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Evid Based Nurs 9:56 doi:10.1136/ebn.9.2.56
  • Treatment

Review: existing evidence does not support nurse led interventions in chronic obstructive pulmonary disease


 
 Q In patients with chronic obstructive pulmonary disease (COPD), are nurse led chronic disease management innovations more effective than usual care?

METHODS

GraphicData sources:

16 English language and 8 Dutch language citation databases (1980 to January 2005), conference proceedings of 7 respiratory associations, and researchers and practitioners in the field.

GraphicStudy selection and assessment:

randomised controlled trials (RCTs) that evaluated clinical service interventions or care packages aimed at improving the management of community dwelling patients with COPD and were led, coordinated, or delivered by nurses. Trials that evaluated drugs, hospital at home or early discharge for acute exacerbations, or educational interventions for healthcare providers, or trials with a minority of patients with COPD were excluded. Methodological quality of individual studies was assessed using the Delphi list and the 5 point Jadad scale.

GraphicOutcomes:

mortality, use of healthcare resources, activities of daily living (ADL), patients’ health related quality of life (HRQOL), and carers’ quality of life.

MAIN RESULTS

9 RCTs (n = 1428, mean age 63–71 y) and 1 systematic review that included 4 of the individual RCTs met the selection criteria. Methodological quality of the trials was generally low. 2 RCTs involved brief interventions (about 1 mo in duration) after a hospital admission; 7 RCTs involved intensive or long term interventions (about 1 y in duration). 5 RCTs included home visits by a nurse, 1 RCT was exclusively clinic based, and 3 did not provide a clear description. The interventions used a case management approach and promoted self care, including education about medication and advice on smoking cessation, fitness, and identifying acute exacerbations. Meta-analysis of 7 long term or intensive intervention trials showed no difference in mortality (table). The 2 RCTs on brief interventions showed no difference in hospital readmissions. Among the long term trials, 2 showed a reduction in readmissions favouring nurse led interventions, and 3 showed no difference. Meta-analysis of 3 RCTs measuring HRQOL with the St George’s respiratory questionnaire at 3–6 months of follow up showed no difference between groups (Cohen’s d standardised difference 0.06, 95% CI –0.14 to 0.26). The evidence was insufficient or too weak to show an effect on patients’ ADL or carers’ quality of life.

CONCLUSION

Little or no evidence exists that nurse led chronic disease management innovations are more effective than usual care in patients with chronic obstructive pulmonary disease.

Commentary

  1. Bruce Leonard, RN, PhD, FNP, NP-C, BC
  1. University of Texas Medical Branch, Galveston, Texas, USA

      Taylor et al present the limitations and inconsistencies among the limited number of RCTs on nurse led chronic disease management interventions for COPD. The results are mirrored in a systematic review of nurse led outreach services for COPD.1 Wide variation exists in the management models identified within the included studies. The authors did not describe the control conditions in the included studies and so it is difficult to determine how much the interventions differed from usual care. The authors highlighted that few of the studies reviewed involved the use of care pathways or written protocols for the nurse led interventions and did not reflect new evidence for best practices in the management of this chronic disease. This may account for the lack of difference in outcomes between intervention and control groups. In several studies, sample size was hindered by difficulties in recruitment.2,3 Variation in the outcomes measured and how the results were reported limited the meta-analysis.

      The natural history of COPD, with its continued irreversible decline in lung function over time, makes patients with severe disease less likely to benefit from programme interventions such as those reviewed. Some weak evidence exists that knowledge gained by patients with COPD through nurse led interventions can increase awareness of factors that may worsen their condition.3 The fast moving pace of clinical change in this area means that research focusing on disease self management and home based management programmes for patients with COPD is urgently needed.

      References

      Nurse led interventions v usual care for chronic obstructive pulmonary disease*

      
 
 Q In patients with chronic obstructive pulmonary disease (COPD), are nurse led chronic disease management innovations more effective than usual care?

      Footnotes

      • For correspondence: Dr S J Taylor, Centre for Health Sciences, Barts and the London, Queen Mary’s School of Medicine and Dentistry, London, UK. s.j.c.taylor{at}qmul.ac.uk

      • Source of funding: NHS Research and Development Service Delivery and Organisation Programme.

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