2019年10月8日出版的《美国医学会杂志》公布了美国约翰霍普金斯医学院Hanan Aboumatar小组的最新成果，他们分析了由医院发起的结合过渡期护理和长期自我管理支持的项目对慢性阻塞性肺病（COPD）住院患者预后的影响。

2015年3月至2016年5月，研究组在美国马里兰州巴尔的摩进行了一项单点随机临床试验，共招募了240名COPD住院患者，将其随机分组，其中干预组120名，接受为期3个月的综合护理项目，由经过特殊训练的护士采用标准化工具来帮助患者及其家属进行COPD的长期自我管理；常规护理组120名，仅出院后30天内进行过渡性支持，以增强其依从性。采用圣乔治呼吸问卷（SGRQ）对患者的健康相关生活质量进行评估，0-100分，分数越高生活质量越差。

共有203例（85%）参与者完成了试验及随访。出院时，干预组的基线SGRQ评分为62.3分，常规护理组为63.6分。6个月后，干预组SGRQ评分增加了2.81分，常规护理组减少了2.69分。干预组人均COPD相关急性治疗事件（再住院或急诊就诊）为1.40例，常规护理组为0.72例，差异有统计学意义。研究期间，共有15例参与者死亡，其中干预组8例，常规护理组7例；339例次患者再次住院，其中干预组202例次，常规护理组137例次。

总之，在这项针对COPD住院患者的临床试验中，结合了过渡期护理和长期自我管理的3个月综合护理项目增加了COPD的再住院率和急诊就诊率，且生活质量并未显著提升，临床实践中应认真权衡是否实施该计划。

据悉，因COPD加重而住院的患者往往有较高的再住院率，且生活质量降低。

附：英文原文

Title: Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

Author: Hanan Aboumatar, Mohammad Naqibuddin, Suna Chung, Hina Chaudhry, Samuel W. Kim, Jamia Saunders, Lee Bone, Ayse P. Gurses, Amy Knowlton, Peter Pronovost, Nirupama Putcha, Cynthia Rand, Debra Roter, Carol Sylvester, Carol Thompson, Jennifer L. Wolff, Judith Hibbard, Robert A. Wise

Issue&Volume: Vol 322 No 14

Abstract: 

Importance  Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life.

Objective  To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes.

Design, Setting, and Participants  Single-site randomized clinical trial conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016.

Interventions  The intervention (n = 120) involved a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by nurses with special training on supporting patients with COPD using standardized tools. Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care.

Main Outcomes and Measures  The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants’ health-related quality of life measured by the St George’s Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful).

Results  Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; 61.7% women), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 62.3 (18.8) in the intervention group and 63.6 (17.4) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 1.40 (95% CI, 1.01-1.79) in the intervention group vs 0.72 (95% CI, 0.45-0.97) in the usual care group (difference, 0.68 [95% CI, 0.22-1.15]; P = .004). The mean change in participants’ SGRQ total score at 6 months was 2.81 in the intervention group and −2.69 in the usual care group (adjusted difference, 5.18 [95% CI, −2.15 to 12.51]; P = .11). During the study period, there were 15 deaths (intervention: 8; usual care: 7) and 339 hospitalizations (intervention: 202; usual care: 137).

Conclusions and Relevance  In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding.

DOI: 10.1001/jama.2019.11982

Source: https://jamanetwork.com/journals/jama/article-abstract/2752467