***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Background Chronic obstructive pulmonary disease ( COPD ) is a complex condition with pulmonary and extra-pulmonary manifestations . This study describes the heterogeneity of COPD in a large and well characterised and controlled COPD cohort ( ECLIPSE ) . Methods We studied 2164 clinical ly stable COPD patients , 337 smokers with normal lung function and 245 never smokers . In these individuals , we measured clinical parameters , nutritional status , spirometry , exercise tolerance , and amount of emphysema by computed tomography . Results COPD patients were slightly older than controls and had more pack years of smoking than smokers with normal lung function . Co-morbidities were more prevalent in COPD patients than in controls , and occurred to the same extent irrespective of the GOLD stage . The severity of airflow limitation in COPD patients was poorly related to the degree of breathlessness , health status , presence of co-morbidity , exercise capacity and number of exacerbations reported in the year before the study . The distribution of these variables within each GOLD stage was wide . Even in subjects with severe airflow obstruction , a substantial proportion did not report symptoms , exacerbations or exercise limitation . The amount of emphysema increased with GOLD severity . The prevalence of bronchiectasis was low ( 4 % ) but also increased with GOLD stage . Some gender differences were also identified . Conclusions The clinical manifestations of COPD are highly variable and the degree of airflow limitation does not capture the heterogeneity of the disease Exacerbations are an important cause of morbidity and mortality in COPD . We assessed treatment initiation and health care use at exacerbation in patients receiving a self-management education program including an action plan . COPD patients were r and omly assigned to  usual care or to a  comprehensive self-management program “ Living Well with COPD ” including a written action plan and case manager support , and were followed-up for 12 months . Patients in the usual care were managed by their respective practitioners . Patients in the self-management program received , as part of a written action plan , a prescription of antibiotics and prednisone for self-initiation in case of aggravation of 2 or more symptoms ( dyspnea , sputum volume , sputum purulence ) for at least 24 hours , and they had the support of a case-manager for reinforcement and monthly telephone follow-ups . At 12 months , 166 patients presented with at least one exacerbation . Exacerbations ( 606 ) were confirmed by aggravation of at least one symptom ; 403 ( 67.6 % ) presented 2 or more . Antibiotics were used in 61.6 % of exacerbations and prednisone in 47.9 % . In exacerbations presenting aggravation of 2 or more symptoms ,  antibiotics  and prednisone were used together more often in the action plan than in the usual care group ( 54.4 % vs. 34.8 % , p < 0.001 ) . In the action plan , compared to the usual care group , 17.2 % vs. 36.3 % exacerbations result ed in a hospitalization ( p < 0.001 ) . Self-management with the successful use of an action plan for acute exacerbation of COPD holds promise for reducing health care use Background Exacerbations affect morbidity in chronic obstructive pulmonary disease ( COPD ) . We sought to evaluate the association between exacerbation frequency and spirometric and health status changes over time using data from a large , long-term trial . Methods This retrospective analysis of data from the 4-year UPLIFT ® ( Underst and ing Potential Long-term Impacts on Function with Tiotropium ) trial compared tiotropium with placebo . Annualized rates of decline and estimated mean differences at each time point were analyzed using a mixed-effects model according to subgroups based on exacerbation frequency ( events per patient-year : 0 , > 0–1 , > 1–2 , and > 2 ) . Spirometry and the St George ’s Respiratory Question naire ( SGRQ ) were performed at baseline and every 6 months ( also at one month for spirometry ) . Results In total , 5992 patients ( mean age 65 years , 75 % male ) were r and omized .  