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Health Coaching in Severe COPD After a Hospitalization: A Qualitative Analysis of a Large Randomized Study
Abstract
Background:
We recently demonstrated in a randomized study the feasibility and effectiveness of telephone-based health coaching using motivational interviewing on decreasing hospital readmissions and improving quality of life at 6 and 12 months after hospital discharge. In this qualitative study, we sought to explore the health-coaching intervention as seen from the perspective of the participants who received the intervention and the coaches who delivered it.
Methods:
Semistructured participant interviews (n = 24) and a focus group of all health coaches (n = 3) who participated in this study were conducted. Interviews and focus group were recorded and transcribed verbatim. Transcripts were analyzed using coding and categorizing techniques and thematic analysis. Mixed-method triangulation was used to merge quantitative and qualitative data.
Results:
Content analysis revealed 4 predominant themes of the coaching intervention: health-coaching relationship, higher participant confidence and reassurance (most related to improvement in physical quality of life), improved health-care system access (most related to decreased hospital readmissions), and increased awareness of COPD symptoms (most related to improvement in emotional quality of life). The strongest theme was the relationship with the health coach, including coach style and motivational interviewing approach. Health coaches' focus group also noted the importance of the coaching relationship as the most significant theme.
Conclusions:
This study provided themes to further inform the delivery and implementation of health-coaching interventions in patients with COPD after hospital discharge. Health coaching forged partnerships and created a platform for patient engagement, which was confirmed by both participants and health coaches.
... Despite the lack of significant effects of SMS on readmissions, several qualitative studies have shown that patients value SMS and similar interventions due to the collaborative relationship and psychological support these interventions provide (Barlow et al., 2005;Benzo et al., 2017;Booker et al., 2008;Dwarswaard et al., 2016;Sandberg et al., 2014;Taylor et al., 2014;Walters et al., 2012). ...
... Some qualitative intervention studies have included both patients and professionals' views (Benzo et al., 2017), while other studies have included only professionals' experiences of providing support (Dwarswaard et al., 2016). Similar to other interventions, PaHS provides SMS and coaching to help participants develop the skills needed to act on their own symptoms and health issues (Benzo et al., 2017;Sandberg et al., 2014;Walters et al., 2012). ...
... Some qualitative intervention studies have included both patients and professionals' views (Benzo et al., 2017), while other studies have included only professionals' experiences of providing support (Dwarswaard et al., 2016). Similar to other interventions, PaHS provides SMS and coaching to help participants develop the skills needed to act on their own symptoms and health issues (Benzo et al., 2017;Sandberg et al., 2014;Walters et al., 2012). Aside from an initial face-to-face session, the intervention is organized around regular telephone contact from trained RNs. ...
Aim:
Proactive Health Support is a telephone-based self-management intervention that is carried out in Denmark by Registered Nurses who provide self-management support to people at risk of hospital admission. We aimed to explore participants' experiences of Proactive Health Support and to identify what the participants find important and meaningful during the intervention process.
Design:
Qualitative design involving semi-structured interview.
Methods:
Using a phenomenological-hermeneutical framework, we conducted semi-structured interviews with 62 participants in their own homes (32 women, 30 men; aged 20-81 years) in spring and fall 2018.
Results:
The participants felt confident that they could discuss every matter with the nurses. Participants benefitted from accessibility to the nurses' professional and medical competences and they felt relief that the nurses contacted them via the telephone due to their multiple health conditions. The participants felt that the nurses were available and helped them to navigate the healthcare system.
Conclusion:
The participants valued the intervention because they benefitted from the nurses' holistic approach. They described the nurses' knowledge and professionalism in relation to their symptoms, treatments, and medicine as important and meaningful. Accordingly, the intervention seemed to promote feelings of independence and self-management among the participants.
Impact:
From a nursing perspective, the study highlights that it is possible to establish a close relationship and behavioural change among participants through regular telephone contact.
... We recently reported the effectiveness of health coaching in decreasing re-hospitalizations and emergency department visits, and in improving the quality of life up to 12 months in subjects with COPD after the hospital discharge. 3,16 This report extended our initial publication by suggesting that health coaching delivered by a respiratory therapist or a nurse improved self-management abilities as measured by the Chronic Respiratory Disease Questionnaire mastery at 6-month after hospitalization. The improvement in self-management abilities was beyond the minimum clinically important difference (Ͼ0.5 points) at 6 months after hospital discharge. ...
... On the contrary, our results were opposed to a recent report that states that supported self-management did not reduce readmission rates at 3 months compared with usual care. 32 We hypothesized that the degree of engagement attained between the patient and the coach we found in our intervention, 16 perhaps supported by the style of communication used through motivational interviewing, was key to our success; however, we acknowledge that our results need replication, which continues to be a limitation in the evidence related to health coaching in COPD. ...
Background:
Self-management of patients with COPD has received increasing attention in recent years given its association with improved outcomes. There is a scarcity of feasible interventions that can improve self-management abilities. We recently reported the positive effect of health coaching, started at the time of hospital discharge, on re-hospitalizations and emergency department visits for patients with COPD admitted for an exacerbation. In this substudy, we aimed to investigate the effects of health coaching delivered by a respiratory therapist or a nurse compared with guideline-based usual care on self-management abilities in COPD.
Methods:
Self-management was measured by using the Chronic Respiratory Disease Questionnaire mastery domain and was assessed at baseline, at 6 months, and at 12 months after hospitalization.
Results:
Two hundred and fifteen subjects hospitalized for a COPD exacerbation were randomized to the intervention or the control. The mean change in the Chronic Respiratory Disease Questionnaire mastery score from baseline to month 6 was Δ0.58 32 ± 1.29 on the intervention arm and Δ0.17 32 ± 1.14 on the control arm (P = .02). Of the intervention subjects, 55% had at least a 0.5-point increase in Chronic Respiratory Disease Questionnaire mastery (minimum clinically important difference) compared with 38% in the control group. Health coaching was an independent predictor of the minimum clinically important difference or greater change in the Chronic Respiratory Disease Questionnaire mastery score at 6 months after initiation of the intervention (odds ratio 1.95, 95% CI 1.01-3.79). The changes in the Chronic Respiratory Disease Questionnaire mastery score at 12 months showed a trend but did not attain statistical significance.
Conclusions:
Health coaching delivered by a respiratory therapist or a nurse improved self-management abilities when applied to subjects with COPD after hospital discharge for an exacerbation. (ClinicalTrials.gov Identifier: NCT01058486, Mayo IRB 09-004341).
... Peer coaching has been successfully used in inpatient settings to teach primary PC skills (Jacobsen et al., 2017 (Rosa et al., 2021a). Coaching can help nurses adopt a personcentered practice but can also be used to prevent ill health and reduce the impact of chronic conditions (Barr & Tsai, 2021;Benzo et al., 2017;Fazio et al., 2019;Singh et al., 2022). 3. Interprofessional coaching. ...
Palliative care nurses experience huge pressures, which only increased with coronavirus disease 2019 (COVID-19). A reflection on the new demands for nursing care should include an evaluation of which evidence-based practices should be implemented in clinical settings. This paper discusses the impacts and challenges of incorporating coaching strategies into palliative care nursing. Evidence suggests that coaching strategies can foster emotional self-management and self-adjustment to daily life among nurses. The current challenge is incorporating this expanded knowledge into nurses' coping strategies. Coaching strategies can contribute to nurses' well-being, empower them, and consequently bring clinical benefits to patients, through humanized care focused on the particularities of end-of-life patients and their families.
... While these studies indicate some positive effects of MI-counselling on PA in the short-term, no conclusive evidence is available on which strategy, using MI techniques in the PR setting, could be effective in promoting long-term adherence to an active lifestyle. Both patients and health professionals have emphasized that the coaching style and the relationship are important aspects of PA counselling [28]. Furthermore, the individual stage of change, based on the transtheoretical model of health behavior change [29], may be relevant to tailoring MIcounselling. ...
Background
Counselling is considered to be a promising approach to increasing physical activity (PA) in people with chronic obstructive pulmonary disease (COPD). The aim of the current study was to investigate whether a PA counselling program for people with COPD, when embedded in a comprehensive outpatient pulmonary rehabilitation (PR) program, increased their daily PA.
Methods
A two-armed, single blind randomized controlled trial was conducted as a component of a 12-week outpatient pulmonary rehabilitation program. The participants randomized into the intervention group received five counselling sessions, based on the principles of motivational interviewing (MI), with a physiotherapist. The participants’ steps per day and other proxies of PA were measured using an accelerometer (SenseWear Pro®) at baseline, at the end of the PR program, and three months later. The group-by-time interaction effect was analyzed.
Results
Of the 43 participants,17 were allocated to the intervention group and 26 to the usual-care control group (mean age 67.9 ± 7.9; 21 (49%) males; mean FEV1 predicted 47.1 ± 18.6). No difference between groups was found for any measure of PA at any point in time.
Conclusions
In this study, counselling, based on MI, when embedded in a comprehensive PR program for people with COPD, showed no short-term or long-term effects on PA behavior. To investigate this potentially effective counselling intervention and to analyze the best method, timing and tailoring of an intervention embedded in a comprehensive outpatient PR program, further adequately powered research is needed.
Trial registration: Clinical Trials.gov NCT02455206 (05/21/2015), Swiss National Trails Portal SNCTP000001426 (05/21/2015).
... The results from the study also indicated that health coaching programme improved stroke survivors' QoL at 6-month follow-up. This positive outcome parallels the results from previous studies, which showed that health coaching contributed to a better QoL for patients with chronic obstructive pulmonary disease [24,25]. However, findings from a systematic review revealed that health coaching strategies usually improved stroke survivors' QoL for 3 months [12]. ...
Objective
To evaluate the effects of a nurse-led health coaching program for stroke survivors and family caregivers in hospital-to-home transition care.
