Australian and New Zealand Pulmonary Rehabilitation Guidelines.

BACKGROUND AND OBJECTIVE: The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts. METHODS: The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts. RESULTS: The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary. CONCLUSION: The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

A randomized controlled trial of telephone-mentoring with home-based walking preceding rehabilitation in COPD.

PURPOSE: With the limited reach of pulmonary rehabilitation (PR) and low levels of daily physical activity in chronic obstructive pulmonary disease (COPD), a need exists to increase daily exercise. This study evaluated telephone health-mentoring targeting home-based walking (tele-rehab) compared to usual waiting time (usual care) followed by group PR. PATIENTS AND METHODS: People with COPD were randomized to tele-rehab (intervention) or usual care (controls). Tele-rehab delivered by trained nurse health-mentors supported participants' home-based walking over 8-12 weeks. PR, delivered to both groups simultaneously, included 8 weeks of once-weekly education and self-management skills, with separate supervised exercise. Data were collected at three time-points: baseline (TP1), before (TP2), and after (TP3) PR. The primary outcome was change in physical capacity measured by 6-minute walk distance (6MWD) with two tests performed at each time-point. Secondary outcomes included changes in self-reported home-based walking, health-related quality of life, and health behaviors. RESULTS: Of 65 recruits, 25 withdrew before completing PR. Forty attended a median of 6 (4) education sessions. Seventeen attended supervised exercise (5±2 sessions). Between TP1 and TP2, there was a statistically significant increase in the median 6MWD of 12 (39.1) m in controls, but no change in the tele-rehab group. There were no significant changes in 6MWD between other time-points or groups, or significant change in any secondary outcomes. Participants attending supervised exercise showed a nonsignificant improvement in 6MWD, 12.3 (71) m, while others showed no change, 0 (33) m. The mean 6MWD was significantly greater, but not clinically meaningful, for the second test compared to the first at all time-points. CONCLUSION: Telephone-mentoring for home-based walking demonstrated no benefit to exercise capacity. Two 6-minute walking tests at each time-point may not be necessary. Supervised exercise seems essential in PR. The challenge of incorporating exercise into daily life in COPD is substantial.

Patient Anxiety and Depression Moderate the Effects of Increased Self-management Knowledge on Physical Activity: A Secondary Analysis of a Randomised Controlled Trial on Health-Mentoring in COPD.

OBJECTIVE: Anxiety and depression are common comorbidities in people with chronic obstructive pulmonary disease (COPD). While these comorbidities could potentially lead to a higher motivation to learn about self-management, they could also inhibit patients from translating this knowledge into appropriate self-management behaviours. This paper explores the moderating effects of anxiety and depression on a health-mentoring intervention, focusing on mechanisms of change (mediation). METHODS: 182 COPD patients participated in an RCT, with anxiety and depression assessed by the Hospital Anxiety and Depression Scale (HADS), self-management knowledge by the Partners in Health Scale, and spontaneous physical activity using accelerometers, all measured at baseline, 6 and 12 months. The moderated mediation model tested the intervention's effect on physical activity, mediated via changes in self-management knowledge, at different levels of anxiety and depression. RESULTS: Knowledge mediated the effect of the intervention on changes in physical activity only for participants reporting low levels of anxiety or depression. Both acted as moderators: Increased knowledge led to more physical activity among participants reporting low anxiety or depression and to less activity among highly anxious or depressed participants. CONCLUSION: Although health-mentoring interventions can be an effective tool to increase knowledge and physical activity among COPD patients, it is essential to take anxiety and depression into account, as increased knowledge may have detrimental effects in highly anxious or depressed participants. This suggests that patients with elevated anxiety or depression may need to be treated appropriately before engaging in chronic disease self-management interventions.

Chronic disease self-management and exercise in COPD as pulmonary rehabilitation: a randomized controlled trial.

