Fidelity of primary care nurses' delivery of a behavioural change intervention enhancing physical activity in patients at risk of cardiovascular disease: an observational study

Objective To evaluate the fidelity of delivery of a nurse-led intervention to enhance physical activity in patients at risk for cardiovascular diseases, the Activate intervention, by assessing: (1) self-reported fidelity of delivery; (2) observed fidelity of delivery; (3) quality of delivery of the Activate intervention and (4) nurses' beliefs about their capability, motivation, confidence and effectiveness towards delivering the Activate intervention, including behavioural change techniques.Design An observational study.Setting General practices in the Netherlands.Participants Primary care nurses (n=20) from 16 general practices.Primary and secondary outcome measures Nurses' self-reported fidelity was evaluated using checklists (n=282), and the observed fidelity and quality of delivery were examined using audiorecordings of consultations of the delivery of the Activate intervention (n=42). Nurses' beliefs towards delivering the intervention were assessed using questionnaires (n=72).Results The self-reported fidelity was 88.1% and observed fidelity was 85.4%, representing high fidelity. The observed fidelity of applied behavioural change techniques was moderate (75.0%). The observed quality of delivery was sufficient and varied among nurses (mean 2.9; SD 4.4; range 0-4). Nurses' beliefs about their capability, motivation, confidence and effectiveness towards delivering the intervention increased over time.Conclusions Nurses delivered most intervention components as intended with sufficient quality. Nurses believed they were capable, motivated and confident to deliver the intervention. They believed the intervention was effective to increase patients' physical activity level. Despite the high fidelity and moderate fidelity of applied behavioural change techniques, the varying quality of delivery within and across nurses might have diluted the effectiveness of the Activate intervention.Cardiolog

SAFE@HOME: Digital health platform facilitating a new care path for women at increased risk of preeclampsia – A case-control study

Objective: In women at risk of developing preeclampsia, we evaluated the use of a digital health platform for telemonitoring blood pressure and symptoms combined with a minimal antenatal visit schedule. Study design: A case-control study for women with chronic hypertension, history of preeclampsia, or maternal cardiac or kidney disease. A care path was designed with reduced visits enhanced with a digital platform (SAFE@HOME) for daily blood pressure and symptom monitoring starting from 16 weeks of gestation. Homemeasurements were monitored in-hospital by obstetric professionals, taking actions upon alarming results. This prospective SAFE@HOME group was compared to a retrospective control group managed without self-monitoring. Main outcome measures: Primary: healthcare consumption (number of antenatal visits, ultrasounds, admissions and diagnostics), user experiences of the platform. Secondary: mate

Self-management and early detection of exacerbations in patients with COPD

Exacerbations of COPD are a major global importance. They have a profound negative effect on patients, resulting in poor health status; they accelerate the progression of the disease; and account for a large proportion the increasing healthcare spending on COPD. Yet, controversies remain over the definition of exacerbations, how they should be monitored and their underlying mechanisms. Early recognition of exacerbations and prompt treatment (decreased treatment delay) have shown to ameliorate recovery while improving health-related quality of life and reducing the risk of hospital admission. This thesis deals with different aspects of exacerbations, i.e. definitions, self-management behaviour during periods of symptom-aggravation and potential methods to enhance early detection and treatment of such events. To answer our main research questions we performed two systematic reviews, and three prospective cohort studies including a multicenter randomized trial (ACZiE study). In summary the main conclusions and recommendations were: 1) There is insufficient evidence to distinguish ‘harmless’ subtypes of exacerbations not necessitating anticipation by patients or healthcare providers. For now, current practice guidelines, indicating prompt recognition and treatment of each exacerbation, should be followed. 2) An individualized action plan is a low-burden intervention, which accelerates exacerbation recovery, severity and impact of exacerbations on health status. 3) Action plans are clearly not single-moment paper interventions, but concerns an individually tailored and dynamic process of systematic updates and reinforcement. Effective implementation requires a designated case-manager and clear arrangements between patients and healthcare providers. 4) Although evidence for effectiveness of telemedicine interventions is still relatively scarce, partly due to high heterogeneity of interventions, it has shown to be feasible in patients with COPD. Current technological developments provide an almost infinite variety of flexible solutions to closely monitor patients’ health status and to provide remote self-management support. 5) Strategies to enhance early detection and prompt treatment of exacerbations should be individually tailored. The pivotal objective remains to change patient behaviour for better disease control, and adequate anticipation in the event of an exacerbation. However, for certain sub-populations of patients this might not be sufficient and additional treatment modalities (surveillance / monitoring) might be indicated or should be augmented (self-management support / reinforcement). Future research implications were: 1) Before concluding EXACT-PRO to be the new ‘golden standard’, prospective studies are needed to evaluate its diagnostic properties in assessing exacerbation onset, covering the heterogeneity of COPD and its exacerbations. In absence of a ‘golden standard’, future prospective trials should assess exacerbations using the modified Anthonisen algorithm, completed by event–based counts. 2) To ensure optimal validity of diary-based exacerbation assessment, at least five vital requirements should be met (general discussion). 3) In addition to the importance of exacerbation frequency, future trials evaluating effectiveness of new treatments should also include severity, duration and health status impact. 4) Future trials are needed to compare simple and more sophisticated (tele-)monitoring modalities. Evaluation of effectiveness should also include exacerbation-related outcome: frequency, severity, duration and treatment-delay

