Evidence Based Health Research And Practice In COPD And Smoking: An Australian Aboriginal Perspective

Interest in the topic

Discuss About The Evidence Based Health Research And Practice.

Chronic Obstructive Pulmonary Disease refers to an umbrella term that describes progressive lung disorders that include chronic bronchitis, emphysema, and refractory asthma, primarily characterized by breathlessness (López?Campos, Tan & Soriano, 2016). The main factors that increase susceptibility of an individual to COPD include an exposure to irritants that damage the lungs. Owing to the fact that COPD symptoms worsen over time, there is a need to determine the association of this disorder with its risk factors.

I hold the opinion that early detection of COPD would facilitate its prevention and management in an appropriate way. I gained an interest in conducting this research due to presence of mounting evidences that smoking is significantly related to high rates of mortality due to COPD. I also wanted to gain an understanding of factors that might increase incidence of COPD among non-smokers.

The research aims to examine the impact of smoking as a risk factor in contracting COPD among the Australian aboriginal population.

• McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., &Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane Library.DOI: 1002/14651858.CD003793.pub3

McCarthy, Casey, Devane, Murphy, Murphy and Lacasse, (2015) are renowned individuals in the field of biological/clinical research and their work have been cited by several other researchers. The primary aim of the review was to compare the impacts of pulmonary rehabilitation with usual care strategies on health-related QoL, in addition to the exercise capacity among COPD patients. This review selected RCTs from the Cochrane Airways Group Specialised Register that focused on pulmonary rehabilitation in COPD patients that measured HRQoL and maximal or functional exercise capacities. The mean differences were calculated by random-effects model. No significant difference was observed in baseline demographics between individuals in the intervention group and those receiving usual care. Pulmonary rehabilitation produced statistically significant outcomes for fatigue, emotional function, mastery and dyspnoea. Improvements were also observed in functional and maximal exercise capacities. The authors concluded that pulmonary rehabilitation can be administered for improving emotional function and relieving symptoms of fatigue and breathlessness and dyspnoea in COPD patients.

• Vogelmeier, C. F., Criner, G. J., Martinez, F. J., Anzueto, A., Barnes, P. J., Bourbeau, J., …& Frith, P. (2017). Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease 2017 report. Respirology, 22(3), 575-601.https://doi.org/10.1111/resp.13012

Vogelmeier et al., (2017) are well established academicians, interested in investigating the underlying factors that contribute to a range of cardiovascular and respiratory abnormalities and their prevention strategies. The aim of the executive summary was to discuss the assessment of COPD, the risk factors that increase the likelihood of suffering from it, and impacts of prevention therapy, rehabilitation, education and disease self-management. The review utilized a plethora of available evidences to define the pathogenesis of the disease and the factors that influence a progression of the disease. Comprehensive and succinct information was provided on the symptoms, medical history, assessment and co-morbidities. The authors suggested that bronchodilators and anti-inflammatory drugs are effective in treating COPD. Furthermore, they also concluded that in addition to the aforementioned treatment, non-pharmacological treatment such as, rehabilitation programmes, exercise, self-management, education and palliative care must also be employed for COPD prevention and management.

• Zwar, N. A., Bunker, J. M., Reddel, H. K., Dennis, S. M., Middleton, S., Van Schayck, O. C., …&Xuan, W. (2016). Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: a cluster randomized trial. Family practice, 33(6), 663-670.https://doi.org/10.1093/fampra/cmw077

Aim

Credibility of the authors Zwar et al., (2016) can be established by the fact that they are associated with esteemed healthcare and medical institutes in Australia. The authors aimed to investigate the effectiveness of early nursing interventions on the QoL and care process of recently diagnosed COPD patients, compared to those receiving usual care. The RCT was a multicentred, pragmatic one conducted over a period of 12 months, with blinded outcomes. Primary outcome measurement was related to HRQoL. Knowledge about the disease, lung function, smoking and immunisation status, inhaler technique and use of health service were some of the secondary outcomes. The study findings stated that very few patients in intervention group saw the nurses. No significant group differences were obtained for the SGRQ scores. Furthermore, higher rates of influenza immunisation were also observed in the intervention group. The authors concluded that uptake of intervention was considerably low and did not produce any additional benefits.