Methods
A total of 140 dyads of stroke survivors and their family caregivers were recruited and randomly assigned to either the intervention group (received a 12-week nurse-led health coaching program) or the usual care group. The primary outcome was self-efficacy, and secondary outcomes were quality of life (QoL), stroke-related knowledge, and caregiver-related burden. The outcomes were measured at baseline, 12 and 24 weeks.
Results
Stroke survivors in the intervention group demonstrated a significant improvement in self-efficacy at 12 weeks (x̅: 24.9, 95%CI: 20.2 to 29.6, p<0.001) and at 24 weeks (x̅: 23.9, 95%CI: 19.2 to 28.6, p<0.001) compared to the usual care group. Findings also demonstrated significant increases in stroke survivors’ QoL, stroke-related knowledge, and reduction in unplanned hospital readmissions and caregiver-related burden. There were no statistically significant changes in other outcomes between the two groups.
Conclusion
The nurse-led health coaching program improved health outcomes for both stroke survivors and their caregivers.
Practice Impaction
Findings from the study suggest that nurse-led health coaching should be incorporated into routine practice in hospital-to-home transitional care for stroke survivors and their caregivers.
... We previously published the feasibility and effectiveness of telephonic health coaching in decreasing re-hospitalization and sustainably improving the quality of life in subjects with very severe COPD. 11,12 Health coaching may therefore represent an effective addition to home-based rehabilitation programs that may add a behavior change component to home-based interventions. ...
Background:
Pulmonary rehabilitation is an effective treatment for patients with COPD, but patient uptake and adherence to the current offering of center-based pulmonary rehabilitation is modest due to transportation, access, poverty, and frailty, and even more so in the context of the COVID pandemic. Home-based options have been proposed and were found noninferior to center-based rehabilitation; however, there is a lack of home-based programs, and more understanding is needed. We aimed to test the feasibility, uptake, and adherence to a home-based program for COPD rehabilitation with health coaching.
Methods:
We conducted a randomized trial with a wait-list controlled design to evaluate the effects of a home-based program with health coaching on breathlessness in subjects with moderate to severe COPD unable to attend the regular pulmonary rehabilitation program. The 8-week intervention consisted of video-guided exercises to be done 6 times a week and captured with a computer tablet. Health coaching was done weekly over the telephone to review subject activity and symptoms and to provide an opportunity for the subject to define their weekly goals. The primary outcomes were uptake, adherence, and Chronic Respiratory Questionnaire (CRQ) Dyspnea Domain. Secondary outcomes were self-management abilities and CRQ Emotions-Mastery-Fatigue.
Results:
154 subjects with moderate to severe COPD were randomized. Subject adherence was 86% to the proposed 6-times a week exercise routine. There (P = .062) was no significant difference in breathlessness (CRQ dyspnea). There was a significant improvement in self-management abilities (P < .001). The results of the qualitative interviews showed high levels of acceptability of the program.
Conclusions:
The tested home-based rehabilitation program with health coaching was feasible, highly acceptable, showed a high degree of adherence, and improved self-management abilities. This study offers seminal information for home-based rehabilitation programs to design alternative options of rehabilitation to individuals with COPD that cannot attend to the well-established center-based pulmonary rehabilitation. (ClinicalTrials.gov registration NCT02557178.).
... Researchers studying HC among adults with chronic conditions have found that it can increase patient activation (Nouri et al., 2019), self-efficacy (Tuluce & Kutluturkan, 2018), and medication adherence (Wolever & Dreusicke, 2016), and also improve HRQoL (Benzo et al., 2016) and lifestyle behaviors (O'Hara et al., 2013). Benzo et al. (2017) found that HC was a cost-effective strategy for reducing healthcare use, although Hale and Giese (2017) concluded that the findings are inconclusive, at least in the short term. Importantly, much of the evidence related to HC in primary care comes from disease-specific interventions (Thom, 2019) delivered by phone (Härter et al., 2016), with limited consideration of either on-site methods or multimorbidity, despite the prevalence of the latter (Smith et al., 2016). ...
Prevalence of chronic diseases and multimorbidity is rising, and it remains unclear what the best strategy is for activating people with chronic conditions in their self‐care. We designed a two‐group quasi‐experimental time series trial to examine the effectiveness of a nurse‐led, face‐to‐face, individually‐tailored health coaching (HC) intervention in improving patient activation and secondary outcomes (self‐efficacy, quality of life, anxiety and depression symptoms, medication adherence, hospitalization and emergency visits) among primary care users with chronic conditions. A total of 118 people with chronic conditions were recruited through a primary care center and allocated to either the intervention group (IG) (n = 58) or control group (CG) (n = 60). The IG received a nurse‐led individually‐tailored HC intervention involving 4–6 face‐to‐face multicomponent sessions covering six core activation topics. The CG received usual primary care. Data were collected at baseline, after the intervention (6 weeks after baseline for controls) and at 6 and 12 months from baseline. Compared with controls, the IG had significantly higher patient activation scores after the intervention (73.29 vs. 66.51, p = .006). However, this improvement was not maintained at follow‐up and there were no significant differences in secondary outcomes across the study period. HC may be an effective strategy for achieving short‐term improvements in the activation of primary care users with chronic conditions. Further studies with different methodological approaches are needed to elucidate how HC may improve and sustain changes in patient activation.
... It has been argued that the relationship between the health coach and the program participant is crucial to ensure positive health outcomes (18,53,54). Core competencies to help health coaches build support are (1) facilitating participant-centered health coaching activities; (2) helping participants to identify their own goals for change; (3) enabling participant self-discovery of processes to improve self-management; (4) understanding how to help participants be accountable to themselves and self-monitor; (5) knowing how to help participants adapt to the processes of behavior change; and (6) demonstrating interpersonal skills to integrate content information into the change process (18). ...
Background Hospital to home transition care is a most stressful period for stroke survivors and their caregivers to learn self-management of stroke-related health conditions and to engage in rehabilitation. Health coaching has been identified as a strategy to enhance self-management of poststroke care at home. However, interventions in this field that are informed by a health coaching framework are scarce. This study will address a gap in research by testing the hypothesis that a nurse-led health coaching intervention can improve health outcomes for stroke survivors and their family caregivers in hospital to home transition care.
Methods This is a single-blind, two-arm parallel randomized controlled trial of a nurse-led health coaching program versus routine care situated in two tertiary hospitals in Chongqing, China. Stroke survivors and their primary family caregivers will be recruited together as “participant dyads”, and the estimated sample size is 140 (70 in each group). The intervention includes a 12-week nurse-led health coaching program in hospital to home transition care commencing at discharge from the hospital. The primary outcomes are changes in self-efficacy and quality of life of stroke survivors at 12 weeks from the baseline. The secondary outcomes are changes in stroke survivors’ functional ability, stroke-related knowledge, the number of adverse events, and unplanned hospital admissions, and caregivers’ self-efficacy and caregiver-related burden at 12 weeks from the baseline. The outcomes will be measured at 12 weeks and 24 weeks from the baseline.
Discussion This study will examine the effect of nurse-led health coaching on hospital to home transition care for stroke survivors and their caregivers. It is anticipated that findings from this trial will provide research evidence to inform policy, and resource and practice development to improve hospital to home transition care for stroke survivors and their caregivers.
... It has been argued that the relationship between the health coach and the program participant is crucial to ensure positive health outcomes (18, 53,54). Core competencies to help health coaches build support are ...
Background: Hospital to home transition care is a most stressful period for stroke survivors and their caregivers to learn self-management of stroke-related health conditions and to engage in rehabilitation. Health coaching has been identified as a strategy to enhance self-management of poststroke care at home. However, interventions in this field that are informed by a health coaching framework are scarce. This study will address a gap in research by testing the hypothesis that a nurse-led health coaching intervention can improve health outcomes for stroke survivors and their family caregivers in hospital to home transition care.
Methods: This is a single-blind, two-arm parallel randomized controlled trial of a nurse-led health coaching program versus routine care situated in two tertiary hospitals in Chongqing, China. Stroke survivors and their primary family caregivers will be recruited together as “participant dyads”, and the estimated sample size is 140 (70 in each group). The intervention includes a 12-week nurse-led health coaching program in hospital to home transition care commencing at discharge from the hospital. The primary outcomes are changes in self-efficacy and quality of life of stroke survivors at 12 weeks from the baseline. The secondary outcomes are changes in stroke survivors’ functional ability, stroke-related knowledge, the number of adverse events, and unplanned hospital admissions, and caregivers’ self-efficacy and caregiver-related burden at 12 weeks from the baseline. The outcomes will be measured at 12 weeks and 24 weeks from the baseline.
Discussion: This study will examine the effect of nurse-led health coaching on hospital to home transition care for stroke survivors and their caregivers. It is anticipated that findings from this trial will provide research evidence to inform policy, and resource and practice development to improve hospital to home transition care for stroke survivors and their caregivers.
Trial registration: The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000321145, registered on 1st March 2019.
... It has been argued that the relationship between the health coach and the program participant is crucial to ensure positive health outcomes [18,49,50]. Core competencies to help health coaches build support are (1) facilitating participant-centered health coaching activities; ...
Background:
Hospital to home transition care is a most stressful period for stroke survivors and their caregivers to learn self-management of stroke-related health conditions and to engage in rehabilitation. Health coaching has been identified as a strategy to enhance self-management of poststroke care at home. However, interventions in this field that are informed by a health coaching framework are scarce. This study will address a gap in research by testing the hypothesis that a nurse-led health coaching intervention can improve health outcomes for stroke survivors and their family caregivers in hospital to home transition care.
Methods:
This is a single-blind, two-arm parallel randomized controlled trial of a nurse-led health coaching program versus routine care situated in two tertiary hospitals in Chongqing, China. Stroke survivors and their primary family caregivers will be recruited together as "participant dyads", and the estimated sample size is 140 (70 in each group). The intervention includes a 12-week nurse-led health coaching program in hospital to home transition care commencing at discharge from the hospital. The primary outcome is changes in self-efficacy of stroke survivors at 12 weeks from the baseline. The secondary outcomes are changes in stroke survivors' and quality of life, functional ability, stroke-related knowledge, the number of adverse events, and unplanned hospital admissions, and caregivers' self-efficacy and caregiver-related burden at 12 weeks from the baseline. The outcomes will be measured at 12 weeks and 24 weeks from the baseline.