PURPOSE: Both exercise and self-management are advocated in pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD). The widely used 6-week, group-based Chronic Disease Self-Management Program (CDSMP) increases self-reported exercise, despite supervised exercise not being a program component. This has been little explored in COPD. Whether adding supervised exercise to the CDSMP would add benefit is unknown. We investigated the CDSMP in COPD, with and without a formal supervised exercise component, to address this question. PATIENTS AND METHODS: Adult outpatients with COPD were randomized to the CDSMP with or without one hour of weekly supervised exercise over 6 weeks. The primary outcome measure was 6-minute walk test distance (6MWD). Secondary outcomes included self-reported exercise, exercise stage of change, exercise self-efficacy, breathlessness, quality of life, and self-management behaviors. Within- and between-group differences were analyzed on an intention-to-treat basis. RESULTS: Of 84 subjects recruited, 15 withdrew. 6MWD increased similarly in both groups: CDSMP-plus-exercise (intervention group) by 18.6±46.2 m; CDSMP-alone (control group) by 20.0±46.2 m. There was no significant difference for any secondary outcome. CONCLUSION: The CDSMP produced à small statistically significant increase in 6MWD. The addition of a single supervised exercise session did not further increase exercise capacity. Our findings confirm the efficacy of a behaviorally based intervention in COPD, but this would seem to be less than expected from conventional exercise-based pulmonary rehabilitation, raising the question of how, if at all, the small gains observed in this study may be augmented.

Effects of telephone health mentoring in community-recruited chronic obstructive pulmonary disease on self-management capacity, quality of life and psychological morbidity: a randomised controlled trial.

OBJECTIVES: To assess benefits of telephone-delivered health mentoring in community-based chronic obstructive pulmonary disease (COPD). DESIGN: Cluster randomised controlled trial. SETTING: Tasmanian general practices: capital city (11), large rural (3), medium rural (1) and small rural (16). PARTICIPANTS: Patients were invited (1207) from general practitioner (GP) databases with COPD diagnosis and/or tiotropium prescription, response rate 49% (586), refused (176) and excluded (criteria: smoking history or previous study, 68). Spirometry testing (342) confirmed moderate or severe COPD in 182 (53%) patients. RANDOMISATION: By random numbers code, block stratified on location, allocation by sequentially numbered, opaque and sealed envelopes. INTERVENTION: Health mentor (HM) group received regular calls to manage illness issues and health behaviours from trained community health nurses using negotiated goal setting: problem solving, decision-making and action planning. CONTROL: usual care (UC) group received GP care plus non-interventional brief phone calls. OUTCOMES: Measured at 0, 6 and 12 months, the Short Form 36 (SF-36) and St George's Respiratory Questionnaire (SGRQ, primary); Partners In Health (PIH) Scale for self-management capacity, Hospital Anxiety and Depression Scale (HADS), Center for Epidemiologic Studies-Depression (CES-D) questionnaire, Post-Traumatic Stress Disorder Checklist, Satisfaction with life and hospital admissions (secondary). RESULTS: 182 participants with COPD (age 68±8 years, 62% moderate COPD and 53% men) were randomised (HM=90 and UC=92). Mixed model regression analysis accounting for clustering, adjusting for age, gender, smoking status and airflow limitation assessed efficacy (regression coefficient, ß, reported per 6-month visit). There was no difference in quality of life between groups, but self-management capacity increased in the HM group (PIH overall 0.15, 95% CI 0.03 to 0.29; knowledge domain 0.25, 95% CI 0.00 to 0.50). Anxiety decreased in both groups (HADS A 0.35; 95% CI -0.65 to -0.04) and coping capacity improved (PIH coping 0.15; 95% CI 0.04 to 0.26). CONCLUSIONS: Health mentoring improved self-management capacity but not quality of life compared to regular phone contact, which itself had positive effects where decline is generally expected.

Supporting cystic fibrosis with ICT.

ICT use in cystic fibrosis management provides an alternative means of information supply to individuals, families, health care professionals and other stakeholders. The purpose of this paper is to present the evolution of a series of projects culminating in a project that translates the previous research into practice. In this paper the sequential nature of the projects will be detailed. The three projects explored are the Pathways Home for Respiratory Illness Project (Pathways Home), Enhancing Self-Efficacy for Self-Management in People with Cystic Fibrosis and the Tasmanian Community Fund Project (myCF pilot).

Entering a world of uncertainty: community nurses' engagement with information and communication technology.

Achieving adoption, use, and integration of information and communication technology by healthcare clinicians in the workplace is recognized as a challenge that requires a multifaceted approach. This article explores community health nurses' engagement with information and communication technology as part of a larger research project that investigated the delivery of self-management support to people with chronic obstructive pulmonary disease. Following a survey of computer skills, participants were provided with computer training to support use of the project information system. Changes in practice were explored using action research meetings and individual semistructured interviews. Results highlight three domains that affected nurses' acceptance, utilization, and integration of information and communication technology into practice; environmental issues; factors in building capacity, confidence, and trust in the technology; and developing competence. Nurses face individual and practice challenges when attempting to integrate new processes into work activities, and the use of participatory models to support adoption is recommended.