The selected articles that best matched the PICO question were a systematic review, an executive summary, and a randomised controlled trial, respectively. Strength of the study conducted by McCarthy, Casey, Devane, Murphy, Murphy and Lacasse, (2015) can be attributed to the fact that it was a synthesis or overview of all available evidences related to the particular research question. Inclusion of 65 studies that involved 3822 patients with COPD is significant for the research as the large number of included studies provided a definitive answer to the question about the impact of pulmonary rehabilitation on COPD. Summarising the large body of evidence helped the review to provide exhaustive information on the latest developments in this COPD management approach. Furthermore, the review indicates how well the findings could be implemented to everyday clinical practice, thereby establishing the generalisability of the findings.

Relevance of the results can be confirmed by other studies that show consistency with the findings. Better responses in exercise performance, and levels of physical activity in pulmonary rehabilitation subjected COPD patients, were also proved by another cohort study (Maddocks et al., 2016). However, limitations can be related to the fact that relevant, unpublished articles might have been excluded from the study, thereby contributing to publication bias.

Strength of the executive summary by Vogelmeier et al., (2017) can be attributed to the fact that provided comprehensive and detailed information on the diagnosis, management and treatment of COPD, on a global scale. One major advantage is related to the wide body of epidemiological evidence that the authors have used to describe the pathophysiology of the disease and the risk factors that result in airflow limitation, a primary characteristic of the condition. Furthermore, detailed information on COPD symptoms such as, sputum, dyspnoea, wheezing and cough show consistency with other research articles. The summary presented information on the medical history of COPD patient that might put them at risk for the condition, thereby adding to clinical practice guidelines. The summary showed consistency with articles that related use of bronchodilator therapy with reduced COPD symptoms and PA related difficulties (Troosters et al., 2016). The summary was also effective in explaining about the impacts of non-pharmacological COPD interventions, such as, rehabilitation, self-management and education, supported by evidences. However, lack of statistical data to prove the effectiveness of the stated interventions fails to establish reliability and validity of the article.

Presenting the evidence

The RCT conducted by Zwar et al., (2016) has several advantages associated with the fact that it compared one form of treatment (early intervention) with another (usual care), with the aim of establishing superiority of one. The study design helped in deriving causal inferences as it is one of the strongest empirical evidence for efficacy of a treatment. Further strengths can also be related to the minimisation of allocation and selection bias. Furthermore, blinding helped to reduce assessment bias. However, there were several limitations related to falling short of the recruitment target because the study enrolled patients with early COPD, thereby raising questions about considering smoking cessation as a primary outcome. Furthermore, no significant effect of self-management intervention on HRQoL showed discrepancies with previous findings (Bischoff, Akkermans, Bourbeau, van Weel, Vercoulen & Schermer, 2012). The RCT has other limitations as well that can be attributed to low attendance rates of the PNs and GPs and their non-adherence to the care planning and education tools. In addition, lack of representativeness of the practices in Australia is associated with sending the invitations via the professional healthcare organisations. Failure to deliver the intervention according to the plan was another major drawback, which proves that lack of reliability of the results. 

The three basic principles of evidence-based practice (EBP) that can be implemented include use of best available evidences, clinical expertise and paying attention to the values and preferences of the patients. Findings obtained from the articles discussed above can be implemented in a clinical scenario by utilizing the fact that implementation of pulmonary rehabilitation intervention in COPD patients will allow them to adhere to a program of education, exercise and self-management and will also provide the necessary support to help them learn breathing and functioning at the highest possible levels (Grosbois et al., 2015). Use of the available evidences will allow the healthcare professionals to improve the physical condition of the patients, by taking into account their health history, level of activity and exposure to risk factors. Patient preferences might include avoidance of breathlessness and dyspnoea, and night-time waking due to their presenting complaints (Spruit et al., 2013). Increased availability of information and a positive patient-physician relationship, with autonomy maintenance are other preferences.

