Does Working with a Health Coach Help Patients with COPD Improve Their Quality of Life and Breathe Easier? [Internet]

Excerpt

Background: Socioeconomically disadvantaged patients, who bear a disproportionate burden from chronic obstructive pulmonary disease (COPD), often lack resources to optimize management of their disease, including limited access to pulmonary specialists. We conducted a randomized controlled trial (RCT) to assess the efficacy of a health coaching model to improve COPD-related quality of life (QOL) and self-management for patients with COPD.

Objectives: The specific aims of the study were to compare patients receiving health coaching with patients receiving usual care with respect to COPD-related QOL, including degree of dyspnea, number of COPD exacerbations, exercise capacity, and patient self-efficacy of managing COPD.

Methods: We conducted an RCT of 9 months of health coaching vs usual care for low-income English- or Spanish-speaking patients at least 40 years of age with moderate to severe COPD from 7 primary care practices serving low-income, urban adults. Patients randomized to the intervention arm were assigned a health coach who supported them in working toward personal health goals and in self-management skills such as correct inhaler use. Coaches accompanied patients to their primary care and specialty visits and met with them between visits. Coaches facilitated review of patient care plans by a pulmonary nurse practitioner. Patients in the usual care arm received any resources their provider and their clinic offered as part of standard care, including access to COPD educators, respiratory therapists, COPD education classes, pulmonary rehabilitation, or smoking cessation classes. The primary outcomes were COPD-related QOL and the dyspnea subscale of the Chronic Respiratory Disease Questionnaire (CRQ). Secondary outcomes were self-efficacy for COPD self-management, exercise capacity (6-Minute Walk Test [6MWT]), and number of COPD exacerbations. Additional outcomes included the Patient Assessment of Chronic Illness Care (PACIC) mean item score (range 1-5); COPD symptoms measured by the COPD Assessment Test; forced expiratory volume at 1 second percentage predicted, measured by spirometry; smoking status by patient self-report; number of bed days due to COPD in past 4 weeks; adequate inhaler use (observed using checklist of steps); and COPD knowledge (4 questions). We assessed outpatient visits related to COPD, emergency department (ED) visits, and hospitalizations, both COPD related and not COPD related, by review of medical records. Additional outcomes not prespecified were concordance with international Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for COPD management and symptoms of depression measured with the Patient Health Questionnaire (PHQ). We used generalized linear mixed modeling to adjust for differences in baseline values and to account for clustering by clinic.

Results: We enrolled 192 of 282 patients determined to be eligible (68%), of whom 158 (82%) completed 9-month follow-up. Patients enrolled were representative of the target population with similar characteristics by study arm. Mean age was 61 years; 66% were male; 32% had less than a high school education; 44% reported an income of <$10 000/year; 15% were homeless or marginally housed; and 51% had a diagnostic code for tobacco use, 17% for alcohol abuse, and 29% for other substance use. Most (92%) reported a high level of COPD symptoms (GOLD classification B or D). There was no significant difference at 9 months between health coached and usual care arms for the primary outcome of improvement in QOL, either by total CRQ score (4.58 vs 4.43; adjusted difference = 0.14; 95% CI, −0.15 to 0.43) or CRQ dyspnea domain score (4.98 vs 4.78; adjusted difference = 0.26; 95% CI, −0.13 to 0.65). There were also no significant differences in the secondary outcomes of number of exacerbations, exercise capacity, or self-efficacy. Among other prespecified outcomes, we saw significant differences in favor of the health coached arm for quality of care and adequate inhaler use. At 9 months, patients in the health coached arm reported higher quality of care on the PACIC (adjusted difference in mean item score = 0.38; 95% CI, 0.07-0.68; P = .02) and were more likely to demonstrate adequate inhaler use (adjusted difference = 39.7%; 95% CI, 19.6-59.8; P < .001). None of the differences for the remaining prespecified outcomes were significantly different. Patients in the health coached arm were more likely to receive guideline-concordant treatment (adjusted difference = 14.6%; 95% CI, 3.3-25.9; P = .01) and were less likely to report symptoms of moderate to severe depression (adjusted difference = −18.9%; 95% CI, −33.1 to −4.8; P = .01) (both post hoc outcomes).

Conclusions: Using unlicensed health coaches to work with patients, primary care providers, and pulmonary specialists did not improve of QOL or exercise capacity or reduce the number of COPD exacerbations, the primary and secondary outcomes of the study. We did find evidence for improvement in quality of care, both as reported by patients and as seen in adherence to guidelines.

Limitations: Limitations of the study were that patients, rather than primary care providers or clinics, were randomized and the intervention was not blinded, which may have caused a halo effect whereby patients in the usual care arm may have benefited from the presence of health coaching, as clinicians were aware of coaching activities. These results should help inform expectations regarding the limitations and benefits of health coaching for patients with COPD. Results may be useful to health policy experts in assessing the potential value of reimbursement and incentives for health coaching-type activities for patients with chronic disease. Future studies could explore targeted versions of a model focusing on the positive outcomes noted in the current study.