Supporting health behaviour change in chronic obstructive pulmonary disease with telephone health-mentoring: insights from a qualitative study.

BACKGROUND: Adoption and maintenance of healthy behaviours is pivotal to chronic disease self-management as this influences disease progression and impact. This qualitative study investigated health behaviour changes adopted by participants with moderate or severe chronic obstructive pulmonary disease (COPD) recruited to a randomised controlled study of telephone-delivered health-mentoring. METHODS: Community nurses trained as health-mentors used a patient-centred approach with COPD patients recruited in general practice to facilitate behaviour change, using a framework of health behaviours; 'SNAPPS' Smoking, Nutrition, Alcohol, Physical activity, Psychosocial well-being, and Symptom management, through regular phone calls over 12 months. Semi-structured interviews in a purposive sample sought feedback on mentoring and behaviour changes adopted. Interviews were analysed using iterative thematic and interpretative content approaches by two investigators. RESULTS: Of 90 participants allocated to health-mentoring, 65 (72%) were invited for interview at 12-month follow up. The 44 interviewees, 75% with moderate COPD, had a median of 13 mentor contacts over 12 months, range 5-20. Interviewed participants (n=44, 55% male, 43% current smokers, 75% moderate COPD) were representative of the total group with a mean age 65 years while 82% had at least one additional co-morbid chronic condition. Telephone delivery was highly acceptable and enabled good rapport. Participants rated 'being listened to by a caring health professional' as very valuable. Three participant groups were identified by attitude to health behaviour change: 14 (32%) actively making changes; 18 (41%) open to and making some changes and 12 (27%) more resistant to change. COPD severity or current smoking status was not related to group category. Mentoring increased awareness of COPD effects, helping develop and personalise behaviour change strategies, even by those not actively making changes. Physical activity was targeted by 43 (98%) participants and smoking by 14 (74%) current smokers with 21% reporting quitting. Motivation to maintain changes was increased by mentor support. CONCLUSIONS: Telephone delivery of health-mentoring is feasible and acceptable to people with COPD in primary care. Health behaviours targeted by this population, mostly with moderate disease, were mainly physical activity and smoking reduction or cessation. Health-mentoring increased motivation and assisted people to develop strategies for making and sustaining beneficial change. TRIAL REGISTRATION: ACTR12608000112368.

Engaging general practice nurses in chronic disease self-management support in Australia: insights from a controlled trial in chronic obstructive pulmonary disease.

The growing burden of chronic disease will increase the role of primary care in supporting self-management and health behaviour change. This role could be undertaken to some extent by the increased practice nurse workforce that has occurred over recent years. Mixed methods were used to investigate the potential for general practice nurses to adopt this role during a 12-month randomised controlled study of telephone-delivered health mentoring in Tasmanian practices. Nurses (general practice and community health) were trained as health mentors to assist chronic obstructive pulmonary disease patients to identify and achieve personal health related goals through action plans. Of 21% of invited practices that responded, 19 were allocated to health mentoring; however, general practice nurses were unable to train as health mentors in 14 (74%), principally due to lack of financial compensation and/or workload pressure. For five general practice nurses trained as health mentors, their roles had previously included some chronic disease management, but training enhanced their understanding and skills of self-management approaches and increased the focus on patient partnership, prioritising patients' choices and achievability. Difficulties that led to early withdrawal of health mentors were competing demands, insufficient time availability, phone calls having lower priority than face-to-face interactions and changing employment. Skills gained were rated as valuable, applicable to all clinical practice and transferable to other health care settings. Although these results suggest that training can enhance general practice nurses' skills to deliver self-management support in chronic disease, there are significant system barriers that need to be addressed through funding models and organisational change.

Investigating the feasibility of promoting and sustaining delivery of cardiac rehabilitation in a rural community.

