Older Patients' Perspectives of Online Health Approaches in Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) is a complex, chronic condition. Patients commonly have limited access to face-to-face support due to decreased mobility, symptom burden, and availability of services. Online health care approaches provide the potential for increased access to self-management education and support. This study sought to understand older patients with COPD's perspectives of online approaches to health care. Materials and Methods: Participants older than 65 years were recruited from a respiratory service at an academic medical center. Qualitative, focus groups were used and recorded, transcribed verbatim, and analyzed using thematic analysis to identify key and repeated emergent themes. Results: Focus groups were undertaken between January and May 2014. Thematic analysis resulted in five overall themes: (1) concern over risks in the online environment; (2) multimedia and technology use as part of everyday life; (3) online resources as an opportunity for revision of forgotten knowledge; (5) potential for facilitation of decision-making support across geographical and physical barriers; and (4) perceived benefits of online peer support for people with COPD. Conclusions: Overall, these older participants with COPD had positive views of online health information, but did raise the need for guidance to ensure valid and reliable online sources. The capacity for online sources to increase access to decision support and up-to-date information was viewed positively, as was the ability to interact with peers who had similar experiences. Telecommunication tools and approaches are already being utilized in health care interactions. Further research is required into the most appropriate, feasible, and sustainable online health approaches to support patients with chronic illnesses such as COPD.

Depression is a common and chronic comorbidity in patients with interstitial lung disease.

BACKGROUND AND OBJECTIVE: Little is known about depression in interstitial lung disease (ILD). The aim of this study was to determine the prevalence of depression, characterize the association of depression with clinical variables and describe the natural history of depression in patients with ILD. METHODS: In this prospective cohort study, clinical variables were recorded at baseline and 6 months. Depression was measured with the Centre for Epidemiologic Studies Depression scale. Depression prevalence was determined using the established threshold of >15 points. Multivariate linear regression was used to determine the baseline features that independently correlated with baseline depression score and that predicted depression severity at follow-up. RESULTS: Fifty-two subjects were enrolled, and 45 returned for follow-up (three deaths, one lung transplant). Prevalence of depression was 21% at baseline. Independent predictors of depressive symptoms at baseline included dyspnoea severity, pain severity, sleep quality and forced vital capacity (R(2) 0.67). The odds of clinically meaningful depression at follow-up were 34-fold higher for subjects who had clinically meaningful depression at baseline compared with those who were not (95% confidence interval 3.5-422, P < 0.0005). Baseline depression score was the strongest predictor of depression score at follow-up (r 0.59, P < 0.00005). CONCLUSIONS: Depressive symptoms in ILD are common, persistent, and strongly and independently correlated with dyspnoea, pain, sleep quality and forced vital capacity. Clinically meaningful depression at baseline is the most important predictor of depressive symptoms at follow-up. Patients with ILD should routinely be screened for depression.

Effects of automated prompts for logging symptom and exercise data on mobile devices in patients with chronic obstructive pulmonary disease.

Traditional approaches to patient-reported outcomes diaries have been largely paper based. However, paper-based approaches have inherent inefficiencies such as an inability to communicate the entries in real time to the healthcare team, issues related to transport and mobility, and no tailored output related to what is entered. Traditional paper-based approaches also lack the ability to prompt users at regular intervals to record data. This lack of prompting may lead to delays in entering symptoms and exercises (diary hoarding). Electronic mobile devices have addressed some of these limitations. However, until recently these electronic devices have not been able to deliver the data in real time, thus limiting the ability of the care team to interact and respond. With the emergence of wireless mobile devices, which provide real-time linkages between the patient and the researchers, these limitations are largely eliminated. Yet, it is unclear (whether diary hoarding still occurs and) whether prompts are effective in reducing hoarding over the course of many months. The purpose of this analysis was to conduct a summative evaluation of 7474 automated prompts sent to participants with chronic obstructive pulmonary disease (n = 19). These participants were provided with mobile devices for logging exercise and symptom data over a 6-month period as part of a clinical trial. We found a marginal association between length in the study and delay in submission of exercise and symptom data in response to electronic prompts. Factors associated with delayed response to the prompts included older age, limited computer skills, and reports of no exercise. We recommend that future investigators who are using mobile devices in their research pay careful attention to usability issues as well as strategies that might keep patients engaged and motivated.

