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Include nurse-led CBT in routine COPD clinical care pathways

CBT intervention by respiratory nurses was more clinically and cost-effective than leaflets alone

Louise Prime

Tuesday, 27 November 2018

Cognitive behavioural therapy (CBT) delivered by respiratory nurses is a clinically and cost-effective treatment for anxiety in patients with chronic obstructive pulmonary disease (COPD) compared with self-help leaflets, research* led from the RVI Hospital in Newcastle upon Tyne has shown. The team behind the study, published in ERJ Open Research, recommended that CBT intervention should be incorporated into routine clinical care pathways because it significantly lowered hospital admissions and attendance at emergency departments, as well as patients’ anxiety scores.

The researchers randomised 279 participants aged 41-88 years (mean 66 years) with COPD to either CBT or self-help leaflets. CBT was delivered by four respiratory nurses trained in CBT – two of whom had completed a postgraduate diploma in CBT, while the other two did three days’ CBT training – and comprised two to four fortnightly sessions lasting about 30-minutes, done at home or in clinic, using cognitive and behavioural techniques to reduce symptoms of anxiety. All patients also had standard medical care: spirometry, medical review, pharmacological treatment (such as respiratory medication, antidepressants and anxiolytics) and pulmonary rehabilitation if eligible.

The research team assessed patients’ anxiety, depression and quality of life at baseline and again at three, six and 12 months. The primary outcome for anxiety was the change in the group mean Hospital Anxiety and Depression Scale – Anxiety Subscale at three months from baseline. Secondary outcomes included the change in group mean HADS-Anxiety Subscale at six and 12 months from baseline; and group mean change in score on the generic quality of life questionnaire EuroQol-5D (EQ-5D) 3L at three, six and 12 months from baseline.

At baseline, all participants had scored at least 8 on the HADS-Anxiety Subscale, with a mean of 12.3 for the CBT group and 12.0 for the leaflets group; scores of 8-10 are considered to show mild symptoms, 11-14 indicate moderate symptoms, and scores of more than 15 severe symptoms.

At three-month follow-up, the CBT group was superior to the leaflets group. The group mean change in HADS-Anxiety score from baseline was 3.4 for the CBT group compared with 1.88 in the leaflet group – a mean difference between groups of 1.52. Patients randomised to CBT had fewer hospital admissions and fewer emergency department attendances (0.6 vs 1.01 and 0.37 vs 1.01, respectively).

The study authors calculated that the CBT intervention initially cost £175 more per patient (including staff training, delivery and supervision time) than the self-help leaflets. However, this was more than offset by lower subsequent costs of respiratory hospital admissions compared with the leaflet group (mean saving of £1,088 per patient) and emergency department attendances (mean saving of £63 per patient). The mean overall cost saving between groups was £977.

They noted that their results for EQ-5D 3L showed that both groups experienced an increase in quality-adjusted life-years (QALYs); however, the CBT arm gained more QALYs and was the most effective, with an average mean difference of 0.079. They pointed out: “Thus, the CBT intervention was less expensive and more effective than self-help leaflets alone.”

They concluded: “A brief CBT intervention, uniquely delivered by respiratory nurses, was clinically effective at reducing anxiety symptoms and was cost-effective. Costs were reduced by lower resource use with lower hospital admissions and a reduction in emergency department attendances. Respiratory nurses with dual respiratory and CBT skills can address common comorbid symptoms of anxiety that were previously undertreated.

“CBT should be incorporated into routine clinical care pathways.”


* Heslop-Marshall K, Baker C, Carrick-Sen D, et al. Randomised controlled trial of cognitive behavioural therapy in COPD. ERJ Open Res 2018; 4: 00094-2018.

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