Critical Appraisal of a Primary Research Article and an Informatics Tool on Managing Chronic Obstructive Pulmonary Disease
Introduction
Chronic Obstructive Pulmonary Disease, often referred to as COPD, is a debilitating condition causing breathing difficulties for sufferers that tend to worsen over time. As outlined by the National Health Service, NHS, there are two lung conditions that are categorised under the umbrella of COPD which includes emphysema and chronic bronchitis. Emphysema involves damage to the air sacs found in the lungs whilst chronic bronchitis relates to long-term inflammation of the airways (NHS,2018). Both have the ability to restrict air flow and oxygen transference to the rest of the body. Symptoms typically include: shortness of breath, wheezing, coughing and an increase in sputum or phlegm production. In particularly severe cases loss of appetite, weight loss and swollen ankles can also cause discomfort and have negative health impacts on a person with COPD(BLF,2018). These symptoms can make a person feel fatigued and unable to complete everyday tasks such as washing and dressing without assistance.
There are approximately 1.2 million people in the UK living with COPD and it is thought there are many more undiagnosed cases yet to be reported (Bupa,2018). With so many people living with COPD, there needs to be a focus on developing coping strategies to effectively manage the condition as it gradually worsens in order to improve patient’s quality of life. By designing treatments and coping mechanisms that can be implemented soon after diagnosis, the economic implications of COPD on the NHS could be significantly improved as the condition is currently costing the NHS an estimated £1.9 billion each year (Trueman, Woodcock, Hancock, 2017). With such a high expenditure it is critical that the condition is effectively managed and occupational therapy is one of many allied health professions that could provide a way of reducing these costs. The article being appraised in this report examines the effectiveness of occupational therapy in the management of COPD. If the therapeutic methods in the article focusing on improving occupational performance are shown to be effective, this could significantly reduce the economic impact COPD has on the NHS as sufferers require less professional care and are not as frequently admitted to hospital. Additionally, technological developments in app production have enabled sufferers with COPD to self-manage their condition more effectively and keep track of their symptoms with ease. The combination of occupational therapy methods and guidance from informatics tools could promote independence for those with COPD, improving their health and quality of life.
Article Search Method
The research article chosen for appraisal titled The effect of occupational therapy in patients with chronic obstructive pulmonary disease: A randomised controlled trial (Martinsen et al. 2017) was published under the Scandinavian Journal of Occupational Therapy. This article was found using the CINAHL database under the search terms COPD AND occupational therapy which generated 25 results, allowing for the selection of the relevant article required for this report. The initial search containing the terms COPD OR chronic obstructive pulmonary disease AND occupational therapy generated 8,383 results so by eliminating chronic obstructive pulmonary disease from the search an article more relevant to the report being conducted was easier to find.
Article Appraisal
To appraise the article written by Martinsen, Bentzen, Holter, Nilsen, Skullerud, Mowinckel and Kjeken regarding the effectiveness of occupational therapy in managing COPD the critical appraisal skills programme, commonly referred to as CASP, was used. The specific CASP checklist selected focuses on randomised controlled trials.
1. The first point to be considered is whether or not the trial addresses a clearly focused issue. The trial does clearly focus on the effects of occupational therapy in patients with COPD (intervention group) in comparison to the effects of their typical treatment (control group) as outlined under the trial design. The patients selected to participate in the trial all had either moderate or severe cases of COPD and were under the age of 80 years so they were similar in this regard. Therefore the sample from the population of people with COPD is sufficient enough to address the clearly focused issue.
2. The CASP checklist then asks if the assignment of patients to treatments was randomised. Patients were randomly assigned to either the intervention or control group using a computer-generated system after completing a baseline assessment.
3. Another criteria asks if all of the patients who entered the trial were properly accounted for at its conclusion. The study started with 52 patients but only 44 patients went on to complete the study. The remaining patients stayed in the groups they were assigned to at the beginning of the trial.
Of the 24 patients assigned to the intervention group, 21 patients remained at 4 months and 18 patients were recorded at the 12 month follow up. In the control group of 28 patients, 26 patients were present at both the 4 month and 12 month follow up.
4. Both the study personnel and the patients were blinded to the random allocation process. The assessments at 4 months and 12 months ‘were performed by a therapist blinded for group allocation and patients were requested not to reveal their group allocation during their follow-up assessments’.
5. The groups at the start of the trial varied greatly in age as anyone under the age of 80 years was eligible for the trial. Therefore the age range of patients may provide a more generalisable finding as the influences on therapy across generations can be observed. There were 34 women and 18 men making up the sample of 52 patients. This unequal ratio between genders may have affected the results as men and women may have responded differently to the treatments they were offered.
6. Aside from the experimental intervention, there is no reference made in the article to participants being treated differently in the trial.
7. The treatment effect was small for this trial. The primary outcome is clearly outlined in the article as being occupational performance which was ‘assessed using a modified version of the COPM’. No significance was found between the groups in the primary outcome COPM at 4 months and 12 months. When performing an individually chosen activity at exertion the intervention group performed better than the control group. This is also the case in the activity dimension of St George’s Respiratory Questionnaire. Therefore, only small changes were observed between the intervention and control group.
8. No estimate of the treatment effect is outlined in the article by the researchers. However, within the introduction it is mentioned that the role of occupational therapy in training patients in energy conservation methods could help to ‘reduce energy expenditure and dyspnoea perception in certain activities’.
9. Patients were sampled from both hospital and community settings, suggesting that the results can be applied to the local population as it represents both moderate and severe cases of COPD. However, the results provided would not be useful for recently diagnosed patients or patients with mild COPD as this strata is not represented in the trial so the effects of treatment may not be true or applicable in this circumstance.
10. The article considers clinically important outcomes and addresses occupational performance as a primary outcome effectively through the use of the COPM. Descriptions of challenging occupational tasks were collected and the importance of each occupation was rated on a 1-10 point scale.
11. The final requirement of the CASP checklist examines whether the benefits are worth the harms and costs. From an individual perspective it can be judged that the trial produced a useful insight into the effectiveness of occupational therapy as an intervention for COPD without exposing patients to harmful situations. All patients had the right to withdraw from the trial if they wished to do so and the therapies offered to them aimed to improve their condition safely under the supervision and care of qualified health professionals.
Informatics Tool Appraisal
The informatics tool selected for appraisal has been produced in the form of an app to help patients with COPD self-manage their condition more effectively. The app developed by ‘@point of Care’ is called COPD Manager and is currently available on the Apple App Store to download at no cost. This app was found through searching the key terms ‘COPD’ and ‘Management’ in the Apple App Store toolbar. It is categorised as a medical app that aims to give patients with chronic conditions more control over their lives by being able to track progress, manage medications and share data with healthcare providers.