BMJ  2005;331:485 (3 September), doi:10.1136/bmj.38512.664167.8F (published 10 August 2005)

Paper

Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence

¹ Centre for Health Sciences, Barts and The London, Queen Mary's School of Medicine and Dentistry, London E1 2AT, ² Public Health and Primary Care Unit, St Bartholomew School of Nursing and Midwifery, City University, London EC1A 7QN, ³ Department of Nursing Science, Maastricht University, PO Box 616, 6220 MD Maastricht, Netherlands, ⁴ Department of Adult Nursing, City University, St Bartholomew School of Nursing and Midwifery, London E1 2EA, ⁵ Academic Unit of Respiratory Medicine, Barts and The London, Queen Mary's School of Medicine and Dentistry, St Bartholomew's Hospital, London EC1A 7BE

Objective To determine the effectiveness of innovations in management of chronic disease involving nurses for patients with chronic obstructive pulmonary disease (COPD).

Design Systematic review of randomised controlled trials.

Data sources 24 electronic databases searched for English or Dutch language studies published between January 1980 and January 2005.

Review methods Included studies described inpatient, outpatient, and community based interventions for chronic disease management that were led, coordinated, or delivered by nurses. Hospital at home and early discharge schemes for acute exacerbations of COPD were excluded.

Results We identified nine relevant randomised controlled trials, most of which had some potential methodological flaws. All the interventions seemed to be variations on a case management model. The interventions described could be divided into brief (one month) and longer term (around a year) or more intensive interventions. Only two studies examined the effect of brief interventions, these found little evidence of any benefit. Meta-analysis of the long term interventions failed to detect any influence on mortality at 9-12 months' follow-up (Peto odds ratio 0.85, 95% confidence interval 0.58 to 1.26). There was evidence that the long term interventions had not improved patients' health related quality of life, psychological wellbeing, disability, or pulmonary function. The evidence on whether long term interventions reduced readmissions to hospital was equivocal, but the only study exclusively directed at patients on long term oxygen therapy reported a reduction in readmission. We identified several outcomes where little or no evidence was available; these included patients' satisfaction, self management skills, adherence with treatment recommendations, the likelihood of smoking cessation, and the effect of the interventions on carers.

Conclusion 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.

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