Respiratory Self-Management Education for clients with COPD

Ana Hutchinson, Caroline Brand, Michelle Thompson, Lou Irving.

Clinical Epidemiology & Health Service Evaluation Unit and Dept of Respiratory & Sleep Medicine, Melbourne Health.

Does Exacerbation Management Training improve Quality of Life

Level II Evidence

UK-based study RCT of 12 patient education sessions over 2 months.

Improved Client Quality of Life.

Bourbeau, J. et al. (2003) New-Zealand –based study No effect on Quality of Life, Mental Health or Self-reported Outcomes McGeoch, GRB et al. (2006)

Does Education Improve Knowledge & Skills (Inhaler Techniques) Level II Evidence

RCT of Education by a GP–Based Practice Assistant in Inhaler Techniques Significant Improvement in the Treatment Group over 12 months.

Hesselink, AE (2004) Patient Education & Counselling New Zealand Study of Self-management & Structured education Self-management knowledge at 12-months in the Intervention vs Control Groups.

McGeoch GRB et al. (2006) Respirology, 11. 611 to 618.

Can Self-Management Reduce Risks and Result in Behavioural Change ?

Level II Evidence

• • • • RCT in Chronic Heart Failure improved self-monitoring of weight, diet, and having a personal physician. no difference between groups in self-care abilities but significant differences between intervention and control groups in self care behaviours (p =0.001). Jaarsma et al (2000) • RCT in COPD Knowledge of exacerbation management Self-initiation of treatment with antibiotics & steroids Bourbeau (2003)

Does Exacerbation Self-Mx Training Acute Health Care Utilisation

Level II Evidence

All Re-admissions 57% P = 0.01

COPD Re-admissions 40% P = 0.01

Emergency Attendances 41% P = 0.02

Unscheduled Physician Visits 59% P = 0.003

% Exacerbations that Require Inpatient Care Bourbeau (2003)

Training Plus Follow-up support …….Short & Long term Acute Health Care Utilisation

Level II Evidence

Year-1 Year-2 All Re-admissions / pt / yr -0.70 -0.44 Emergency / pt / yr -1.30 -0.70 Gadoury (2005) ERJ

Chronic Disease Management Programs Education Interventions in the Context of a Multi-disciplinary Program Level II Evidence New Zealand Study ----

Randomization of GP Practices Intervention: Provision of Educational materials\ • Development of an Individualized Care Plan • • Achievable Goals for Life-style Change Action Plan / Initial Treatment Options / When to contact the GP • • Patient Education about inhaler techniques, smoking cessation Recommend Immunisation & Exercise Rehabilitation At 12-month follow-up: hospitalisations over 12 months (P = 0.03) Rea H. (2004) Internal Medicine Journal; 34: 608-614.

Does Exacerbation Mx Training Acute Health Care Utilisation

Negative Outcome

RCT conducted in Tasmania 139 participants Use of Written Action Plans increased appropriate care of Exacerbations Intervention group more likely to have treatment with antibiotics or short course oral corticosteroids.

No impact on health care utilisation (GP consultations, Emergency attendances or hospitalisations).

McGeoch, GRB (2006 Respirology 11, 611-618).

COPD ACTION PLANS & EXACERBATION MANAGEMENT TRAINING Negative Evidence

Evidence that COPD Action Plans have no effect on Emergency Admissions or Hospitalisations • Cockcroft (1987) • Littlejohns • • Gallefoss McGeoch (2006) Why are there contradictory study findings?

• Intensity of the Intervention • Differences in Health Services where the intervention was provided • ? Inappropriate or Inadequate intervention

COPD is a complex Disease …….

Anxiety / Depression Exercise Intolerance Social Isolation Functional Impairment Nicotinine Dependence Muscle Wasting & Osteoporosis Re-current Infections Respiratory Failure / Domiciliary Oxygen use Action Plans in Isolation will be inadequate to meet all the complex needs of those with advanced disease (Bourbeau 2003)

A complex condition may need complex multi-component intervention to achieve consistent results

Elements 1.

Integrated systems based across both the community and acute care providers.

2.

Information technology designed to support an integrated model of care.

3.

Self-management training & ongoing support.

4.

Encouragement of equal partnerships & ongoing interaction between clients and health care providers.

5.

Health Information Systems Adams SG et al (2007) Arch Internal Medicine 167: 551-561.

Chronic Care Model for COPD …….including self management training

Level -1 Evidence

Systematic Review of 8 Studies (1) An Extensive Self-management Program (2) Advanced Access to Care ---- Advanced Trained Health Care Providers (3) Guideline–Based / Evidence –Based Therapies (4) Clinical Registry / or Information Management System.

Programs with > 2 elements had an impact on health care utilisation Emergency Visits (RR 0.58 [0.42 to 0.79]; Hospitalisations (RR 0.78 [0.66 to 0.94]). Limitations: 1. Self management in isolation did not reduce Acute Health Care Utilisation .

2. Limited application of evidence–based & effective interventions • Intensive Smoking Cessation Programs • Management of Anxiety & Depression

Need for increased implementation of Evidence based interventions…..as part of chronic care model

1. Smoking Cessation.

2. Assessment and Active Treatment of Anxiety & Depression.

3. Training in Monitoring Cardiac Failure.

4. Appropriate use of Domiciliary Oxygen.

5. Exercise Rehabilitation and maintenance exercise programs.

acknowledgements

Clinical Epidemiology & Health Service Evaluation Unit, RMH.

Melbourne Easy Breathers Programs Respiratory & Sleep Medicine Vincent Bacon Jane Wiles David Smallwood Abe Rubinfeld Sue Hii