Results Summary
What was the research about?
Chronic obstructive pulmonary disease, or COPD, is a lung disease that makes it hard to breathe. Managing symptoms of COPD may improve patients’ quality of life and reduce the need for urgent healthcare visits.
In this study, the research team wanted to learn if including peer support in a COPD self-management support program improved quality of life and reduced use of urgent health care. Peer support included outreach from a peer supporter and group meetings with other patients and family caregivers. Peer supporters had well-managed COPD and had received training to provide support. The team compared patients receiving self-management support with and without peer support.
What were the results?
After six months, patients with and without peer support didn’t differ in quality of life.
During the program, patients with peer support had fewer COPD-related hospital and emergency room, or ER, visits than patients without peer support. This difference wasn’t present at nine months—three months after peer support ended.
At nine months, patients with and without peer support didn’t differ in the overall number of hospital and ER visits for any cause or rate of deaths.
Who was in the study?
The study included 292 patients with COPD and 50 family caregivers. Patients received care at clinics within a health system in Maryland. Of these patients, 71 percent were White, 26 percent were African American, and 3 percent were another race. The average age was 67, and 61 percent were women.
What did the research team do?
The research team assigned patients by chance to the self-management support program with or without peer support. In the program, a respiratory therapist met with patients and their family caregivers for one hour. The therapist described how to use medicines, inhalers, and oxygen and provided a written guide and contact information for follow-up questions.
In the peer support group, patients and caregivers received the same program. The research team also matched each patient with a peer supporter for one-on-one support. In addition, patients could attend up to eight group meetings over six months. At these meetings, patients talked about living with and managing COPD.
The research team interviewed patients in person at the start of the study and again by phone three, six and nine months later. The team collected data about hospital and ER visits from the state of Maryland.
Patients with COPD and their caregivers, healthcare providers, and patient advocates gave input throughout the study.
What were the limits of the study?
This study took place in one health system in one state. Results may differ in other states or health systems. Many patients didn’t take part in the peer support activities, which may have affected study results.
Future research could look at ways to encourage more patients to take part in peer support activities.
How can people use the results?
Health systems can use these results when considering how to support patients with COPD.
Professional Abstract
Objective
To compare the effectiveness of a self-management intervention delivered by a respiratory care practitioner alone or with peer supporters on improving quality of life (QOL) and reducing acute care visits for patients with chronic obstructive pulmonary disease (COPD)
Study Design
| Design Element | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 292 patients ages 40 and older with physician-diagnosed COPD and 50 family caregivers |
| Interventions/ Comparators |
|
| Outcomes |
Primary: health-related QOL Secondary: number of all-cause and COPD-related acute care visits (hospitalizations and emergency department visits), mortality rates |
| Timeframe | 6-month follow-up for primary outcome |
This randomized controlled trial compared the effectiveness of two ways to provide a six-month self-management support intervention for patients with COPD.
Researchers randomly assigned patients to one of two groups. One group received support from a respiratory care practitioner and peer supporters. The comparison group received support from a respiratory care practitioner alone. In both groups, patients and a family caregiver could attend a one-hour self-management support session with a respiratory care practitioner. The practitioner discussed COPD self-management and provided a written guide on this topic; reviewed proper use of medications, inhalers, and oxygen devices as needed; and provided contact information for follow-up questions.
In the group receiving peer support, patients and caregivers could attend up to eight meetings with other patients and caregivers to discuss COPD experiences. Researchers also matched each patient with a peer supporter who had COPD, successfully stopped smoking, and completed a COPD pulmonary rehabilitation program. Peer supporters interacted with patients by phone and at group meetings.
The study included 292 patients with COPD and 50 caregivers. Patients received care at clinics affiliated with two hospitals in a Maryland health system. Of these patients, 71% were White, 26% were African American, and 3% were another race. The average age was 67, and 61% were female.
Researchers interviewed participants about QOL in person at baseline and again by phone after three, six, and nine months. They collected acute care visit data from the state of Maryland.
Patients with COPD and their caregivers, healthcare providers, and patient advocates provided input throughout the study.
Results
The two groups did not differ significantly in QOL changes between baseline and six months.
The group receiving peer support had significantly lower COPD-related acute care use than the comparison group at one month (p<0.001), three months (p=0.02), and six months (p=0.04). This difference was no longer significant at nine months—three months after peer support ended. All-cause acute care use was significantly lower at one month for the group receiving peer support compared with the comparison group (p=0.001) but not at other time points. Mortality rates did not differ between the groups at any time point.
Limitations
This study took place in a single geographic area and health system. Results may differ for other areas and health systems. Participation in peer support activities was low, particularly among patients recruited from inpatient settings, which may have limited the impact.
Conclusions and Relevance
Receiving support from a respiratory care practitioner and peer supporters did not improve QOL more than support from a respiratory care practitioner alone. However, adding peer support reduced COPD-related acute care use during the intervention period.
Future Research Needs
Future research could examine ways to engage patients in peer support activities, particularly patients with recent acute health problems.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked whether the definition of adherence to the intervention developed before or after the researchers saw the attendance results. The researchers confirmed that they established the adherence definition as part of the statistical analysis plan and before the study interventions and data collection were completed. The researchers based their definition of adherence, defined as attending half of planned peer encounters, on earlier studies of group interventions and on early stages of the trial.
- The reviewers noted that a major problem with the study was that the low levels of participation in peer support meetings and calls hampered the ability to assess the efficacy of peer support. The reviewers asked about possible barriers to participation. The researchers responded that peer support participation was low mainly for reasons that did not relate to the content or organization of the peer support sessions, such as being too sick, having transportation issues, and having other medical problems that were more important at the time. Many study participants were recruited when they were hospitalized, and not necessarily for respiratory conditions, and some were sent to rehabilitation facilities or were rehospitalized, which interfered with their ability to participate in peer support activities. Participation was higher among patients recruited from an outpatient setting.
- The reviewers commented that the participation rates seemed low especially in contrast to the enthusiasm participants expressed about keeping the peer support program running longer. The researchers said that the most frequently requested improvement to the program was to continue the peer support intervention. The researchers noted that participants often have times when they are too ill or have too many other commitments to participate in the peer intervention but would like to have the continued opportunity to participate when they are able to do so.
- Reviewers questioned the researchers’ conclusions that living alone was an important contributor to poor treatment adherence, stating that the presented data pointed more to socioeconomic barriers as contributing to poor adherence. The researchers agreed that the results appear to indicate that differences in socioeconomic factors like education and income contributed to adherence differences among participants but went on to say that it was difficult to tease out whether poor adherence was actually driven by higher disease burden among participants with low socioeconomic status. The researchers also conducted more detailed analyses looking at variables that might have affected intervention adherence. They found that lower education level and lower self-reported emotional health significantly related to lower adherence.
- Reviewers asked the researchers to speculate on why in the program incorporating peer support, caregivers showed increases in emotional support while patients in the same program showed increases in informational and instrumental support. The researchers posited that because caring for a loved one with chronic obstructive pulmonary disease can be very stressful, caregivers needing more emotional support may have been more interested in and driven to participating in the intervention and therefore were more likely to benefit. The researchers went on to say that while patients may receive emotional support from their family members and healthcare professionals, caregivers may not want to increase the burden on family and friends by sharing their own concerns.