Higher exacerbation frequency was associated with lower baseline postbronchodilator forced expiratory volume in one second ( FEV1 ) ( 1.40 , 1.36 , 1.26 , and 1.14 L ) and worsening SGRQ scores ( 43.7 , 44.1 , 47.8 , and 52.4 units ) . Corresponding rates of decline in postbronchodilator FEV1 ( mL/year ) were 40 , 41 , 43 , and 48 ( control ) , and 34 , 38 , 48 , and 49 ( tiotropium ) . Values for postbronchodilator forced vital capacity decline ( mL/year ) were 45 , 56 , 74 , and 83 ( control ) , and 43 , 57 , 83 , and 95 ( tiotropium ) . The rates of worsening in total SGRQ score ( units/year ) were 0.72 , 1.16 , 1.44 , and 1.99 ( control ) , and 0.38 , 1.29 , 1.68 , and 2.86 ( tiotropium ) . The proportion of patients who died ( intention-to-treat analysis until four years [ 1440 days ] ) for the entire cohort increased with increasing frequency of hospitalized exacerbations . Conclusion Increasing frequency of exacerbations worsens the rate of decline in lung function and health-related quality of life in patients with COPD . Increasing rates of hospitalized exacerbations are associated with increasing risk of death BACKGROUND New care modes in primary care may affect patients ' experienced continuity of care .  AIM To analyse whether experienced continuity for patients with chronic obstructive pulmonary disease ( COPD ) changes after different care modes are introduced , and to analyse the relationship between continuity of care and patients ' quality of life . DESIGN AND SETTING R and omised controlled trial with 2-year follow-up in general practice in the Netherl and s. METHOD A total of 180 patients with COPD were r and omly assigned to three different care modes : self-management , regular monitoring by a practice nurse , and care provided by the GP at the patient 's own initiative ( usual care ) . Experienced continuity of care as personal continuity ( proportion of visits with patient 's own GP ) and team continuity ( continuity by the primary healthcare team ) was measured using a self-administered patient question naire . Quality of life was measured using the Chronic Respiratory Question naire . RESULTS Of the final sample ( n = 148 ) , those patients receiving usual care experienced the highest personal continuity , although the chance of not contacting any care provider was also highest in this group ( 29 % versus 2 % receiving self-management , and 5 % receiving regular monitoring ) . There were no differences in experienced team continuity in the three care modes . No relationship was found between continuity and changes in quality of life . CONCLUSION Although personal continuity decreases when new care modes are introduced , no evidence that this affects patients ' experienced team continuity or patients ' quality of life was found . Patients still experienced smooth , ongoing care , and considered care to be connected . Overall , no evidence was found indicating that the introduction of new care modes in primary care for patients with COPD should be discouraged Chronic obstructive pulmonary disease ( COPD ) is disabling , with symptoms such as chronic cough , phlegm , wheezing , shortness of breath and increased infections of the respiratory passage . The aim was to examine the effects of a structured educational intervention programme at a nurse-led primary health care clinic ( PHCC ) on quality of life ( QoL ) , knowledge about COPD and smoking cessation in patients with COPD . This study had an experimental design in which 52 patients with COPD from a Swedish primary care setting were r and omized into two groups ( intervention or control ) . Both groups received st and ard care but patients in the intervention group were also offered two visits to a nurse specialized in COPD care . The purpose of the visits was to increase the patients ' self-care ability and their knowledge about COPD . The study was approved by the local Research Ethics Committee . Data were collected using two question naires , one pertaining to knowledge about COPD and smoking habits and St. George 's Respiratory Question naire , addressing how QoL was affected by the patients ' respiratory symptoms . The intervention and control groups answered both question naires on their first and last visits to the PHCC . A statistically significant increase was noted in the intervention group on QoL , the number of patients who stopped smoking and patients ' knowledge about COPD at the follow-up , 3 - 5 months after intervention . However , a confounding factor may have been that one of the research ers ( Eva Osterlund Efr aims son ) , as a nurse in the PHCC , performed the intervention . This implies that patients were in a dependent relationship which may have affected the responses in a favourable direction . Our findings show that conventional care alone did not have an effect on patients ' QoL and smoking habits . Instead , the evidence suggests that a structured programme with self-care education is needed to motivate patients for life-style changes Objectives : To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease ( AE COPD ) . Design : R and omised controlled trial . Setting : Community and hospital care in west London . Participants : 122 patients with COPD . Intervention : A care package incorporating initial pulmonary rehabilitation and self-management education , provision of a written , personalised COPD action plan , monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years . Main outcome measure : Hospital readmission rate . Secondary outcomes : Unscheduled primary care consultations and quality of life . Results : There were no differences in hospital admission rates or in exacerbation rates between the two groups . Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics , and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves . 12 patients in the control group died during the 2 year period , eight as a result of COPD , compared with six patients in the intervention group , of whom one died from COPD . This is a significant difference . When the numbers were adjusted to reflect the numbers still alive at 2 years , in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner ( GP ) and in the control group , 280 contacts . The number needed to treat was 0.558—ie , for every one COPD patient receiving the intervention and self-management advice , there were 1.79 fewer unscheduled contacts with the GP . Conclusions : An intermediate care package incorporating pulmonary rehabilitation , self-management education and the receipt of a written COPD action plan , together with regular nurse contact , is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate Background The effects of written action plans on recovery from exacerbations of chronic obstructive pulmonary disease ( COPD ) have not been well studied . The aims of this study were to assess the effects of adherence to a written action plan on exacerbation recovery time and unscheduled healthcare utilisation and to explore factors associated with action plan adherence . Methods This was a 1-year prospect i ve cohort study embedded in a r and omised controlled trial . Exacerbation data were recorded for 252 patients with COPD who received a  written action plan for prompt treatment of exacerbations with the instructions to initiate st and ing prescriptions for both antibiotics and prednisone within 3 days of exacerbation onset . Following the instructions was defined as adherence to the action plan . Results From the 288 exacerbations reported by 143 patients , start date s of antibiotics or prednisone were provided in 217 exacerbations reported by 119 patients ( 53.8 % male , mean age 65.4 years , post-bronchodilator forced expiratory volume in 1 s ( FEV1 ) 43.9 % predicted ) . In 40.1 % of exacerbations , patients adhered to their written action plan . Adherence reduced exacerbation recovery time with statistical ( p=0.0001 ) and clinical ( −5.8 days ) significance , but did not affect unscheduled healthcare utilisation ( OR 0.94 , 95 % CI 0.49 to 1.83 ) . Factors associated with an increased likelihood of adherence were influenza vaccination , cardiac comorbidity , younger age and lower FEV1 as percentage predicted . Conclusions This study shows that adherence to a written action plan is associated with a reduction in exacerbation recovery time by prompt treatment . Knowing the factors that are associated with proper and prompt utilisation of an action plan permits healthcare professionals to better focus their self-management support on appropriate patients Objective To determine whether supported self management in chronic obstructive pulmonary disease ( COPD ) can reduce hospital readmissions in the United Kingdom . Design R and omised controlled trial . Setting Community based intervention in the west of Scotl and . Participants Patients admitted to hospital with acute exacerbation of COPD . Intervention Participants in the intervention group were trained to detect and treat exacerbations promptly , with ongoing support for 12 months . Main outcome measures The primary outcome was hospital readmissions and deaths due to COPD assessed by record linkage of Scottish Morbidity Records ; health related quality of life measures were secondary outcomes . Results 464 patients were r and omised , stratified by age , sex , per cent predicted forced expiratory volume in 1 second , recent pulmonary reh 
    Output:
    
Low- quality evidence showed no benefit for psychological morbidity as measured with the Hospital Anxiety and Depression Scale ( HADS ) .
Use of COPD exacerbation action plans with a single short educational component along with ongoing support directed at use of the action plan , but without a comprehensive self-management programme , reduces in-hospital healthcare utilisation and increases treatment of COPD exacerbations with corticosteroids and antibiotics .
Use of COPD action plans in this context is unlikely to increase or decrease mortality .