Facilitators and Barriers of Adherence to Multi-Disease Exacerbation Action Plans in COPD Patients - A Qualitative Study.

Whereas exacerbation action plans to self-manage Chronic Obstructive Pulmonary Disease (COPD) significantly improve health outcomes, patients' adherence to those action plans is often poor. This study aimed to identify facilitators and barriers of adherence to tailored multi-disease exacerbation action plans. We also explored patients' perspectives toward disease management roles. Individual semi-structured interviews were conducted with a sample of COPD patients who completed a Dutch-Australian self-management intervention evaluating tailored exacerbation action plans for COPD and relevant comorbidities. Interviews were thematically analyzed using a deductive approach guided by the Capability, Opportunity and Motivation of Behavior (COM-B) model. In 2016, ten patients (5 Australian; 5 Dutch; 6 men; age 59-83 years) were interviewed at the end of their one-year follow-up. Facilitators of adherence included improved patients' comprehension of disease and treatment, positive feelings about the intervention, improved self-confidence, and professional support. Barriers included difficulties to recognize symptoms, dislike toward daily symptom monitoring, negative feelings about the intervention, negative mood state, and complexity of symptom diaries and action plans. Patients indicated three distinctive perspectives of their own and their healthcare professional's role in their disease management: 1) patients felt mainly responsible; 2) patients felt shared responsibility with their healthcare professional; and 3) patients felt not responsible as they perceived their healthcare professional to be mainly responsible. We successfully used the COM-B model as a guide to identify facilitators and barriers of patients' adherence to multi-disease exacerbation action plans. Improving patients' adherence in future self-management interventions by targeting specific facilitators or barriers should be considered.

COPD care in Saudi Arabia: physicians' awareness and knowledge of guidelines and barriers to implementation.

OBJECTIVE: To assess Saudi physicians' awareness and knowledge about chronic obstructive pulmonary disease (COPD) guideline recommendations. METHODS: Cross-sectional study including physicians involved in COPD care in five hospitals in the Eastern Province of Saudi Arabia. The level of physicians' knowledge was considered as satisfactory (score > 80%), fair (score 50-80%) or poor (<50% of total score). RESULTS: Among the 44 physicians included in the study, the mean ± standard deviation knowledge score was 29.5 ± 4.2 out of 45 points (65.5%). Most physicians appeared to be unaware of any COPD guidelines (n = 27, 61.4%), and reported not adhering to guidelines (n = 28, 63.6%). CONCLUSION: Saudi physicians' knowledge about Global Initiative for Chronic Obstructive Lung Disease guidelines was assessed as fair. It is therefore highly recommended to increase physicians' awareness and knowledge about COPD-related guidelines.

(Cost)-effectiveness of self-treatment of exacerbations on the severity of exacerbations in patients with COPD: the COPE II study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a chronic disease with a high prevalence and rapidly increasing incidence rates. The effect of self-treatment of COPD exacerbations on the severity of exacerbations during a 1-year period was examined and a cost-effectiveness analysis was performed. METHODS: Patients were randomly allocated to four 2-hour self-management sessions, with or without training in self-treatment of exacerbations. Patients in the self-treatment group received an action plan with the possibility to initiate a course of prednisolone (with or without antibiotics). During follow-up, all participants kept a daily symptom diary. These provided the data to calculate the frequency of exacerbations, the number of exacerbation days and mean daily severity scores. RESULTS: Data were analysed for 142 randomised patients (self-treatment: n = 70; control: n = 72). The frequency of exacerbations was identical in both study groups (mean (SD) 3.5 (2.7)). Patients in the self-treatment group reported fewer exacerbation days (median 31 (interquartile range (IQR) 8.9-67.5) in the self-treatment group vs 40 (IQR 13.3-88.2) in the control group; p = 0.064); the difference was significant in the group of patients with a high number of exacerbation days per year (>137 (90th percentile of the whole study population); p = 0.028). The mean severity score of an exacerbation day was equal in both groups. No between-group differences were found in health-related quality of life. Cost-effectiveness analyses showed that applying self-treatment saved euro154 per patient, with a trend towards a lower probability for hospital admissions (0.20/patient/year in the self-treatment group vs 0.33/patient/year in the control group; p = 0.388) and a significant reduction of health care contacts (5.37/patient/year in the self-treatment group vs 6.51/patient/year in the control group; p = 0.043). CONCLUSION: Self-treatment of exacerbations incorporated in a self-management programme leads to fewer exacerbation days and lower costs.

