Self management for patients with chronic obstructive pulmonary disease

Background

Symptoms of patients with COPD slowly worsen over the years. This leads to loss of well-being in these patients. In research, another word for well-being is health-related quality of life. Self management training teaches patients the skills and behaviours they need to successfully manage their disease. Self-management training is becoming more and more important in the treatment of COPD. However, debate on the most effective content is ongoing. Therefore, we reviewed the evidence on the effects of self management on health-related quality of life and on healthcare use in patients with COPD. The evidence is current to August 2011.

Study characteristics

In this review, we assessed 29 studies that evaluated the effects of self management. Patients in these studies were followed for two to 24 months. Twenty-three studies had a control group that received usual care. A total of 3189 patients participated in these studies. In six studies, different components of self management were compared on a head-to-head basis. Content and duration of the self management programmes were diverse.

Key results

Analysis of the studies revealed that self management training improved health-related quality of life in patients with COPD compared with usual care. Also, the number of patients with at least one hospital admission related to lung disease and other causes was reduced among those who participated in a self management intervention. These patients also experienced less shortness of breath. We found trials that compared different types of self management interventions versus each other. We had hoped that these trials would help us identify the most effective components of self management. However, all interventions were different, and we were unable to draw out the key themes.

The studies assessed in this review were diverse. Self management programmes differed in content and duration. Also, types of participants differed across studies. Therefore, no clear recommendations on the most effective content of self management training can be made at this time.

Authors' conclusions: 

Self management interventions in patients with COPD are associated with improved health-related quality of life as measured by the SGRQ, a reduction in respiratory-related and all cause hospital admissions, and improvement in dyspnoea as measured by the (m)MRC. No statistically significant differences were found in other outcome parameters. However, heterogeneity among interventions, study populations, follow-up time and outcome measures makes it difficult to formulate clear recommendations regarding the most effective form and content of self management in COPD.

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Background: 

Self management interventions help patients with chronic obstructive pulmonary disease (COPD) acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable patients to control their disease. Since the first update of this review in 2007, several studies have been published. The results of the second update are reported here.

Objectives: 

1. To evaluate whether self management interventions in COPD lead to improved health outcomes.

2. To evaluate whether self management interventions in COPD lead to reduced healthcare utilisation.

Search strategy: 

We searched the Cochrane Airways Group Specialised Register of trials (current to August 2011).

Selection criteria: 

Controlled trials (randomised and non-randomised) published after 1994, assessing the efficacy of self management interventions for individuals with COPD, were included. Interventions with fewer than two contact moments between study participants and healthcare providers were excluded.

Data collection and analysis: 

Two review authors independently assessed trial quality and extracted data. Investigators were contacted to ask for additional information. When appropriate, study results were pooled using a random-effects model. The primary outcomes of the review were health-related quality of life (HRQoL) and number of hospital admissions.

Main results: 

Twenty-nine studies were included. Twenty-three studies on 3189 participants compared self management versus usual care; six studies on 499 participants compared different components of self management on a head-to-head basis. Although we included non-randomised controlled clinical trials as well as RCTs in this review, we restricted the primary analysis to RCTs only and reported these trials in the abstract.

In the 23 studies with a usual care control group, follow-up time ranged from two to 24 months. The content of the interventions was diverse. A statistically relevant effect of self management on HRQoL was found (St George's Respiratory Questionnaire (SGRQ) total score, mean difference (MD) -3.51, 95% confidence interval (CI) -5.37 to -1.65, 10 studies, 1413 participants, moderate-quality evidence). Self management also led to a lower probability of respiratory-related hospitalisations (odds ratio (OR) 0.57, 95% CI 0.43 to 0.75, nine studies, 1749 participants, moderate-quality evidence) and all cause hospitalisations (OR 0.60; 95% CI 0.40 to 0.89, 6 studies, 1365 participants, moderate-quality evidence). Over one year of follow-up, eight (95% CI 5 to 14) participants with a high baseline risk of respiratory-related hospital admission needed to be treated to prevent one participant with at least one hospital admission, and 20 (95% CI 15 to 35) participants with a low baseline risk of hospitalisation needed to be treated to prevent one participant with at least one respiratory-related hospital admission.

No statistically significant effect of self management on mortality (OR 0.79, 95% CI 0.58 to 1.07, 8 studies, 2134 participants, very low-quality evidence) was detected. Also, dyspnoea measured by the (modified) Medical Research Council Scale ((m)MRC) was reduced in individuals who participated in self management (MD -0.83, 95% CI -1.36 to -0.30, 3 studies, 119 participants, low-quality evidence). The difference in exercise capacity as measured by the six-minute walking test was not statistically significant (MD 33.69 m, 95% CI -9.12 to 76.50, 6 studies, 570 participants, very low-quality evidence). Subgroup analyses depending on the use of an exercise programme as part of the intervention revealed no statistically significant differences between studies with and without exercise programmes in our primary outcomes of HRQoL and respiratory-related hospital admissions.

We were unable to pool head-to-head trials because of heterogeneity among interventions and controls; thus results are presented narratively within the review.

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