Ciro

Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory condition with potentially major implications for the lives of those it affects. In the past decade, the identification of clinically relevant patient characteristics - 'treatable traits' (TTs) - has received wide support as an important means of improving care. These traits can be categorised into three domains: pulmonary, extra-pulmonary and behavioural. Many patients with COPD have multiple TTs in various combinations. For this reason, the successful application of a TT approach requires a thorough assessment of the patient's health status to elicit relevant TTs. Combined with the patient's preferences and priorities, these traits enable the formulation of an individualised treatment plan. Execution of this plan often requires interprofessional collaboration among relevant healthcare providers and case management. Although international consensus appears to exist concerning the benefits of providing care according to the TT concept, widespread implementation in care is slow. Although pulmonary rehabilitation programmes have adopted the concept by definition, it has yet to be applied widely in practice, especially in primary and secondary care. We have used the TT model to develop a comprehensive model of care that contains all three elements (assessment, treatment plan and execution) and that provides insight into considerations and decisions regarding where such care should be provided. This paper describes the process, results and challenges of our attempts to design and implement this integrated care concept.

IntroductionLearning-centred education is a paramount component of pulmonary rehabilitation. A variability in educational needs exists among patients with a chronic respiratory disease referred for pulmonary rehabilitation and their significant others. Healthcare professionals play a crucial role in meeting these needs by facilitating opportunities for learner-centred education. This study aimed to explore the perceptions of healthcare professionals involved in pulmonary rehabilitation regarding optimisation of patient education for people with a chronic respiratory disease referred for pulmonary rehabilitation and their significant others.MethodsFocus groups were conducted, which took place on-site at Ciro, a centre of expertise for patients with chronic organ failure, and online. Focus groups consisted of 1) an interprofessional team of healthcare professionals affiliated with Ciro; and 2) hospital-based healthcare professionals who refer patients to Ciro for pulmonary rehabilitation. Focus groups were audiotaped, transcribed verbatim and analysed thematically by two independent researchers.ResultsThree focus groups were held, involving 17 healthcare professionals representing various disciplines. Four main themes were identified: facilitators for optimal patient education, barriers for optimal patient education, involving significant others in patient education and healthcare professionals’ preferences for education.DiscussionTo enhance patient education in pulmonary rehabilitation, key recommendations include adopting personalised education, integrating e-health applications to complement face-to-face education and strengthening interprofessional collaboration for continuous and accessible education for both patients and their significant others.

BackgroundFrailty is common in old age and associated with decreased cognition, depression, and anxiety. Since transitioning between frailty states can offer targets for interventions, the aims of the current study were to assess the prevalence of frailty and changes over time as well as the impact of mental health, living environment (rural vs. urban) and sex on frailty transition.Methods683 participants ≥ 65 years were categorized into three frailty stages (robust, pre-frail, frail) according to the Fried frailty phenotype during two consecutive visits (mean assessment interval: 4 years). Aspects of mental health including anxiety and depression (Hospital Anxiety and Depression Scale, HADS) and cognition (mini-mental state examination, MMSE, and number connection test, NCT) were assessed for the purposes of this study.ResultsAt visit 1, 35% of participants were classified as robust and 64.1% as pre-frail. More than 40% of participants transitioned between frailty states between visits. For the analysis, frailty status was dichotomized into two categories: robust and pre-frail/frail. A mixed-effect logistic model indicated that the HADS depression subscale was significantly associated with the risk of being pre-frail/frail [odds ratio (OR): 1.28 (95% confidence interval (CI): 1.21–1.36), p < 0.001] and that participants from rural areas were less likely to be pre-frail/frail [OR: 0.57 (95% CI: 0.44–0.75), p = 0.001]. Similar findings were obtained with independent sex-specific models, whereas multivariate logistic regression revealed a positive association between a higher baseline HADS anxiety score and the risk of worsening frailty in females [OR: 1.12 (95% CI: 1.00-1.25), p = 0.05], but not in males.ConclusionsDepression and anxiety are two potentially treatable conditions contributing to frailty over time, with anxiety specifically affecting women. As frailty status can change from pre-frail to robust over time, recognizing pre-frailty is paramount to start interventions at this stage with the aim of improving frailty status.