Self-management education for patients with chronic obstructive pulmonary disease.

BACKGROUND: There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterised by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. Self-management is a term applied to educational programmes aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. In COPD, the value of self-management education is not yet clear. The first Cochrane review about self-management was published in 2003. It was intended to shed light on the effectiveness of self-management programmes in COPD and the relative efficacy of their constitutive elements. No conclusions about the effectiveness of self-management could be drawn because of the large variation in outcome measures used in the limited number of included studies. This article describes the first update of this review. OBJECTIVES: The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programmes on health outcomes and use of health care services. SEARCH STRATEGY: We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences. SELECTION CRITERIA: Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on pulmonary rehabilitation and studies without usual care as a control group were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information. MAIN RESULTS: The reviewers included 15 group comparisons drawn from 14 trials. They assessed a broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 0.89)). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD -2.58; 95% CI (-5.14 to -0.02)) and impact domain (WMD -2.83; 95% CI (-5.65 to -0.02)), but these difference did not reach the clinically relevant improvement of 4 points. A small but significant reduction was detected in dyspnoea measured with the BORG-scale (WMD -0.53; 95% CI (-0.96 to -0.10)). No significant effects were found either in number of exacerbations, emergency department visits, lung function, exercise capacity, and days lost from work. Inconclusive results were observed in doctor and nurse visits, on symptoms other than dyspnoea, the use of courses of oral corticosteroids and antibiotics, and the use of rescue medication. AUTHORS' CONCLUSIONS: It is likely that self-management education is associated with a reduction in hospital admissions with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending self-management education in COPD. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.

Body weight-supported treadmill training in chronic incomplete spinal cord injury: a pilot study evaluating functional health status and quality of life.

STUDY DESIGN: A controlled single-case design: A1 (baseline: 6 weeks), B (intervention: 12 weeks of treadmill training (TT), maximally five times a week/30 min a day), A2 (wash-out: 6 weeks), follow-up measurement: 6 months. OBJECTIVE: To investigate the effects of TT on functional health status (FHS) and quality of life (QoL) in subjects with a chronic incomplete spinal cord injury (ISCI). SETTING: Rehabilitation Department, University Medical Centre Utrecht, The Netherlands. METHODS: Three male subjects with a stable (>48 months postinjury) ISCI, American Spinal Injury Association (ASIA) class C (n=2) and D (n=1). Performance-based walking, subject's perception concerning quality of life (SEIQoL) and activities of daily living Canadian Occupational Performance Measure (COPM). RESULTS: The results of the three subjects were variable. Changes in QoL were relatively small and diverse. After 6 months' follow-up, QoL was unchanged in subjects 1 and 2, and improved in subject 3. In subject 2, performance of activities of daily living (ADL) was significantly improved, consistent with his perception of improvement (P<0.05), and this improvement was sustained throughout the follow-up period. Walking ability improved in subject 3 (P<0.05) but performance of other activities remained stable. Performance of ADL decreased slightly in subject 1 whereas his walking speed and Get up and Go performance improved (P<0.05). CONCLUSIONS: This study demonstrates positive effects of TT on FHS. A randomised clinical trial should be executed before definite conclusions about the effect of TT on FHS and QoL can be drawn. SPONSORSHIP: KF Hein Foundation and Rehabilitation Centre De Hoogstraat Scientific Foundation.