Effects of automated prompts for logging symptom and exercise data on mobile devices in patients with chronic obstructive pulmonary disease.

Traditional approaches to patient-reported outcomes diaries have been largely paper based. However, paper-based approaches have inherent inefficiencies such as an inability to communicate the entries in real time to the healthcare team, issues related to transport and mobility, and no tailored output related to what is entered. Traditional paper-based approaches also lack the ability to prompt users at regular intervals to record data. This lack of prompting may lead to delays in entering symptoms and exercises (diary hoarding). Electronic mobile devices have addressed some of these limitations. However, until recently these electronic devices have not been able to deliver the data in real time, thus limiting the ability of the care team to interact and respond. With the emergence of wireless mobile devices, which provide real-time linkages between the patient and the researchers, these limitations are largely eliminated. Yet, it is unclear (whether diary hoarding still occurs and) whether prompts are effective in reducing hoarding over the course of many months. The purpose of this analysis was to conduct a summative evaluation of 7474 automated prompts sent to participants with chronic obstructive pulmonary disease (n = 19). These participants were provided with mobile devices for logging exercise and symptom data over a 6-month period as part of a clinical trial. We found a marginal association between length in the study and delay in submission of exercise and symptom data in response to electronic prompts. Factors associated with delayed response to the prompts included older age, limited computer skills, and reports of no exercise. We recommend that future investigators who are using mobile devices in their research pay careful attention to usability issues as well as strategies that might keep patients engaged and motivated.

Determinants of frequency, duration, and continuity of home walking in patients with COPD.

The purpose of this study was to identify determinants of frequency (days per week), duration (minutes per session), and continuity (persistence over 1 year) of home walking in 103 patients with chronic obstructive pulmonary disease (COPD) who participated in a dyspnea self-management program. Dimensions of home walking exercise were measured by logs and reports of biweekly telephone calls with the intervention nurse. The selection of personal, cognitive, and environmental determinants of home walking was guided by social cognitive theory. Participants walked more frequently if they were exercising before they entered the study, had less depressive symptoms, and were living with friends or family. Duration of walks was influenced by supervised exercise training; living with spouse, friends, or family; and physical conditioning. Participants who walked most consistently over the course of the year had more supervised exercise sessions as part of the dyspnea self-management program, exercised regularly before entering the program, and perceived a gain in social support over the year. These findings can be used to tailor exercise interventions to the specific needs of patients and improve the likelihood of consistent exercise participation.

Factors influencing patient assignment to level 2 and level 3 within the 5-level ESI triage system.

INTRODUCTION: Prospectively assessing factors that influence triage nurse assignment of patients to the higher risk level 2 compared to the lower risk level 3 has not previously been explored within the 5-level Emergency Severity Index (ESI) triage system. Considering the large amount of information available about the patient, less experienced triage nurses often struggle in deciding what patient information is truly relevant when assessing if a high-risk situation exists. The primary aim of this study was to identify specific factors used by triage nurses to differentiate level 2 patients from level 3 patients. METHODS: A convenience sample of triage nurses was recruited from 2 ED sites. If at the completion of the nurse-patient triage interaction the nurse assigned the patient to either level 2 or level 3, the triage nurse then completed a questionnaire related to factors that influenced patient assignment. RESULTS: Overall, 18 triage nurses participated in the study with a total of 334 nurse-patient triage interactions collected. Patient age, vital signs, and need for a timely intervention were found to be significant factors that influenced patient assignment to level 2 while expected number of resources influenced patient assignment to level 3. DISCUSSION: Utilizing experienced triage nurses on average, this study identified specific, objective factors that, combined with factors already delineated in the ESI Version 4 Implementation Manual, have useful implications for less experienced triage nurses by providing a more comprehensive and relevant foundation for data gathering and decision making.