Discussion:
This study will examine the effect of nurse-led health coaching on hospital to home transition care for stroke survivors and their caregivers. It is anticipated that findings from this trial will provide research evidence to inform policy, and resource and practice development to improve hospital to home transition care for stroke survivors and their caregivers.
Trial registration:
The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000321145. Registered on 1 March 2019.
... Researchers studying HC among adults with chronic conditions have found that it can increase patient activation (Nouri et al., 2019), self-efficacy (Tuluce & Kutluturkan, 2018), and medication adherence (Wolever & Dreusicke, 2016), and also improve HRQoL (Benzo et al., 2016) and lifestyle behaviors (O'Hara et al., 2013). Benzo et al. (2017) found that HC was a cost-effective strategy for reducing healthcare use, although Hale and Giese (2017) concluded that the findings are inconclusive, at least in the short term. Importantly, much of the evidence related to HC in primary care comes from disease-specific interventions (Thom, 2019) delivered by phone (Härter et al., 2016), with limited consideration of either on-site methods or multimorbidity, despite the prevalence of the latter (Smith et al., 2016). ...
Background:
. The 13-item Patient Activation Measure (PAM-13) is an instrument that assesses people's knowledge, skills and confidence for self-management of their health and health care. Scores on the PAM-13 have been shown to predict adherence to health behaviours, health-related outcomes and health care costs.
Objectives:
. To develop a European Spanish adaptation of the original PAM-13 and to examine its psychometric properties in a sample of chronic patients.
Methods:
. The PAM-13 was forward-backward translated and then completed by chronic patients attending a primary health care centre. Data were analysed with a Rasch model. We assessed the functioning of the rating scale, its reliability, the item goodness-of-fit, differential item functioning (DIF), local dependence, unidimensionality and correlation analysis.
Results:
. A total of 208 patients (80%) completed the questionnaire. Data showed a fit to the Rasch model. More than 50% of patients endorsed all the items. Item rank for the Spanish sample was similar to the original, with few differences. We found significant differences (P < 0.05) in PAM-13 measures according to adherence to prescribed medicines and positive correlations with self-efficacy and physical quality of life.
Conclusions:
. The European Spanish PAM-13 is a reliable and valid instrument for assessing activation in patients with chronic disease in Spain. We suggest adding new items to the instrument so as to examine patients with higher activation levels in the future. Further studies are needed to evaluate the usefulness of this new Spanish PAM-13 in different settings and populations, as well as to examine the relationship between PAM-13 scores and other health-related outcomes.
Pulmonary rehabilitation is an effective therapy that improves day-to-day symptoms and quality of life in patients with chronic obstructive pulmonary disease. In this review, we look at the role of virtual programs, implementation of artificial intelligence, emerging areas of improvement within the educational components of programs, and the benefit of advanced practice providers in directorship roles.
Objective:
To identify the characteristics of an effective health coach and describe how these characteristics can be developed.
Methods:
A qualitative descriptive design was used to obtain insights from a convenience, homogenous sample of health coaches, social workers, and research staff members collaborating as members of a team providing a health coaching telehealth intervention for lay caregivers. Individual interviews were analyzed using thematic analysis.
Results:
The 11 study participants interviewed were predominately married (75 %), female (92 %) and Caucasian (83 %). Ages ranged from 27 to 66 with an average age of 42 years. The sample was highly educated, with five having attained a terminal degree (PhD or DNP). The participants described three themes of characteristics that contributed to the success of health coaches: personal characteristics, professional characteristics, and program characteristics.
Conclusions:
These characteristics expand what is known about attributes that contribute to successful health coaching. Most can be trained or used in developing programs and interventions.
Practice implications:
Our findings suggest that many of the core skills of an effective health coach can be developed through individual training, program design, and peer support. Innate personal characteristics such as trustworthiness, integrity, and compassion are hard to influence but can be identified in the hiring process.
Background
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with high morbidity and mortality, and frequent readmissions.
Research Question
What is the effectiveness of a COPD transition bundle, with and without a care-coordinator, on re-hospitalizations and emergency department (ED) revisits?
Study Design and Methods
Two patient cohorts were selected: 1) exposed to the transition bundle group, and 2) non-exposed (usual care group). Patients exposed were subsequently randomized to a care-coordinator. An AECOPD transition bundle was implemented in hospital; patients randomized to the care-coordinator were contacted ≤72-hours post-discharge. 604 patients (320 care-coordinator; 284 routine care) who met eligibility criteria from five hospitals across three cities in Alberta, Canada were exposed to the transition bundle while 3,106 patients discharged from the same hospitals received usual care. Primary outcomes were 7-, 30-, and 90-day readmissions, median length of stay (LOS) and 30-day ED revisits.
Results
The transition bundle cohort were 83% (Relative Risk: 0.17; 95% Confidence Interval: 0.07, 0.35) less likely to be readmitted within 7-days, and 26% (0.74; 0.60, 0.91) less likely to be readmitted within 30-days of discharge. Ninety-day readmissions were unchanged (1.05; 0.93, 1.18). The transition bundle was associated with a 7.3% (1.07; 1.0, 1.15) relative increase in LOS and a 76% (1.76; 1.53, 2.02) greater risk of a 30-day ED revisit. The care-coordinator did not influence readmission or ED revisits.
Interpretation
The COPD transition bundle reduced 7- and 30-day hospital readmissions, while increasing LOS and ED revisits. The care-coordinator did not improve outcomes.
Introduction:
Therapeutic alliance, a goal-orientated partnership between clients and practitioners, can enhance program engagement and adherence, and improve treatment outcomes and satisfaction.
Objectives:
To develop an empirical model that describes how therapeutic alliances can be operationalized in clinical and research settings and use this in our evaluation of the Coaching for Healthy Ageing (CHAnGE) trial.
Methods:
Secondary analysis of interviews with participants in the CHAnGE trial (n = 32) and a focus group with the physiotherapists who delivered health coaching in that trial (n = 3). Analysis was inductive (thematic) and deductive (using a therapeutic alliance model derived from a literature review and informed by earlier analyses).
Results:
Data from participants and physiotherapists indicated that health coaching in CHAnGE built effective therapeutic alliances (i.e. it facilitated collaborative decision-making and trusting person-centered relationships) which were underpinned by professional skills and structural supports. Components of the intervention that strengthened therapeutic alliance were health coaching training, home visits, the coaching format, and provision of free activity monitors.
Conclusion:
This study identifies key concepts and practical 'building blocks' of therapeutic alliance, showing how these were operationalized within an intervention. This may help those in clinical and research settings to recognize the importance and characteristics of therapeutic alliance and put it into practice.
A convergence of economic, technological, policy, and scientific forces are driving changes in the nature and scope of cancer rehabilitation services, who receives and provides them, and where they are provided. The possibilities for cancer rehabilitation service provision created by shifts away from fee-for-service are profound. They open the door to a radical reconceptualization of healthcare delivery, and create a pressing need for evidence to inform strategies to render care delivery more patient-centric while simultaneously preserving effectiveness and enhancing value. Remote and hybrid (combination remote-center based) approaches have been validated that evaluate, educate, and treat patients with cancer to address diverse clinical targets. For example, two randomized controlled trials that provided collaborative telecare via phone calls and web-based interfaces noted clinically meaningfully benefits and were cost effective. “Big data,” or population-level aggregated data collected in the course of care delivery and billing, has held the attention of clinical researchers for over a decade, but that interest and related expectations have intensified. Current efforts to systematically collect functional and rehabilitation-related outcome data through the electronic health records will likely fuel future AI-based approaches. Multimodal pain management with an emphasis on nonpharmacological approaches has become a renewed topic of investigative attention. In addition to new analgesic molecule and device development, current research efforts are developing new approaches to care delivery that may prove highly relevant to cancer rehabilitation.
The aim of modern therapy for chronic obstructive pulmonary disease (COPD) is to reduce the severity of symptoms and prevent the development of relapse exacerbations, maintain pulmonary function at an optimal level and improve the quality of life of patients. The solution to these problems is pulmonary rehabilitation. Search for effective ways of providing an educational component, assessing the impact of various training programs and implementing a self-management strategy continues. Purpose: to analyze modern approaches, advantages and disadvantages of educational programs on self-management of people with COPD and establish the role of a physical therapy specialist in providing them. Material & Methods: the search was conducted on the resource of the US National Center for Biotechnological Information PubMed and in the database of scientific evidence on physical therapy PEDro. According to the results of the search in the databases, 329 links were obtained, of which, after excluding those that did NOT meet the necessary criteria, 14 publications were selected for subsequent analysis. Results: 29 educational topics related to self-management education were identified, which in different combinations are recommended for study in educational programs for patients with COPD. Training topics were grouped into four training modules that took into account the goals and objectives of the self-management strategy and ensure their solution. The most often competent in implementing educational programs for patients with COPD are a pulmonologist, physical therapist, nurse, pharmacist, occupational therapist, and social worker. The content, results, advantages and limitations of various self-management training programs are analyzed. Conclusions: today there are not enough practical recommendations and clear criteria that training programs on self-management for patients with COPD should meet. The analysis of modern clinical studies on the introduction of self-management training is the basis for the development of Ukrainian-language training programs.
Purpose:
Health coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention.
Methods:
We performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures.
Results:
290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months.
Conclusions:
Results support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.
Introduction:
The way in which telemedicine contributes to promote coping and independence might be undervalued in the development of telemedicine solutions and the implementation of telemedicine interventions. This study explored how home-living patients diagnosed with chronic obstructive pulmonary disease (COPD) experienced follow-up using telemedicine, and the extent to which the implemented technology was able to support and improve the patients' coping resources and independence.
