The IMPROVE Trial
by Elaine Bevan-Smith and Lucy Speakman
ARNS committee members Elaine Bevan-Smith and Lucy Speakman attended a conference recently to hear the results of the IMPROVE trial. This trial looked at using pulmonary rehabilitation (PR) volunteers, known as ‘PR buddies’ to try and improve uptake and completion of PR programmes. This trial followed an initial feasibility study, which successfully demonstrated the intervention had potential (1).
Poor completion of PR is well documented, with only a 40% completion rate, 35% of patients dropping out in-between referral and first assessment. However, most people who complete a programme are very enthusiastic about the benefits of PR, raising the question of whether their enthusiasm could be used to improve uptake amongst newly referred patients. The greatest number of PR referrals come from primary care, where GPs may not be good at referral or have the time to spend persuading the patient of the benefits of PR.
The IMPROVE trial was a multi-centre NIHR funded randomised controlled trial with an open cluster-based design. PR sites across the UK were recruited and randomly allocated to either the control group, to deliver usual care, or the intervention group, where patient volunteers were used to support new patients who were referred to PR. The aim was to increase uptake and completion of PR testing the effectiveness of the buddy system to determine if it could be implemented across all PR sites. The primary outcome was the rate (%) of PR uptake and completion at study sites rather than numbers in individual patients.
‘Buddies’ were recruited from patients with COPD who had completed PR. Potential recruits went through an application and interview process with a DBS check. They were given comprehensive training over 3 days which included activities such as role play. Buddies initially received training in communication skills, behaviour change techniques, boundary setting and confidentiality. All were given work phones for the trial. Patients in the intervention sites were allocated to a buddy who helped the person overcome obstacles to PR and to change their behaviour boosting their self-belief. The buddies were there for support only and were not responsible for the patient’s attendance at PR.
Thirty-one PR sites recruited with 15 control sites and 14 experiential sites, 2 sites withdrew. The PR team at each site received 2.5 days training and then were required to recruit, support and train 8 PR buddies.
The trial team are awaiting the final quantitative data which will show definitively whether PR buddies increase uptake and completion of PR including an economic evaluation. Those results will be available in mid- November. However, we were able to hear about the process evaluation which examined implementation of the IMPROVE study by sites to explore anything that might have affected the trial outcome. This part of the study added an additional qualitative element to the trial. A process evaluation explores elements such as fidelity, adaptation, contextual factors, barriers and facilitators of intervention delivery. In a real-world context this qualitative data we felt was very useful and practical for PR teams who are looking to develop similar service designs. The process evaluation demonstrated that the implementation of the IMPROVE protocol had been faithfully delivered.
Data was collected about the experiences of all participants, both patients and clinicians. All patients completed an end of study questionnaire and 20 were interviewed across 11 sites. The buddies themselves found the experience rewarding, gaining some personal benefits including a reduction in isolation and boosting in confidence. There were mixed views from patients about the stranger status of the buddies, but most patients welcomed the support of the buddies. The experience of the site staff was generally that the recruitment of buddies was difficult. The reasons for this, interestingly, were the same barriers for patients not taking up PR itself.
Staff experiences:
- Concerns initially about the extra work involved in recruiting and training PR buddies. Teams were busy already, so this added to workload.
- Training manuals issued to clinical teams were perceived as being very helpful.
- It gave staff pleasure to see the patient volunteers.
- Staff felt it was rewarding to make the service more patient focussed
- Staff felt it was a good experience.
- Input was needed to Keep buddies motivated to take the next patient.
We look forward to the quantitative results of the IMPROVE with much anticipation and interest. Any intervention which demonstrates increased completion of PR is highly valued and we congratulate the researchers and participating PR sites for trying to find a solution to this very frustrating problem.
- White P, Gilworth G, Lewin S, Hogg L, Tuffnell R, Taylor SJ, Hopkinson NS, Hart N, Singh SJ, Wright AJ. Improving uptake and completion of pulmonary rehabilitation in COPD with lay health workers: feasibility of a clinical trial. International journal of chronic obstructive pulmonary disease. 2019 Mar 12:631-43.
Lucy Speakman
As a Respiratory Nurse from Oxford Community Trust, my colleague Chris Swindale (physio) and I attended the IMPROVE conference with particular an interest as we were one of the control sites in the study. Chris was the Principal Investigator (PI) and as this was his first role as PI, he was somewhat disappointed that despite the training and need to select, consent and recruit patients to the study it was “business as usual” at our PR classes. I consented patients for the study so was blinded (as to whether we were a control or buddy sight) in order not to sway patients when deciding whether to take part. The day offered excellent insight into the clear benefits of the scheme, hearing directly from a buddy it was clear that being able to ‘give back’ was an affirming aspect of the role for the gentleman sharing his experience. When life is blighted by COPD, these opportunities are few and far between. The team from KCL and Leeds University put together excellent resources to support implementation of the buddy program which we hope will be made available to share as part of their published findings.