Additional evidence for the affective dimension of dyspnea in patients with COPD.

The primary purpose of this secondary analysis was to determine whether 103 participants with chronic obstructive pulmonary disease rated the affective dimension of dyspnea (dyspnea-related anxiety and dyspnea-related distress) separately from the sensory dimension (intensity) during baseline exercise testing conducted as part of a randomized clinical trial. A secondary purpose was to determine if dyspnea-related anxiety and distress were rated distinctly different from other measurements of anxiety. At the end of a 6-minute walk and an incremental treadmill test, participant ratings of the magnitude of dyspnea-related anxiety and distress on the Modified Borg Scale were significantly different from their ratings of the intensity of dyspnea. Dyspnea-related anxiety and distress also appeared to be concepts independent from measures of state anxiety, negative affect, and anxiety before a treadmill test.

Randomized controlled trial of an internet-based versus face-to-face dyspnea self-management program for patients with chronic obstructive pulmonary disease: pilot study.

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) continue to experience dyspnea with activities of daily living (ADL) despite optimal medical management. Information and communication technologies may facilitate collaborative symptom management and could potentially increase the reach of such interventions to those who are unable to attend face-to-face pulmonary rehabilitation or self-management programs. OBJECTIVE: The purpose of this randomized study was to test the efficacy of two 6-month dyspnea self-management programs, Internet-based (eDSMP) and face-to-face (fDSMP), on dyspnea with ADL in people living with COPD. METHODS: We randomly assigned 50 participants with moderate to severe COPD who were current Internet users to either the eDSMP (n = 26) or fDSMP (n = 24) group. The content of the two programs was similar, focusing on education, skills training, and ongoing support for dyspnea self-management, including independent exercise. The only difference was the mode (Internet/personal digital assistant [PDA] or face-to-face) in which the education sessions, reinforcement contacts, and peer interactions took place. Participants returned to one of two academic clinical sites for evaluation at 3 and 6 months. The primary outcome of dyspnea with ADL was measured with the Chronic Respiratory Questionnaire. Secondary outcomes of exercise behavior, exercise performance, COPD exacerbations, and mediators, such as self-efficacy and social support, were also measured. A satisfaction survey was administered and a semistructured exit interview was conducted at the final visit. RESULTS: The study was stopped early due to multiple technical challenges with the eDSMP, but follow-up was completed on all enrolled participants. Data were available for 39 participants who completed the study (female: 44%; age: 69.5 +/- 8.5 years; percent predicted forced expiratory volume in 1 s: 49.6 +/- 17.0%). The fDSMP and eDSMP showed similar clinically meaningful changes in dyspnea with ADL from baseline to 3 months (fDSMP: + 3.3 points; eDSMP: + 3.5 points) and sustained these improvements at 6 months (fDSMP: + 4.0 points; eDSMP: + 2.5 points; time effects P < .001; group by time P = .51). Self-reported endurance exercise time (P = .001), physical functioning (P = .04), and self-efficacy for managing dyspnea (P = .02) also showed positive improvements over time in both groups with no significant differences with respect to program modality. Participants who completed the study reported favorable satisfaction with the programs. CONCLUSIONS: Although there were numerous technical challenges with the eDSMP, both dyspnea self-management programs were effective in reducing dyspnea with ADL in the short term. Our findings will need to be confirmed in a larger randomized trial with more mature Web and personal digital assistant tools, use of a control group, and longer follow-up.

Associations between symptoms, functioning, and perceptions of mastery with global self-rated health in patients with COPD: a cross-sectional study.

