The cost-effectiveness of a structured education pulmonary rehabilitation programme for chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial.

OBJECTIVE: To assess the cost-effectiveness of a structured education pulmonary rehabilitation programme (SEPRP) for chronic obstructive pulmonary disease (COPD) relative to usual practice in primary care. The programme consisted of group-based sessions delivered jointly by practice nurses and physiotherapists over 8 weeks. DESIGN: Cost-effectiveness and cost-utility analysis alongside a cluster randomised controlled trial. SETTING: 32 general practices in Ireland. PARTICIPANTS: 350 adults with COPD, 69% of whom were moderately affected. INTERVENTIONS: Intervention arm (n=178) received a 2 h group-based SEPRP session per week over 8 weeks delivered jointly by a practice nurse and physiotherapist at the practice surgery or nearby venue. The control arm (n=172) received the usual practice in primary care. MAIN OUTCOME MEASURES: Incremental costs, Chronic Respiratory Questionnaire (CRQ) scores, quality-adjusted life years (QALYs) gained estimated using the generic EQ5D instrument, and expected cost-effectiveness at 22 weeks trial follow-up. RESULTS: The intervention was associated with an increase of €944 (95% CIs 489 to 1400) in mean healthcare cost and €261 (95% CIs 226 to 296) in mean patient cost. The intervention was associated with a mean improvement of 1.11 (95% CIs 0.35 to 1.87) in CRQ Total score and 0.002 (95% CIs -0.006 to 0.011) in QALYs gained. These translated into incremental cost-effectiveness ratios of €850 per unit increase in CRQ Total score and €472 000 per additional QALY gained. The probability of the intervention being cost-effective at respective threshold values of €5000, €15 000, €25 000, €35 000 and €45 000 was 0.980, 0.992, 0.994, 0.994 and 0.994 in the CRQ Total score analysis compared to 0.000, 0.001, 0.001, 0.003 and 0.007 in the QALYs gained analysis. CONCLUSIONS: While analysis suggests that SEPRP was cost-effective if society is willing to pay at least €850 per one-point increase in disease-specific CRQ, no evidence exists when effectiveness was measured in QALYS gained. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52 403 063.

COPD in primary care settings in Ireland: stories from usual care.

The aim of the PRINCE study was to determine the effectiveness of a structured education pulmonary rehabilitation programme for those living with COPD in primary care in Ireland. This qualitative element of the larger PRINCE trial aims to describe the constituents of 'usual care' for patients allocated to the control arm of the study. A descriptive qualitative study was used to explore the constituents of usual care. A convenience sample of participants (n=20) allocated to the usual care group were interviewed. Three main themes arose from the study: experiences of having and managing COPD, lifestyle advice, and factors that helped or hindered self-management. Usual care left many people grappling in the dark trying to manage their COPD. It was found that usual care was not at its optimum for people with COPD in the control arm of the PRINCE study.

The effectiveness of a structured education pulmonary rehabilitation programme for improving the health status of people with moderate and severe chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial.

OBJECTIVE: To evaluate the effectiveness of a structured education pulmonary rehabilitation programme on the health status of people with chronic obstructive pulmonary disease (COPD). DESIGN: Two-arm, cluster randomised controlled trial. SETTING: 32 general practices in the Republic of Ireland. PARTICIPANTS: 350 participants with a diagnosis of moderate or severe COPD. INTERVENTION: Experimental group received a structured education pulmonary rehabilitation programme, delivered by the practice nurse and physiotherapist. Control group received usual care. MAIN OUTCOME MEASURE: Health status as measured by the Chronic Respiratory Questionnaire (CRQ) at baseline and at 12-14 weeks postcompletion of the programme. RESULTS: Participants allocated to the intervention group had statistically significant higher mean change total CRQ scores (adjusted mean difference (MD) 1.11, 95% CI 0.35 to 1.87). However, the CI does not exclude a smaller difference than the one that was prespecified as clinically important. Participants allocated to the intervention group also had statistically significant higher mean CRQ Dyspnoea scores after intervention (adjusted MD 0.49, 95% CI 0.20 to 0.78) and CRQ Physical scores (adjusted MD 0.37, 95% CI 0.14 to 0.60). However, CIs for both the CRQ Dyspnoea and CRQ Physical subscales do not exclude smaller differences as prespecified as clinically important. No other statistically significant differences between groups were seen. CONCLUSIONS: A primary care based structured education pulmonary rehabilitation programme is feasible and may increase local accessibility to people with moderate and severe COPD. TRIAL REGISTRATION: ISRCTN52403063.

Life with chronic obstructive pulmonary disease: striving for 'controlled co-existence'.

AIMS AND OBJECTIVES: To understand the meaning of chronic obstructive pulmonary disease (COPD) for people and their response to this disease. BACKGROUND: COPD is a major cause of disability and death. The symptoms of COPD have the potential to impact on every aspect of a person's day-to-day life. To date most published qualitative studies have focused on the 'experience' of breathlessness and its impact on the person. Few studies have sought to 'understand' the meaning of COPD to people and their response to this disease. This study aimed to address this gap. DESIGN: Straussian grounded theory guided study design. Grounded theory was considered appropriate for this study because of its focus on how people respond to and act on the problems they encounter. METHODS: Data were collected through semi-structured interviews with 26 people with COPD. Study participants were recruited from general practices on the western seaboard of Ireland. RESULTS: Two interrelated categories were identified as contributing to 'co-existing with COPD': 'hiding' and 'battling'. 'Co-existing with COPD' was conceptualised as the core category. The potential to 'co-exist' with COPD was influenced by mediating factors. CONCLUSION: The Theory of Co-existing with COPD was generated from the data. This theory explains the delicate balance people with COPD maintain to 'co-exist with COPD'. 'Controlled co-existence' enables the person to feel in control and live life to the optimum. This is a fragile balance however and the unpredictability of COPD can tip the person into 'strained co-existence' or 'uncontrolled co-existence'. RELEVANCE TO CLINICAL PRACTICE: Understanding the experience of living with COPD and the balances involved in 'co-existing with COPD' can help health professionals provide more focused and empowered client care. Enabling people to achieve 'controlled co-existence' with COPD challenges health professionals to educate people with COPD on how to effectively manage their disease.

