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The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care

Saskia W.M. Weldam, Marieke J. Schuurmans, Pieter Zanen, Monique J.W.M. Heijmans, Alfred P.E. Sachs, Jan-Willem J. Lammers
ERJ Open Research 2017 3: 00115-2016; DOI: 10.1183/23120541.00115-2016
Saskia W.M. Weldam
1Dept of Respiratory Diseases, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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  • For correspondence: S.Weldam@umcutrecht.nl
Marieke J. Schuurmans
2Dept of Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Pieter Zanen
1Dept of Respiratory Diseases, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Monique J.W.M. Heijmans
3Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands
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Alfred P.E. Sachs
4Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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Jan-Willem J. Lammers
1Dept of Respiratory Diseases, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Figures

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  • FIGURE 1
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    FIGURE 1

    Flow chart of the study. PCP: primary care practice; HCS: home care service; COPD-GRIP: Chronic Obstructive Pulmonary Disease – Guidance, Research on Illness Perception.

  • FIGURE 2
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    FIGURE 2

    Clinical COPD Questionnaire (CCQ) scores over time. Data are presented as mean (95% CI).

  • FIGURE 3
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    FIGURE 3

    Mean health-directed behaviour scores over time. Data are presented as mean (95% CI).

  • FIGURE 4
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    FIGURE 4

    Mean Brief Illness Perception Questionnaire (B-IPQ) personal control scores over time. Data are presented as mean (95% CI)

Tables

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  • Supplementary Materials
  • TABLE 1

    The COPD-GRIP (Chronic Obstructive Pulmonary Disease – Guidance, Research on Illness Perception) intervention

    The COPD-GRIP intervention is applied individually for each patient and consists of three face-to-face consultations, each lasting ∼30 min
    The three consultations are scheduled at ∼3-week intervals
    The specific content is individualised, based on the patient's questions, responses and the needs of the patient
    First consultation: understanding the patient's illness perceptions1) Identifying and understanding patient's illness perceptions;
    2) Assessing and discussing illness perceptions using the B-IPQ as a guide for tailoring the intervention
    Second consultation: identifying the link between illness perceptions and behaviour1) Identifying the link between illness perceptions and behaviour
    2)  Improving the patient's understanding of the relationship between their perceptions
     and their behaviour, by challenging them to draw up an individual care plan (a
     short-term goal and a long-term goal, with strategies to achieve these)
    Third consultation: evaluating and discussing the individual care plan1) Evaluating and discussing the individual care plan
    2)  Evaluating and assessing whether the individual care plan was successful and what new actions are necessary for the future
    3) If the patient did not describe a care plan, discussing actions for the future

    B-IPQ: Brief Illness Perception Questionnaire.

    • TABLE 2

      Patient characteristics

      InterventionUsual care
      Subjects10099
      Clusters1718
      Age years68.04±9.6465.78±9.61
      Male45 (45.9)45 (45.4)
      FEV1 % predicted60.6±17.660.5±20.1
      GOLD stage#
       I (mild)9 (9.2)9 (9.0)
       II (moderate)61 (62.2)63 (63.6)
       III (severe)23 (23.5)18 (18.2)
       IV (very severe)5 (5.1)9 (9.1)
      Education level
       Lower secondary or less70 (71.4)65 (65.6)
       Upper secondary18 (18.4)21 (21.2)
       College/university10 (10.2)8 (8.1)
      Current smoker27 (27.6)32 (32.3)
      Living alone44 (44.9)39 (39.4)
      Contact with healthcare professional¶
       Nurse268195
       GP323263
       Physiotherapist414360
       Dietician633
      Increase of complaints+248 (30.3)177 (22.3)
      Hospital admissions§1311
      Comorbidities
       Myocardial infarction9 (9.1)6 (6.1)
       Heart failure11 (11.1)4 (4.1)
       Cerebrovascular accident6 (6.1)3 (3.1)
       Diabetes5 (5.1)21 (21.1)

