Long term conditions (LTCs) also known as chronic diseases or non-communicable diseases have been defined by the World of Health Organisation (WHO) as conditions that have origins at young ages take decades to be fully established, with their long duration, requiring a long term and systematic approach to treatment (Pruitt et al, 2002). Currently over 15 million people in England live with a LTC such as diabetes, chronic lung disease, heart disease, cancer and dementia (Department of Health, 2009, pp.32).Plans to transform care for patients with long term conditions are based on continuing to maintain focus on early intervention and prevention; supporting integrated services shall help the patients and the public have a clear set of rights and patients in turn shall help the health care by undertaking the necessary steps, to take good care of their own health: promoting a preventive, people-centred, and productive care to be delivered (Department of Health, 2009).
Goodwin et al (2010, pp.61) reported that the population management of LTCs involves of two parts; correctly recognising which patients are at high risk of being hospitalised and prioritise them and correctly identify the level of risk upon admission so a cost-effective and appropriate intervention can be applied. Together, these will allow the patient to self-manage their condition and increase their quality of life by reducing the number of hospital visits.
Director General of WHO expressed that, “the lives of far too many people in the world are being blighted and cut short by chronic diseases, this is very serious situation, both for public health and for the societies and economies affected” (WHO, 2005, p.VII), which has raised a need for long term conditions to be managed differently. Chronic diseases have place a heavy burden on the health care with demand for services and cost for treatment; the economic cost levels incurred; directly by the health care and indirectly by the individuals has also increased, and also increased use of hospital resources, raising need to manage the differently (Canada. Department of Health and Community Services, 2011, p.7).
They are time-consuming and some do not require the expertise and skill of a physician, but rather, may be managed by other members of the health care team. Chronic conditions have an effect on workplaces as regards productively losses, where modifications have to be made by employers who attain workers with long term conditions; so there is a need to manage them differently.
Department of Health (2012) published a policy framework to support the management of LTC thus improving the quality of life for patients who suffer from them. Majority of the health care systems of middle-income countries, including Malaysia, are organised around models of healthcare developed in western countries, such systems are clearly at odds when dealing with long-term and continuing illness that require collaboration across health care sectors and where patient behaviour change forms the primary focus (Yasmin et al, 2012, p.3). Malaysia is now implementing the Innovative Care for Chronic Conditions Model (ICCC), for it was developed, recognising the challenges of the under-resource and non-integrated health systems in low-and-middle income countries; but still holds focus on encouraging behaviour change at an individual level through improving self-management (Yasmin et al, 2012, p.4.)
Managing LTC requires key principles to be applied for health care to continue being focussed and keep up with the transformation of care. The Department of Health, Social Services and Public Safety (2012) identify six key principles that should be used when creating an intervention to manage a LTC. These include; working in partnership with patients and carers, supporting self-management, provide appropriate and timely information and advice to patients, support individuals with their medication, working with carers in planning and delivering interventions and creating person-centred, flexible and integrated services across all areas.
In this assignment, a scenario of a patient who has been referred to the Pulmonary Rehabilitation following a recent hospital admission with bronchopneumonia, is going to be discussed, regarding her clinical findings outlined in the pro-forma. Margaret is 64-year-old, married and retired woman who has suffered from Chronic Obstructive Pulmonary Disease (COPD) for the past 20 years. She is slowing deconditioning and continues to repeating suffer from acute exacerbations.
COPD is lung disease by which there is a chronic obstruction of airflow within the lungs that interferes with normal breathing and is not fully treatable. However, patients are able to manage their symptoms and achieve a good quality of life through proper management. COPD is an umbrella term for a number of chronic lung conditions but the more commonly known ones are chronic bronchitis and emphysema (WHO, 2018). The symptoms include; shortness of breath (especially during physical activities), wheezing, chest tightness, mucus production, chronic cough, lack of energy and in the later stages, unintended weight loss (Mayo Clinic, 2018). According to Public Health England, COPD prevalence in England was 1,087,908 in 2016/17 and is continuing to increase. Also in 2016, the Global Burden of Disease Study reported a prevalence of 251 million cases of COPD globally (WHO, 2016).
In 2010, the National Institute of Health and Clinical Excellence (NICE) defined pulmonary rehabilitation (PR) as a multi-disciplinary team led programme of care for patients with long term pulmonary conditions. The programme is person-centred and includes exercise, education, nutrition, psychological and behavioural within the intervention. The recommended timescale of PR for an individual attending is two supervised sessions a week for 6-12 weeks along with an additional session unsupervised (British Thoracic Society, 2013). The British Lung Foundation (2017) additionally supports these guidelines but advises a 6-8 week programme with bi-weekly sessions is just as effective. However, Troosters, Gosselink, Janssens and Decramer (2010) reported patients who attended three sessions weekly over an 8 week period had the same improvement. Although the overall intervention time is the same, patients did struggle to commitment to attend all three sessions a week.
The main reason Margaret has been referred to PR is due to her recent acute exacerbation with bronchopneumonia. According to the Chartered Society of Physiotherapy (CSP) (2018), physiotherapy led PR reduces exacerbations by 33% and can prevent 26,600 hospital admissions. This indicates that PR will be beneficial for Margaret as it will help her control her symptoms and reduce the number of hospital admissions – she has been admitted four times within the past eighteen months. Seymour et al (2010) conducted a report on whether post-exacerbation (PE) PR can reduce hospital admissions after the completion of the PR over the following three months. They compared the results from two groups – one received usual care post-exacerbation and one received PEPR – within one week of being discharged. The results showed that patients re-admitted to hospital with another exacerbation was 33% in the usual care group compared to 7% in the PEPR group. This further supports that PR can reduce re-exacerbations with patients with COPD within a three-month period.
