Does an integrated care intervention for COPD patients have long-term effects on quality of life and patient activation? A prospective, open, controlled single-center intervention study

Background Implementation of the COPD-Home integrated disease management (IDM) intervention at discharge after hospitalizations for acute exacerbations of COPD (AECOPD) led to reduced hospital utilization during the following 24 months compared to the year prior to study start. Aims To analyze the impact of the COPD-Home IDM intervention on health related quality of life, symptoms of anxiety and depression, and the degree of patient activation during 24 months of follow-up and to assess the association between these outcomes. Methods A single center, prospective, open, controlled clinical study. Changes in The St. George Respiratory Questionnaire (SGRQ), the Hospital anxiety (HADS-A) and depression (HADS-D) and the patient activation measure (PAM) scores were compared between the patients in the integrated care group (ICG) and the usual care group (UCG) 6, 12 and 24 months after enrolment. Results The questionnaire response rate was 80–96%. There were no statistically significant differences in the change of the SGRQ scores between the groups during follow up. After 12 months of follow-up there was a trend towards a reduction in the mean HADS–A score in the ICG compared to the UCG. The HADS-D scores remained stable in the ICG compared with an increasing trend in the UCG. Clinically significant difference in the PAM score was achieved only in the ICG, 6.7 (CI95% 0.7 to 7.5) compared to 3.6 (CI95% -1.4 to 8.6) in the UCG. In a logistic regression model a higher HADS-D score and current smoking significantly increased the odds for a low PAM score.publishedVersio

What determines subjective health status in patients with chronic obstructive pulmonary disease: importance of symptoms in subjective health status of COPD patients

<p>Abstract</p> <p>Background</p> <p>Subjective health status is the result of an interaction between physiological and psychosocial factors in patients with chronic obstructive pulmonary disease (COPD). However, there is little understanding of multivariate explanations of subjective health status in COPD. The purpose of this study was to explore what determines subjective health status in COPD by evaluating the relationships between background variables such as age and sex, predicted FEV₁%, oxygen saturation, breathlessness, anxiety and depression, exercise capacity, and physical and mental health.</p> <p>Methods</p> <p>This study had a cross-sectional design, and included 100 COPD patients (51% men, mean age 66.1 years). Lung function was assessed by predicted FEV₁%, oxygen saturation by transcutaneous pulse oximeter, symptoms with the St George Respiratory Questionnaire and the Hospital Anxiety and Depression Scale, physical function with the Incremental Shuttle Walking Test, and subjective health status with the SF-36 health survey. Linear regression analysis was used.</p> <p>Results</p> <p>Older patients reported less breathlessness and women reported more anxiety (p < 0.050). Women, older patients, those with lower predicted FEV₁%, and those with greater depression had lower physical function (p < 0.050). Patients with higher predicted FEV₁%, those with more breathlessness, and those with more anxiety or depression reported lower subjective health status (p < 0.050). Symptoms explained the greatest variance in subjective health status (35%–51%).</p> <p>Conclusion</p> <p>Symptoms are more important for the subjective health status of patients with COPD than demographics, physiological variables, or physical function. These findings should be considered in the treatment and care of these patients.</p

Distinct pain profiles in patients with chronic obstructive pulmonary disease

Background: Few studies have examined changes in the pain experience of patients with COPD and predictors of pain in these patients. Objectives: The objectives of the study were to examine whether distinct groups of COPD patients could be identified based on changes in the occurrence and severity of pain over 12 months and to evaluate whether these groups differed on demographic, clinical, and pain characteristics, and health-related quality of life (HRQoL). Patients and methods: A longitudinal study of 267 COPD patients with very severe COPD was conducted. Their mean age was 63 years, and 53% were females. The patients completed questionnaires including demographic and clinical variables, the Brief Pain Inventory, and the St Georges Respiratory Questionnaire at enrollment, and 3, 6, 9, and 12 months follow-up. In addition, spirometry and the 6 Minute Walk Test were performed. Latent class analysis was used to identify subgroups of patients with distinct pain profiles based on pain occurrence and worst pain severity. Results: Most of the patients (77%) reported pain occurrence over 12 months. Of these, 48% were in the “high probability of pain” group, while 29% were in the “moderate probability of pain” group. For the worst pain severity, 37% were in the “moderate pain” and 39% were in the “mild pain” groups. Females and those with higher body mass index, higher number of comorbidities, and less education were in the pain groups. Patients in the higher pain groups reported higher pain interference scores, higher number of pain locations, and more respiratory symptoms. Few differences in HRQoL were found between the groups except for the symptom subscale. Conclusion: Patients with COPD warrant comprehensive pain management. Clinicians may use this information to identify those who are at higher risk for persistent pain.publishedVersio

Comparison of pre- and post-bronchodilator lung function as predictors of mortality:The HUNT Study

