Bremner, SA

Devine, A

Eldridge, S

Griffiths, CJ

Sohanpal, R

Taylor, SJC

Thorax

English

Queen Mary Research Online

PILOT RANDOMISED CONTROLLED TRIAL OF A 7-WEEK DISEASE-SPECIFIC SELF-MANAGEMENT PROGRAMME FOR PATIENTS WITHCOPD: BELLA (BETTER LIVING WITH LONG TERM AIRWAYSDISEASE STUDY)Taylor, SJC; Sohanpal, R; Bremner, SA; Devine, A; Eldridge, S; Griffiths, CJ       For additional information about this publication click this link.http://qmro.qmul.ac.uk/jspui/handle/123456789/1005   Information about this research object was correct at the time of download; we occasionallymake corrections to records, please therefore check the published record when citing. Formore information contact scholarlycommunications@qmul.ac.uk 2009;64;A95-A97 Thorax     Current strategies in pulmonary rehabilitation http://thorax.bmj.com/cgi/content/full/64/Suppl_4/A95Updated information and services can be found at:  These include: serviceEmail alertingthe top right corner of the article Receive free email alerts when new articles cite this article - sign up in the box atTopic collections (9778 articles) Clinical trials (epidemiology)  (19801 articles) General practice / family medicine   Articles on similar topics can be found in the following collections  Notes    http://journals.bmj.com/cgi/reprintformTo order reprints of this article go to:  http://journals.bmj.com/subscriptions/ go to: ThoraxTo subscribe to  on 3 December 2009 thorax.bmj.comDownloaded from areas of good practice have been identified. The data presented heremap the current and proposed areas of good practice against theGold Standards Framework (GSF)1 which has been adopted as abuilding block towards cohesive palliative care service provision.Methods The 2008 national audit of hospital COPD care included asurvey of resources and organisation of care within which was a freetext box to describe current examples of good practice and proposedservice developments. These elements were mapped against theseven key standards from the GSF. All 184 acute trusts admittingCOPD exacerbations from the four countries of the UK wereincluded in the survey during the spring of 2008.Results 180 NHS acute trusts (98% of those eligible) comprising 239hospital units completed the survey. Mapping the examples ofpractice identified against the seven key GSF standards revealedcurrent and proposed service development is focused on threestandards alone while others are neglected. The following stan-dards—control of symptoms (eg, guideline development andadvance care planning), care in the dying phase (eg, use of theLiverpool care pathway) and continued learning (eg, COPD teamslearning palliative care skills) were identified as areas of develop-ment, both current and proposed. Other standards such ascommunication, co-ordination, support for carers and continuityof care including out-of-hours and advance planning for reductionin crisis admissions have, to date, been overlooked.Conclusions Palliative care service provision for COPD patientsremains in its infancy with current service development predomi-nantly focusing on three of the seven key standards recommendedin the GSF. If a successful holistic palliative care service is to beprovided, those involved in COPD end-of-life care need to widen thescope of their current thinking.1. Thomas K, Department of Health. Gold Standards Framework: a programme forcommunity palliative care. 2005. www.goldstandardsframework.nhs.uk.P49 COPD CASE-FINDING PILOT EVALUATION: ‘‘FINDING OURMISSING THOUSANDS’’L Chandler, H Laird, L Wheater, E Smith, SPL Meghjee. NHS Wakefield District,Wakefield, UKdoi:10.1136/thx.2009.127134wAim Early detection of chronic obstructive pulmonary disease(COPD) is critical in order to reduce the burden of disease on theindividual and to reduce costs on the wider health economy.However, patients often present late in the disease process. The useof screening spirometry for symptomatic patients in communityhealth settings has been proposed as a mechanism for increasingaccess to advice and