BACKGROUND: Self-rated health has been shown to be a significant predictor of mortality. However, there is limited knowledge on what factors contribute to the global perception of self-rated health in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To describe the associations between physical and psychological symptoms, physical and mental health functioning, and perceptions of mastery with concurrent and longitudinal global self-rated health (GSRH) in patients with COPD and to determine if gender modifies these relationships. DESIGN: Cross-sectional analysis of data from a longitudinal clinical trial. SETTING: University medical center in the United States. PARTICIPANTS: 115 patients with moderate to severe COPD. METHODS: GSRH was measured using one question from the Medical Outcomes Study, SF-36 which states, "In general, would you say your health is: excellent, very good, good, fair, or poor". Physical and psychological symptoms were measured with the Shortness of Breath Questionnaire, Chronic Respiratory Questionnaire (CRQ), and Center for Epidemiologic Studies Depression Scale (CESD); the SF-36 was used to measure physical and mental health functioning; mastery was measured by a sub-scale of the CRQ. The BODE index, a multidimensional disease severity grading system, was also included. Stepwise logistic regression analyses were performed. RESULTS: In cross-sectional analyses, only disease severity as measured by the BODE index was associated with GSRH [odds ratio, 1.52; 95% confidence interval, CI (1.08, 2.15)]. Stratified analyses by gender showed that the association between the BODE index and the GSRH held up for men, but not for women. Higher perception of symptom control was associated with positive health ratings in women. Subjects with less fatigue at baseline had a lower risk of reporting poor health 12 months later [OR 0.84; 95% CI (0.72, 0.98)]. CONCLUSIONS: For patients with COPD, ratings of global health were mostly influenced by measures that reflect their physical state, e.g. disease severity and fatigue. While additional work is needed to better understand gender differences in factors that contribute to GSRH, therapeutic nursing interventions might place greater focus on symptom management if the goal is to improve patients' perceptions of their global health.

Adherence to a home-walking prescription in patients with chronic obstructive pulmonary disease.

BACKGROUND: We know little about long-term exercise behavior and adherence in patients with chronic obstructive pulmonary disease (COPD). PURPOSE: The study's purpose was (1) to describe exercise behavior and adherence to a home-walking exercise prescription over 12 months in a sample of patients with COPD; and (2) to validate categories of exercise adherence over time in this population. DESIGN: This was a secondary analysis of a randomized controlled trial. SUBJECTS: A total of 103 participants with COPD who were randomly assigned to one of three versions of a dyspnea self-management program participated. MEASURES: The components of exercise frequency, duration, and intensity were measured by exercise/dyspnea daily logs, and participants were classified into categories on the basis of their pattern of exercise adherence over the year. RESULTS: Participants walked an average of 3 days per week initially, with a decline to 2.5 days per week over the year. On average, participants walked longer than the prescribed duration of 20 minutes per session. Dyspnea intensity at the end of the walk tended to remain stable at a mean level of 4 over the year. Classification by adherence category distinguished differences in 6-minute walk distance, endurance treadmill test time, Short Form-36 physical function, and Short Form-36 mental health, with endurance treadmill test time and physical function improvements mirroring increases in exercise adherence, and mental health highest among occasional lapse and lowest among relapser and recycle categories. CONCLUSIONS: This investigation provides a description of long-term exercise behavior and adherence in a sample of patients with COPD. The categories suggest that physical benefits are related to consistent adherence, whereas mental health improvements are related to regular exercise with some flexibility in the schedule. Future research should test interventions to improve exercise adherence in patients with COPD and identify characteristics of patients who are most likely and least likely to adhere over time.

The effects of childbirth self-efficacy and anxiety during pregnancy on prehospitalization labor.

OBJECTIVE: To describe levels of anxiety and self-efficacy for childbirth in nulliparous women during the late third trimester and to identify relationships among those variables, prehospitalization labor pain, management strategies, and hospital admission status. DESIGN: A longitudinal, descriptive study. PARTICIPANTS: Thirty-five English-speaking nulliparous women, 18 to 40 years of age, more than or equal to 38 week's gestation, with uncomplicated pregnancies. All participants had a significant other (husband or partner) and attended childbirth education programs. MAIN OUTCOME MEASURES: Spielberger Trait Anxiety Inventory, Prenatal Self-Evaluation Questionnaire, Childbirth Self-Efficacy Inventory, McGill Pain Questionnaire-Short Form, postpartum interviews, and medical records review. RESULTS: Prenatal anxiety was significantly related to self-efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor, and admitting cervical dilation. The number of management strategies used was related to pain scores during labor before hospital admission. Women who spent longer periods of time at home in labor arrived at the hospital with a greater cervical dilation. CONCLUSIONS: Antenatal characteristics influence intrapartal outcomes in nulliparas. Labor environment, at home and in the hospital, is recognized as an important component of the first childbirth experience.

