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      Exploring transitions in care from pulmonary rehabilitation to home for persons with chronic obstructive pulmonary disease: A descriptive qualitative study

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          Abstract

          Background

          Individuals with chronic obstructive pulmonary disease (COPD) often experience high health‐care utilization following pulmonary rehabilitation, suggesting suboptimal transitions to home.

          Objective

          To understand the experiences of persons with COPD and health‐care professionals regarding transitions from pulmonary rehabilitation to home, including factors impacting these transitions.

          Design

          A descriptive qualitative study.

          Setting and participants

          Health‐care professionals working at, and persons with COPD who attended, an inpatient or outpatient pulmonary rehabilitation programme at one large, urban health‐care centre. The centre is located in Ontario, Canada.

          Main variable studied

          Experiences of participants with care transitions between pulmonary rehabilitation and home. Semi‐structured interviews were audio‐recorded, transcribed verbatim, and thematically analysed.

          Results

          Ten patients and eight health‐care professionals participated. Four main themes were identified around the overall experiences with pulmonary rehabilitation and transitions to home: (a) pulmonary rehabilitation as a safe environment; (b) pulmonary rehabilitation as a highly structured environment; (c) contrasting perceptions of the role of pulmonary rehabilitation; and (d) dependency on pulmonary rehabilitation programmes. Persons with COPD and health‐care professionals identified three key factors that influenced this transition: (a) patients' social support, (b) application of self‐management strategies prior to discharge, and (c) patients' physical and mental health.

          Conclusion

          Participants agreed that some patients with COPD experienced suboptimal transitions from pulmonary rehabilitation to home that were characterized by suboptimal self‐management. Further research is needed to develop and evaluate interventions to improve transitions. Such interventions should include strategies to elicit long‐term behaviour change to assist patients when they return into the community.

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          Most cited references 20

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          Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention.

          Self-management interventions improve various outcomes for many chronic diseases. The definite place of self-management in the care of chronic obstructive pulmonary disease (COPD) has not been established. We evaluated the effect of a continuum of self-management, specific to COPD, on the use of hospital services and health status among patients with moderate to severe disease. A multicenter, randomized clinical trial was carried out in 7 hospitals from February 1998 to July 1999. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and patient health status. Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group (P =.01), and admissions for other health problems were reduced by 57.1% (P =.01). Emergency department visits were reduced by 41.0% (P =.02) and unscheduled physician visits by 58.9% (P =.003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months. A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice.
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            Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management.

            Implementation of the chronic care model (CCM) has been shown to be an effective preventative strategy to improve outcomes in diabetes mellitus, depression, and congestive heart failure, but data are lacking regarding the effectiveness of this model in preventing complications in patients with chronic obstructive pulmonary disease. We searched the MEDLINE, CINAHL, and Cochrane databases from inception to August 2005 and included English-language articles that enrolled adults with chronic obstructive pulmonary disease and (1) contained intervention(s) with CCM component(s), (2) included a comparison group or measures at 2 points (before/after), and (3) had relevant outcomes. Two reviewers independently extracted data. Symptoms, quality of life, lung function, and functional status were not significantly different between the intervention and control groups. However, pooled relative risks (95% confidence intervals) for emergency/unscheduled visits and hospitalizations for the group that received at least 2 CCM components were 0.58 (0.42-0.79) and 0.78 (0.66-0.94), respectively. The weighted mean difference (95% confidence interval) for hospital stay was -2.51 (-3.40 to -1.61) days shorter for the group that received 2 or more components. There were no significant differences for those receiving only 1 CCM component. Limited published data exist evaluating the efficacy of CCM components in chronic obstructive pulmonary disease management. However, pooled data demonstrated that patients with chronic obstructive pulmonary disease who received interventions with 2 or more CCM components had lower rates of hospitalizations and emergency/unscheduled visits and a shorter length of stay compared with control groups. The results of this review highlight the need for well-designed trials in this population.
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              Self-management education for patients with chronic obstructive pulmonary disease.

              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. 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. We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences. 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. Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information. 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. 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.
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                Author and article information

                Contributors
                Role: Physical Therapist
                Role: Physical Therapist
                Role: Physical Therapist
                Role: Physical Therapist
                Role: Physical Therapist
                Role: Research Coordinator
                Role: Professor and Head of Respiratory Medicine
                Role: Professor
                Role: Research Coordinator
                Role: Assistant Professorsara.guilcher@utoronto.ca
                Journal
                Health Expect
                Health Expect
                10.1111/(ISSN)1369-7625
                HEX
                Health Expectations : An International Journal of Public Participation in Health Care and Health Policy
                John Wiley and Sons Inc. (Hoboken )
                1369-6513
                1369-7625
                01 January 2020
                April 2020
                : 23
                : 2 ( doiID: 10.1111/hex.v23.2 )
                : 414-422
                Affiliations
                [ 1 ] Department of Physical Therapy University of Toronto Toronto ON Canada
                [ 2 ] Department of Respiratory Medicine West Park Healthcare Centre York ON Canada
                [ 3 ] Rehabilitation Sciences Institute University of Toronto Toronto ON Canada
                [ 4 ] School of Rehab Science McMaster University Hamilton ON Canada
                [ 5 ] Leslie Dan Faculty of Pharmacy University of Toronto Toronto ON Canada
                [ 6 ] Institute of Health Policy, Management and Evaluation University of Toronto Toronto ON Canada
                Author notes
                [* ] Correspondence

                Sara J. T. Guilcher, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON M5S 3M2, Canada.

                Email: sara.guilcher@ 123456utoronto.ca

                Article
                HEX13012
                10.1111/hex.13012
                7104647
                31893574
                © 2019 The Authors Health Expectations published by John Wiley & Sons Ltd

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 0, Tables: 3, Pages: 9, Words: 6400
                Product
                Funding
                Funded by: Canadian Institutes of Health Research (#147869) , open-funder-registry 10.13039/501100000024;
                Funded by: Ontario Physiotherapy Association ‐ Central Toronto District
                Categories
                Original Research Paper
                Original Research Papers
                Custom metadata
                2.0
                April 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.8 mode:remove_FC converted:30.03.2020

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