Background and objective Post‐bronchodilator (BD) lung function is recommended for the diagnosis of chronic obstructive pulmonary disease (COPD). However, often only pre‐BD lung function is used in clinical practice or epidemiological studies. We aimed to compare the discrimination ability of pre‐BD and post‐BD lung function to predict all‐cause mortality. Methods Participants aged ≥40 years with airflow limitation (n = 2538) and COPD (n = 1262) in the second survey of the Nord‐Trøndelag Health Study (HUNT2, 1995–1997) were followed up until 31 December 2015. Survival analysis and time‐dependent area under the receiver operating characteristic curves (AUC) were used to compare the discrimination ability of pre‐BD and post‐BD lung function (percent‐predicted forced expiratory volume in the first second (FEV1) (ppFEV1), FEV1 z‐score, FEV1 quotient (FEV1Q), modified Global Initiative for Chronic Obstructive Lung Disease (GOLD) categories or GOLD grades). Results Among 2538 participants, 1387 died. The AUC for pre‐BD and post‐BD ppFEV1 to predict mortality were 60.8 and 61.8 (P = 0.005), respectively, at 20 years' follow‐up. The corresponding AUC for FEV1 z‐score were 58.5 and 60.4 (P < 0.001), for FEV1Q were 68.7 and 70.1 (P = 0.002) and for modified GOLD categories were 62.3 and 64.5 (P < 0.001). Among participants with COPD, the AUC for pre‐BD and post‐BD ppFEV1 were 57.0 and 58.8 (P < 0.001), respectively. The corresponding AUC for FEV1 z‐score were 53.1 and 55.8 (P < 0.001), for FEV1Q were 63.6 and 65.1 (P = 0.037) and for GOLD grades were 56.0 and 57.0 (P = 0.268). Conclusion Mortality was better predicted by post‐BD than by pre‐BD lung function; however, they differed only by a small margin. The discrimination ability using GOLD grades among COPD participants was similar

Collaboration between municipal and specialist public health care in tuberculosis screening in Norway

Background: About 90% of new tuberculosis (TB) cases in Norway appear among immigrants from high incidence countries. There is a compulsory governmental tuberculosis screening programme for immigrants; immigrants with positive screening results are to be referred from municipal health care to the specialist health care for follow-up. Recent studies of the screening programme have shown inadequate follow-up. One of the main problems has been that patients referred for follow-up have not attended their appointment at the specialist health care. TB screening in the municipality of Trondheim is done by two different teams: the Refugee Healthcare Centre (RHC) screens refugees and the Vaccination and Infection Control Office (VICO) screens all the other groups. Patients with positive findings on screening are referred to the hospital’s Pulmonary Out-patient Department (POPD). The municipal and referral level public health care initiated a project aiming to improve follow-up through closer collaboration. Methods: An intervention group and a pre-intervention control group were established for each screening group. During meetings between staff from the municipality and the POPD, inadequacies in the screening process were identified, and changes in procedures for summoning patients, and time and place for tests were implemented. For both the intervention group and the control group, time from referral until consultation at the POPD and number of patients that attended their first appointment were registered and compared. Results: In the VICO group, 97/134 (72%) of the controls and 109/123 (89%) of the intervention group attended their first appointment at the POPD after 30 weeks (median) and 10 weeks, respectively. In the RHC group 28/46 (61%) of the controls and 55/59 (93%) in the intervention group attended their first appointment after 15 and 8 weeks (median) respectively. Conclusion: Increased collaboration between the municipal and specialist health care can improve the follow-up of positive TB screening results. Keywords: Tuberculosis, Screening, Asylum seekers, Refugees, Contact tracing, Collaboration

Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: A single centre controlled study

Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality globally. In Trondheim in 2008 an integrated care model (COPD-Home) consisting of an education program, self-management plan, home visits and a call centre for patient support and communication was developed. The objective was to determine the efficacy of an intervention according to the COPD-Home model in reducing hospital utilization among patients with COPD stage III and IV (GOLD 2007) discharged after hospitalization for acute exacerbations of COPD (AECOPD). Methods A single centre, prospective, open, controlled clinical study comparing COPD-Home integrated care (IC) with usual care (UC). Results Ninety-one versus 81 patients mean age 73.4 ± 9.3 years (57% women) were included in the IC group (ICG) and the UC group (UCG) respectively, and after 2 years 51 and 49 patients were available for control in the respective groups. During the year prior to study start there were 71 hospital admissions (HA) in the ICG and 84 in the UCG. There was a 12.6% reduction in HA in the ICG during the first year of follow-up and a 46.5% reduction during the second year (p = 0.01) compared to an 8.3% increase during the first year and no change during the second year in the ICG. During the year prior to study start, the number of hospital days (HD) was 468 in the ICG and 479 in the UCG. In the IC group, the number of HD was reduced by 48.3% during the first year (p = 0.01), and remained low during the second year of follow-up (p=0.02). In the UC group, the number of HD remained unchanged during the follow-up period. There was a trend towards a shorter survival time among patients in the ICG compared to the UCG, hazard ratio 1.33 [95% CI 0.77 to 2.33]. Conclusion Intervention according to the COPD-Home model reduced hospital utilization in patients with COPD III and IV with a persisting effect throughout the 2 years of follow-up. However, there was a trend towards a shorter survival time in the intervention group