Methods:
A qualitative approach with individual semi-structured interviews was used. Ten patients diagnosed with COPD participated. The data were transcribed verbatim and a qualitative content analysis method was used, including analyses of the manifest and latent content of the texts.
Results:
The participants' positive attitude to handling and understanding the technology and the positive and negative feelings related to use the technology derived the theme: "The telemedicine solution is experienced as comprehensible and manageable and provides meaning in daily life". The importance of telemedicine services that provided trust and confidence, the intervention's impact on independence and self-management and the intervention's ability to support integrity and meaning in life, derived the theme: "The telemedicine intervention contributes to stress reduction caused by illness burden and facilitates living as normally as possible".
Discussion:
The impact of a telemedicine intervention might be influenced by the experience of a technological solution that requires little effort to deal with, while it must also provide meaning in life. Furthermore, the telenurses' expertise and the intervention's flexibility, i.e. possibilities for individual adaption, might promote coping to facilitate living as normally as possible despite illness.
Purpose
This project examined potential changes in health behaviors following wellness coaching.
Design
In a single cohort study design, wellness coaching participants were recruited in 2011, data were collected through July 2012, and were analyzed through December 2013. Items in the study questionnaire used requested information about 11 health behaviors, self-efficacy for eating, and goalsetting skills.
Setting
Worksite wellness center.
Participants
One-hundred employee wellness center members with an average age of 42 years; 90% were female and most were overweight or obese.
Intervention
Twelve weeks of in-person, one-on-one wellness coaching.
Method
Participants completed study questionnaires when they started wellness coaching (baseline), after 12 weeks of wellness coaching, and at a 3-month follow-up.
Results
From baseline to week 12, these 100 wellness coaching participants improved their self-reported health behaviors (11 domains, 0- to 10-point scale) from an average of 6.4 to 7.7 (p < .001), eating selfefficacy from an average of 112 to 142 (on a 0- to 180-point scale; p < .001), and goal-setting skills from an average of 49 to 55 (on a 16- to 80-point scale; p < .001).
Conclusion
These results suggest that participants improved their current health behaviors and learned skills for continued healthy living. Future studies that use randomized controlled trials are needed to establish causality for wellness coaching.
Home telehealth can provide considerable benefits to people diagnosed with chronic obstructive pulmonary disease, yet 20% of patients abandon telehealth. Identifying the factors that affect whether or not a patient decides to continue using telehealth is therefore crucial to the goal of mainstreaming telehealth. However, studies to date have only assessed the perceptions of patients who are not currently using telehealth, have used telehealth in experimental sessions, or are enrolled in a trial. The aim of the present study was to explore the beliefs and perceptions of patients with chronic obstructive pulmonary disease currently using home telehealth and who are not enrolled in a trial.
Semistructured interviews were conducted with 8 patients with chronic obstructive pulmonary disease. Interviews were analyzed using interpretative phenomenological analysis.
Four superordinate themes are presented: (a) perceiving benefits of "being watched over" as providing peace of mind, (b) learning about the health condition and the impacts on self-management behavior, (c) active engagement in health service provision and better access to health care, and (d) valuing the importance of in-person care.
Users generally describe home telehealth in positive terms; however, patients still value face-to-face contact with health care professionals. The positive aspects of home telehealth, such as better access to health care and providing peace of mind, could be communicated to prospective users to improve uptake. Similarly, sustained use of telehealth is likely to be ensured if occasional visits from health care professionals are maintained. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Objective To investigate whether an early rehabilitation intervention initiated during acute admission for exacerbations of chronic respiratory disease reduces the risk of readmission over 12 months and ameliorates the negative effects of the episode on physical performance and health status.
Design Prospective, randomised controlled trial.
Setting An acute cardiorespiratory unit in a teaching hospital and an acute medical unit in an affiliated teaching district general hospital, United Kingdom.
Participants 389 patients aged between 45 and 93 who within 48 hours of admission to hospital with an exacerbation of chronic respiratory disease were randomised to an early rehabilitation intervention (n=196) or to usual care (n=193).
Main outcome measures The primary outcome was readmission rate at 12 months. Secondary outcomes included number of hospital days, mortality, physical performance, and health status. The primary analysis was by intention to treat, with prespecified per protocol analysis as a secondary outcome.
Interventions Participants in the early rehabilitation group received a six week intervention, started within 48 hours of admission. The intervention comprised prescribed, progressive aerobic, resistance, and neuromuscular electrical stimulation training. Patients also received a self management and education package.
Results Of the 389 participants, 320 (82%) had a primary diagnosis of chronic obstructive pulmonary disease. 233 (60%) were readmitted at least once in the following year (62% in the intervention group and 58% in the control group). No significant difference between groups was found (hazard ratio 1.1, 95% confidence interval 0.86 to 1.43, P=0.4). An increase in mortality was seen in the intervention group at one year (odds ratio 1.74, 95% confidence interval 1.05 to 2.88, P=0.03). Significant recovery in physical performance and health status was seen after discharge in both groups, with no significant difference between groups at one year.
Conclusion Early rehabilitation during hospital admission for chronic respiratory disease did not reduce the risk of subsequent readmission or enhance recovery of physical function following the event over 12 months. Mortality at 12 months was higher in the intervention group. The results suggest that beyond current standard physiotherapy practice, progressive exercise rehabilitation should not be started during the early stages of the acute illness.
Trial registration Current Controlled Trials ISRCTN05557928.
To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia.
Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation.
General practices in Victoria, Australia.
59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate.
Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient.
The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group.
The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months' follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval -0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups.
A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective.
Current Controlled Trials ISRCTN50662837.
There is no conclusive evidence about the way to a promote behavior change in self-management programs for patients with chronic obstructive pulmonary disease (COPD). The latter is a significant knowledge gap as there is a need to promote a sustained effect in interventions like Pulmonary Rehabilitation or Supporting Programs. Embracing patient's values seems to be a key ingredient to ignite genuine motivation for behavior change. This manuscript describes two pilot qualitative studies carried out in patients with severe COPD aimed to engage the patient inner experience and promote self-management: a trial testing motivational interviewing (MI) as one style of helping patients with severe COPD make changes in their behavior and second a trial testing a mindfulness-based intervention. The MI study consisted of a 3-month program of weekly coaching phone calls after one face-to-face visit. The following themes were outstanding: patients value the supportive communication with coach and believe the MI-based coaching created increased level of awareness and accountability. They perceived an increase in physical activity and reported "feeling better" or other benefits not directly related to exercise. The Mindfulness for Health Program was a mandatory 8-week program that consisted on 2-hour classes aimed to cultivate nonjudgmental attention in the moment (through different meditative practices and sharing) plus monthly face-to-face encounters aimed to sustain practice and sharing of life experiences for 1 year. The following themes (at 1 year) were outstanding: appreciating life by seeing hardships as opportunities, valuing the self through compassion and awareness, cultivating connectedness with others, acquiring joy, and adopting healthy behaviors. In the search for the "holy grail" for self-management programs that can promote a behavior change, mindfulness and MI seem promising for cultivating a way to live a life in which people are fully present and consciously agree with.
Objective:
To examine the effectiveness of telephone-based coaching services for the management of patients with chronic diseases.
Methods:
A rapid scoping review of the published peer reviewed literature, using Medline, Embase, CINAHL, PsychNet and Scopus. We included studies involving people aged 18 years or over with one or more of the following chronic conditions: type 2 diabetes, congestive cardiac failure, coronary artery disease, chronic obstructive pulmonary disease and hypertension. Patients were identified as having multi-morbidity if they had an index chronic condition plus one or more other chronic condition. To be included in this review, the telephone coaching had to involve two-way conversations by telephone or video phone between a patient and a provider. Behaviour change, goal setting and empowerment are essential features of coaching.
Results:
The review found 1756 papers, which was reduced to 30 after screening and relevance checks. Most coaching services were planned, as opposed to reactive, and targeted patients with complex needs who had one or more chronic disease. Several studies reported improvements in health behaviour, self-efficacy, health status and satisfaction with the service. More than one-third of the papers targeted vulnerable people and telephone coaching was found to be effective for these people.
Conclusions:
Telephone coaching for people with chronic conditions can improve health behaviour, self-efficacy and health status. This is especially true for vulnerable populations who had difficulty accessing health services. There is less evidence for improvements in quality of life and patient satisfaction with the service. The evidence for improvements in health service use was limited. This rapid scoping review found that telephone-based coaching can enhance the management of chronic disease, especially for vulnerable groups. Further work is needed to identify what models of telephone coaching are most effective according to patients' level of risk and co-morbidity. What is known about the topic? With the increasing prevalence of chronic diseases more demands are being made of limited health services and resources. Telephone health coaching for people with or at risk of chronic diseases is seen as a means of supporting people to manage their health and reducing the burden on the healthcare system. What does this paper add? Telephone coaching interventions were effective for vulnerable people with chronic disease(s). Often the vulnerable populations had worse control of their chronic condition at baseline and demonstrated the greatest improvement compared with those with better control at baseline. Planned (i.e. weekly or monthly telephone calls to support the patients with chronic disease) and unscripted telephone coaching interventions appear to be most effective for improving self-management skills in people from vulnerable groups: the planned telephone coaching services had the advantage of regular contact and helping people develop their skills over time, whereas the unscripted aspect allowed the coach to tailor support to the patient's individual needs What are the implications for practitioners? Telephone coaching is an effective means of supporting people with chronic diseases to manage their own health. Further work is needed to embed telephone coaching within existing services. Good linkages with the patient's general practitioner are important. This might be a regular report, updates via the patient e-health record, or provision for contact if a problem is identified or linking to the patient e-health record.
