Key points from the evidence

Community respiratory teams (CRTs)

1. An observational study⁵ compared the rate of COPD emergency admissions for people aged 65 years or older, before and after the implementation of a CRT in North West Glasgow. Over a 21-month period, a small reduction of 0.85 COPD emergency admissions per 1,000 population was attributable to the introduction of the CRT service. Given the relevant population of 26,021 people with COPD, this equated to approximately 13 fewer emergency admissions per year in North West Glasgow.

Hospital at home (H@H): admission avoidance and early supported discharge

2. A systematic review of reviews¹³ found that for patients with COPD who were cared for through H@H services there was no difference in risk of hospital readmission or death compared with inpatients with COPD.

Supported self-management and home based pulmonary rehabilitation

3. A Cochrane review of 52 randomised controlled trials⁹ (RCTs, n=21,086) found that multidisciplinary programmes, that included elements of self-management support, were associated with statistically significant improvements in health related quality of life (HRQoL), and reductions in respiratory hospital admissions and all-cause accident and emergency (A&E) attendance, among patients with COPD.

4. A systematic review and a systematic review with meta-analysis^26,27 found no consistent evidence of an effect of supported self-management on quality of life, hospital admissions or A&E attendance compared with usual care in primary care patients with COPD.

5. A meta-analysis¹⁰ (10 RCTs, n=1,716) within a health technology assessment (HTA) compared supported self-management within 6 weeks of hospital discharge with usual care in patients with COPD. While there were no statistically significant between-group differences in all-cause mortality or hospital admissions, there was a statistically significantly greater improvement in HRQoL in patients receiving supported self- management.

• A second meta-analysis within the HTA explored the impact of an ‘enhanced care’ self-management component. Enhanced care was associated with statistically significantly greater improvements in HRQoL after 3 months follow up and reductions in hospital admissions at 1 year follow up, compared with usual care in patients with COPD.

6. A Cochrane review²⁸ (26 RCTs, n=6,008) found that self-management (support not specified) was associated with statistically significantly greater improvements in HRQoL and reductions in respiratory hospital admissions and A&E attendance, compared with usual care in patients with COPD.

7. A systematic review of reviews and a meta-analysis¹¹ (15 RCTs, n=1,800), compared home based pulmonary rehabilitation with usual care or centre based pulmonary rehabilitation for patients with COPD:

• compared with usual care, home based pulmonary rehabilitation was associated with statistically significantly greater improvements in HRQoL and exercise capacity
• comparisons of home based and centre based pulmonary rehabilitation found no statistically significant differences in HRQoL or exercise capacity.

Supported self-management

8. In a systematic review of reviews²⁹ supported self-management was associated with statistically significantly greater improvements in HRQoL and reductions in hospitalisation rates, A&E attendance and unscheduled consultations, compared with usual care in patients with asthma.

9. A network meta-analysis³⁰ (105 RCTs, n=27,767) comparing intensity of support in self- management interventions for patients with asthma, found that more regularly or intensely supported self-management resulted in significant reductions in healthcare use by patients with asthma compared with usual care.

10. A qualitative study³⁷ (n=89) explored the views of patients with COPD on H@H:

• perceived benefits were access to home comforts, feeling independent, a perception of a quicker recovery, improved sleep, convenience for visitors and developing one to one relationships with healthcare professionals
• perceived barriers were fear of being alone when unwell, privacy concerns and concerns about relatives’ perceptions of home care.

11.Two systematic reviews of qualitative studies^38,39 explored patient perspectives and experiences of supported self-management:

• patients with COPD, asthma or both, described the value of education, psychological support, person centred care, a collaborative support relationship, trust, continuity of carer and easily accessible support
• patients with COPD described feeling empowered through acquiring knowledge and felt that psychological wellbeing, engaging with peers and increasing physical activity after supported self-management, were important.

12. In a qualitative study⁴⁰ (n=24) patients with COPD wanted more information about community pulmonary rehabilitation and described barriers to access, such as location and timing of classes. There were concerns about the safety of taking exercise and feeling inferior in a group setting.

13. A patient organisation submission from Asthma + Lung UK described how:

• people with lung conditions need digitals tools, access to information and advice to support self-management from the point of diagnosis
• there is increased strain on healthcare services because of the COVID-19 pandemic, which has impacted on self-management of respiratory conditions.

14. Evidence on the cost effectiveness of CRTs in Scotland is sparse. Based on patient level EQ-5D-5L data from the Glasgow pilot CRT service, admission avoidance H@H, supported self-management and early supported discharge are associated with improvements in patients’ average utility scores on discharge from the service. While there is no direct comparative evidence, and uncertainties remain around the per patient cost estimates for CRTs, based on findings from the literature and high level cost estimates by SHTG:

• supported self-management may be more expensive but more effective than usual care
• it is likely that, compared with inpatient care, early supported discharge and admission avoidance H@H provide similar benefits in terms of HRQoL, mortality and hospital readmission rates, and are cost saving.