Facilitating education in pulmonary rehabilitation using the living well with COPD programme for pulmonary rehabilitation: a process evaluation.

BACKGROUND: Standardised evidenced-based materials and mechanisms to facilitate the delivery of the education component of pulmonary rehabilitation are not widely available. The aims of this study were: 1) to adapt the self-management programme Living Well with COPD (LWWCOPD) programme, for embedding in pulmonary rehabilitation; and, 2) to conduct a process evaluation of the adapted programme. METHODS: The adaptations to the LWWCOPD programme were informed by focus groups, current practice, relevant research and guideline documents. Pulmonary rehabilitation sites used the adapted programme, the LWWCOPD programme for pulmonary rehabilitation, to deliver the education component of pulmonary rehabilitation. A process evaluation was conducted: elements included reach (patients' attendance rates), dose delivered (amount of programme delivered), dose received (health professional and patient satisfaction) and fidelity (impact on patients' knowledge, understanding and self-efficacy on the Understanding COPD questionnaire). Descriptive statistics (mean, SD) were used to summarise demographics and key data from the feedback questionnaires. Qualitative feedback on the programme was collated and categorised. Changes in the Understanding COPD questionnaire were examined using paired t-tests. RESULTS: The LWWCOPD programme for pulmonary rehabilitation was delivered in eleven hospital- and community-based programmes (n=25 health professionals, n=57 patients with COPD). It consisted of six weekly 30-45 minute sessions. The process evaluation showed positive results: 62.3% of patients attended ≥ 4 education sessions (reach); mean (SD) 90 (10)% of the session content were delivered (dose delivered); the majority of sessions were rated as excellent or good by health professionals and patients. Patients' satisfaction was high: mean (SD) Section B of the Understanding COPD questionnaire: 91.67 (9.55)% (dose received). Knowledge, understanding and self-efficacy improved significantly: mean change (95% CI): Section A of the Understanding COPD questionnaire: 26.75 (21.74 to 31.76)%, BCKQ 10.64 (6.92 to 14.37)% (fidelity). CONCLUSION: This rigorous process evaluation has demonstrated that the LWWCOPD programme for pulmonary rehabilitation can be used to deliver high quality, consistent and equitable education sessions during hospital and community-based pulmonary rehabilitation. This programme is now available worldwide (http://www.livingwellwithcopd.com/living-well-and-pulmonary-rehabilitation.html). TRIAL REGISTRATION: This study was registered with clinicaltrials.gov (reference number: NCT01226836).

Assessing education in pulmonary rehabilitation: the Understanding COPD (UCOPD) questionnaire.

There is currently no questionnaire available that comprehensively assesses patients' understanding, self-efficacy and satisfaction with the education component of pulmonary rehabilitation. The aim of this study was to develop the Understanding COPD (UCOPD) questionnaire. The key stages in the development of the UCOPD questionnaire were: (i) Generation of questions, and assessment of face and content validity, user-centredness, acceptability and feasibility; (ii) Assessment of plain English and readability; (iii) Assessment of structural validity; (iv) Assessment of test-retest reliability and internal consistency; (v) Assessment of the responsiveness, convergent validity and floor and ceiling effects. The UCOPD questionnaire assesses understanding, self-efficacy and use of key self-management skills (Section A) and satisfaction (Section B). It has good validity and practical properties, and readability was acceptable. It has good test-retest reliability (Section A: ICC range: 0.87 to 0.96; Section B: Wilcoxon: p > 0.05) and internal consistency (Cronbach's Alpha range: 0.78 to 0.95). It is responsive to pulmonary rehabilitation (Mean change: About COPD: 18.26 [12.12 to 24.40]%, Managing Symptoms 20.94 [13.86 to 28.01]%, Accessing Help and Support 24.06 [14.53 to 33.60]%, Total 20.59 [14.43 to 26.75]%, p < 0.001). It had a moderate correlation with the Bristol COPD Knowledge Questionnaire (BCKQ): pre-pulmonary rehabilitation: r = 0.41, p = 0.02; post-pulmonary rehabilitation: r = 0.35, p = 0.047. In conclusion, the UCOPD questionnaire offers the opportunity to assess the benefit of the education component of pulmonary rehabilitation in terms of its effect on understanding, self-efficacy and satisfaction. Further research is needed across different pulmonary rehabilitation settings to demonstrate the robustness of the UCOPD questionnaire, and to establish the minimum clinically important difference.

Impact of cough across different chronic respiratory diseases: comparison of two cough-specific health-related quality of life questionnaires.