Adoption and maintenance of healthy behaviours is pivotal to chronic disease self-management as this influences disease progression and impact. This qualitative study investigated health behaviour changes adopted by participants with moderate or severe chronic obstructive pulmonary disease (COPD) recruited to a randomised controlled study of telephone-delivered health-mentoring.
Community nurses trained as health-mentors used a patient-centred approach with COPD patients recruited in general practice to facilitate behaviour change, using a framework of health behaviours; 'SNAPPS' Smoking, Nutrition, Alcohol, Physical activity, Psychosocial well-being, and Symptom management, through regular phone calls over 12 months. Semi-structured interviews in a purposive sample sought feedback on mentoring and behaviour changes adopted. Interviews were analysed using iterative thematic and interpretative content approaches by two investigators.
Of 90 participants allocated to health-mentoring, 65 (72%) were invited for interview at 12-month follow up. The 44 interviewees, 75% with moderate COPD, had a median of 13 mentor contacts over 12 months, range 5-20. Interviewed participants (n=44, 55% male, 43% current smokers, 75% moderate COPD) were representative of the total group with a mean age 65 years while 82% had at least one additional co-morbid chronic condition. Telephone delivery was highly acceptable and enabled good rapport. Participants rated 'being listened to by a caring health professional' as very valuable. Three participant groups were identified by attitude to health behaviour change: 14 (32%) actively making changes; 18 (41%) open to and making some changes and 12 (27%) more resistant to change. COPD severity or current smoking status was not related to group category. Mentoring increased awareness of COPD effects, helping develop and personalise behaviour change strategies, even by those not actively making changes. Physical activity was targeted by 43 (98%) participants and smoking by 14 (74%) current smokers with 21% reporting quitting. Motivation to maintain changes was increased by mentor support.
Telephone delivery of health-mentoring is feasible and acceptable to people with COPD in primary care. Health behaviours targeted by this population, mostly with moderate disease, were mainly physical activity and smoking reduction or cessation. Health-mentoring increased motivation and assisted people to develop strategies for making and sustaining beneficial change.
ACTR12608000112368.
The aim was to evaluate the effect of a 12-month individualized health coaching intervention by telephony on clinical outcomes.
An open-label cluster-randomized parallel groups trial. Pre- and post-intervention anthropometric and blood pressure measurements by trained nurses, laboratory measures from electronic medical records (EMR). A total of 2594 patients filling inclusion criteria (age 45 years or older, with type 2 diabetes, coronary artery disease or congestive heart failure, and unmet treatment goals) were identified from EMRs, and 1535 patients (59%) gave consent and were randomized into intervention or control arm. Final analysis included 1221 (80%) participants with data on primary end-points both at entry and at end. Primary outcomes were systolic and diastolic blood pressure, serum total and LDL cholesterol concentration, waist circumference for all patients, glycated hemoglobin (HbA1c) for diabetics and NYHA class in patients with congestive heart failure. The target effect was defined as a 10-percentage point increase in the proportion of patients reaching the treatment goal in the intervention arm.
The proportion of patients with diastolic blood pressure initially above the target level decreasing to 85 mmHg or lower was 48% in the intervention arm and 37% in the control arm (difference 10.8%, 95% confidence interval 1.5–19.7%). No significant differences emerged between the arms in the other primary end-points. However, the target levels of systolic blood pressure and waist circumference were reached non-significantly more frequently in the intervention arm.
Individualized health coaching by telephony, as implemented in the trial was unable to achieve majority of the disease management clinical measures. To provide substantial benefits, interventions may need to be more intensive, target specific sub-groups, and/or to be fully integrated into local health care.
Trial registration
ClinicalTrials.gov Identifier: NCT00552903
To determine whether supported self management in chronic obstructive pulmonary disease (COPD) can reduce hospital readmissions in the United Kingdom.
Randomised controlled trial.
Community based intervention in the west of Scotland.
Patients admitted to hospital with acute exacerbation of COPD.
Participants in the intervention group were trained to detect and treat exacerbations promptly, with ongoing support for 12 months.
The 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.
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).
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.
To test the effectiveness of two interventions compared to usual care in decreasing attitudinal barriers to cancer pain management, decreasing pain intensity, and improving functional status and quality of life (QOL).
Randomized clinical trial.
Six outpatient oncology clinics (three Veterans Affairs [VA] facilities, one county hospital, and one community-based practice in California, and one VA clinic in New Jersey)Sample: 318 adults with various types of cancer-related pain.
Patients were randomly assigned to one of three groups: control, standardized education, or coaching. Patients in the education and coaching groups viewed a video and received a pamphlet on managing cancer pain. In addition, patients in the coaching group participated in four telephone sessions with an advanced practice nurse interventionist using motivational interviewing techniques to decrease attitudinal barriers to cancer pain management. Questionnaires were completed at baseline and six weeks after the final telephone calls. Analysis of covariance was used to evaluate for differences in study outcomes among the three groups.
Pain intensity, pain relief, pain interference, attitudinal barriers, functional status, and QOL.
Attitudinal barrier scores did not change over time among groups. Patients randomized to the coaching group reported significant improvement in their ratings of pain-related interference with function, as well as general health, vitality, and mental health.
Although additional evaluation is needed, coaching may be a useful strategy to help patients decrease attitudinal barriers toward cancer pain management and to better manage their cancer pain.
By using motivational interviewing techniques, advanced practice oncology nurses can help patients develop an appropriate plan of care to decrease pain and other symptoms.
Hospital readmission for acute exacerbation of COPD (AECOPD) occurs in up to 30% of patients, leading to excess morbidity and poor survival. Physiological risk factors predict readmission, but the impact of modifiable psychosocial risk factors remains uncertain. We aimed to evaluate whether psychosocial risk factors independently predict readmission for AECOPD in patients referred to early discharge services (EDS).
This prospective cohort study included 79 patients with AECOPD cared for by nurse led EDS in the UK, and followed up for 12 months. Data on lung function, medical comorbidities, previous hospital admissions, medications, and sociodemographics were collected at baseline; St George's Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS), and social support were measured at baseline, 3 and 12-months. Exploratory multivariate models were fitted to identify psychosocial factors associated with readmission adjusted for known confounders.
26 patients were readmitted within 90 days and 60 patients were readmitted at least once during follow-up. Depression at baseline predicted readmission adjusted for sociodemographics and forced expiratory volume in 1 second (odds ratio 1.30, 95% CI 1.06 to 1.60, p = 0.013). Perceived social support was not significantly associated with risk of readmission. Home ownership was associated with the total number of readmissions (B = 0.46, 95% CI -0.86 to -0.06, p = 0.024). Compared with those not readmitted, readmitted patients had worse SGRQ and HADS scores at 12 months.
Depressive symptoms and socioeconomic status, but not perceived social support, predict risk of readmission and readmission frequency for AECOPD in patients cared for by nurse-led EDS. Future work on reducing demand for unscheduled hospital admissions could include the design and evaluation of interventions aimed at optimising the psychosocial care of AECOPD patients managed at home.
The purpose of this study was to evaluate the effectiveness of integrative health (IH) coaching on psychosocial factors, behavior change, and glycemic control in patients with type 2 diabetes.
Fifty-six patients with type 2 diabetes were randomized to either 6 months of IH coaching or usual care (control group). Coaching was conducted by telephone for fourteen 30-minute sessions. Patients were guided in creating an individualized vision of health, and goals were self-chosen to align with personal values. The coaching agenda, discussion topics, and goals were those of the patient, not the provider. Preintervention and postintervention assessments measured medication adherence, exercise frequency, patient engagement, psychosocial variables, and A1C.
Perceived barriers to medication adherence decreased, while patient activation, perceived social support, and benefit finding all increased in the IH coaching group compared with those in the control group. Improvements in the coaching group alone were also observed for self-reported adherence, exercise frequency, stress, and perceived health status. Coaching participants with elevated baseline A1C (>/=7%) significantly reduced their A1C.
A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs. Fundamentals of IH coaching may be applied by diabetes educators to improve patient self-efficacy, accountability, and clinical outcomes.
Psychological functioning is an important determinant of health outcomes in chronic lung disease. To better define the role of anxiety in chronic obstructive pulmonary disease (COPD), a study was conducted of the inter-relations between anxiety and COPD in a large cohort of subjects with COPD and a matched control group.
Data were used from the FLOW (Function, Living, Outcomes, and Work) cohort of patients with COPD (n=1202) and matched controls without COPD (n=302). Anxiety was measured using the Anxiety subscale of the Hospital Anxiety and Depression Scale.
COPD was associated with a greater risk of anxiety in multivariable analysis (OR 1.85; 95% CI 1.072 to 3.18). Among patients with COPD, anxiety was related to poorer health outcomes including worse submaximal exercise performance (less distance walked during the 6-min walk test: -66.3 feet for anxious vs non-anxious groups; 95% CI -127.3 to -5.36) and a greater risk of self-reported functional limitations (OR 2.41; 95% CI 1.71 to 3.41). Subjects with COPD with anxiety had a higher longitudinal risk of COPD exacerbation in Cox proportional hazards analysis after controlling for covariates (HR 1.39; 95% CI 1.007 to 1.90).
COPD is associated with a higher risk of anxiety. Once anxiety develops among patients with COPD, it is related to poorer health outcomes. Further research is needed to determine whether systematic screening and treatment of anxiety in COPD will improve health outcomes and prevent functional decline and disability.
Both disability and depression are common in COPD, but limited information is available on the time-ordered relationship between increases in disability and depression onset.
Subjects were members of a longitudinal cohort with self-reported physician-diagnosed COPD, emphysema, or chronic bronchitis. Data were collected through three annual structured telephone interviews (T1, T2, and T3). Depression was defined as a score >/= 4 on the Geriatric Depression Scale Short Form (S-GDS). Disability was measured with the Valued Life Activities (VLA) scale; three disability scores were calculated: percent of VLAs unable to perform, percent of VLAs affected (unable to perform or with some degree of difficulty), and mean VLA difficulty rating. Disability increases were defined as a 0.5 SD increase in disability score between T1 and T2. Multiple logistic regression analyses estimated the risk of T3 depression following a T1 to T2 disability increase for the total cohort and then excluding individuals who met the depression criterion at T1 or T2.
