Chronic obstructive pulmonary disease (COPD) is debilitating and costly. Self-management is championed to empower individuals to better manage their condition and also to efficiently utilize health resources. As a multi-disciplinary team, we conducted focus group research with individuals living with COPD who were participating in a longitudinal study to use an electronic "diary" to monitor, record, and transmit their own health status, plus receiving regular nurse visits. The main aims of the focus groups were to investigate how far individuals embraced the electronic diary and experienced it as an aid to the self-management of their condition. We also looked at the importance of the nurse visits to the process. Thematic analysis revealed that patients responded positively to the use of technology (the electronic diary), including psychological benefits of perceived support offered by the remote symptom surveillance. Findings also showed patients' increased awareness and monitoring of personal symptoms together with an improved understanding of disease self-management. Nurse support emerged as an important "human" factor in the process. In addition, a reduction in hospital admission was observed, thus reducing costs to the health service.
Background: COPDPredict™ is a novel digital application dedicated to providing early warning of imminent COPD (chronic obstructive pulmonary disease) exacerbations for prompt intervention. Exacerbation prediction algorithms are based on a decision tree model constructed from percentage thresholds for disease state changes in patient-reported wellbeing, forced expiratory volume in one second (FEV 1 ) and C-reactive protein (CRP) levels. Our study determined the validity of COPDPredict™ to identify exacerbations and provide timely notifications to patients and clinicians compared to clinician-defined episodes. Methods: In a 6-month prospective observational study, 90 patients with COPD and frequent exacerbations registered wellbeing self-assessments daily using COPDPredict™ App and measured FEV 1 using connected spirometers. CRP was measured using finger-prick testing. Results: Wellbeing self-assessment submissions showed 98% compliance. Ten patients did not experience exacerbations and treatment was unchanged. A total of 112 clinician-defined exacerbations were identified in the remaining 80 patients: 52 experienced 1 exacerbation; 28 had 2.2±0.4 episodes. Sixty-two patients self-managed using prescribed rescue medication. In 14 patients, exacerbations were more severe but responded to timely escalated treatment at home. Four patients attended the emergency room; with 2 hospitalised for <72 hours. Compared to the 6 months pre-COPDPredict™, hospitalisations were reduced by 98% (90 vs 2, p<0.001). COPDPredict™ identified COPD-related exacerbations at 7, 3 days (median, IQR) prior to clinician-defined episodes, sending appropriate alerts to patients and clinicians. Cross-tabulation demonstrated sensitivity of 97.9% (95% CI 95.7-99.2), specificity of 84.0% (95% CI 82.6-85.3), positive and negative predictive value of 38.4% (95% CI 36.4-40.4) and 99.8% (95% CI 99.5-99.9), respectively. Conclusion: High sensitivity indicates that if there is an exacerbation, COPDPredict™ informs patients and clinicians accurately. The high negative predictive value implies that when an exacerbation is not indicated by COPDPredict™, risk of an exacerbation is low. Thus, COPDPredict™ provides safe, personalised, preventative care for patients with COPD.
Saliva has numerous practical advantages as a diagnostic bio-sample for management of long term conditions. We have previously demonstrated that C-reactive protein (CRP), procalcitonin (PCT) and neutrophil elastase (NE) can be reliably and reproducibly detected in saliva, offering useful information on health status. This study explores whether proactive monitoring of target analytes provides early warning of COPD exacerbations and re-exacerbation events.Salivary CRP, PCT and NE levels were determined weekly in 55 subjects with established COPD, known to be frequent exacerbators [GOLD Stage I, 7; Stage II, 24; Stage III, 19; Stage IV, 5]. Daily symptom scores were collected using a self-assessment electronic diary. Participants were monitored throughout their stable, prodromal (defined as the 7 days prior to exacerbation onset), exacerbation and post-treatment recovery periods. All three salivary biomarkers could distinguish stable status from onset of patient-defined exacerbations (CRP: p < 0.003, PCT: p < 0.001, NE: p < 0.01); CRP median increase was 1.82 ng/ml, [interquartile range 4.79]; PCT 0.03 ng/ml [0.10] and NE 364 ng/ml [76]. Interestingly, increases over stable baseline were also observed in the prodromal period for salivary CRP 0.53 ng/ml [2.73], (p < 0.001), PCT 0.08 ng/ml [0.01], (p < 0.01) and NE 519 ng/ml [568], (p < 0.007), occurring at 5.4 ± 1.8 days prior to patient-defined onset. Importantly, in those COPD patients experiencing more than 1 exacerbation (n = 15), re-exacerbator salivary CRP was significantly higher at the index exacerbation, 4.08 ng/ml [0.21], (p < 0.04) with a mean time of 11 ± 8 days to re-exacerbation after treatment completion. Diary symptom analysis showed subjective deterioration in symptom trajectory 4 days prior to exacerbation onset (p < 0.01), with re-exacerbators demonstrating a higher baseline symptom burden in the post-treatment period compared to single exacerbators (p < 0.01).In conclusion, salivary biomarker levels can complement patient self-assessment to provide clinically useful cues to enable earlier identification of exacerbations in COPD; salivary CRP potentially offers additional information on re-exacerbation risk. These results support opportunities for patient-reported events and salivary biomarkers to be used synergistically in future near-patient COPD diagnostics for enhanced self-management and prompt exacerbation intervention.
BackgroundThe Holiday Activities and Food (HAF) Programme is a UK Government initiative created to alleviate food insecurity and promote health and well-being among children and their families, who are eligible for Free School Meals (FSM), during the school holidays. This process evaluation investigated factors that facilitated and acted as a barrier to the delivery of the HAF Programme from the perspectives of key stakeholders (Co-ordinators, Providers, and Parents) involved in the HAF Programme across an East Midlands county.MethodsThis evaluation utilized a mixed-methods approach, incorporating focus groups and online surveys to gain rich, multifaceted data. The focus groups were analyzed using a hybrid inductive-deductive thematic analysis and the online surveys were analyzed using mixed-methods approach due to the variation in question type (i.e., quantitative, Likert scale and open response) to align themes to the Government Aims and Standards of the HAF Programme.FindingsThe stakeholders highlighted several factors that facilitated and acted as a barrier to the delivery of the HAF Programme. Facilitating factors included existing and maintaining relationships between Co-ordinators, Providers, and facilities/schools/communities as this improved communication and attendance. Additionally, transport provision for those attending the Programme helped overcome barriers to attendance. The primary barrier of the Programme was the late awarding of the Programme contract as this limited the time available to prepare and organize the Programme. This in turn, had several “knock on” effects that created more barriers and resulted in some of the Government Aims and Standards not being met such as, nutrition education for children and parents. Despite the challenges faced, Co-ordinators and Providers were able to deliver the Programme and positively impact upon the children and their families that attended the Programme.ConclusionFollowing the facilitators and barriers that were highlighted in this evaluation, several recommendations have been made to enhance the delivery of the HAF Programme and ensure Government Aims and Standards, to improve children and family's health and well-being, are attained.
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