Methodological considerations in evaluating eHealth interventions.

Advances in information and communication technologies shape consumers' attitudes towards engagement in their own health and their interface with the health-care system. The use of eHealth tools holds promise for supporting and enabling health behaviour change and the prevention and management of chronic diseases. The authors review issues related to study design, treatment implementation, and outcome measurement in eHealth trials, providing examples from the literature and from their own ongoing studies. Selection of a comparison group and design considerations related to participant preferences are based on the state of the science and current practice in the particular field. Randomized designs allow for control of selection bias and are favoured in both efficacy and effectiveness trials of eHealth interventions. Depending on the choice of comparison groups, eHealth applications must be fairly robust to demonstrate their efficacy above and beyond active controls. Strategies to ensure treatment fidelity and ongoing participant engagement can be challenging and are not always successful. Patient-reported outcomes are common to eHealth studies. Other outcomes, such as the costs associated with new eHealth applications, are equally if not more important for decision-makers. This discussion is intended to inform future trials and thereby serve to advance the science of eHealth.

Association Between Clinical Nurse Specialist's Presence and Open Visitation in US Intensive Care Units.

BACKGROUND: Current evidence shows that an open visitation policy can benefit patients and families during intensive care unit (ICU) stays. Therefore, an unrestricted visitation policy in the ICU has been proposed as part of patient-centered care. PURPOSE: The purpose of this secondary analysis is to explore the likelihood of an ICU with a clinical nurse specialist (CNS) having an open visitation policy when compared with an ICU without a CNS. DESIGN: This is a secondary analysis of a survey conducted between 2008 and 2009, describing the ICU visitation practices in more than 600 hospitals across the United States. METHODS: χ Analysis was performed comparing the presence of CNS in the ICU with visitation policies, with P < 0.05 considered statistically significant. RESULTS: There were data from 347 hospitals used in the analysis, with 47 hospitals (13.5%) having open visitation policies. There were 108 hospitals (31%) that had a CNS present in the ICU; 14 of the hospitals (13%) had open visitation policies. No significant correlation was found between a CNS being present in the ICU and open visitation policy (odds ratio, 0.93; P = .83), regardless of hospital geographic regions. CONCLUSIONS: Although CNS presence was not associated with open visitation in this study, given the strong evidence to support the benefits to patients and the CNS role as a change agent in the hospital system, liberalization of visitation in the ICU is an area that could benefit from CNS advocacy.

Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department 'near miss' for breathlessness: a strengths-based qualitative study.

OBJECTIVES: Breathlessness 'crises' in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED 'near misses' where they considered going to the ED but successfully self-managed instead. DESIGN AND METHODS: A qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen's Transactional Model of Stress and Coping informed interpretive themes. RESULTS: Interviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services. CONCLUSIONS: In addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients' generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.

Effects of treatment on two types of self-efficacy in people with chronic obstructive pulmonary disease.

Self-management is crucial in people with chronic diseases, and self-efficacy has been shown to impact patients' self-management. The purposes of this study were to 1) determine the effect of intervention on self-efficacy and 2) determine the relationship between domain-specific self-efficacy, walking performance, and symptom severity in patients with chronic obstructive pulmonary disease (COPD). Subjects (n=102, forced expiratory volume in 1 second % predicted 44.8+/-14) received one of three self-management interventions. Self-efficacy for walking and managing shortness of breath, walking performance, and shortness of breath severity were measured at baseline and after intervention. Self-efficacy increased after intervention (P<0.01). Self-efficacy for walking was positively related to walking performance (P<0.05). Self-efficacy for managing shortness of breath was positively related to symptom severity (P<0.05). This study examined two types of disease-specific self-efficacy in patients with COPD and demonstrated that improving self-efficacy is an important outcome of self-management interventions. Studies in other domains of self-efficacy are needed.