The lived experience of the person dependent on haemodialysis.

UNLABELLED: The phenomenon of experiencing life dependent on haemodialysis is infinitely multi-faceted. It effects all aspects of people's lives, and not only their lives, but those of the people around them. Busy dialysis units often do not have time to explore these effects on the lives of their patients outside the clinical setting. AIMS: The aim of this qualitative study was to step into the lives of seven patients once they were outside the dialysis unit. METHOD: Seven chronic haemodialysis patients were selected and interviewed using an in-depth semi-structured approach, following the philosophy of Heidegger. Data was analysed using Colaizzi's seven-stage process. RESULTS: The strongest common theme emerged through descriptions of the patient's 'Sense of Self', within which emerged sub-themes; The Future Self, The Living Self, The Mortal/Fragile Self and The Growing/Learning Self. These were further explored and related back to importance of awareness of such findings within the renal haemodialysis practice setting.

Use of peer assessment as a student engagement strategy in nurse education.

This paper describes how peer assessment was implemented in an undergraduate nursing program in Ireland to enhance student engagement, and reports students' (n=37) experiences of the process. The process involved second year Bachelor of Nursing Science students developing marking criteria and marking two of their colleagues' assignments anonymously. A qualitative descriptive design using focus group interviews was used to collect data on students' experiences. Demographic data were collected through questionnaires. The analysis identified three themes: (i) impact on student engagement; (ii) challenges of peer assessment; and (iii) making it better. The findings revealed that most students enjoyed the process, and that peer assessment facilitates and enhances student engagement. The findings also provide evidence to support the self-regulation theory of learning. A detailed account of the methods used to implement peer assessment is also provided, which might be useful for other nurse educators seeking to implement peer assessment at an undergraduate level.

Developing a structured education programme for clients with COPD.

This article describes the development of a Structured Education Pulmonary Rehabilitation Programme (SEPRP), for the PRINCE (Pulmonary Rehabilitation In Nurse-led Community Environments) study. This process involved a literature review of existing PR programmes, a content analysis of national and international PR programmes and a concept analysis of empowerment. Secondly, two small descriptive qualitative studies were undertaken to further inform programme content exploring the views of health professionals and clients on programme content, as well as their perceptions of living with COPD. The findings of these two stages led to the development of the eight-week PRINCE SEPRP, based on a philosophy of empowerment and the SEPRP was underpinned by the Transtheoretical model (TTM) of behaviour change. Programme content included managing medications and managing breathlessness, knowing and managing symptoms, recognizing and managing acute exacerbations as well as an individualized exercise programme. Participants' experiences of self management following participation in the SEPRP were also examined. The findings indicate that nurses working in primary care have an important role in informing the development of SEPRP as well as having a key role in their delivery. They have the potential to work in empowering ways with COPD clients and the PRINCE SEPRP is just one example of how this can be put into practice.

A cluster randomised controlled trial evaluating the effectiveness of a structured pulmonary rehabilitation education programme for improving the health status of people with chronic obstructive pulmonary disease (COPD): The PRINCE Study protocol.

BACKGROUND: A key strategy in improving care for people with chronic obstructive pulmonary disease (COPD) is the provision of pulmonary rehabilitation programmes. Pulmonary rehabilitation programmes have been successful in improving patients' sense of dyspnoea and Health Related Quality of Life. However, the effectiveness of structured education pulmonary rehabilitation programmes delivered at the level of the general practice on the health status of people with COPD remains uncertain and there is a need for a robust and fair assessment of this. The PRINCE study will evaluate the effectiveness of a Structured Education Pulmonary Rehabilitation Programme (SEPRP), delivered at the level of the general practice, on the health status of people with COPD. METHODS/DESIGN: The PRINCE Trial is a two-armed, single blind cluster randomised trial conducted in the primary care setting in Ireland. Randomisation to control and intervention is at the level of the General Practice. Participants in the intervention arm will receive a SEPRP and those allocated to the control arm will receive usual care. Delivery of the SEPRP will be by a practice nurse and physiotherapist in the General Practice (GP) site. The primary outcome measure of the study will be health status as measured by the Chronic Respiratory Questionnaire (CRQ). Blinded outcome assessment will be undertaken at baseline and at twelve-fourteen weeks after completion of the programme. A comparison of outcomes between the intervention and control sites will be made to examine if differences exist and, if so, to what extent between control and experimental groups. Sample size calculations estimate that 32 practices with a minimum of 10 participants per practice are required, in total, to be randomised to control and intervention arms for power of at least 80% with alpha levels of 0.05, to determine a clinically significant change of 0.5 units in the CRQ. A cost effectiveness analysis will also be conducted. DISCUSSION: The results of this trial are directly applicable to primary care settings in Ireland. Should a SEPRP delivered by practice nurses and physiotherapists in primary care be found to be effective in improving patients' sense of dyspnoea and HRQoL, then the findings would be applicable to many thousands of individuals in Ireland and beyond.