<bold>Introduction:</bold> Many COPD patients referred for pulmonary rehabilitation (PR) have abnormal body composition. Exercise training and dietary counselling are expected to positively impact lean mass (LM) and fat mass (FM) in these patients. To date, a detailed analysis of the impact of PR on LM and FM is lacking. Therefore, this study assessed the effects of inpatient PR on body composition in patients with COPD. <bold>Methods:</bold> 2936 patients (52% women; age: 66 (60-72) years, BMI 25.8 (22.5-29.6) kg/m2, FEV1: (44 (32-61) %pred) who completed an 8-week inpatient PR program in Ciro were analysed. Patients were grouped by baseline BMI: underweight (UW) <18.5; normal weight (NW) 18.5-24.9, overweight (OW) 25-29.9, obese (OB) 30-34.9, severely obese 35-39.9 (sOB) or morbidly obese (mOB) >39.9 kg/m2) and baseline fat-free mass index (FFMI; age-, sex- and BMI-specific cut-offs were used; Franssen et al. JAMDA 2014). LM and FM were measured by DXA before and after PR. <bold>Results:</bold> Overall, in 47.6% of the patients the increase in FFMI exceeded the MCID (Jenkins et al. Pulmonology 2024) of 0.35 kg/m2. The largest median improvements in LM were found in UW, NW and OW (+1.6, +1.1 and +0.8 kg, respectively). Largest median reductions in FM were observed in OB, sOB and mOB (-2.0, -2.5, -3.2 kg, respectively), with preserved or even increased LM. Patients with low FFMI had a larger increase in LM within all BMI groups except for sOB and mOB when compared to normal FFMI. <bold>Conclusion:</bold> Pulmonary rehabilitation, including exercise training and nutritional counselling results in improvements in body composition in COPD patients, irrespective of baseline body weight or composition. <bold>Funding:</bold> Lung Foundation Netherlands (Grant #5.1.18.232).

ObjectivesThere are substantial barriers to initiate advance care planning (ACP) for persons with chronic-progressive disease in primary care settings. Some challenges may be disease-specific, such as communicating in case of cognitive impairment. This study assessed and compared the initiation of ACP in primary care with persons with dementia, Parkinson’s disease, cancer, organ failure and stroke.DesignLongitudinal study linking data from a database of Dutch general practices’ electronic health records with national administrative databases managed by Statistics Netherlands.Setting and participantsData from general practice records of 199 034 community-dwelling persons with chronic-progressive disease diagnosed between 2008 and 2016.Outcome measureIncidence rate ratio (IRR) of recorded ACP planning conversations per 1000 person-years in persons with a diagnosis of dementia, Parkinson’s disease, organ failure, cancer or stroke, compared with persons without the particular diagnosis. Poisson regression and competing risk analysis were performed, adjusted for age, gender, migration background, living situation, frailty index and income, also for disease subsamples.ResultsIn adjusted analyses, the rate of first ACP conversation for persons with organ failure was the lowest (IRR 0.70 (95% CI 0.68 to 0.73)). Persons with cancer had the highest rate (IRR 1.75 (95% CI 1.68 to 1.83)). Within the subsample of persons with organ failure, the subsample of persons with dementia and the subsample of stroke, a comorbid diagnosis of cancer increased the probability of ACP. Further, for those with organ failure or cancer, comorbid dementia decreased the probability of ACP.ConclusionsConsidering the complexity of initiating ACP for persons with organ failure or dementia, general practitioners should prioritise offering it to them and their family caregivers. Policy initiatives should stimulate the implementation of ACP for people with chronic-progressive disease.