information and the earlier identification ofCOPD in a wider population. This pilot aimed to evaluate the use ofa screening tool and screening spirometer in community settings tosupport case finding of symptomatic COPD patients.Methods Five GP practices, five pharmacies and the NHS Quit Shopacted as recruitment sites. Patients who presented at the sites wererecruited to the pilot and asked to complete a screening questionnaire.Patients who met selection criteria completed screening spirometry.All patients were given information and those with abnormal resultsreferred to their GP. Patient satisfaction questionnaires were sent toall service users and a focus group held for pilot sites.Results 377 people underwent assessment, 106 (28.2%) were referredfor diagnostic spirometry and 59 (55.7%) attended their GP practices.There was a significant difference between the number of patientsthat were screened at each setting (p = 0.007), with the Quit Shopscreening a higher proportion of patients (40.6%) than GPs (27.6%)and pharmacies (31.8%). No significant difference between theproportions of diagnoses across the three settings was found(p = 0.88). 32 people (53.3%) were diagnosed with COPD, 5 (8.3%)with asthma, 7 (11.7%) with ‘‘other’’ problems and in 16 (26.7%) noproblem was identified. Staff and patient satisfaction surveys werepositive. Staff suggested that the service should continue alongsidestop smoking services in all settings and should be linked withcardiovascular disease risk assessments.Conclusions Overall the pilot appears to have been successful in raisingawareness of COPD in local communities. There remain concernsregarding the number of false positives and the number of patientswho did not go on to attend diagnostic spirometry with their GPpractice. Further work is required to decide whether the service will becommissioned as an ‘‘add on’’ to services already commissioned.P50 SMOKING PREVALENCE AND ATTITUDES IN MEDICALINPATIENTS IN LIVERPOOL1S Huq, 1MI Hasan, 1A Nwosu, 1J Hadcroft, 2M Walshaw. 1Royal Liverpool UniversityHospital, Liverpool, UK; 2Liverpool Heart and Chest Hospital, Liverpool, UKdoi:10.1136/thx.2009.127134xIntroduction Liverpool has a high incidence of smoking-related illnessand higher rates of smokers than the rest of the UK. The ‘‘SmokeFreeLiverpool’’ campaign run by the City Council aims to reduce smokingamong the population. However, ill patients may have a differentperspective. To study this, we compared attitudes towards smokingin medical inpatients with the results of the 2008 ‘‘SmokeFreeLiverpool’’ survey for the general population of Liverpool.Methods A prospective cross-sectional survey of 100 consecutiveinpatients (mean¡SD age 61¡15.5 years, 49 men) on generalmedical wards at the Royal Liverpool University Hospital (an 850-bed facility serving the city of Liverpool) who were able to respondto our questionnaire. Data related to smoking status, smokingbehaviour in household and cars, intention to stop and support forcurrent and possible future smoke-free legislation were gathered.Results Smoking prevalence was higher in medical patientscompared with the general population (39% vs 29%) and theywere more likely to smoke inside housing (36% vs 27%) and vehicles(12% vs 5%). Inpatient smokers were predominantly male (51%male and 27% female patients were smokers) and in the 25–64-yearage group. More smokers in hospital declared their intention to stop(79% vs 55%) and the majority (54% vs 13%) were hopeful ofstopping within a month. Support for the 2007 smoke-freelegislation was higher among the hospitalised smokers (69% vs57%). 