      Data are presented as n, mean±sd or n (%). FEV1: forced expiratory volume in 1 s; GOLD: Global Initiative for Chronic Obstructive Lung Disease; GP: general practitioner. #: I (mild): FEV1 ≥80% pred; II (moderate): FEV1 ≥50% to <80% pred; III (severe): FEV1 ≥30% to <50% pred; IV (very severe): FEV1 <30% pred; ¶: total counts of contacts during study period (intervention period of 6 weeks and 9-month follow-up); +: total counts of reported increase of complaints during study period (intervention period of 6 weeks and 9-month follow-up); §: total counts of reported hospital admissions during study period (intervention period of 6 weeks and 9-month follow-up).

      • TABLE 3

        Baseline measurements

        InterventionUsusal careReference range
        CCQ#1.9±1.21.6±1.10–6
         Symptoms2.2±1.22.0±1.1
         Functional state2.0±1.51.7±1.4
         Mental state1.0±1.30.9±1.1
        B-IPQ
         Consequences5.5±2.94.9±2.80.0–10.0
         Timeline9.5±1.69.6±1.70.0–10.0
         Personal control5.5±2.76.4±2.30.0–10.0
         Treatment control7.0±2.67.0±2.00.0–10.0
         Identity5.4±2.54.9±2.70.0–10.0
         Concern5.0±3.05.4±3.10.0–10.0
         Comprehensibility7.6±2.47.1±2.60.0–10.0
         Emotional response3.9±3.23.6±2.90.0–10.0
        MRC+2.2±1.31.9±1.40–5
        CRQ-SAS§
         Dyspnoea5.8±1.45.6±1.51–8
         Fatigue4.5±1.44.7±1.41–7
         Emotional5.0±1.25.2±1.21–7
         Mastery5.4±1.25.4±1.31–7
        FPI§1.7±0.71.8±0.61–3
        heiQ§
         Health-directed behaviour2.9±0.73.1±0.71–4
         Positive and active engagement in life3.0±0.63.1±0.51–4
         Emotional distress3.1±0.73.1±0.71–4
         Self-monitoring and insight3.1±0.43.1±0.41–4
         Constructive attitudes and approaches3.2±0.63.3±0.51–4
         Skill and technique acquisition3.0±0.43.0±0.51–4
         Social integration and support3.0±0.63.0±0.61–4
         Health service navigation3.2±0.43.2±0.41–4

        Data are presented as mean±sd or n. CCQ: Clinical COPD Questionnaire; B-IPQ: Brief Illness Perception Questionnaire; MRC: Medical Research Council dyspnoea score; CRQ-SAS: self-administered Chronic Respiratory Disease Questionnaire short form; FPI: Functional Performance Inventory; heiQ: Health Education Impact Questionnaire. #: lower scores mean better health-related quality of life (HRQoL); ¶: lower scores on consequences, timeline, identity, concern and emotional response and higher scores on personal control, treatment control and comprehensibility mean more positive perceptions; +: lower scores mean less burden of dyspnoea; §: higher scores mean better HRQoL, functional performance and health education impact.

        • TABLE 4

          Clinical outcomes, corrected for clustering, time, treatment and Medical Research Council dyspnoea score# for the COPD-GRIP (Chronic Obstructive Pulmonary Disease – Guidance, Research on Illness Perception) intervention group and the usual-care group

