Critically appraised paper: In people hospitalised with chronic obstructive pulmonary disease, a combined transition and self-management program increased healthcare utilisation [commentary]

摘要

Question: In people hospitalised with an exacerbation of chronic obstruc-tive pulmonary disease, is a program that combines transition support andself-management more effective than usual care at reducing future hospi-talisations and visits to emergency departments? Design: Randomisedcontrolled trial with blinded outcome assessment. Setting: Communityhospital in Baltimore, USA. Participants: Inclusion criteria were peopleaged . 40 years, with a smoking history of . 10 pack-years and admittedwith an acute exacerbation of chronic obstructive pulmonary disease.Exclusion criteria were those with terminal illness (, 6-month life expec-tancy) or severe cognitive dysfunction, or who were homeless. Random-isationof240participantsallocated120toaninterventiongroupand120toacontrolgroup.Interventions:Theinterventiongroupunderwentanurse-led program that started during the hospital stay and continued for 3months after discharge. The program, which was co-developed with pa-tients, caregivers and other stakeholders, included three components thatfocused on transition support, individualised self-management and facili-tated access to community programs and services. The control groupreceived usual transitional care provided at the study site, which includedassigning a general transition coach to assist with the first 30 days afterdischarge.Thecoachassistance focused onadherencetothedischargeplanand connecting to outpatient care. Outcome measures: The primaryoutcome was the number of disease-related acute care events, defined ashospitalisations and emergency department visits per participant over the6 months after discharge. The secondary outcome measure was health-related quality of life measured via the St George’s Respiratory Question-naire at 6 months after discharge. Results: At 6 months, 225 participantswere alive (112 in the intervention group and 113 in the control group) andthe mean number of disease-related acute care events per participant wasgreater in the intervention group (MD 0.68, 95% CI 0.22 to 1.15). There wasnobetween-groupdifferenceinhealth-relatedqualityoflife(MD5.5,95%CI22.6 to 13.6). Conclusion: In people hospitalised due to an exacerbation ofchronic obstructive pulmonary disease, a 3-month program that combinedtransition and long-term self-management support resulted in greaterdisease-relatedhospitalisationsandemergencydepartmentvisits,withoutimprovement in quality of life.