91% of respondents (95% of smokers) supported futurelegislation imposing a ban on smoking inside cars with children.Regarding quitting, 67% of inpatient current smokers had receivedmedical advice and 85% had unsuccessful prior attempts (60% usedsome form of pharmacotherapy).Conclusion This survey demonstrates that the prevalence of smokingin Liverpool is higher in hospitalised patients, particularly in men.However, although these individuals expressed a stronger intentionto quit than the normal population, they had found this hard tocarry out. This indicates that the targeting of antismoking resourcesto the hospital sector may produce a better yield in helping patientsto quit this potentially lethal habit.Current strategies in pulmonary rehabilitationP51 PILOT RANDOMISED CONTROLLED TRIAL OF A 7-WEEKDISEASE-SPECIFIC SELF-MANAGEMENT PROGRAMME FORPATIENTS WITH COPD: BELLA (BETTER LIVING WITH LONGTERM AIRWAYS DISEASE STUDY)SJC Taylor, R Sohanpal, SA Bremner, A Devine, S Eldridge, CJ Griffiths. Barts and TheLondon School of Medicine, Queen Mary, University of London, London, UKdoi:10.1136/thx.2009.127134yIntroduction Trials of self-management (SM) interventions forchronic obstructive pulmonary disease (COPD) have often hadPoster sessionsThorax 2009;64(Suppl IV):A75–A174 A95 on 3 December 2009 thorax.bmj.comDownloaded from disappointing results. A recent Cochrane review suggested SM mayreduce hospital admissions but concluded data are still insufficientto formulate recommendations.1Objectives To conduct a pilot randomised controlled trial of a newdisease-specific self-management programme for COPD.Methods The intervention was based on the UK Expert PatientsProgramme (EPP) which is underpinned by the sociocognitive self-efficacy theory.2 It was distinct in three ways: (1) COPD relevantcontent; (2) sessions delivered by a trained lay tutor with COPDwho ‘‘models’’ good SM; (3) involvement of a respiratory clinician(COPD patients have significant information needs). It involvedseven weekly 2.5 h group sessions. Patients were recruited fromprimary care disease registers and randomised (2:1) to interventionor usual care. The St George Respiratory Questionnaire (SGRQ),Hospital Anxiety and Depression Scale (HADS), EQ-5D, exerciselevels and self-efficacy (confidence) to manage COPD were collectedat baseline, 2 and 6 months, as were all costs and healthcareresource use.Results 224 (44%) patients replied to invitation letters and 116(22%) were enrolled and randomised (78 intervention; 38control). 46% were male, mean¡SD age 69.5¡9.8 years, meanforced expiratory volume in 1 s (FEV1)% predicted 54%, 78% hadhad unscheduled COPD care in the previous 12 months. Groupswere roughly similar at baseline. 35% of intervention patientsdid not attend any course sessions, 40% attended 5 or moresessions. The results at 6 months suggest that the interventionmay increase exercise levels by a modest amount and increasehealth-related quality of life as measured by the EQ-5D (nooverall effect on Total SGRQ score was detected) (table 1).Economic analyses suggested that, with a willingness to paythreshold of £10 000 per quality adjusted life year gained(QALY), the intervention would have a 70% probability ofbeing cost effective.Conclusions The intervention may be unappealing or inaccessible tomany patients. Despite this, the pilot study suggests the interven-tion may improve quality of life and is likely to meet NICE criteriafor a cost-effective intervention.1. Effing, 2007.2. Bandura, 1977.P52 RANDOMISED CONTROLLED TRIAL OF A SELF-MANAGEMENTPROGRAMME OF ACTIVITY, COPING AND EDUCATION (SPACE)FOR COPD1LD Apps, 2K Wagg, 2L Sewell, 2J Williams, 1SJ Singh, 2SJ Singh. 1CoventryUniversity, Coventry, UK; 2University Hospitals of Leicester, Leicester, UKdoi:10.1136/thx.2009.127134zSelf-management programmes in chronic obstructive pulmonarydisease (COPD) have been explored with some positive results.However, the recent Cochrane Review (2007) concluded that, whilethere is some evidence for self-management education, furtherresearch was required to provide clear guidelines about its use. Thisstudy is a randomised controlled trial conducted in primary care todetermine the effectiveness of a stand alone self-management manualfor COPD (SPACE for COPD, A Self-management Programme ofActivity, Coping & Education) compared with usual care.Participants were recruited from primary care registers andrandomised to usual care or self-management. The