Some of the barriers in this EBP might be associated with smoking status of the aboriginal patients, and the availability of social support. Smoking status has been identified as a major predictor of adherence and attendance to PR. Smokers tend to display less inclination towards adoption of PR based health promotion behaviours. Furthermore, women with lack of social support are less likely to develop compliance towards this prevention program (Hayton et al., 2016). Most aboriginal participants might not be aware of the existence of pulmonary rehabilitation programs, thereby demonstrating uncertainty about the evidence. Lack of appropriate knowledge regarding referral of patients to the intervention and difficulties of the aboriginal COPD patients to attend the rehabilitation programs outside their home will also act as barriers (Johnston, Young, Grimmer, Antic & Frith, 2013). Negative views of the relative benefits and costs of the program also need to be considered. Therefore, efforts should be taken to eliminate or reduce all the barriers, before implementation of the evidence-based intervention.

References

Bischoff, E. W., Akkermans, R., Bourbeau, J., van Weel, C., Vercoulen, J. H., &Schermer, T. R. (2012). Comprehensive self management and routine monitoring in chronic obstructive pulmonary disease patients in general practice: randomised controlled trial. Bmj, 345, e7642.https://doi.org/10.1136/bmj.e7642

Grosbois, J. M., Gicquello, A., Langlois, C., Le Rouzic, O., Bart, F., Wallaert, B., & Chenivesse, C. (2015). Long-term evaluation of home-based pulmonary rehabilitation in patients with COPD. International journal of chronic obstructive pulmonary disease, 10, 2037. doi:  10.2147/COPD.S90534

Hayton, C., Clark, A., Olive, S., Browne, P., Galey, P., Knights, E., … & Wilson, A. M. (2013). Barriers to pulmonary rehabilitation: characteristics that predict patient attendance and adherence. Respiratory medicine, 107(3), 401-407. doi: 10.1016/j.rmed.2012.11.016

Johnston, K. N., Young, M., Grimmer, K. A., Antic, R., & Frith, P. A. (2013). Barriers to, and facilitators for, referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners: a qualitative study. Primary Care Respiratory Journal, 22, 319-324. doi:10.4104/pcrj.2013.00062

López?Campos, J. L., Tan, W., & Soriano, J. B. (2016). Global burden of COPD. Respirology, 21(1), 14-23. https://doi.org/10.1111/resp.12660

Maddocks, M., Kon, S. S., Canavan, J. L., Jones, S. E., Nolan, C. M., Labey, A., …& Man, W. D. (2016). Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study. Thorax, thoraxjnl-2016., 71. doi: 10.1136/thoraxjnl-2016-209462

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., &Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane Library.DOI: 10.1002/14651858.CD003793.pub3

Safka, K. A., & McIvor, R. A. (2015). Non-pharmacological management of chronic obstructive pulmonary disease. The Ulster medical journal, 84(1), 13. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330800/pdf/umj0084-0013.pdf

Spruit, M. A., Singh, S. J., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., … & Pitta, F. (2013). An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. American journal of respiratory and critical care medicine, 188(8), e13-e64. https://doi.org/10.1164/rccm.201309-1634ST 

Troosters, T., Lavoie, K., Leidy, N., Maltais, F., Sedeno, M., Janssens, W., …&Bourbeau, J. (2016). LATE-BREAKING ABSTRACT: Effects of bronchodilator therapy and exercise training, added to a self-management behaviour-modification programme, on physical activity in COPD.,48: PA713. DOI: 10.1183/13993003.congress-2016.PA713

Vogelmeier, C. F., Criner, G. J., Martinez, F. J., Anzueto, A., Barnes, P. J., Bourbeau, J., …& Frith, P. (2017). Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease 2017 report. Respirology, 22(3), 575-601.https://doi.org/10.1111/resp.13012

Zwar, N. A., Bunker, J. M., Reddel, H. K., Dennis, S. M., Middleton, S., Van Schayck, O. C., …&Xuan, W. (2016). Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: a cluster randomized trial. Family practice, 33(6), 663-670.https://doi.org/10.1093/fampra/cmw077

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