Approximately 30% of subjects met the depression criterion each year. Eight percent to 19% experienced a T1 to T2 disability increase, depending on the disability measure. Including all cohort members and controlling for baseline S-GDS scores, T1 to T2 increases in disability yielded a significantly elevated risk of T3 depression (% affected odds ratio [OR] =3.6; 95% CI, [1.7, 7.7]; % unable OR = 6.1 [17, 21.8]; mean difficulty OR= 3.6 [1.7, 8.0]). Omitting individuals depressed at T1 or T2 yielded even stronger risk estimates for % unable (OR = 13.4 [2.0, 91.4]) and mean difficulty (OR = 3.9 [1.3, 11.8]).
Increases in VLA disability are strongly predictive of the onset of depression.
In the 26 years since it was first introduced in this journal, motivational interviewing (MI) has become confused with various other ideas and approaches, owing in part to its rapid international diffusion.
Based on confusions that have arisen in publications and presentations regarding MI, the authors compiled a list of 10 concepts and procedures with which MI should not be addled.
This article discusses 10 things that MI is not: (1) the transtheoretical model of change; (2) a way of tricking people into doing what you want them to do; (3) a technique; (4) decisional balance; (5) assessment feedback; (6) cognitive-behavior therapy; (7) client-centered therapy; (8) easy to learn; (9) practice as usual; and (10) a panacea.
Clarity about what does (and does not) constitute MI promotes quality assurance in scientific research, clinical practice, and training.
Emergency department visits and rehospitalization are common after hospital discharge.
To test the effects of an intervention designed to minimize hospital utilization after discharge.
Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.
General medical service at an urban, academic, safety-net hospital.
749 English-speaking hospitalized adults (mean age, 49.9 years).
A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.
Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.
Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.
This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.
A package of discharge services reduced hospital utilization within 30 days of discharge.
Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.
Depression and anxiety are significant comorbid and potentially modifiable conditions in chronic obstructive pulmonary disease (COPD), but their effects on exacerbations are not clear.
To investigate the independent effect of depression and anxiety on the risk of COPD exacerbations and hospitalizations.
A multicenter prospective cohort study in 491 patients with stable COPD in China. Multivariate Poisson and linear regression analyses were used, respectively, to estimate adjusted incidence rate ratios (IRRs) and adjusted effects on duration of events.
Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) at baseline. Other measurements included sociodemographic, clinical, psychosocial, and treatment characteristics. Patients were then monitored monthly for 12 months to document the occurrence and characteristics of COPD exacerbations and hospitalizations. Exacerbation was determined using both symptom-based (worsening of > or =1 key symptom) and event-based definitions (> or =1 symptom worsening plus > or =1 change in regular medications). A total of 876 symptom-based and 450 event-based exacerbations were recorded, among which 183 led to hospitalization. Probable depression (HADS depression score > or = 11) was associated with an increased risk of symptom-based exacerbations (adjusted IRR, 1.51; 95% confidence interval [CI], 1.01-2.24), event-based exacerbations (adjusted IRR, 1.56; 95% CI, 1.02-2.40), and hospitalization (adjusted IRR, 1.72; 95% CI, 1.04-2.85) compared with nondepression (score < or = 7). The duration of event-based exacerbations was 1.92 (1.04-3.54) times longer for patients with probable anxiety (HADS anxiety score > or = 11) than those with no anxiety (score < or = 7).
This study suggests a possible causal effect of depression on COPD exacerbations and hospitalizations. Further studies are warranted to confirm this finding and to test the effectiveness of antidepressants and psychotherapies on reducing exacerbations and improving health resource utilizations.
The Chronic Respiratory Questionnaire (CRQ) is an established measure of health status for chronic obstructive pulmonary disease (COPD). It has been found to be reproducible and sensitive to change, but as an interviewer led questionnaire is very time consuming to administer. A study was undertaken to develop a self-reported version of the CRQ (CRQ-SR) and to compare the results of this questionnaire with the conventional interviewer led CRQ (CRQ-IL).
Fifty two patients with moderate to severe COPD participated in the study. Subjects completed the CRQ-SR 1 week after completing the CRQ-IL, and a further CRQ-SR was administered 1 week later. For patients in group A (n=27) the dyspnoea provoking activities that they had previously selected were transcribed onto the second CRQ-SR, while patients in group B (n=25) were not informed of their previous dyspnoea provoking activities when they completed the second CRQ-SR. To assess the short term reproducibility and reliability of the CRQ-SR it was then administered twice at an interval of 7-10 days to a further group of 21 patients. The CRQ-IL was not administered. Longer term reproducibility was examined in 39 stable patients who completed the CRQ-SR at initial assessment and then again 7 weeks later.
Mean scores per dimension, mean differences, and limits of agreement are given for each dimension in the comparison of the two questionnaires. There were no statistically significant differences between the CRQ-IL and CRQ-SR in the mastery and fatigue dimensions (p>0.05). A statistically significant difference between the two scores was found in the dyspnoea dimension (p=0.006) and the emotional function dimension (p=0.04), but these differences were well within the minimum clinically important threshold. No statistically significant difference in the mean dyspnoea score was seen between groups A and B. The CRQ-SR was found to be reproducible both in the short term and after the longer period of 7 weeks, with no statistically or clinically significant differences in any dimension. Test-retest reliability was found to be high in each dimension, both in the short and longer term.
The CRQ-SR is a reproducible, reliable, and stable measure of health status. It compares well with the CRQ-IL but cannot be used interchangeably. The main advantage of the CRQ-SR over the CRQ-IL is that is quick to administer, reducing assessment time and hence cost.
Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF).
To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs.
We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field.
We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome.
Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner.
Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials).
Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
Treatment fidelity refers to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions. This article describes a multisite effort by the Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium (BCC) to identify treatment fidelity concepts and strategies in health behavior intervention research. The work group reviewed treatment fidelity practices in the research literature, identified techniques used within the BCC, and developed recommendations for incorporating these practices more consistently. The recommendations cover study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. Funding agencies, reviewers, and journal editors are encouraged to make treatment fidelity a standard part of the conduct and evaluation of health behavior intervention research.
The aim of the present study was to analyse the risk of rehospitalisation in patients with chronic obstructive pulmonary disease and associated risk factors.
This prospective study included 416 patients from a university hospital in each of the five Nordic countries. Data included demographic information, spirometry, comorbidity and 12 month follow-up for 406 patients. The hospital anxiety and depression scale and St. George's Respiratory Questionnaire (SGRQ) were applied to all patients.
The number of patients that had a re-admission within 12 months was 246 (60.6%). Patients that had a re-admission had lower lung function and health status. A low forced expiratory volume in one second (FEV 1 ) and health status were independent predictors for re-admission. Hazard ratio (HR; 95% CI) was 0.82 (0.74–0.90) per 10% increase of the predicted FEV 1 and 1.06 (1.02–1.10) per 4 units increase in total SGRQ score. The risk of rehospitalisation was also increased in subjects with anxiety (HR 1.76 (1.16–2.68)) and in subjects with low health status (total SGRQ score >60 units). When comparing the different subscales in the SGRQ, the closest relation between the risk of rehospitalisation was seen with the activity scale (HR 1.07 (1.03–1.11) per 4 unit increase).
In patients with low health status, anxiety is an important risk factor for rehospitalisation. This may be important for patient treatment and warrants further studies.
Disease management programmes (DMPs) have evolved as an innovative clinical practice system to enhance the discharge outcomes of older people with heart failure. Yet, clinical trials which have examined their effectiveness have reported inconsistent findings. This may be explained by variations in the design of DMPs. The aim is to identify the characteristics of DMPs which are crucial to reducing hospital readmission and/or mortality of older people with heart failure.
A systematic computerized search was conducted to identify randomized controlled trials of the last 10 years, which examined the effects of DMPs on hospital readmission and mortality of older people with heart failure. The identified DMPs were classified as effective and ineffective, according to statistically significant changes in discharge outcomes. Twenty-one trials were identified, 11 (52.4%) of which reported DMPs improving the discharge outcomes of older people with heart failure. The results indicate that an effective DMP should be multi-faceted and consists of an in-hospital phase of care, intensive patient education, self-care supportive strategy, optimization of medical regimen, and ongoing surveillance and management of clinical deterioration. Cardiac nurse and cardiologist should be actively involved and a flexible approach should be adopted to deliver the follow-up care.
This study defines precisely the characteristics of the care team and the organization content and delivery method of the DMP which are crucial to enhance the discharge outcomes of older people with heart failure.
Rationale:
Hospital readmission in Chronic Obstructive Pulmonary Disease (COPD) has attracted attention due to the burden to patients and the Health Care system. There is a knowledge gap on approaches to reduce COPD readmissions.
Objective:
Determine the effect of comprehensive Health Coaching, on the rate of COPD readmissions. Methods 215 hospitalized for a COPD exacerbation were randomized at hospital discharged to Motivational Interviewing based Health Coaching plus a written action plan for exacerbations and a brief exercise advice versus usual care. Measures Rate of COPD related hospitalization during the year-followup.
Results:
The Absolute Risk Reduction of COPD related re-hospitalization by health coaching was 7.5% p=0.01, 11.0% p=0.02, 11.6% p=0.03, 11.4% p=0.05 and 5.4% p=0.24 at 1, 3, 6, 9, and 12 months compared to the control group. The Odds Ratio for COPD Hospitalization on the Intervention Arm Compared to the Control was 0.08 (CI 0.01-0.70) at 1 month post discharge, 0.35 (CI 0.13-0.93) at 3 months post discharge, 0.30 (CI 0.12-0.73) at 6 months and 0.49 (CI 012-1.11) at 1 year post discharge. Missing value rate for the primary outcome was 0.4% (1 patient). Disease specific quality of life improved significantly in the health coaching group compared to the control group at 6 and 12 months by the Chronic Respiratory Questionnaire (CRQ) Emotional Score (Emotion-Mastery) and Physical Score (Dyspnea-Fatigue) p<0.05. There were no differences in the physical activity measured at any time points between groups. Conclusion Health Coaching may represent a feasible and possibly effective intervention to reduce COPD readmissions. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01058486.
