The effect of a respiratory home nurse intervention in patients with chronic obstructive pulmonary disease (COPD). Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease. Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. The cost and efficacy of home care for patients with chronic lung disease. Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill. A randomized, controlled trial of an intensive community nurse-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease. A randomized trial of two types of nurse-assisted home care for patients with COPD.
Chronic obstructive pulmomary disease (COPD) is associated with substantial mortality, morbidity, and costs to the health care system. With the increasing interest in outreach care programmes it is important to evaluate their impact upon patients and health services, for conditions such as COPD.
                To determine the effectiveness of an outreach respiratory nurse in a shared care approach, with collaboration between general practitioners and hospital services, in the management of patients with severe COPD.
                Patients with severe COPD attending The Queen Elizabeth Hospital, Adelaide participated in a randomised controlled trial of a home based nursing intervention (HBNI) over 12 months with outcome measures including mortality rate, hospital service utilisation, FEV1 and health related quality of life (HRQL) using a modified Dartmouth Primary Care Co-operative Quality of Life questionnaire.
                There were 48 subjects in each study arm, with no differences in mortality rate (eight deaths in the HBNI group and seven in the control group), hospital admissions, length of stay, number of outpatient and Emergency Service visits. The study had inadequate follow-up of FEV1 and HRQL within the control group. Within the HBNI group, a small improvement in HRQL (in three of ten indices measured) was demonstrated, despite a deterioration in FEV1 (11% reduction, p=0.04) compared to baseline. Quality of life of HBNI subjects' carers did not change.
                An increased level of care given by an outreach respiratory nurse in a shared care approach for patients with severe COPD produced small improvements in HRQL but did not result in the prevention of deaths or reduced health care utilisation. To evaluate usefulness of limited community based care for patients with chronic obstructive pulmonary disease after discharge from hospital. Design: Randomised controlled trial.
                Liverpool Health Service and Macarthur Health Service in outer metropolitan Sydney between September 1999 and July 2000.
                177 patients randomised into an intervention group (84 patients) and a control group (93 patients) which received current usual care.
                Home visits by community nurse at one and four weeks after discharge and preventive general practitioner care.
                Frequency of patients' presentation and admission to hospital; changes in patients' disease-specific quality of life, measured with St George's respiratory questionnaire, over three months after discharge; patients' knowledge of illness, self management, and satisfaction with care at discharge and three months later; frequency of general practitioner and nurse visits and their satisfaction with care.
                Intervention and control groups showed no differences in presentation or admission to hospital or in overall functional status. However, the intervention group improved their activity scores and the control group worsened their symptom scores. While intervention group patients received more visits from community nurses and were more satisfied with their care, involvement of general practitioners was much less (with only 31% (22) remembering receiving a care plan). Patients in the intervention group had higher knowledge scores and were more satisfied. There were no differences in general practitioner visits or management.
                This brief intervention after acute care improved patients' knowledge and some aspects of quality of life. However, it failed to prevent presentation and readmission to hospital. A randomised controlled trial was undertaken to determine whether a respiratory health worker was effective in reducing the respiratory impairment, disability, and handicap experienced by patients with chronic airflow limitation attending a respiratory outpatient department. The 152 adults (aged 30-75 years) who participated had a prebronchodilator forced expiratory volume in one second (FEV1) below 60% predicted and no other disease. They were randomised to receive the care of a respiratory health worker or the normal services provided by the outpatient department. The respiratory health worker provided health education and symptom and treatment monitoring in liaison with primary care services. After one year there was little difference between the two groups in spirometric values (FEV1 and forced vital capacity before and after salbutamol 200 micrograms), disability (six minute walking distance and paced step test), and handicap (sickness impact profile, hospital anxiety and depression scale). Patients not looked after by the respiratory health worker were more likely to die (relative risk 2.9 (95% confidence limits 0.8, 10.2); when age and FEV1 were controlled for this risk increased to 5.5 (95% confidence limits 1.2, 24.5). Patients looked after by the respiratory health worker attended their general practitioner more frequently and were prescribed a greater range of drugs. This is the third study to have found limited measurable benefit in terms of morbidity from the intervention of a respiratory health worker. This may be due to the ability of such workers to keep frail patients alive. 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. A randomized controlled trial was conducted to assess efficacy and cost of sustained home nursing care for patients with chronic lung disease. Three hundred one patients were randomly assigned to a respiratory home care group (RHC) that received care from respiratory home care nurses, a standard home care group (SHC) that received care from regular home care nurses, or an office care group (OC) that received whatever care they needed except for home care. Patients were followed for 1 year. At the end of the study year, there was no difference in survival, pulmonary function, or everyday functioning among the three groups. Average annual cost of care for all study patients was $7,647 (1981-82 dollars). The average annual health care costs for patients in the RHC group was $9,768; for those in the SHC group, $8,058; and for those in the OC group, $5,051 (F = 6.45, df = 2/298, P = 0.02). These results suggest that the current policy of limited coverage of home nursing services by Medicare and other third-party payers may be appropriate. To document outcomes of a randomized trial of the PhoenixCare demonstration program of palliative care and coordinated care/case management for seriously chronically ill individuals who simultaneously received active treatment from managed care organizations (MCOs).
