Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Honesty in commentary
- Sandra V Dunn (24 September 2005)
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Nurse led COPD management: need for individualised outcome
- Erik W.M.A. Bischoff, Patrick J.P. Poels, Tjard R.J. Schermer, Chris van Weel (25 September 2005)
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Response to the article on the effectiveness of innovations in nurse led chronic disease management for patients with COPD
- Nick Morrell, Adrian O'Reilly (10 October 2005)
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Authors' response
- Stephanie JC Taylor, Bridget Candy, Rosamund M. Bryar, Jean Ramsay, Hubertus J.M. Vrijhoef, Glenda Esmond, and Chris J. Griffiths. (15 October 2005)
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Comments on article
- Karen Heslop, stpehanice Taylkor, Bridget Candy, Rosamund Bryar (15 November 2005)
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Sandra V Dunn, Chair in Clinical Nursing Flinders University/Flinders Medical Centre 5042
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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 |
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Erik W.M.A. Bischoff, physician and researcher Radboud University, Department of General Medicine, Nijmegen, 6500 HB, Netherlands, Patrick J.P. Poels, Tjard R.J. Schermer, Chris van Weel
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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 |
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Nick Morrell, Reader in Respiratory Medicine/Honorary Consultant University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, CB2 2QQ, Adrian O'Reilly
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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
Competing interests: None declared |
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Stephanie JC Taylor, Senior Clinical Lecturer Health Services Research and Development Barts and The London, Queen Mary's School of Medicine and Dentistry, E1 2AT, Bridget Candy, Rosamund M. Bryar, Jean Ramsay, Hubertus J.M. Vrijhoef, Glenda Esmond, and Chris J. Griffiths.
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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 |
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Karen Heslop, Respiratory Nurse Specialist Chest Clinic, RVI, Newcastle NE1 4LP, stpehanice Taylkor, Bridget Candy, Rosamund Bryar
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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 |
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