          Baseline6 weeks3 months9 monthsMean difference (95% CI)Treatment*time interaction at 9 months
          p-values
          CCQ total¶0.04 (−0.09–0.17)0.197
           Intervention1.9±1.21.8±1.12.0±1.32.0±1.2
           Usual care1.6±1.11.7±1.11.8±1.11.7±1.1
          CRQ-SAS+ fatigue−0.06 (−0.28–0.16)0.631
           Intervention4.5±1.44.5±1.54.5±1.54.4±1.4
           Usual care4.7±1.44.8±1.44.7±1.34.7±1.4
          CRQ-SAS+ dyspnoea0.16 (−0.13–0.04)0.162
           Intervention5.8±1.45.6±1.65.6±1.55.5±1.6
           Usual care5.6±1.55.6±1.55.6±1.45.7±1.5
          CRQ-SAS+ emotional0.03 (−0.21–0.27)0.463
           Intervention5.0±1.25.2±1.35.2±1.35.1±1.3
           Usual care5.2±1.25.3±1.25.2±1.15.3±1.2
          CRQ-SAS+ mastery0.09 (−0.11–0.28)0.375
           Intervention5.4±1.05.4±1.15.3±1.35.3±1.2
           Usual care5.4±1.35.4±1.35.4±1.25.5±1.2
          FPI+−0.12 (−0.33–0.08)0.074
           Intervention1.7±0.71.6±0.71.6±0.71.5±0.7
           Usual care1.8±0.61.8±0.71.7±0.71.8±0.7
          B-IPQ§ (control)−0.22 (−0.70–0.26)0.005
           Intervention5.5(2.76.5±2.16.1±2.56.6±2.2
           Usual care6.4±2.36.5±2.16.9±1.76.2±2.3
          heiQ+ (HDB)−0.12 (−0.26–0.03)0.024 (6 weeks)
           Intervention2.8±0.73.1±0.73.0±0.52.9±0.8
           Usual care3.1±0.73.1±0.63.1±0.63.1±0.6

          Data are presented as mean±sd, unless otherwise stated. CCQ: Clinical COPD Questionnaire; CRQ-SAS: self-administered Chronic Respiratory Disease Questionnaire short form; FPI: Functional Performance Inventory; B-IPQ: brief illness perception questionnaire; heiQ: Health Education Impact Questionnaire; HDB: health-directed behaviour. #: lower scores mean less burden of dyspnoea; ¶: lower score means better health-related quality of life (HRQoL); +: higher scores mean better HRQoL, functional performance and health education impact; §: lower scores on consequences, identity, concern and emotional response and higher scores on timeline, personal control, treatment control and comprehensibility mean more positive perceptions.

          • TABLE 5

            Subgroup analyses: differences between the COPD-GRIP (Chronic Obstructive Pulmonary Disease – Guidance, Research on Illness Perception) intervention group and the usual-care group in Clinical COPD Questionnaire scores

            Subjects nBaseline6 weeks3 months9 monthsTreatment*time interaction
            p-values
            MRC score ≤20.595
             Intervention641.3±0.71.3±0.71.3±0.91.5±0.8
             Usual care681.2±0.81.2±0.81.3±0.81.3±0.7
            MRC score >20.165
             Intervention203.0±1.13.0±1.13.2±1.13.2±1.1
             Usual care232.7±0.92.9±1.03.0±0.93.0±1.0
            Male0.811
             Intervention331.8±1.31.4±0.91.8±1.31.7±1.0
             Usual care411.7±1.01.9±1.11.8±1.11.8±1.3
            Female0.126
             Intervention512.2±1.32.1±1.22.3±1.42.2±1.3
             Usual care531.6±1.11.6±1.21.8±1.11.6±1.0

            Data are presented as mean±sd, unless otherwise stated. MRC: Medical Research Council.

            Supplementary Materials

            • Figures
            • Tables
            • Supplementary Material

              J-W.J. Lammers 00115-2016_Lammers

              S.W.M. Weldam 00115-2016_Weldam

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            The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care
            Saskia W.M. Weldam, Marieke J. Schuurmans, Pieter Zanen, Monique J.W.M. Heijmans, Alfred P.E. Sachs, Jan-Willem J. Lammers
            ERJ Open Research Oct 2017, 3 (4) 00115-2016; DOI: 10.1183/23120541.00115-2016

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            The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care
            Saskia W.M. Weldam, Marieke J. Schuurmans, Pieter Zanen, Monique J.W.M. Heijmans, Alfred P.E. Sachs, Jan-Willem J. Lammers
            ERJ Open Research Oct 2017, 3 (4) 00115-2016; DOI: 10.1183/23120541.00115-2016
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