Using Phone-Based Peer Health Coaching to Improve Home Oxygen Use and Health in Patients with Chronic Obstructive Pulmonary Disease – the PELICAN Study [Internet]

Excerpt

Background: Underuse and overuse of long-term oxygen therapy (LTOT) at home is common in patients with chronic obstructive pulmonary disease (COPD). The need for evidence-based interventions to promote appropriate use of LTOT in this population was identified as a critical knowledge gap in multi-stakeholder COPD workshops.

Objectives: (1) Engage patients with COPD prescribed home oxygen and their caregivers to identify gaps in knowledge, self-management skills, and outcomes of importance to patients. (2) Pilot test study procedures for the PELICAN trial. (3) Evaluate the comparative effectiveness of proactive vs reactive PELICAN interventions vs usual care on adherence to oxygen (primary outcome) and multiple patient-centered outcomes in a multicenter pragmatic clinical trial of patients with COPD prescribed LTOT 24 hours per day, 7 days per week. (4) Examine heterogeneity of treatment effects of proactive and reactive PELICAN interventions in patient subgroups. (5) Understand barriers and facilitators of successfully implementing the PELICAN proactive intervention.

Methods: Patients with COPD prescribed LTOT were randomly allocated 1:1:1 to proactive coaching (patient-directed educational materials and phone-based peer coaching delivered during 5 sessions over 60 days); reactive coaching (same educational materials, with support from peer coaches offered only in response to inbound calls by participants); or usual care (more limited set of patient-directed educational materials). Research coordinators masked to intervention assignment conducted follow-up visits by phone over the course of 90 days. The primary outcome was adherence to LTOT, defined as mean use of ≥17.7 hours per day over the 0- to 60-day interval (yes vs no), after accounting for potential confounders in multivariable logistic regression models. We calculated LTOT use using oxygen concentrator meter readings and number of compressed oxygen tanks used, as recorded by participants on worksheets developed for the study. The mean level of LTOT use in participants who had improved survival in the previous clinical trial of LTOT was 17.7 hours per day; we therefore used this cut point to define adherence to LTOT in the current study. Adherence to LTOT in the reactive vs usual care and in proactive vs usual care groups over 60 days (0-60 days after randomization) were prespecified as coprimary comparisons (using a 2-sided P < .025 and a 97.5% CI to identify a significant difference for each comparison). Secondary analyses employed a 2-sided P < .05 and a 95% CI to identify significant differences and included comparisons of adherence to LTOT at other time intervals (0-30, 30-60, and 60-90 days) and LTOT use as a continuous outcome. Secondary outcomes included Patient-Reported Outcomes Measurement Information System measures of physical, emotional, and social health, and patient-reported acute care utilization.

Results: Of 444 participants (142 usual care, 148 reactive, 154 proactive), the proportion adherent to LTOT (mean use ≥17.7 hours/day) over the 0- to 60-day interval was 74% in the usual care, 84% in the reactive coaching, and 70% in the proactive coaching groups. Reactive coaching (adjusted odds ratio [OR] for adherence to LTOT vs usual care: 1.77; 97.5% CI, 0.80-3.90; P = .10) and proactive coaching (adjusted OR for adherence to LTOT vs usual care = 0.70; 97.5% CI, 0.34-1.46; P = .28) groups did not significantly differ in the odds of adherence to LTOT in the 0- to 60-day interval compared with the usual care group. We observed similar findings when we compared LTOT use as a continuous outcome (secondary analyses). However, proactive coaching significantly reduced the odds of adherence to LTOT compared with the reactive coaching (adjusted OR for adherence to LTOT = 0.40; 95% CI, 0.20-0.79; P = .008; secondary analyses). In addition, proactive coaching significantly reduced depressive symptoms compared with both usual care (adjusted difference in T score: −3.2; 95% CI, −5.1 to −1.3; P < .01; secondary outcome) and with reactive coaching (adjusted difference in T score: −2.5; 95% CI, −4.4 to −0.6; P < .01; secondary outcome), and reduced sleep disturbance compared with usual care (adjusted difference in T score: −2.0; 95% CI, −3.9 to −0.1; P = .04; secondary outcome) in the 0- to 60-day interval. We did not find a significant difference in acute care utilization among the study groups.

Conclusions: Proactive or reactive peer coaching did not significantly improve adherence to LTOT compared with usual care. The potential for proactive peer coaching as a strategy to promote improvements in depressive symptoms and sleep disturbance requires further study.

Limitations and Subpopulation Considerations: Missing oxygen use data (27% of participants) and the risk of nonsystematic and systematic reporting errors for oxygen use are potential limitations. We did not observe significant evidence of heterogeneity of treatment effects on oxygen use.