INTRODUCTION: Members of rural communities face the dual burden of high rates of cardiovascular disease and barriers to accessing cardiac rehabilitation programs (CRPs). While rural healthcare providers recognise the need for local delivery of such programs, they are constrained by funding and resource limitations. METHODS: This research sought to explore the feasibility, acceptance and support for the delivery of a secondary prevention CRP in a rural community. Eight local participants were recruited to a pilot CRP following cardiac surgery, diagnosis of cardiovascular disease and/or identification by health practitioners as being at risk of developing cardiovascular disease. The key measures of success were the ability of the team to provide a program based on self-management principles, with a local and collaborative focus. The Health Education Impact Questionnaire (HeiQ) was used to measure the effectiveness and outcomes of the CRP. Qualitative data were also used in order to enhance understandings of the efficacy of CRPs in rural settings from the participant perspective. RESULTS: The delivery of a pilot program that engaged local healthcare providers in partnerships with local residents was successful. Local provision was clearly a positive aspect of the program. Participants described the program as supportive, holistic and convenient, providing new information in a framework that supported self-management. The program encouraged local collaboration that enabled continuation of the program. CONCLUSIONS: Local support from health professionals and participants provided strong motivation for attendance; however, the location of the program in a rural setting did not remove all travel barriers. Adhering to the principles of empowerment inherent in a self-management approach to rehabilitation meant accepting fluctuating attendance as individuals managed priorities in their lives.

Enhancing self-efficacy for self-management in people with cystic fibrosis.

This paper reports on a research trial designed to evaluate the benefits of a health mentoring programme supported with a web and mobile phone based self-monitoring application for enhancing self-efficacy for self-management skills and quality of life for people with CF. This randomised, single-blind controlled trial evaluated two strategies designed to improve self-management behaviour and quality of life. Task-specific self-efficacy was fostered through mentorship and self-monitoring via a mobile phone application. Trial participants were randomised into one of three groups: Control, Mentor-only and Mentor plus mobile phone. Analysis and discussion focus on the experiences of participants through a methodology utilising descriptive statistics and semi-structured interviews. The results highlight the challenges of stimulating self-management behaviours particularly in adolescents and in the evaluation of the role of mobile applications in supporting them.

Pathways Home: comparing voluntary IT and non-IT users participating in a mentored self-management project.

This research paper examines the challenges in the development and adoption of an electronic patient diary within the Pathways Home for Respiratory Illness Project. This project supported community-based patients suffering from chronic obstructive pulmonary disease (COPD) to achieve increased levels of self-management and self-efficacy using electronic-monitoring techniques and mentoring by community health nurses. Participants had the option of voluntarily adopting an electronic patient diary to support their self-monitoring, which provided patients, nurses and clinicians with access to symptom and psycho-social data. This aimed to improve the identification, comprehension and initiation of early action in relation to alterations in their conditions. The paper presents data on technology adoption, electronic diary usage and, self-reported data quality, as well as examining the impact of the technology on hospitalisations (frequency and duration). The participants who chose to use the online patient diary continued their involvement with the project for the entire trial period (85% vs 54% completion). Participants were more likely to maintain use of the online patient diary than the paper diary. Both the groups experienced a positive improvement in their self-efficacy to self-manage their condition scores. The data highlight the problems implicit in some of the assumptions underpinning existing information systems models, especially in evaluating impact and the end-points presumed to be relevant in systems development life cycles.

Transforming clinical practice amongst community nurses: mentoring for COPD patient self-management.

AIMS AND OBJECTIVES: To report on the process of transforming clinical practice amongst community nurses through a mentoring programme implemented to support self-management amongst community-based sufferers of chronic obstructive pulmonary disease. BACKGROUND: The increasing incidence of and health burden from, chronic diseases has led to the emergence of more proactive, integrated chronic disease management approaches across the acute and primary care sectors. An important part of these approaches is the direct involvement of patients in their own care. Despite some difficulties with comparing the benefits of chronic disease self-management programmes, many evaluations report some benefit and all highlight the importance of health professionals in supporting self-management behaviours. In the primary care sector, community nurses are ideally situated to support these behaviours, but to do this effectively transformation of nursing practice must occur. DESIGN: Qualitative, longitudinal study informed by action research methods and involving monthly group discussions with community nurse mentors. METHODS: Community nurses from four community health centres in Tasmania were trained in motivational interviewing techniques to promote self-management amongst chronic obstructive pulmonary disease patients. Nurses' mentoring experiences were monitored during group discussions and subjected to thematic analysis. RESULTS: The paper reports the findings of the first 12 months of the project. In this phase, nurses experienced a transformation in their constructions of chronic obstructive pulmonary disease and their clinical practice. This involved a shift from a fatalistic, prescriptive, biomedical approach to a primary healthcare approach characterised by empathy, consultation, facilitation and a holistic focus. CONCLUSIONS: Community nurses face challenges in supporting chronic disease self-management. These challenges can be overcome and a transformation in clinical practice instilled. RELEVANCE TO CLINICAL PRACTICE: This study highlights that it is possible to support community nurses to take a lead role in the ongoing management of chronic disease in the community.