primary outcomemeasure was health status (Self-Reported Chronic RespiratoryQuestionnaire (CRQ-SR)) measured at baseline and 6 weeks.Exercise performance (Incremental Shuttle Walking Test (ISWT)and Endurance Shuttle Walk Test (ESWT)) was recorded as well asscores on the Hospital Anxiety and Depression Scale (HADS).To date, 36 patients have completed measures at 6 weeks, 19 fromusual care (mean (SD) age 71.21 (9.17) years; forced expiratory volumein 1 s (FEV1) 1.45 (0.49) l; 12 men) and 17 from self-management(mean (SD) age 65.41 (10.16) years; FEV1 1.53 (0.62) l; 8 men). Paired ttests were performed and the results are shown in table 1 for alloutcome measures. There were statistically significant improvementsin the self-management group for CRQ-SR domain of dyspnoea with amean change of 0.74. There were no significant changes in thestandard care group in all CRQ-SR domains of dyspnoea, fatigue,emotion and mastery. Mean changes were 0.41, 0.16, 0.23 and 0.10,respectively. Statistically significant between-group differences werefound for ISWT (p,0.01), ESWT (p,0.001), CRQ emotion domainand anxiety (p,0.05). In addition, the CRQ domain of emotionattained the minimal clinically important threshold of .0.5.Abstract P51 Table 1 Outcomes at baseline and 6 months and differences between intervention and controlgroups at 6 months (available case analysis)Control (n = 30) Intervention (n = 61)*Estimateddifference (95% CI)Direction ofeffect favoursBaseline 6 months Baseline 6 monthsSGRQSymptoms 58.0 50.4 54.9 52.5 4.7 (23.0 to 12.4) ControlActivities 57.3 58.7 55.5 53.0 24.8 (211.3 to 1.8) InterventionImpacts 34.4 31.8 36.6 33.9 20.3 (25.1 to 5.7) InterventionTotal score 45.3 43.1 45.4 42.8 20.4 (25.1 to 4.4) InterventionStrengthening exercise (min/week)22.0 9.0 22.6 21.6 12.4 (23.8 to 28.6) InterventionAerobic exercise (min/week) 56.0 43.5 65.7 59.1 10.1 (216.3 to 35.5) InterventionSelf-efficacy to communicatewith doctors8.0 7.7 8.5 8.2 0.2 (20.6 to 1.1) InterventionSelf-efficacy to managedisease7.4 7.8 7.6 7.4 20.5 (21.0 to 0.1) ControlHADSAnxiety 6.7 6.7 6.1 5.7 20.5 (21.8 to 0.9) InterventionDepression 4.8 5.1 5.4 5.7 0.2 (20.8 to 1.3) ControlEQ-5D 0.76 0.57 0.73 0.68 0.12 (20.02 to 0.26) Intervention*Using ANCOVA, regression coefficient of intervention versus control.Poster sessionsA96 Thorax 2009;64(Suppl IV):A75–A174 on 3 December 2009 thorax.bmj.comDownloaded from This shows that it is feasible to deliver a self-managementpackage in primary care as a stand alone manual, with significantimprovements demonstrated in dyspnoea, exercise performance andanxiety.P53 PULMONARY REHABILITATION USING THE SPACE (A SELF-MANAGEMENT PROGRAMME OF ACTIVITY, COPING ANDEDUCATION) MANUAL AT HOME: A RANDOMISEDCONTROLLED TRIAL1K Wagg, 2E Wilcock, 1J Williams, 1L Sewell, 1M Steiner, 1M Morgan, 2S Singh.1University Hospitals Leicester, Leicester, UK; 2Coventry University, Coventry, UKdoi:10.1136/thx.2009.127142aPulmonary rehabilitation is an established intervention for patientswith chronic obstructive pulmonary disease (COPD), howevercapacity across the UK is low. The traditional model of rehabilita-tion is 6–8 weeks of supervised exercise and education. We havedeveloped a self-management manual for COPD (SPACE: A Self-management Programme of Activity, Coping and Education). If aself-managed pulmonary rehabilitation programme is effective,alternative forms of pulmonary rehabilitation may become morewidely available. The aim of this study is to determine theeffectiveness of a self-management programme against conven-tional rehabilitation.Participants with COPD were recruited following a standardpulmonary rehabilitation assessment and randomly allocated toeither a 7-week conventional rehabilitation course or self-managedrehabilitation using the SPACE manual. The primary outcomemeasure was peak exercise performance (Incremental ShuttleWalking Test (ISWT)) measured at initial assessment and 7 weeks.Other outcome measures were Endurance Shuttle Walk Test(ESWT), Self-Reported Chronic Respiratory Questionnaire (CRQ-SR) Dyspnoea Domain and the Medical Research CouncilDyspnoea Scale (MRC). 