                Patients, continuously enrolled between July 1999, and March 2001, were randomly assigned to the PhoenixCare program or a control group receiving usual MCO care.
                Hospice of the Valley, Phoenix, Arizona.
                Participants were 192 patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF), who had an estimated 2-year life expectancy.
                Intensive home-based case management provided by registered nurse casemanagers, in coordination with patients' existing source of medical care, comprised the intervention. Program foci included disease and symptom management, patient self-management of illness and knowledge of illness-related resources, preparation for end-of life, physical and mental functioning, and utilization of medical services.
                Outcomes, assessed every 3 months by telephone interview, included measures related to all program foci; the SF-36 was used to evaluate physical and mental functioning; emergency department visits exemplified medical service utilization.
                Compared to controls, PhoenixCare patients exhibited significantly better outcomes on self-management of illness, awareness of illness-related resources, and legal preparation for end of life. They reported lower symptom distress, greater vitality, better physical functioning and higher self-rated health than randomized controls. Emergency department utilization was equivalent across groups. Patients with COPD showed stronger responsiveness to the intervention.
                A novel model of patient care that combined greatly enhanced palliative carefocused case management with ongoing MCO-based treatment was associated with improved functioning of chronically severely ill patients in the last years of life. To evaluate the effectiveness of an intensive community nurse (CN)-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease (CLD).
                Randomized, controlled trial.
                Two acute hospitals in the same health region in Hong Kong.
                One hundred fifty-seven hospitalized patients aged 60 and older with a primary diagnosis of CLD and at least one hospital admission in the previous 6 months.
                CNs made home visits within 7 days of discharge, then weekly for 4 weeks and monthly until 6 months. CNs coordinated closely with a geriatric or respiratory specialist in hospital. Subjects had telephone access to CNs during normal working hours from Monday to Saturday.
                The primary outcome was the rate of unplanned readmission within 6 months. The secondary outcomes were the rate of unplanned readmission within 28 days, number of unplanned readmissions, hospital bed days, accident and emergency room attendance, functional and psychosocial status, and caregiver burden.
                One hundred forty hospitalized patients completed the trial. Intervention group subjects had a higher rate of unplanned readmission within 6 months than control group subjects (76% vs 62%, P=.080, chi2 test). There was no significant group difference in any of the secondary outcomes except that intervention group subjects did better on social handicap scores.
                There was no evidence that an intensive CN-supported discharge program can prevent hospital readmissions in older patients with CLD. Whereas pulmonary rehabilitation reduces symptoms and improves the quality of life of patients with COPD and is recommended in management guidelines, few patients have access to rehabilitation services. The purpose of this study was to investigate the effectiveness of increasing access to selected components of pulmonary rehabilitation by providing nurse-assisted home care that was composed of patient education, efforts to improve patient self-management skills, and enhanced follow-up.
                We conducted a 6-month, randomized, controlled trial.
                Primary care clinics associated with an urban academic health system.
                Patients were > or = 45 years of age with a physician diagnosis of COPD, and had a > or = 20-pack-year smoking history, had experienced at least one respiratory symptom during the past 12 months, and had airflow obstruction (ie, FEV1/FVC ratio, < 70%; FEV1, < 80%).
                Four nurses were trained in the use of the Global Initiative for Chronic Obstructive Lung Disease guidelines, and two of the four nurses received additional training in collaborative management. Patients were randomly assigned to usual care (UC), nurse-assisted medical management (MM), or nurse-assisted collaborative management (CM).
                The main outcome measures were of generic (Medical Outcome Study 36-item short form [SF-36], illness intrusiveness) and disease-specific (St. George's respiratory questionnaire [SGRQ]) quality of life and self-reported health-care utilization.
                Overall, 151 patients (UC group, 51 patients; MM group, 49 patients; and CM group, 51 patients) completed the study, their average age was 69 years, and 56.9% were women. The average change in the SF-36 general health domain for the MM group vs the UC group was 1.1 (95% confidence interval [CI], -7.9 to 11.2), and for the CM group vs the UC group the average change was 2.5 (95% CI, -7.0 to 12.3). The corresponding changes in SGRQ total domain were -2.9 (95% CI, -9.8 to 4.1) and -2.6 (95% CI, -9.5 to 4.3). There was no change in the number of self-reported emergency department visits or hospitalizations, but the utilization of these services was infrequent.
                The findings of our investigation and those from the published literature suggest that interventions to enhance patient education, self-management skills, and follow-up among patients with COPD do not result in clinically meaningful improvements in health status or self-reported health-care utilization. Moreover, future studies of disease management programs for patients with COPD need to evaluate interventions that address associated comorbidities, exercise, and social support.
Outreach nursing programmes for COPD improved disease-specific HRQL. However the effect on hospitalisations was heterogeneous, reducing admissions in one study, but increasing them in others, therefore we could not draw firm conclusions for this outcome.