Digital Follow-up Program for People with Chronic Obstructive Pulmonary Disease in Primary Healthcare
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: Guided self-determination (GSD) follow-up approach by primary care nurses..
- Who it may be relevant to
- Registry conditions: COPD Chronic Obstructive Pulmonary Disease. Basic parameters: 35 years — 80 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- Norway
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
Unsure about the terms? Read our patient guide →
Official title
A Guided Self-determination Follow-up Program Delivered Within a Digital Platform for People with Chronic Obstructive Pulmonary Disease in Primary Care
Overview
Chronic Obstructive Pulmonary Disease (COPD), characterized by non-reversible airflow obstruction, contributes to high mortality and morbidity rates worldwide, including Norway. Individuals with COPD experience symptoms and complications that impede daily activities and diminish their quality of life. COPD places a growing burden on healthcare systems presently and in the future. Interventions to empower individuals to self-manage their health effectively are needed to help the challenges of living with COPD, and work towards a sustainable healthcare system. As part of the broader healthcare policy agenda, this project aligns with the increasing emphasis on digital homebased primary healthcare. The intervention in this study will combine digital homebased care and guided self-determination follow-ups (GSD) within a general practice setting. This project consists of 1) explore the feasibility of a COPD specific GSD counselling program delivered within a digital platform in primary care, 2) explore patients' and nurses' experiences applying the program, 3) examine the treatment fidelity of the intervention amongst healthcare professionals. This project is a pilot cluster-randomized controlled trial (RCT), including individuals diagnosed with COPD, conducted in primary healthcare settings, and assessment of feasibility and uncertainties before conducting a later full-scale cluster-RCT. The intervention draws upon the Medical Research Council's revised guidelines for developing complex intervention studies, focusing on the initial phases of intervention development and pilot testing. Primary care clinics are randomly assigned into either an intervention- or a control group. The intervention consists of the GSD counselling program with follow-up within a digital platform. The control group provide regular care. The project will include both qualitative (individual semi-structured interviews), and quantitative data (questionnaires and clinical data). In conclusion, this project explores an innovative intervention offering personalized strategies for COPD management in primary care clinic, by containing a digitalized homebased care program and follow-ups. The study aims to improve the daily living for people with COPD, while contributing to the future sustainability of healthcare systems.
Interventions
- Behavioral Guided self-determination (GSD) follow-up approach by primary care nurses.
The GSD counseling program consists of four scheduled consultations with a nurse and a digital platform with tools to help people better manage their health. The consultations will be facilitated by using reflection sheets to stimulate written reflection in the context of GSD.
Primary outcome measures
- Medical journal [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Qualitative data [Time frame: 6 - 18 months from baseline]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
- Questionnaire [Time frame: Baseline, and 3, 6, 9 and 12 months]
Eligibility criteria
Inclusion criteria
- Diagnosed with COPD living at home
- Post-bronchodilator forced expiratory volume 1 s (FEV1) to forced vital capacity (FVC) below lower limit of normality
Exclusion criteria
- Severe somatic disease
- Severe psychiatric diagnosis
- Not able to provide informed consent
- Do not write, speak or understand Norwegian
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Open label
- Primary purpose
- Treatment
Study locations
Norway · 1 center
- Western Norway University of Applied Sciences — Bergen
Publications
- Kolltveit BH, Graue M, Borge CR, Frisk B. Patients' experiences with participating in a team-based person-centred intervention for patients at risk of or diagnosed with COPD in general practice. Pilot Feasibility Stud. 2023 Sep 25;9(1):164. doi: 10.1186/s40814-023-01398-9. PMID 37749601
- Kvidaland HK, Iversen MM, Frisk B, Richards DA, Lomborg K, Borge CR, Kolltveit BH. Recruitment for a digitally based follow-up program for people with chronic obstructive pulmonary disease: a pilot cluster randomized controlled trial. Pilot Feasibility Stud. 2026 May 9;12(1):91. doi: 10.1186/s40814-026-01832-8. PMID 42106871
Identifiers
NCT: NCT06401512 · 656382