Objective To determine whether supported self management in chronic obstructive pulmonary disease (COPD) can reduce hospital readmissions in the United Kingdom.
Design Randomised controlled trial.Setting Community based intervention in the west of Scotland.Participants Patients admitted to hospital with acute exacerbation of COPD.Intervention Participants in the intervention group were trained to detect and treat exacerbations promptly, with ongoing support for 12 months.
Main outcome measuresThe primary outcome was hospital readmissions and deaths due to COPD assessed by record linkage of Scottish Morbidity Records; health related quality of life measures were secondary outcomes.Results 464 patients were randomised, stratified by age, sex, per cent predicted forced expiratory volume in 1 second, recent pulmonary rehabilitation attendance, smoking status, deprivation category of area of residence, and previous COPD admissions. No difference was found in COPD admissions or death (111/232 (48%) v 108/232 (47%); hazard ratio 1.05, 95% confidence interval 0.80 to 1.38). Return of health related quality of life questionnaires was poor (n=265; 57%), so that no useful conclusions could be made from these data. Pre-planned subgroup analysis showed no differential benefit in the primary outcome relating to disease severity or demographic variables. In an exploratory analysis, 42% (75/150) of patients in the intervention group were classified as successful self managers at study exit, from review of appropriateness of use of self management therapy. Predictors of successful self management on stepwise regression were younger age (P=0.012) and living with others (P=0.010). COPD readmissions/deaths were reduced in successful self managers compared with unsuccessful self managers (20/75 (27%) v 51/105 (49%); hazard ratio 0.44, 0.25 to 0.76; P=0.003).Conclusion Supported self management had no effect on time to first readmission or death with COPD. Exploratory subgroup analysis identified a minority of participants who learnt to self manage; this group had a significantly reduced risk of COPD readmission, were younger, and were more likely to be living with others.Trial registration Clinical trials NCT 00706303.
IntroductionSelf management has a well established evidence base for asthma and has been actively investigated as a useful strategy for patients with chronic obstructive pulmonary disease (COPD), with a growing evidence base for beneficial and unhelpful practices.1-3 It aims to develop patients' coping skills to maintain as active a lifestyle as possible, promote correct use of drugs, and encourage the early identification of increasing symptoms heralding an exacerbation, so that these can be treated early. Early treatment of exacerbations has been shown to reduce morbidity and effect on quality of life. 4 Case management is a related technique for the support of patients with chronic disease, concentrating on the provision of support by health professionals so that patients can obtain prompt and appropriate a...
Although pre-surgical psychiatric assessment alone cannot predict outcome, an absence of preoperative psychiatric illness should not reassure surgeons who should be mindful of postoperative psychiatric sequelae, particularly BED. The importance of providing an integrated biopsychosocial model of care in bariatric teams is highlighted.
Unrealistic expectations and anxiety are known to predict non-adherence. Constant negative affects may be self-modulated by grazing. The results are explored in the context of Self-efficacy Theory, a socio-cognitive account of illness behavior.
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