Evaluation of a transitional care programme for patients with chronic obstructive pulmonary disease in Guangzhou China : a randomized controlled trial

Abstract

Background: Chronic obstructive pulmonary disease (COPD) exerts an enormous burden on patients, the healthcare services and society as a whole. The impacts of COPD can be minimised if effective management strategies are implemented, particularly when patients are transferred from hospital to home after suffering an acute exacerbation. However, postdischarge support is still an unmet need for many patients, and an issue that has not received enough attention from healthcare providers and the healthcare system in mainland China. It is necessary to build up research evidence to guide clinical practice, research and policy-making in the development of transitional care in China. Aim: To evaluate the effectiveness of a COPD transitional care programme (COPD-TCP) for Chinese patients with COPD, as measured by clinical, psychosocial, functional, fiscal and satisfaction outcomes. Method: The study constituted a randomised controlled trial (RCT). Sixty subjects admitted with COPD to a respiratory disease institute in Guangzhou, China from November 2008 to December 2009 were recruited and randomly assigned to an intervention group (n = 30) and a control group (n = 30). Both groups received the usual discharge care offered in the site hospital. The intervention group underwent a COPD-TCP delivered by four trained nurse case managers (NCMs) with support from a clinical team comprising physician, nutrition specialist, programme coordinator and nursing manager. The COPD-TCP commenced within 72 hours before discharge and lasted until the sixth week of the transition to home postdischarge, involving one inpatient visit, two home visits, four telephone follow-ups and a 24-hour NCM hotline. The main outcome measures were the 6-minute walk distance (6MWD) test, Seattle Obstructive Disease Scale (SOLQ) scores, COPD Self-Efficacy Scale (CSES) scores, COPD-related readmission and direct cost of readmission, and COPD Transitional Care Patient Satisfaction Questionnaire (CTCPSQ) scores. Data collection was conducted at baseline (T0), immediately post-intervention (T1) and three months follow-up (T2). Both Intention-to-treat (ITT) and Per-Protocol (PP) analyses were performed. Group comparisons were computed by repeated measures analysis of variance (ANOVA), repeated measures analysis of covariance (ANCOVA), and the Pearson chi-square test or Mann-Whitney U-test. Results: The ITT analyses revealed a significant between-group difference in the 6MWD test (F(₁.₅₇) = 4.90, p = 0.031), with a minimal important difference of 36.36 metres. A significant interaction between group and time was found in the two subscale scores of the SOLQ (physical function: F(₁.₅₆₈, ₉₀.₉₄₉) = 4.47, p = 0.021; emotional function: F(₁.₅₃₁,₈₈.₈₀₇) = 3.53, p = 0.045), as well as in the total score of the CSES (F(₁.₅₆₈, ₉₀.₉₂₇) = 13.87, p < 0.001). Significant differences were also found between the control and intervention groups in the COPD-related readmission rate at 12 weeks postdischarge (12/30[40.0%] vs. 5/30[16.7%], χ² = 4.02, p = 0.045) and in the cost of COPD-related readmissions at 6 weeks postdischarge (interquartile range: 7638.9 vs. 5718.0, U = 3.00, p = 0.014). Moreover, the intervention group was more satisfied than the control group (service satisfaction score: Med. = 95.83 vs. Med. = 75.00, U = 123.00, p < 0.001; education satisfaction score: Med. = 93.75 vs. Med. = 56.23, U = 65.50, p < 0.001). Conclusion: The COPD-TCP was found effective in improving exercise capacity, self-efficacy and quality of life, reducing the COPD-related readmission rate and direct cost of readmission, and enhancing patient satisfaction. The results of this study suggest that transitional care contributes to enhancing the health of COPD patients during the recovery stage following hospitalisation for an exacerbation episode. This study provides evidence in support of the healthcare reforms in mainland China, informing healthcare providers that transitional care support benefits patients in terms of both health outcomes and healthcare costs.