Objectives:
We sought to test the hypothesis that training medical assistants to provide health coaching would improve patients' experience of care received and overall satisfaction with their clinic.
Study design:
Randomized controlled trial.
Methods:
Low-income English- or Spanish-speaking patients aged 18 to 75 years with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were randomized to receive either a health coach or usual care for 12 months. Patient care experience was measured using the Patient Assessment of Chronic Illness Care (PACIC) scale at baseline and at 12 months. Patient overall satisfaction with the clinic was assessed with a single item asking if they would recommend the clinic to a friend or family member. PACIC and satisfaction scores were compared between study arms using generalized estimating equations to account for clustering at the clinician level.
Results:
PACIC scores were available from baseline and at 12 months on 366 (76%) of the 441 patients randomized. At baseline, patients receiving health coaching were similar to those in the usual care group with respect to demographic and other characteristics, including mean PACIC scores (3.00 vs 3.06) and the percent who would "definitely recommend" their clinic (73% and 73%, respectively). At 12 months, coached patients had a significantly higher mean PACIC score (3.82 vs 3.13; P < .001) and were more likely to report they would definitely recommend their clinic (85% vs 73%; P = .002).
Conclusions:
Using medical assistants trained in health coaching significantly improved the quality of care that low-income patients with poorly controlled chronic disease reported receiving from their healthcare team.
Objective
To learn more about the potential psychosocial benefits of wellness coaching. Although wellness coaching is increasing in popularity, there are few published outcome studies.
Patients and Methods
In a single-cohort study design, 100 employees who completed the 12-week wellness coaching program were of a mean age of 42 years, 90% were women, and most were overweight or obese. Three areas of psychosocial functioning were assessed: quality of life (QOL; 5 domains and overall), depressive symptoms (Patient Health Questionnaire-9), and perceived stress level (Perceived Stress Scale-10). Participants were recruited from January 1, 2011, through December 31, 2011; data were collected up to July 31, 2012, and were analyzed from August 1, 2012, through October 31, 2013.
Results
These 100 wellness coaching completers exhibited significant improvements in all 5 domains of QOL and overall QOL (P<.0001), reduced their level of depressive symptoms (P<.0001), and reduced their perceived stress level (P<.001) after 12 weeks of in-person wellness coaching, and they maintained these improvements at the 24-week follow-up.
Conclusion
In this single-arm cohort study (level 2b evidence), participating in wellness coaching was associated with improvement in 3 key areas of psychosocial functioning: QOL, mood, and perceived stress level. The results from this single prospective cohort study suggest that these areas of functioning improve after participating in wellness coaching; however, randomized clinical trials involving large samples of diverse individuals are needed to establish level 1 evidence for wellness coaching.
Rationale:
Secondhand smoke exposure (SHSe) is a significant modifiable risk for respiratory health in children. Although SHSe is declining overall, it has increased for low-income and minority populations. Implementation of effective SHSe interventions within community organizations has the potential for significant public health impact.
Objectives:
To evaluate the effectiveness of motivational interviewing (MI) delivered in the context of a SHS education reduction initiative within Head Start to reduce preschool children's SHSe.
Methods:
A total of 350 children enrolled in Baltimore City Head Start whose caregivers reported a smoker living in the home were recruited. Caregivers were randomized to MI + education or education alone. Assessments were conducted at baseline, 3, 6, and 12 months.
Measurements and main results:
The primary outcome measure was household air nicotine levels measured by passive dosimeters. Secondary outcomes included child salivary cotinine, self-report of home smoking ban (HSB), and smoking status. Participants in the MI + education group had significantly lower air nicotine levels (0.29 vs. 0.40 mg), 17% increase in prevalence of caregiver-reported HSBs, and a 13% decrease in caregiver smokers compared with education-alone group (all P values < 0.05). Although group differences in salivary cotinine were not significant, among all families who reported having an HSB, salivary cotinine and air nicotine levels declined in both groups (P < 0.05).
Conclusions:
MI may be effective in community settings to reduce child SHSe. More research is needed to identify ways to tailor interventions to directly impact child SHSe and to engage more families to make behavioral change. Clinical trial registered with www.clinicaltrials.gov (NCT 00927264).
This article defines and examines the construct of self-compassion. Self-compassion entails three main components: (a) self-kindness—being kind and understanding toward oneself in instances of pain or failure rather than being harshly self-critical, (b) common humanity—perceiving one's experiences as part of the larger human experience rather than seeing them as separating and isolating, and (c) mindfulness—holding painful thoughts and feelings in balanced awareness rather than over-identifying with them. Self-compassion is an emotionally positive self-attitude that should protect against the negative consequences of self-judgment, isolation, and rumination (such as depression). Because of its non-evaluative and interconnected nature, it should also counter the tendencies towards narcissism, self-centeredness, and downward social comparison that have been associated with attempts to maintain self-esteem. The relation of self-compassion to other psychological constructs is examined, its links to psychological functioning are explored, and potential group differences in self-compassion are discussed.
: Self-management is proposed as the standard of care in chronic obstructive pulmonary disease (COPD), but details of the process and training required to deliver effective self-management are not widely available. In addition, recent data suggest that patient engagement and motivation are critical ingredients for effective self-management. This article carefully describes a self-management intervention using motivational interviewing skills, aimed to increase engagement and commitment in severe COPD patients.
: The intervention was developed and pilot tested for fidelity to protocol, for patient and interventionist feedback (qualitative) and effect on quality of life. Engagement between patient and interventionists was measured by the Working Alliance Inventory. The intervention was refined on the basis of the results of the pilot study and delivered in the active arm of a prospective randomized study.
: The pilot study suggested improvements in quality of life, fidelity to theory, and patient acceptability. The refined self-management intervention was delivered 540 times in the active arm of a randomized study. We observed a retention rate of 86% (patients missing or not available for only 14% the scheduled encounters).
: A self-management intervention that includes motivational interviewing as the way if guiding patients into behavior change is feasible in severe COPD and may increase patient engagement and commitment to self-management. This provides a very detailed description of the process for the specifics of training and delivering the intervention, which facilitates replicability in other settings and could be translated to cardiac rehabilitation.
Study objectives
To investigate whether psychological factors predict outcome after emergency treatment for obstructive pulmonary disease.
Setting
Emergency department at a university hospital.
Patients
Forty-three patients presenting with exacerbation of asthma or COPD.
Intervention
The patients received emergency treatment and were followed up for 4 weeks.
Measurement
Spirometry, blood sampling, pulse oximetry, breathing rate, pulse rate, and dyspnea score was measured before and during emergency treatment. The psychological status was assessed using the hospital anxiety and depression (HAD) scale questionnaire at the end of the follow-up period.
Results
Anxiety and/or depression was found in 17 patients (40%). Of these patients, nine patients (53%) were admitted to hospital or had a relapse within 1 month, compared with five patients (19%) in the group without anxiety and/or depression (p < 0.05). Among patients who relapsed within 1 month (n = 14), the HAD total score was 12.4 ŷ 5.9 compared with 8.6 ŷ 5.1 (mean ŷ SD) among the patients without a relapse (p < 0.05). After making adjustments for age, gender, atopic status, treatment, and pack-years, the significant association between treatment failure and anxiety and/or depression still remained.
Conclusion
Our study indicates that anxiety and depression are related to the outcome of emergency treatment in patients with obstructive pulmonary disease. Further studies should be conducted evaluating the effect of treatment of anxiety and depression in patients with recurrent exacerbations of asthma and COPD.
To evaluate the impact of motivational interviewing-based health coaching on a chronically ill group of participants compared with non-participants. Specifically, measures that could be directly attributed to a health coaching intervention on chronic illness were assessed.
Quasi-experimental study design.
A large medical university in the north-west United States.
One hundred and six chronically ill programme participants completed a health risk survey instrument prior to enrolment and again at approximately 8 months. Outcomes were compared with 230 chronically ill non-participants who completed the survey twice over a similar time frame. Inverse probability of treatment weights were used in conjunction with the propensity score to correct for selection bias.
Compared with non-participants, programme participants improved their self-efficacy (P = 0.01), patient activation (P = 0.02), lifestyle change score (P = 0.01) and perceived health status (P = 0.03). Fewer participants increased their stages of change risk over time than non-participants (P < 0.01), and more participants decreased their stages of change risk over time than non-participants (P = 0.03).
These results support motivational interviewing-based health coaching as an effective chronic care management intervention in impacting outcome measures that could also serve well as a proxy in the absence of other clinical or cost indices.
Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient's anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions.
Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway.
Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.
Because self-rated health (SRH) is strongly associated with health outcomes, it is important to identify factors that individuals take into account when they assess their health. We examined the role of valued life activities (VLAs), the wide range of activities deemed to be important to individuals, in SRH assessments.
Data were from three cohort studies of individuals with different chronic conditions--rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and chronic obstructive pulmonary disease (COPD). Each cohort's data were collected through structured telephone interviews. Logistic regression analyses identified factors associated with ratings of fair/poor SRH. All analyses included sociodemographic characteristics, general and disease-specific health-related factors, and general measures of physical functioning.
Substantial portions of each group rated their health as fair/poor (RA 37%, SLE 47%, COPD 40%). In each group, VLA disability was strongly associated with fair/poor health (RA: OR=4.44 [1.86,10.62]; SLE: OR=3.60 [2.10,6.16]; COPD: OR=2.76 [1.30,5.85]), even after accounting for covariates.