Systematic review of the effects of chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease

SummaryIntroductionChronic disease management for patients with chronic obstructive pulmonary disease (COPD) may improve quality, outcomes and access to care.ObjectiveTo investigate effectiveness of chronic disease management programmes on the quality-of-life of people with COPD.MethodsMedline and Embase (1995–2005) were searched for relevant articles, and reference lists and abstracts were searched for controlled trials of chronic disease management programmes for patients with COPD. Quality-of-life was assessed as an outcome parameter. Two reviewers independently reviewed each paper for methodological quality and extracted the data.ResultsWe found 10 randomized-controlled trials comparing chronic disease management with routine care. Patient populations, health-care professionals, intensity, and content of the intervention were heterogeneous. Different instruments were used to assess quality of life. Five out of 10 studies showed statistically significant positive outcomes on one or more domains of the quality of life instruments. Three studies, partly located in primary care, showed positive results.ConclusionsAll chronic disease management projects for people with COPD involving primary care improved quality of life. In most of the studies, aspects of chronic disease management were applied to a limited extent. Quality of randomized-controlled trials was not optimal. More research is needed on chronic disease management programmes in patients with COPD across primary and secondary care

Determinants of activation for self-management in patients with COPD

Background: COPD self-management is a complex behavior influenced by many factors. Despite scientific evidence that better disease outcomes can be achieved by enhancing self-management, many COPD patients do not respond to self-management interventions. To move toward more effective self-management interventions, knowledge of characteristics associated with activation for self-management is needed. The purpose of this study was to identify key patient and disease characteristics of activation for self-management. Methods: An explorative cross-sectional study was conducted in primary and secondary care in patients with COPD. Data were collected through questionnaires and chart reviews. The main outcome was activation for self-management, measured with the 13-item Patient Activation Measure (PAM). Independent variables were sociodemographic variables, self-reported health status, depression, anxiety, illness perception, social support, disease severity, and comorbidities. Results: A total of 290 participants (age: 67.2±10.3; forced expiratory volume in 1 second predicted: 63.6±19.2) were eligible for analysis. While poor activation for self-management (PAM-1) was observed in 23% of the participants, only 15% was activated for self-management (PAM-4). Multiple linear regression analysis revealed six explanatory determinants of activation for self-management (P,0.2): anxiety (β: -0.35; -0.6 to -0.1), illness perception (β: -0.2; -0.3 to -0.1), body mass index (BMI) (β: -0.4; -0.7 to -0.2), age (β: -0.1; -0.3 to -0.01), Global Initiative for Chronic Obstructive Lung Disease stage (2 vs 1 β: -3.2; -5.8 to -0.5; 3 vs 1 β: -3.4; -7.1 to 0.3), and comorbidities (β: 0.8; -0.2 to 1.8), explaining 17% of the variance. Conclusion: This study showed that only a minority of COPD patients is activated for self-management. Although only a limited part of the variance could be explained, anxiety, illness perception, BMI, age, disease severity, and comorbidities were identified as key determinants of activation for self-management. This knowledge enables health care professionals to identify patients at risk of inadequate self-management, which is essential to move toward targeting and tailoring of self-management interventions. Future studies are needed to understand the complex causal mechanisms toward change in self-managemen