Changes in and predictors of pain and mortality in patients with chronic obstructive pulmonary disease

This longitudinal study of patients with chronic obstructive pulmonary disease (COPD) aimed to investigate changes in pain characteristics (i.e., occurrence, intensity, and interference) and covariates associated with pain from study enrollment to 12 months, and to investigate if the different pain characteristics were associated with 5-year mortality. In total, 267 patients with COPD completed questionnaires five times over 1 year. The mean age of the patients was 63 years (standard deviation: 9.0), 53% were women, and 46% had very severe COPD. Median number of comorbidities was 2.0 (range: 0–11) and 47% of patients reported back/neck pain. Mixed models and Cox regression models were used for analyses. In total, 60% of the patients reported pain at baseline, and 61% at 12 months. The mixed model analyses revealed that those with better forced expiratory volume in 1 second (% predicted), more comorbidities, only primary school education, and more respiratory symptoms reported significantly higher average pain intensity. Moreover, those with more comorbidities, more respiratory symptoms, and more depression reported higher pain interference with function. At the 5-year follow-up, 64 patients (24%) were deceased, and the cumulative 5-year mortality rate was 22% (95% confidence interval [19–25]). Older age, lower forced expiratory volume in 1 second (% predicted), and higher pain interference at enrollment were all independently and significantly associated with higher 5-year mortality. Our findings show that many patients with COPD have persistent pain, and awareness regarding comorbidities and how pain interferes with their lives is needed.acceptedVersio

Comparison of procalcitonin, C-reactive protein, white blood cell count and clinical status in diagnosing pneumonia in patients hospitalized with acute exacerbations of COPD: A prospective observational study

Lower respiratory tract infection is the most common cause of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of the present study was to compare the accuracy of procalcitonin (PCT), C-reactive protein (CRP) and white blood cell count (WBC) as single diagnostic tests and in combination with clinical signs and symptoms to diagnose pneumonia in patients hospitalized with AECOPD. This was a prospective, single centre observational study. Patients with spirometry-confirmed COPD who were hospitalized due to AECOPD were consecutively recruited at the hospital’s Emergency Unit. Pneumonia was defined as a new pulmonary infiltrate on chest X-ray. The values of PCT, CRP and WBC were determined at admission. Receiver operating characteristic (ROC) curve analysis was used to study the accuracy of various diagnostic tests. Of the 113 included patients, 35 (31%) had pneumonia at admission. Area under the ROC curve (AUC) for PCT, CRP and WBC as a single test to distinguish between patients with and without pneumonia was 0.67 (95% CI 0.55–0.79), 0.73 (95% CI 0.63–0.84) and 0.67 (95% CI 0.55–0.79), respectively (p = 0.42 for the test of difference). The AUC for a model of clinical signs and symptoms was 0.84 (95% CI 0.76–0.92). When biomarkers were added to the clinical model, the AUCs of the combined models were not significantly different from that of the clinical model alone (p = 0.54). PCT had about the same accuracy as CRP and WBC in predicting pneumonia in patients hospitalized with AECOPD both as a single test and in combination with clinical signs and symptoms

Distinct symptom experiences in subgroups of patients with COPD

This is an open access article originally published in the International Journal of COPD.Background: In addition to their respiratory symptoms, patients with COPD experience multiple, co-occurring symptoms. Objectives: The aims of this study were to identify subgroups of COPD patients based on their distinct experiences with 14 symptoms and to determine how these subgroups differed in demographic and clinical characteristics and disease-specific quality of life. Patients and methods: Patients with moderate, severe, and very severe COPD (n = 267) completed a number of self-report questionnaires. Latent class analysis was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of self-reported symptoms using the Memorial Symptom Assessment Scale. Results: Based on the probability of occurrence of a number of physical and psychological symptoms, three subgroups of patients (ie, latent classes) were identified and named “high”, “intermediate”, and “low”. Across the three latent classes, the pairwise comparisons for the classification of airflow limitation in COPD were not significantly different, which suggests that measurements of respiratory function are not associated with COPD patients’ symptom burden and their specific needs for symptom management. While patients in both the “high” and “intermediate” classes had high occurrence rates for respiratory symptoms, patients in the “high” class had the highest occurrence rates for psychological symptoms. Compared with the “intermediate” class, patients in the “high” class were younger, more likely to be women, had significantly more acute exacerbations in the past year, and reported significantly worse disease-specific quality of life scores. Conclusion: These findings suggest that subgroups of COPD patients with distinct symptom experiences can be identified. Patients with a higher symptom burden warrant more detailed assessments and may have therapeutic needs that would not be identified using current classifications based only on respiratory function