Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

Background
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent
exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more
severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.
Objectives
To assess the effectiveness of any single intervention for COPD adapted or tailored their comorbidity(s) compared to any other intervention
for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life,
exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain and depression and anxiety .
To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the
management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of
the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality,
pain and depression and anxiety.
To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or
providing care to manage multimorbidities (qualitative data).
Search methods
We searched multiple databases including CENTRAL, MEDLINE, Embase, CINAHL, and the Cochrane Airways Trials Register to identify
relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was
conducted in January 2021.
Selection criteria
Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s)
compared to any other intervention or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities compared to usual care. We included qualitative studies or mixed
methods studies to identify themes.
Data collection and analysis
We used the standard Cochrane methods for analysis of the RCTs. We used Cochrane's Risk of Bias tool for the RCTs and the CASP checklist
of the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed methods studies,
but none were found. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The
primary outcome measures for this review were quality of life and exacerbations.
Main results
Quantitative studies
We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary
rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with
usual care or an active comparator (such as land-based exercise training). Durations of trials ranged from 4 to 52 weeks. Mean age of
participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD
and a specific comorbidity (including included cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and
musculoskeletal conditions), or with one or more comorbidities of any type.
Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to methodological quality of
included trials and imprecision of eJect estimates.
Intervention versus usual care
Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with pulmonary rehabilitation
compared to usual care at 52 weeks (MD -10.85, 95% CI -12.66 to -9.04; 1 study; 70participants, low certainty evidence). Pulmonary
rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.6;
1 study; 70 participants, moderate certainty evidence) and with a multi-component telehealth intervention at 52 weeks (MD -6.9, 95% CI
-9.35 to -4.45; moderate certainty). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions
on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management
compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants, very low certainty evidence).
For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent
interventions at 38 to 52 weeks (low certainty evidence). A multi-component intervention may result in fewer people being
admitted to hospital at 17 weeks, though there may be little to no difference in a telemonitoring intervention. There may be little to no
difference between intervention and usual care for mortality.
Intervention versus active comparator
We included one study comparing water-based and land-based exercise (30 participants). No evidence was identified for quality of life or
exacerbations.
There may be little to no difference between water and land-based exercise for 6MWD (MD 5 m, 95% CI -22 to 32, 38 participants, very low
certainty evidence).
Qualitative studies
One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long term conditions, and
researchers and health professionals who were involved in an RCT of telemonitoring equipment.
Several themes were identified including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use,
factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in health care utilisation.
We judged the qualitative evidence presented as very low certainty overall.
Authors' conclusions
Owing to paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were
unable to provide a robust synthesis of data. Pulmonary rehabilitation or multi-component interventions may improve quality of life and
functional status (6MWD), however, the evidence is too limited to make a robust conclusion. The key take-home message from this review
is the lack of data from RCTs on treatments for people living with COPD and comorbidities.
Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual
patient data are required to determine these effects.