Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38512.664167.8F (Published 01 September 2005) Cite this as: BMJ 2005;331:485
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We are grateful for the interest in this study. Our findings may be
uncomfortable for those working in the area but we believe systematic
reviews have an important role in reporting the quality of existing
research in an area and in highlighting the areas where the evidence is
sparse. Synthesising the evidence around disease management in chronic
obstructive pulmonary disease (COPD) is particularly relevant at a time
when the UK Department of Health is actively promoting case management and
disease specific care management for long term conditions [1]. We also
believe our study has helped to set a research agenda for the evaluation
of disease management in COPD.
Reference
[1] Department of Health. Supporting people with long term
conditions. An NHS and social care model to support local innovation and
integration, January 2005.
Competing interests:
None declared
Competing interests: No competing interests
This article was a meta-analysis of a heterogeneous group of studies
of outcomes following nurse led interventions in COPD. The Cambridge City
and South Cambridgeshire Respiratory Care Pathway Group has been focussing
attention on improving COPD outcomes through nurse led interventions in
the community. The negative findings of this research published in a high
profile medical journal have called that approach into question.
However,
the findings of this study did not support the negative headlines which
accompanied it. The study consisted of poorly defined interventions and
diverse outcomes. The overall conclusion of the study was that “there is
little evidence to date to support the widespread implementation of nurse
led management interventions for COPD, but the data are too sparse to
exclude any clinically relevant benefit or harm arising from such
interventions”. It is surprising that such a poorly designed study with
such an uninformative conclusion should have sparked such headline
commentaries as “Nurse led programmes don’t improve COPD”. As one
Professor of Clinical Nursing pointed out in response to this article:
“the interventions in the articles reviewed are so varied and so poorly
described that the only two points they have in common are that there were
nurses involved and the patients had COPD”. In this meta-analysis the
characteristics of the nurses were not identified, interventions were
totally inconsistent, and methodology and outcomes were diverse. The
quality of the trial data available for input into this study was poor.
The only conclusion that can safely be drawn from these data is that more,
and better quality, research is needed in this area. Thus we feel that our
own data strongly support continued efforts at admission avoidance and
early supported discharge and the above article provides no evidence
question this approach.
Dr Nick Morrell and Dr Adrian O'Reilly
On behalf of The Cambridge City and South Cambridgeshire Respiratory Care
Pathway Group
Competing interests:
None declared
Competing interests: No competing interests
In their systematic review Taylor et al. report on the effectiveness
of innovations in nurse led chronic disease management for patients with
chronic obstructive pulmonary disease (COPD)(1). The authors conclude that
there is only little evidence to support the widespread implementation of
nurse led management interventions for COPD.
However, the conclusions of the authors are not new and are
comparable with those found in other systematic reviews on this topic (2).
A wide variation in management models, different outcome measures and
methodological limitations in reviewed COPD management studies make it
hard to conduct meta analysis and weaken the conclusions drawn.
We think that nurse led COPD management could be valuable. Especially
self management programmes in which trained nurses act as case managers or
coaches could have a high potential. We agree with the authors that
several potentially important outcomes have not been fully evaluated, and
suggest to use existing programmes in new studies instead of creating
another model for nurse led disease management.
However, the heterogeneity of the COPD population makes it inevitable
to focus on – and measure in its achievement – individual treatment goals:
patients’ satisfaction with care and patients’ coping and self-efficacy as
suggested by Taylor et al.(1), next to disease specific quality of life
and hospital readmissions. A longterm study is needed to allow tailored to
the needs of the individual patient to develop, with the nurses’ role as
coach, rather than carer. We currently study this over a period of 24
months (3) and adopted the self management programme developed and
evaluated by Bourbeau et al.(4) We slightly adjusted this programme to fit
into the Dutch primary care setting.
Hopefully the individualised outcome allows a more favourable
assessment for the in our view valuable role of nurses in COPD disease
management in primary care.