62 patients were recruited and allocatedto conventional rehabilitation (n = 29; mean (SD) age 67.93 (7.47);forced expiratory volume in 1 s (FEV1) 1.38 (0.52); body mass index(BMI) 26.27 (5.91); 18 men) or self-management (n = 33; mean (SD)age 66.75 (8.00); FEV1 1.16 (0.36); BMI 26.77 (5.76); 2 men).Patients were re-assessed at 7 weeks and paired t tests wereperformed for all outcome measures.There were statistically significant improvements for bothconventional rehabilitation and self-managed rehabilitation inISWT with mean changes of 54.48¡89.06 and 40.30¡70.02,respectively. There were also statistically significant improvementsfor ESWT, CRQ-SR Dyspnoea and MRC in both groups; meanchanges in conventional rehabilitation being 500.62, 0.64 and 0.80,respectively, and in self-managed rehabilitation being 331.33, 0.77and 0.71, respectively (table 1). There were no statisticallysignificant between-group differences found in ISWT, ESWT,CRQ Dyspnoea and MRC (p.0.05).Participants who completed both conventional rehabilitation anda self-management programme showed significant improvements inexercise performance and perceived dyspnoea. There were nosignificant differences between the outcomes for each group. Thisshows that a self-managed rehabilitation programme is an effectivealternative to conventional rehabilitation.P54 COPD PATIENTS’ BELIEFS AND EXPECTATIONS OFPULMONARY REHABILITATION1J O’Connor, 1T Cartwright, 2C Lee, 2L Nabarro, 1P Evans, 1A Clow, 1D Peters,2SL Elkin. 1Department of Psychology, University of Westminster, London, UK;2Imperial College Healthcare NHS Trust, London, UKdoi:10.1136/thx.2009.127142bIntroduction The effectiveness of pulmonary rehabilitation (PR) forchronic obstructive pulmonary disease (COPD) is tempered by theeffect of time. Little is known about the role of patients’ beliefs andexpectations in outcome response and in maintenance. The aim ofAbstract P52 Table 1 Mean baseline scores and mean changes for Hospital Anxiety and Depression Scale,Self-Reported Chronic Respiratory Questionnaire, Incremental Shuttle Walking Test (ISWT) and EnduranceShuttle Walk Test (ESWT) for usual care and self-management groupsMeasureSelf-management Usual GP careBaseline Mean change (95% CI) Baseline Mean change (95% CI)Anxiety 7.41 21.76 (20.10 to 3.23)* 4.74 0.84 (2.55 to 0.87)Depression 4.88 20.35 (0.91 to 3.43) 3.95 0.53 (1.37 to 0.31)Dyspnoea 3.31 0.74 (1.23 to 0.25)** 3.25 0.41 (0.87 to 0.04)Fatigue 4.13 0.34 (0.97 to 0.29) 4.60 0.16 (0.40 to 0.72)Emotion 4.84 0.51 (1.05 to 0.03) 5.22 0.23 (0.08 to 0.53)Mastery 5.48 0.30 (0.81 to 0.22) 5.62 0.10 (0.24 to 0.44)ISWT (m) 325.29 37.65 (70.44 to 4.85)* 342.63 228.42 (22.60 to 54.24)*ESWT (s) 227.00 358.59 (506.65 to 210.52)*** 369.95 34.53 (98.32 to 29.27)*.0.05; **.0.01; ***.0.001 within subjects.Abstract P53 Table 1 Mean baseline and mean changes for Incremental Shuttle Walking Test (ISWT),Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire Self-Reported (CRQ-SR) DyspnoeaDomain and MRC for conventional rehabilitation and self-management groupsMeasureConventional rehabilitation Self-managementBaseline Mean change (95% CI) Baseline Mean change (95% CI)ISWT 277.24 54.43 (88.36 to 20.60)* 253.33 40.30 (65.13 to 15.47)*ESWT 225.00 500.62 (656.90 to 344.32)** 257.02 331.33 (483.86 to 178.81)**CRQ-SR Dyspnoea 2.61 0.64 (1.11 to 1.72)* 2.14 0.77 (1.19 to 0.34)*MRC 3.40 20.80 (20.48 to 1.12)** 3.19 20.71 (20.35 to 0.07)***.0.01; **.0.001.Poster sessionsThorax 2009;64(Suppl IV):A75–A174 A97 on 3 December 2009 thorax.bmj.comDownloaded from 

PILOT RANDOMISED CONTROLLED TRIAL OF A 7-WEEK DISEASE-SPECIFIC SELF-MANAGEMENT PROGRAMME FOR PATIENTS WITH COPD: BELLA (BETTER LIVING WITH LONG TERM AIRWAYS DISEASE STUDY)

PILOT RANDOMISED CONTROLLED TRIAL OF A 7-WEEK DISEASE-SPECIFIC SELF-MANAGEMENT PROGRAMME FOR PATIENTS WITH COPD: BELLA (BETTER LIVING WITH LONG TERM AIRWAYS DISEASE STUDY)

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