BACKGROUND: Cough is a prominent symptom across a range of common chronic respiratory diseases and impacts considerably on patient health status. METHODS: We undertook a cross-sectional comparison of scores from two cough-specific health-related quality of life (HRQoL) questionnaires, the Leicester Cough Questionnaire (LCQ), and the Cough Quality of Life Questionnaire (CQLQ), together with a generic HRQoL measure, the EuroQol. Questionnaires were administered to and spirometry performed on 147 outpatients with chronic cough (n = 83), COPD (n = 18), asthma (n = 20), and bronchiectasis (n = 26). RESULTS: There was no significant difference in the LCQ and CQLQ total scores between groups (p = 0.24 and p = 0.26, respectively). Exploratory analyses of questionnaire subdomains revealed differences in psychosocial issues and functional impairment between the four groups (p = 0.01 and p = 0.05, respectively). CQLQ scores indicated that chronic coughers have more psychosocial issues than patients with bronchiectasis (p = 0.03) but less functional impairment than COPD patients (p = 0.04). There was a significant difference in generic health status across the four disease groups (p = 0.04), with poorest health status in COPD patients. A significant inverse correlation was observed between CQLQ and LCQ in each disease group (chronic cough r = - 0.56, p < 0.001; COPD r = - 0.49, p = 0.04; asthma r = - 0.94, p < 0.001; and bronchiectasis r = - 0.88, p < 0.001). There was no correlation between cough questionnaire scores and FEV(1) in any group, although a significant correlation between EuroQol visual analog scale component and FEV(1) (r = 0.639, p = 0.004) was observed in COPD patients. CONCLUSION: Cough adversely affects health status across a range of common respiratory diseases. The LCQ and CQLQ can each provide important additional information concerning the impact of cough.

Education in pulmonary rehabilitation: the patient's perspective.

OBJECTIVES: To ascertain from patients' perspectives what should be included in the educational component of pulmonary rehabilitation and how it should be delivered, and to compare those perspectives with the views of health professionals. DESIGN: Qualitative research method using focus groups of patients and health professionals. SETTING: A regional respiratory center and outpatient clinic. PARTICIPANTS: Purposive samples of 32 patients with chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second, 18%-67% predicted) divided into 6 focus groups; 8 health professionals knowledgeable about COPD and pulmonary rehabilitation who attended a multidisciplinary focus group meeting. INTERVENTIONS: Participants attended focus group meetings (2-3 h) guided by a series of questions and topics; results were posted to the participants for their verification. MAIN OUTCOME MEASURE: The educational content of a pulmonary rehabilitation program. RESULTS: Deficits in patients' knowledge, understanding, and management of their disease were identified. Six key educational topics resulted: disease education, management of breathlessness, management of an exacerbation, medication, psychosocial support, and welfare and benefits systems. Patients and health professionals preferred group information sessions provided by knowledgeable people speaking layman's language, with oral presentations being supplemented by written information. CONCLUSIONS: Gaining a greater understanding of patients' educational needs permits health professionals who design pulmonary rehabilitation programs to include these requirements in a format that is acceptable to patients. The key topics, content, and format for delivery of the educational component for pulmonary rehabilitation were identified. Future research should focus on the development of an educational package and assessment of its efficacy, which would facilitate equitable patient access to education in pulmonary rehabilitation.

Prevalence of psychomorbidity among patients with chronic cough.

BACKGROUND: Chronic cough may cause significant emotional distress and although patients are not routinely assessed for co-existent psychomorbidity, a cough that is refractory to any treatment is sometimes suspected to be functional in origin. It is not known if patients with chronic cough referred for specialist evaluation have emotional impairment but failure to recognise this may influence treatment outcomes. In this cross-sectional study, levels of psychomorbidity were measured in patients referred to a specialist cough clinic. METHODS: Fifty-seven patients (40 female), mean age 47.5 (14.3) years referred for specialist evaluation of chronic cough (mean cough duration 69.2 (78.5) months) completed the Hospital Anxiety and Depression (HAD) scale, State Trait Anxiety Inventory (STAI) and the Crown Crisp Experiential Index (CCEI) at initial clinic presentation. Subjects then underwent a comprehensive diagnostic evaluation, after which they were classified as either treated cough (TC) or idiopathic cough (IC). Questionnaire scores were compared between TC (n = 42) and IC (n = 15). RESULTS: Using the HAD scale, 33% of all cough patients were identified as anxious, while 16% experienced depression. The STAI scores suggested moderate or high trait anxiety in 48% of all coughers. Trait anxiety was significantly higher among TC (p < 0.001) and IC patients (p = 0.004) compared to a healthy adult population. On the CCEI, mean scores on the phobic anxiety, somatisation, depression, and obsession subscales were significantly higher among all cough patients than the published mean scores for healthy controls. Only state anxiety was significantly higher in IC patients compared with TC patients (p < 0.05). CONCLUSION: Patients with chronic cough appear to have increased levels of emotional upset although psychological questionnaires do not readily distinguish between idiopathic coughers and those successfully treated.

Psychogenic cough in a schoolboy: evaluation using an ambulatory cough recorder.

Psychogenic cough occurs most commonly in patients under 18 years of age. Making the diagnosis on clinical features alone is problematic, and it is usually a diagnosis of exclusion after several negative clinical investigations. We report on the case of a 13-year-old schoolboy with a 3-month history of persistent dry cough with no other associated symptoms. Clinical examination and investigations revealed no abnormality, and empirical trials of antiasthma and antacid medications proved unsuccessful. An objective assessment of his cough frequency was made using an ambulatory cough monitor. A large number of cough episodes were recorded during the day, but during the time he was in bed there were very few episodes recorded. This suggested a diagnosis of psychogenic cough, and he underwent behavior modification therapy under the guidance of a clinical psychologist, with good result. Objective cough monitoring may therefore improve the evaluation and management of chronic cough.