Is Internet-based support for dyspnea self-management in patients with chronic obstructive pulmonary disease possible? Results of a pilot study.

BACKGROUND: As of 2003, approximately 67% of US adults have Internet access. The purpose of this study was to determine the feasibility and preliminary efficacy of an Internet-based dyspnea self-management program (iDSMP) for people with chronic obstructive pulmonary disease. A related aim was to compare the differential effects of the iDSMP on 2 different groups: (1) to test a "booster" effect and (2) to evaluate the program as a primary intervention. METHODS: Two groups (n = 16) were evaluated at baseline and at 3 months after completing the iDSMP, which included education, exercise, self-monitoring, and support. Dyspnea, self-efficacy, perception of available support, and exercise behavior were measured. Paired, independent t tests and Mann-Whitney U tests were used. RESULTS: Most subjects (87%) reported that the program increased their access to information and resources for managing dyspnea. Dyspnea with activities of daily living and self-efficacy for managing the symptom showed significant improvements (both P < .01), whereas more modest changes were noted in perceived support and exercise behavior in the overall sample. There were no differences between the 2 groups on these outcomes. CONCLUSIONS: The findings suggest that additional investigations of Internet-based interventions to promote self-management in patients with chronic obstructive pulmonary disease are warranted.

Patterns of technology use in patients attending a cardiopulmonary outpatient clinic: a self-report survey.

BACKGROUND: Self-management education for cardiopulmonary diseases is primarily provided through time-limited, face-to-face programs, with access limited to a small percentage of patients. Telecommunication tools will increasingly be an important component of future health care delivery. OBJECTIVE: The purpose of this study was to describe the patterns of technology use in patients attending a cardiopulmonary clinic in an academic medical center. METHODS: A prevalence survey was developed to collect data on participant demographics (age in years, sex, and socioeconomic status); access to computers, Internet, and mobile phones; and use of current online health support sites or programs. Surveys were offered by reception staff to all patients attending the outpatient clinic. RESULTS: A total of 123 surveys were collected between March and April 2014. Technological devices were a pervasive part of everyday life with respondents engaged in regular computer (102/123, 82.9%), mobile telephone (115/117, 98.3%), and Internet (104/121, 86.0%) use. Emailing (101/121, 83.4%), researching and reading news articles (93/121, 76.9%), social media (71/121, 58.7%), and day-to-day activities (65/121, 53.7%) were the most common telecommunication activities. The majority of respondents reported that access to health support programs and assistance through the Internet (82/111, 73.9%) would be of use, with benefits reported as better understanding of health information (16/111, 22.5%), avoidance of difficult travel requirements and time-consuming face-to-face appointments (13/111, 18.3%), convenient and easily accessible help and information (12/111, 16.9%), and access to peer support and sharing (9/111, 12.7%). The majority of patients did not have concerns over participating in the online environment (87/111, 78.4%); the few concerns noted related to privacy and security (10/15), information accuracy (2/15), and computer literacy and access (2/15). CONCLUSIONS: Chronic disease burden and long-term self-management tasks provide a compelling argument for accessible and convenient avenues to obtaining ongoing treatment and peer support. Online access to health support programs and assistance was reported as useful and perceived as providing convenient, timely, and easily accessible health support and information. Distance from the health care facility and a lack of information provision through traditional health sources were both barriers and enablers to telehealth. This is particularly important in the context of a cardiopulmonary clinic that attracts patients from a large geographical area, and in patients who are most likely to have high health care utilization needs in the future. Telecommunication interfaces will be an increasingly important adjunct to traditional forms of health care delivery.