Description of the condition
Chronic obstructive pulmonary disease (COPD) is the fourth most common cause of death internationally and accounts for 3.5% of total years lost due to disability (World Health Organisation 2004). This highly burdensome condition impacts on 80 million people and their families globally. It is characterised by non-reversible airflow limitation in conjunction with progressive debilitating symptoms and systemic effects (Global Initiative for COPD (GOLD) 2010). Increases in bio-fuel use and smoking, particularly in developing countries, are set to increase the prevalence of COPD globally by 30% by 2030 (Buist 2007; Mannino 2002; World Health Organisation 2004).
Despite optimisation of pharmacological treatments such as inhaled medications, a large proportion of individuals with COPD continue to have inadequately managed symptoms and unmet psychosocial needs (Bausewein 2008; Disler 2012; Effing 2007). Comprehensive approaches to disease management that engage "multiple therapies into a patient-centred plan of care" (Make 2003) are necessary to meet these healthcare needs (Craig 2008; Make 2003; Monninkhof 2003).
Description of the interventions
Key non-pharmacological interventions such as pulmonary rehabilitation and self-management programmes are central to COPD management and are highlighted in international COPD management guidelines (ATS/ERS 2011; Global Initiative for COPD (GOLD) 2010; National Institute for Clinical Excellence 2012). Chronic diseases such as COPD require a comprehensive approach to disease management (Make 2003), potentially incorporating a range of diverse non-pharmacological, non-device and non-surgical intervention strategies. The intervention strategies discussed in this overview, and defined below are: pulmonary rehabilitation; self-management programs; action plans as an integrated strategy and management guideline; telehealthcare; and outreach programs (ATS/ERS 2011; Bausewein 2008; Effing 2007; Global Initiative for COPD (GOLD) 2010; Kruis 2011; Lacasse 2006; Make 2003; McLean 2011; World Health Organisation 2004).
Pulmonary rehabilitation focuses on building exercise capacity, disease and nutritional education, and psychological coaching. (ATS/ERS 2011; Celli 2004; Global Initiative for COPD (GOLD) 2010; National Institute for Clinical Excellence 2012; Nici 2006). Pulmonary rehabilitation is defined as "an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease."(ATS/ERS 2011).
Self-management programs are defined as "any formalized patient education programme 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" (Effing 2007). Patients with COPD experience high symptom burden and poor health-related quality of life, and are required to manage their condition over extended periods (Bourbeau 2003). Evidence suggests that self-management education programs that target skills to assist patients in coping are likely to reduce hospital admissions in patients with COPD, but there is heterogeneity in current studies (Effing 2007).
Action plans as part of an integrated strategy and management guideline
Action plans are defined as "the use of guidelines which outline self-initiated interventions (such as changing medication regime or visiting the general practitioner or hospital) which are undertaken appropriately in response to alterations in the state of the patients’ COPD (e.g. increase in breathlessness, increased amount or purulence of sputum) that suggest the commencement of an exacerbation" (Turnock 2005). Patients who receive early intervention for exacerbations of COPD symptoms are shown to recover sooner and experience better quality of life with ongoing optimal management (Wilkinson 2004). Action plans have been shown to be effective in early intervention in asthma management; however the evidence for their efficacy in COPD has been limited (Gallefoss 1999; Turnock 2005).
Telehealthcare is a rapidly expanding field in healthcare and chronic disease management (Inglis 2010; McLean 2011). Telehealthcare in COPD is described by a recent Cochrane Review as "using technology such as telephones, video cameras and the Internet to allow people to stay at home and communicate with a nurse or doctor when they have a period of increased breathlessness" (McLean 2011). Considering the housebound status of people with advanced COPD and the frequency with which patients access acute health services as the disease progresses, telehealthcare has particular applicability in this population (McLean 2011). Telehealthcare has great potential in the resource-limited future of modern health care.
Outreach programs are those interventions that "comprise home visits by a respiratory nurse or similar respiratory health worker, to facilitate health care, provide education, provide social support, identify respiratory deteriorations promptly and reinforce correct technique with inhaler therapy" (Wong 2012). Delivery of care in the community targets those patients who are housebound or frequently reliant on acute services in the advanced stages of COPD. Outreach programs strive to maintain optimal management of disease and assist patients in self-management behaviours, as well as regular monitoring and early intervention in condition deterioration. A recent Cochrane systematic review found that this type of intervention does improve health -elated quality of life; however the current studies are heterogeneous in their approach (Wong 2012).
Why it is important to do this overview
Chronic diseases such as COPD require a comprehensive and multi-dimensional approach to disease management that incorporates a range of integrated intervention components, for example exercise rehabilitation with self-management education (Global Initiative for COPD (GOLD) 2010; Make 2003; World Health Organisation 2004).
Many of these discrete interventions are complex in both design and delivery, and require distillation of essential elements: e.g. the type, frequency and level of intervention intensity, as well as description of the workforce type and scope. Using a pre-specified and standardised taxonomy may assist in providing information to health providers and consumers in design of effective and appropriate interventions for COPD management (Krumholz 2006; Make 2003). Understanding the most efficacious organisation, timing and sequencing of these interventions within a disease management approach, as well as resource requirements for these approaches, are of high interest internationally and will inform policy, healthcare decisions and future research (Disler 2012; Effing 2007; Krumholz 2006; Make 2003).
This overview will summarise evidence for non-pharmacological, non-surgical, non-device programs for the management of COPD, highlight the current gaps in knowledge, provide recommendations for how best to report outcomes for these complex interventions and inform future program improvement and design. Specifically, we will investigate the evidence for pulmonary rehabilitation, self-management programs, action plans as part of an integrated strategy and management guideline, telehealthcare and outreach programs.