Objectives: This study aimed to identify educational needs of people with COPD or asthma referred for pulmonary rehabilitation and their significant others. Methods: In this cross-sectional study, information needs were assessed by the Lung Information Needs Questionnaire. Learning styles were assessed with a multiple-choice question (visual, aural, read/write and kinaesthetic - multiple choices were possible). Psychological profiles were assessed by an instrument distinguishing four profiles: fighter, analyst, optimist or sensitive. Results: 121 patients (57% female; age: 65 ± 10years; 81% COPD) and 67 significant others (55% female; age: 61 ± 12years) were included. Patients and their significant others had a variety of information needs. Patients and their significant others mostly preferred the aural (39% and 49%, respectively) and read/write learning styles (31% and 36%, respectively) as unimodal learners. 49% of patients and 51% of significant others preferred more than one learning style. Most prevalent psychological profiles were optimist in patients (36%) and fighter in significant others (59%). Discussion: The identified variety in educational needs among people with COPD or asthma and their significant others underlines the importance of addressing this diversity of individual needs in education. Learners should have the opportunity to choose among a variety of topics and have access to multiple learning styles. Furthermore, educational interventions should consider to incorporate different communication strategies.

Exercise is safe and effective in the short-term following pulmonary embolism. To date, little is known about the long-term effects. The aim of the study was to investigate whether the effects of exercise-based rehabilitation are maintained 6 months after completion in patients with persistent dyspnea following pulmonary embolism when compared with usual care. A 2-center, randomized controlled trial compared 8 weeks of exercise-based rehabilitation with usual care. Patients were reassessed postintervention and 6 months later. Exercise capacity was measured with the incremental shuttle walk test (ISWT). Dyspnea was assessed with the Shortness of Breath Questionnaire, and health-related quality of life was assessed with disease-specific (Pulmonary Embolism Quality of Life Questionnaire) and generic questionnaires. In total, 159 of 211 randomized patients attended follow-up 6 months postintervention. The significant improvement on the ISWT in the rehabilitation group was maintained at the 6-month follow-up (96 m; SE: 15 m; 95% CI: 66, 127). There were no changes on the ISWT in the control group at either time point. From postintervention to 6×-month follow-up, the rehabilitation group had further improvements in dyspnea compared with the control group (-3 points; SE: 1.4; 95% CI:-6,-1; P= .02). Health-related quality of life improved in both groups although superior improvements were seen in the rehabilitation group. The improvement in exercise capacity after 8 weeks of exercise-based rehabilitation in patients with pulmonary embolism and persistent dyspnea was maintained at the 6-month follow-up, while no improvement was observed in the control group, highlighting the relevance of offering rehabilitation to these patients.

Objective Physical activity (PA), sleep, and sedentary time (SST) are important outcomes to monitor and to improve as part of patients’ asthma management. This study aimed to assess the number of measurement days needed to reliably measure PA and SST. Secondly, the influence of external factors on the reliability of measuring PA and SST was studied. Methods Adult patients with stable asthma were asked to wear a triaxial accelerometer for at least four days, with at least 22.5 h of wear time per day. The Intraclass Correlation Coefficients (ICCs) between different number of measurement days were used to determine reliability. Values ≥0.75 indicated good reliability. Results: Data from 452 patients were analyzed (63% women; age: 49 ± 16 years; FEV1: 87 ± 17% predicted). PA could reliably be measured with four valid measurement days (ICC 0.761). For SST, three days were needed (ICC 0.778). In summer and autumn, three days were needed to reliably measure PA, in winter four, in spring six. For SST, five days were needed in spring for good reliability, and two in all other seasons. Conclusion: Based on data from four valid days, PA and SST can reliably be measured with an accelerometer in patients with asthma. Seasonal influences are present, especially during spring. When measuring for four days, using only weekdays or three weekdays and one weekend day is recommended. The degree of asthma control, dyspnea or spirometric values did not influence the reliability.