VLA disability appears to play a substantial role in individual perceptions of health, over and above other measures of health status, disease symptoms, and general physical functioning.
Varying philosophical and theoretical orientations to qualitative inquiry remind us that issues of quality and credibility intersect with audience and intended research purposes. This overview examines ways of enhancing the quality and credibility of qualitative analysis by dealing with three distinct but related inquiry concerns: rigorous techniques and methods for gathering and analyzing qualitative data, including attention to validity, reliability, and triangulation; the credibility, competence, and perceived trustworthiness of the qualitative researcher; and the philosophical beliefs of evaluation users about such paradigm-based preferences as objectivity versus subjectivity, truth versus perspective, and generalizations versus extrapolations. Although this overview examines some general approaches to issues of credibility and data quality in qualitative analysis, it is important to acknowledge that particular philosophical underpinnings, specific paradigms, and special purposes for qualitative inquiry will typically include additional or substitute criteria for assuring and judging quality, validity, and credibility. Moreover, the context for these considerations has evolved. In early literature on evaluation methods the debate between qualitative and quantitative methodologists was often strident. In recent years the debate has softened. A consensus has gradually emerged that the important challenge is to match appropriately the methods to empirical questions and issues, and not to universally advocate any single methodological approach for all problems.
Disease management programs are often advocated for the care of patients with chronic disease. This systematic review was conducted to determine whether these programs improve outcomes for patients with heart failure.
Randomized clinical trials of disease management programs in patients with heart failure were identified by searching Medline 1966 to 1999, Embase 1980 to 1998, Cinahl 1982 to 1999, Sigle 1980 to 1998, the Cochrane Controlled Trial Registry, the Cochrane Effective Practice and Organization of Care Study Registry, and the bibliographies of published studies. We also contacted experts in the field. Studies were selected and data extracted independently by two investigators, and summary risk ratios (RR) and 95% confidence intervals (CI) were calculated using both the random and fixed effects models.
A total of 11 trials (involving 2,067 patients with heart failure) were identified. Disease management programs were cost saving in 7 of the 8 trials that reported cost data and also appeared to have beneficial effects on prescribing practices. Hospitalizations (RR = 0.87, 95% CI: 0.79 to 0.96) but not all-cause mortality (RR = 0.94, 95% CI: 0.75 to 1.19) were reduced by the programs. However, there were considerable differences in the effects of various interventions on hospitalization rates; specialized follow-up by a multidisciplinary team led to a substantial reduction in the risk of hospitalization (RR = 0.77, 95% CI 0.68 to 0.86, n = 1366), whereas trials employing telephone contact with improved coordination of primary care services failed to find any benefit (RR = 1.15, 95% CI 0.96 to 1.37, n = 646).
Disease management programs for the care of patients with heart failure that involve specialized follow-up by a multidisciplinary team reduce hospitalizations and appear to be cost saving. Data on mortality are inconclusive. Further studies are needed to establish the incremental benefits of the different elements of these programs.
We sought to determine whether a multidisciplinary outpatient management program decreases chronic heart failure (CHF) hospital readmissions and mortality over a six-month period.
Hospital admission for CHF is an important problem amenable to improved outpatient management.
Two hundred patients hospitalized with CHF at increased risk of hospital readmission were randomized to a multidisciplinary program or usual care. A study cardiologist and a CHF nurse evaluated each patient and made recommendations to the patient's primary physician before randomization. The intervention team consisted of a cardiologist, a CHF nurse, a telephone nurse coordinator and the patient's primary physician. Contact with the patient was on a prespecified schedule. The CHF nurse followed an algorithm to adjust medications. Patients in the nonintervention group were followed as usual. The primary outcome was the composite of the number of CHF hospital admissions and deaths over six months, compared by using a log transformation t test by intention-to-treat analysis.
The median age of the study patients was 63.5 years, and 39.5% were women. There were 43 CHF hospital admissions and 7 deaths in the intervention group, as compared with 59 CHF hospital admissions and 13 deaths in the nonintervention group (p = 0.09). The quality-of-life score, percentage of patients on target vasodilator therapy and percentage of patients compliant with diet recommendations were significantly better in the intervention group. Cost per patient, in 1998 U.S. dollars, was similar in both groups.
This study demonstrates that a six-month, multidisciplinary approach to CHF management can improve important clinical outcomes at a similar cost in recently hospitalized high-risk patients with CHF.
Health status (or Health-Related Quality of Life) measurement is an established method for assessing the overall efficacy of treatments for asthma and chronic obstructive pulmonary disease (COPD). Such measurements can indicate the potential clinical significance of a treatment's effect.
This paper is concerned with methods of estimating the threshold of clinical significance for three widely used health status questionnaires for asthma and COPD: the Asthma Quality of Life Questionnaire, Chronic Respiratory Questionnaire and St George's Respiratory Questionnaire. It discusses the methodology used to obtain such estimates and shows that the estimates appear to be fairly reliable; i.e. for a given questionnaire, similar estimates may be obtained in different studies.
These empirically derived thresholds are all mean estimates with confidence intervals around them. The presence of these confidence intervals affects the way in which the thresholds may be used to draw inferences concerning the clinical relevance of clinical trial results. A new system of judging the magnitude of clinically significant results is proposed.
Finally, an attempt is made to translate these thresholds into scenarios that illustrate what a clinically significant change with treatment may mean to an individual patient.
Depressive symptoms are common among patients with chronic obstructive pulmonary disease (COPD), but depression's impact on COPD outcomes has not been fully investigated. We evaluated the impact of comorbid depression on mortality, hospital readmission, smoking behavior, respiratory symptom burden, and physical and social functioning in patients with COPD.
In this prospective cohort study, 376 consecutive patients with COPD hospitalized for acute exacerbation were followed up for 1 year. The independent associations of baseline comorbid depression (designated as a Hospital Anxiety and Depression Scale score of > or =8) with mortality, hospital readmission, length of stay, persistent smoking, and quality of life (determined by responses to the St George Respiratory Questionnaire) were evaluated after adjusting for potential confounders.
The prevalence of depression at admission was 44.4%. The median follow-up duration was 369 days, during which 57 patients (15.2%) died, and 202 (53.7%) were readmitted at least once. Multivariate analyses showed that depression was significantly associated with mortality (hazard ratio, 1.93; 95% confidence interval, 1.04-3.58), longer index stay (mean, 1.1 more days; P = .02) and total stay (mean, 3.0 more days; P = .047), persistent smoking at 6 months (odds ratio, 2.30; 95% confidence interval, 1.17-4.52), and 12% to 37% worse symptoms, activities, and impact subscale scores and total score on the St George Respiratory Questionnaire at the index hospitalization and 1 year later, even after controlling for chronicity and severity of COPD, comorbidities, and behavioral, psychosocial, and socioeconomic variables.
Comorbid depressive symptoms in patients with COPD are associated with poorer survival, longer hospitalization stay, persistent smoking, increased symptom burden, and poorer physical and social functioning. Interventions that reduce depressive symptoms may potentially affect COPD outcomes.
Patient-centered approaches are associated with better patient retention and treatment outcomes, without increased time and cost. Motivational interviewing (MI) is a patient-centered counseling approach that can be briefly integrated into patient encounters and is specifically designed to enhance motivation to change among patients not ready to change. Existing asthma management approaches (eg, education and self-management) increase resistance among patients not ready or willing to follow medical recommendations. MI helps patients resolve their ambivalence about behavior change and builds their intrinsic motivation before providing education. Although MI overlaps with patient-centered communication, it additionally includes some concrete motivational strategies that can be briefly and easily implemented in medical settings (eg, setting an agenda, assessing motivation and confidence for change, helping the patient weigh the costs and benefits of change, and providing medical advice and health feedback). Reflective listening is used to help patients clarify their ambivalence and diffuse resistance. MI has been shown to be efficacious across a wide variety of health behavior change areas. This article will describe the method and spirit of MI as applied to asthma management by reviewing the principles of MI, brief MI strategies to motivate medication adherence, the evidence base for MI, and the costs and benefits of building MI into clinical practice.
To investigate the effect of a 1-year coaching program for healthy physical activity on perceived health status, body function, and activity limitation in patients with early rheumatoid arthritis.
A total of 228 patients (169 women, 59 men, mean age 55 years, mean time since diagnosis 21 months) were randomized to 2 groups after assessments with the EuroQol visual analog scale (VAS), Grippit, Timed-Stands Test, Escola Paulista de Medicina Range of Motion scale, walking in a figure-of-8, a visual analog scale for pain, the Health Assessment Questionnaire disability index, a self-reported physical activity questionnaire, and the Disease Activity Score in 28 joints. All patients were regularly seen by rheumatologists and underwent rehabilitation as prescribed. Those in the intervention group were further individually coached by a physical therapist to reach or maintain healthy physical activity (> or =30 minutes, moderately intensive activity, most days of the week).
The retention rates after 1 year were 82% in the intervention group and 85% in the control group. The percentages of individuals in the intervention and control groups fulfilling the requirements for healthy physical activity were similar before (47% versus 51%; P > 0.05) and after (54% versus 44%; P > 0.05) the intervention. Analyses of outcome variables indicated improvements in the intervention group over the control group in the EuroQol VAS (P = 0.025) and muscle strength (Timed-Stands Test; P = 0.000) (Grippit; P = 0.003), but not in any other variables assessed.
A 1-year coaching program for healthy physical activity resulted in improved perceived health status and muscle strength, but the mechanisms remain unclear, as self-reported physical activity at healthy level did not change.
Health coaching and chronic obstructive pulmonary disease rehospitalization: a randomized study
- R Benzo
- K Vickers
- P J Novotny
- S Tucker
- J Hoult
- P Neuenfeldt
Benzo R, Vickers K, Novotny PJ, Tucker S, Hoult J, Neuenfeldt P,
et al. Health coaching and chronic obstructive pulmonary disease
rehospitalization: a randomized study. Am J Respir Crit Care Med
2016;194(6):672-680.