E.W.M.A Bischoff, MD
P.J.P. Poels, MD
T.R.J. Schermer, PhD
C. van Weel, FRCP
(1) Taylor SJC, Candy B, Bryar RM, et al. Effectiveness of
innovations in nurse led chronic disease management for patients with
chronic obstructive disease management for patients with chronic
obstructive pulmonary disease: systematic review of evidence. BMJ
2005;331:485
(2) Monninkhof EM, van der Valk PDLPM, van der Palen J, et al. Self-
management education for chronic obstructive pulmonary disease. Cochrane
Database Syst Rev 2002;4:CD002990
(3) Bischoff EW, Schermer T, van Weel C. Costs and effects of three modes
for disease management for chronic obstructive pulmonary disease in
general practice. www.clinicaltrials.gov Identifier: NCT00128765
(4) Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital
utilization in patients with chronic obstructive pulmonary disease: a
disease-specific self-management intervention. Arch Intern Med 2003;
163:585-91
Competing interests:
None declared
Competing interests: No competing interests
The title of this article is ‘Effectiveness of innovations in nurse
led chronic disease management for patients with chronic obstructive
pulmonary disease: systematic review of evidence’ however it could just as
easily be ‘Limited evidence available to date demonstrates nurse led
management for patients with COPD are just as effective as interventions
led by other health care professionals’. The biggest take home message
from this review is that it is very, very difficult to conduct a meta-
analysis unless there is reasonable quality of research to analyse.
The interventions in the articles reviewed are so varied and so
poorly described that the only two points they have in common seem to be
that there were nurses involved and the patients had COPD. The
characteristics of the nurses (experience, qualifications, specialist
education, level of autonomous practice etc) were not identified;
interventions (home visits, telephone follow up, clinical based, less than
one month, up to a year, self-management education, monitoring, physical
rehab/activity, multi-disciplinary team involvement etc) were totally
inconsistent; methodology (sample, randomization, data collection points,
outcome measures, measurement tools, etc) was, at best, limited and
certainly inconsistent.
The same critique is applicable to the control groups, that is very
limited, if any, description and varied in all identifiable
characteristics.
The authors themselves state that the 'level of evidence for each of
the individual trials to be either 2b ('low quality randomised controlled
trial') or 1b- (individual RCT with wide confidence interval')'. It is
really not possible to draw any conclusions except that some good quality
research addressing the problems noted above needs to be done, including
outcomes such as readmission rates(reported as 'equivocal’ in this
review), mortality, health related quality of life, psychological well-
being, disability and pulmonary function ('it is possible that these
interventions do confer benefits but that effect size as are too small to
be detected in the studies conducted to date'), cost, self-management
strategies, smoking cessation, carers implications etc ('several
potentially important outcomes have not been fully evaluated' according to
the authors).
I have no arguments with the authors. They have reasonably and
clearly stated the evidence and its limitations. I do have arguments with
the secondary commentators using headlines such as ‘Nurse led programmes
don't improve COPD’ (BMJ 2005;331 (3 September),
doi:10.1136/bmj.331.7515.0-c) to provide a political beat-up over evidence
-based scientific inquiry. Let’s try to maintain the same level of honest
inquiry and unbiased presentation in the reporting of the article as the
authors’ convey in its writing.
Competing interests:
None declared
Competing interests: No competing interests
Comments on article
I read this article with great interest. Many interventions
undertaken by nurses are indeed not actually nursing interventions (such
as chest examination or undertaking blood gases). In my view nurses should
spend more time on the psychological management of these patients if they
wish to show they make a difference. This article stated that nurse
interventions may not improve psychological well being. A common problem
experienced by COPD patients is anxiety and depression but sadly most
clinicians ignore these disabling problems. Treatments such as cognitive
behavioural therapy have the evidence to support their use in anxiety and
depression (NICE, 2004). If nurses help patients with psychosocial
interentions rather than medical interventions we might make a difference!
In addition there is some excellent patient information leaflets on
anxiety and depression which can help patients cope. I would suggest that
much more research is needed into how nurses can improve the psychogical
well being as this seems to affect patients as much as the physical
symptoms.
Competing interests:
None declared
Competing interests: No competing interests