One of the main symptoms of COPD is breathlessness which patients often experience after exerting themselves. This is due to the restriction of air flow and can vary in intensity. When breathlessness is experienced, it can be a frightening experience for the patient and carers which is very difficult to manage. Treatment often consists of pharmacological interventions such as bronchodilators and anti-inflammations (British Thoracic Society, 2013). Breathlessness mostly occurs at home which the patient has to respond to and self-manage. PR is useful for patients with COPD as it can relieve dyspnoea and enhance the patients’ quality of life and increase their confidence as they have more control over their condition. Gysels and Higginson (2009) conducted a qualitative study to discuss the patients’ experiences with breathlessness. They found that patients who participated in PR were the most successful at self-management as they were educated by qualified staff which therefore increased the patient’s knowledge and understanding of their condition.
As Margaret’s physical activity levels have decrease, so has her exercise tolerance. This means that Margaret gets breathless easier than others during physical activity and cannot do a lot. This is another reason why PR would be appropriate for Margaret as there is multiple studies conducted that imply that PR increases exercise tolerance. One outcome measure that supports this is the 6-minute walk test distance (6MWD) which should be completed before and after PR. Hakamy et al (2017) conducted an audit study to evaluate the use and impact of the 6MWD in relation with PR. They found that patients who had a practice test were significantly better during their baseline assessment where the average distance was 34.8 metres. They also found that the practice patients were 17% more likely to complete a PR and attended more scheduled sessions. After the completion of PR, they found that 1,662 patients both completed a baseline and discharge assessment to compare their scores and noticed a mean improvement of 59 metres. However, a limitation in this study is that only 22.6% of patients had a practice test prior to their baseline assessment. This could be more reliable if they had increased the number of patients participating in a practice walk test. It would be suitable to have Margaret complete a 6MWD as she would be able to see how much her walking has improved after 8 weeks at PR as she is only able to walk approximately 40 metres before experiencing dyspnoea. It will also improve her confidence when walking as she is currently being aided by her husband.
Another problem reported by Margaret is that her legs feel weak all the time – particularly when she is ascending and descending stairs. This is a combination of Margaret’s mild COPD and knee osteoarthritis (OA). Knee OA has an impact on the level of muscle impairment of the glutes, hamstrings but particularly the quadriceps. This usually results in significant muscle weakness which can affect activities of daily living (ADL) and physical activity (Alnahdi, Zeni and Snyder-Mackler, 2012). COPD also has an impact on the quadriceps as it is associated with muscle weakness and wasting within patients with mild to severe COPD due limited physical activity (Swallow et al, 2007; Shrikrishna et al, 2012). PR can incorporate resistance training along with usual care to help prevent further deterioration of the quadriceps and aid in building muscle strength. Troosters et al (2010) reported that resistance training aided the prevention of further muscle deterioration during an acute exacerbation of COPD. They also reported that subjects who partook in the resistance training continued to have enhanced quadriceps power one month following the trial and had an improved six-minute walk test. This would help Margaret as it would increase her muscle power and allow her to feel safer when walking. However, a barrier to resistance training would be her OA. Her OA will cause persistent pain when mobilising and may continue to get worse over time leading to further muscle wastage and reduction in strength.
A final benefit of PR for Margaret is the social and independence aspect of it. She reported not being able to go places without help from her husband. Hogg et al (2012) conducted a qualitative study between two focus groups who participated in a block of PR. Both groups reported that they appreciated the peer support and felt it aided in their motivation to attend and excel during the exercise class. They also felt that their confidence increased as they were able to discuss their experience with COPD with other people living with the condition. This further proves that PR would be appropriate for Margaret as she will be able to socialise with other people without her husband and her confidence would increase with managing her condition by hearing other people’s experiences and how they manage.
One thing that is unclear about PR is whether patients with COPD are more active after the completion of the 8-week programme as there is no follow-up. Pitta et al (2008) conducted a longitudinal study looking at the effects of 3 and 6 months of PR. They reported that there was improvement in the physical activities of daily living (ADLs) at 3 months and further improvement at 6. Within 3 months, the mean walking time had increased 7% while it had increased 20% after 6 as well as the intensity from baseline. This was done by short walks within a minute. However, the study did not show the patients’ walking pattern after the 6 months and if the patients increased the shorter 1 minute walks for continual walks over a minute. This does not mirror physical ADLs as patients would normally walk for longer than 1 minute and consider their habits. Long-lasting programmes may be considered if one of the aims of PR is to change a patient’s physical ADLs habits.
Another limitation of PR is that patients often decline participation as studies show that up to 50% of patients with COPD do not attend (Mather, Fastholm, Lange and Larsen, 2017). Mathar, Fasthom, Lange and Larsen (2017) conducted a qualitative study to gather explanations of why patients often decline PR when they are diagnosed with COPD. They interviewed 19 patients (11 females and 8 males) and the results show that patients decline due to their COPD and comorbidities, lack of significance, timing and priorities and no recollection that they have been offered PR when hospitalised. This emphasises that clinicians may need to reiterate the referral to patients after hospital discharge, develop a palliative programme for patients who believe they are too frail to participate and develop separated PR programmes. This may be relevant to Margaret as she may feel that she is too weak to participate and it might increase the pain in her knees from her OA.
In conclusion, PR would be an appropriate intervention within Margaret’ management plan as it helps with the majority of her symptoms and problems being reported. It also focusses on the six key principles of managing a LTC. The programme can be personalised to suit her and allow her to get the best outcome.