR in the UK. We have recently developed a SM programme for patients with COPD (SPACE for COPD) and have completed studies in primary care1. The demand for PR is high but the service is compromised by limited access and drop out rates. Therefore the aim of this study was to determine if SPACE for COPD is noninferior to (as good as) PR for patients with COPD over 7 weeks. Methods 287 patients (187 male: mean (SD) age 67 (9) yrs; FEV1 1.25 (0.55); BMI 27.63 (6.22) kg/m2) with COPD were consented and randomised to either SPACE for COPD or PR. Those who were assigned to the SPACE for COPD group received an introduction to the SPACE for COPD manual and 2 telephone calls at 2 and 4 weeks. Those assigned to PR received 14, 2 hour sessions of education and exercise over 7 weeks. The primary outcome was the Chronic Respiratory Questionnaire (CRQ) dyspnoea, with secondary measure of CRQ fatigue, emotion and mastery, Incremental Shuttle Walk Test (ISWT) and Endurance Shuttle Walk Test (ESWT). Measures were taken at baseline and 7 weeks. Within and between group differences were analysed using paired and unpaired t-tests respectively. Results Please see table 1. Abstract S24 Table 1. SPACE for COPDn=94 Pulmonary Rehabilitationn=84 Between group differences Baseline(SD) 7 weeks(SD) Change(95% CI) Baseline(SD) 7 weeks(SD) Change(95% CI) (95% CI) Dyspnoea 2.58(0.93) 3.11(1.23) 0.55(0.26 to 0.85)p=<0.001 2.42(0.91) 3.38(1.18) 0.87(0.61 to 1.13)p<0.001 -0.32(-0.71 to 0.08)p=0.113 Fatigue 3.42(1.19) 3.71(1.22) 0.13(-0.14 to 0.39)p=0.339 3.36(1.20) 4.09(1.49) 0.54(0.27 to 0.82)p<0.001 -0.41(-0.79 to 0.03)p=0.033 Emotion 4.41(1.24) 4.56(1.20) 0.005(-0.23 to 0.24)p=0.965 4.37(1.24) 4.92(1.03) 0.53(0.26 to 0.79)p<0.001 -0.52(-0.88 to 0.17)p=0.004 Mastery 4.50(1.40) 4.78(1.31) 0.15(-0.11 to 0.40)p=0.259 4.36(1.30) 4.94(1.19) 0.58(0.34 to 0.81)p<0.001 -0.43(-0.77 to 0.09)p=0.014 ISWT (metres) 260.24(147.91) 277.86 (145.59) 17.62(3.26 to 31.98)P=0.17 268.61(149.89) 310.13 (156.46) 41.52(23.91 to 59.12) -23.90(-46.33 to -1.47)p=0.038 ESWT (seconds) 231.42(231.00) 444.33(393.09) 212.91(139.49 to 286.34)P<0.001 189.14(96.25) 534.85 (395.38) 345.70(260.20 to 431.20)p<0.001 -132.78(-244.63 to -20.94)p=0.02 Conclusion SPACE for COPD can improve dyspnoea and endurance capacity over 7 weeks to a similar level to PR, although it remains unclear to its noniferiority to PR. The SPACE for COPD programme does offer a number of health benefits despite it involving limited support and could offer a suitable alternative to patients with COPD who would otherwise not attend conventional rehabilitation. References Mitchell-Wagg K et al. (2012). Thorax 67 (Suppl_2) A25–26.