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Review
, 2014 (3), CD002990

Self Management for Patients With Chronic Obstructive Pulmonary Disease

Affiliations
Review

Self Management for Patients With Chronic Obstructive Pulmonary Disease

Marlies Zwerink et al. Cochrane Database Syst Rev.

Abstract

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 methods: 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 hospitalisation (odds ratio (OR) 0.57, 95% CI 0.43 to 0.75, nine studies, 1749 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 all-cause hospitalisation (OR 0.77, 95% CI 0.45 to 1.30, 6 studies, 1365 participants, low-quality evidence) or 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.

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 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.

Conflict of interest statement

Netherlands Asthma Foundation provided funding for this review but in no way was able to influence the results of the review.

Figures

1
1
Study flow diagram.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Funnel plot of comparison: 1 Self management versus control, outcome: 1.1 HRQoL: SGRQ.
4
4
Funnel plot of comparison: 1 Self management versus control, outcome: 1.7 Respiratory‐related hospital admissions.
5
5
High‐risk participants: In the usual care group, 51 of 100 people had at least one respiratory‐related hospital admission over 52 weeks, compared with 37 (95% CI 31 to 44) of 100 for the self management group.
6
6
Low‐risk participants: In the usual care group, 13 of 100 people had at least one respiratory‐related hospital admission over 52 weeks, compared with 8 (95% CI 6 to 10) of 100 for the self management group.
1.1
1.1. Analysis
Comparison 1 Self management versus control, Outcome 1 HRQoL: SGRQ.
1.2
1.2. Analysis
Comparison 1 Self management versus control, Outcome 2 HRQoL: SGRQ total score: change from baseline.
1.3
1.3. Analysis
Comparison 1 Self management versus control, Outcome 3 HRQoL: CRQ.
1.4
1.4. Analysis
Comparison 1 Self management versus control, Outcome 4 HRQoL: CCQ.
1.5
1.5. Analysis
Comparison 1 Self management versus control, Outcome 5 HRQoL: SIP total score.
1.6
1.6. Analysis
Comparison 1 Self management versus control, Outcome 6 HRQoL: SF‐36.
1.7
1.7. Analysis
Comparison 1 Self management versus control, Outcome 7 Respiratory‐related hospital admissions.
1.8
1.8. Analysis
Comparison 1 Self management versus control, Outcome 8 All‐cause hospital admissions.
1.9
1.9. Analysis
Comparison 1 Self management versus control, Outcome 9 Respiratory‐related hospital admissions: days.
1.10
1.10. Analysis
Comparison 1 Self management versus control, Outcome 10 All‐cause hospital admissions: days.
1.11
1.11. Analysis
Comparison 1 Self management versus control, Outcome 11 Emergency department visits per person per year.
1.12
1.12. Analysis
Comparison 1 Self management versus control, Outcome 12 Doctor and nurse visits: mean number per person per year.
1.13
1.13. Analysis
Comparison 1 Self management versus control, Outcome 13 Participants using at least one course of oral steroids.
1.14
1.14. Analysis
Comparison 1 Self management versus control, Outcome 14 Participants using at least one course of antibiotics.
1.15
1.15. Analysis
Comparison 1 Self management versus control, Outcome 15 (Modified) Medical Research Council Dyspnoea Scale ((m)MRC).
1.16
1.16. Analysis
Comparison 1 Self management versus control, Outcome 16 Days lost from work: mean number per person per year.
1.17
1.17. Analysis
Comparison 1 Self management versus control, Outcome 17 Lung function: FEV1 (litres).
1.18
1.18. Analysis
Comparison 1 Self management versus control, Outcome 18 Lung function: FEV1 (% of predicted).
1.19
1.19. Analysis
Comparison 1 Self management versus control, Outcome 19 Exercise capacity: 6MWT.
1.20
1.20. Analysis
Comparison 1 Self management versus control, Outcome 20 Lung function: FEV1/FVC.
1.21
1.21. Analysis
Comparison 1 Self management versus control, Outcome 21 Mortality.
2.1
2.1. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 1 HRQoL: SGRQ (with CCTs).
2.2
2.2. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 2 HRQoL: SGRQ total score: change from baseline (with CCTs).
2.3
2.3. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 3 Respiratory‐related hospital admissions (with CCTs).
2.4
2.4. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 4 All‐cause hospital admissions (with CCTs).
2.5
2.5. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 5 All‐cause hospital admissions: days (with CCTs).
2.6
2.6. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 6 (Modified) Medical Research Council Dyspnoea Scale ((m)MRC) (with CCTs).
2.7
2.7. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 7 Lung function: FEV1 (liters) (with CCTs).
2.8
2.8. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 8 Lung function: FEV1 (% of predicted) (with CCTs).
2.9
2.9. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 9 Lung function: FEV1/FVC (with CCTs).
2.10
2.10. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 10 Exercise capacity: 6MW (with CCTs).
2.11
2.11. Analysis
Comparison 2 Sensitivity analyses with inclusion of CCTs, Outcome 11 Mortality (with CCTs).
3.1
3.1. Analysis
Comparison 3 Subgroup analyses, Outcome 1 HRQOL: SGRQ total (subgroup by follow‐up).
3.2
3.2. Analysis
Comparison 3 Subgroup analyses, Outcome 2 Respiratory‐related hospital admissions (subgroup by follow‐up).
3.3
3.3. Analysis
Comparison 3 Subgroup analyses, Outcome 3 HRQOL: SGRQ total (subgroup by exercise programme).
3.4
3.4. Analysis
Comparison 3 Subgroup analyses, Outcome 4 Respiratory‐related hospital admissions (subgroup by exercise programme).
3.5
3.5. Analysis
Comparison 3 Subgroup analyses, Outcome 5 Exercise capacity: 6MW (subgroup exercise programme).
3.6
3.6. Analysis
Comparison 3 Subgroup analyses, Outcome 6 HRQOL: SGRQ total (behavioural components).
3.7
3.7. Analysis
Comparison 3 Subgroup analyses, Outcome 7 Respiratory‐related hospital admissions (behavioural components).

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