Improving self-management support and planning in COPD in the North East of England

Overview summary

A research project, funded by Newcastle Gateshead Clinical Commissioning Group (CCG) was developed to address the challenge of unnecessary hospital admissions due to COPD exacerbations by exploring the concept of self-management support and planning between healthcare practitioners (HCPs) and people living with COPD (‘patients’).  The key project objective was to promote and embed self-management support and planning between HCPs and patients with the purpose of improving a number of clinical (e.g. improved COPD symptom management), economic (e.g. reduced cost and burden on health services) and humanistic (e.g. improve the overall quality of life of COPD patients) outcomes.  The programme consisted of various work streams undertaken to summarise the current evidence-base around COPD self-management interventions (SMIs), identify factors affecting self-management of COPD, to generate ideas and solutions to address these factors, and to develop and evaluate a prototype COPD SMI delivered in primary care.

Challenge/problem identified

COPD is characterised by dyspnoea, sputum purulence, and persistent coughing as a consequence of airway inflammation. The disease trajectory is one of progressive decline, punctuated by frequent acute exacerbations in symptoms; these exacerbations are the second biggest cause of unplanned hospital admissions in the UK. As the disease is irreversible and health-related quality of life (HRQOL) in patients is low, optimising HRQOL and reducing hospital admissions have become key priorities in COPD management.

Self-management support and planning is recognised as an essential criteria for the provision of high quality care for COPD and other long-term conditions and is a recognised quality standard of NICE guidelines in the UK.  Self-management interventions (SMIs) encourage patients to monitor symptoms when stable and to take appropriate action when symptoms worsen.

While self-management is widely known to benefit both health service providers and service users, there is no consensus on the form and content of effective SMIs and the variation in content may explain previous heterogeneity in effectiveness. Implementing COPD self-management strategies in routine clinical practice is known to be problematic and there is a clear need for further research to identify and address these barriers within the local population.

Overview of Innovation

Outcome/Impact 

The research programme consisted of 5 work streams; findings are summarised below;

Work stream 1: Systematic review of reviews with meta-analysis

A review of 11 reviews that described 28 SMIs showed that SMIs for patients with COPD were significantly more effective than usual care in (i) improving HRQOL (particularly in patients with severe symptoms) and (ii) reducing the number of emergency department visits for patients, but there is wide variability in effect. Rather than a short-term effect, improvements were more apparent at later follow up. To be effective, future interventions must focus on tackling mental health concerns, should involve some form of follow up and need not entail multi-disciplinary and individual-based SMIs.

Work stream 2: Qualitative synthesis

A review of the qualitative evidence was conducted to identify and explore perspectives and attitudes regarding self-management by patients and HCPs. Clear themes from papers reporting on patient perspectives concerned knowledge and understanding of the condition; self-management, time and adaption; social, emotional and psychological factors, and the relationship with HCPs.  In contrast, themes apparent from papers on HCP perspectives centred on knowledge and understanding of COPD and self-management, prioritising established practice over behaviour change, and views towards patients.

Work stream 3: Qualitative interviews with service users and healthcare professionals

A qualitative study was conducted to explore the perspectives of patients (n=21) and HCPs (n=20) specifically within the geographical area of the Newcastle and Gateshead CCG. Four key themes emerged from the patient interviews: knowledge and understanding, matrix of care, psychological and emotional, and social isolation /’shrinking life world’. Analysis of HCP perspectives were conceptualised into three broad categories:

o             Patient-level factors: Knowledge and understanding (e.g. of COPD, treatment), motivation and taking responsibility (e.g. stop smoking), emotional and psychological issues (anxiety, depression), social/support network (e.g. social isolation, access to appropriate resources), and personal life context (e.g. living conditions, comorbidities).

o             Practitioner-level factors: interest and expertise of HCPs in COPD, variation in understanding of ‘self-management’, use of behaviour change techniques in communication, frustration/treatment futility, normalizing self-management support and planning into routine practice.

o             Organisational/system-level factors: Fragmentation of existing services, resources for COPD patients, systematic focus on biomedical model and outcomes for COPD, reactive system to providing COPD services, communication among different HCP teams, inconsistent referral pathways.

Work stream 4: Participatory workshops with COPD patients and healthcare professionals

Findings from the qualitative interviews informed a series of participatory, problem-solving workshops with patients and practitioners aiming to generate and prioritise ideas and solutions to address factors identified in the previous work streams. The participatory workshops provided the opportunity for participants to map the key resources available to COPD patients within the CCG, and to inform the potential components of a prototype SMI for COPD (work stream 5).

 Work stream 5: Feasibility evaluation of prototype COPD self-management intervention – A shared medical appointments (SMA) intervention

This work stream is currently ongoing and the work undertaken and the early findings have been reported in a separate case study.

Start date: January 2015

End date: June 2017

Plans for the future/Spread and adoption

A full report of the programme of work will be presented to the CCG in May/June 2017; it will include recommendations and guidance to embed self-management support and planning in routine clinical practice within the CCG, as well as areas for further research.

Some of the key findings from the different work streams have and/or are being disseminated via published research articles in peer-reviewed journals, in conference abstracts and conference presentations and via the CCG time out session.

Contact Details

NHS:      Dr. Dapo Ogunbayo and Dr. Sian Russell on behalf of the COPD Self-Management Research Project Team, Institute of Health and Society, Newcastle University.

Email: oladapo.ogunbayo@newcastle.ac.uk or sian.russell@newcastle.ac.uk

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