D3. Self-management

Patients who take appropriate responsibility for their own management may have improved outcomes (Effing 2007Trappenburg 2011) [evidence level II].

A distinction can be made between ‘self-management’ and ‘self-management support’. ‘Self-management’ is a normal part of daily living, and involves the actions individuals take for themselves and their families to stay healthy and to care for minor, acute and long-term conditions. ‘Self-management support’ is the facility that healthcare and social-care services provide to enable individuals to take better care of themselves. The onus is on delivering training for self-management skills to individuals through a range of interventions (Osborne 2008).

There have been a number of systematic reviews evaluating the effect of self-management in COPD.  Whilst these have consistently resulted in improvements to quality of life, there have been conflicting findings in terms of their effect on healthcare utilisation (Jolly 2016, Jonkman 2016a, Jonkman 2016b, Majothi 2015, Zwerink 2016). A Cochrane Review (Zwerink 2014) of trials published between 1995 and August 2011 found a benefit for self-management interventions on health related quality of life and lower probability of respiratory-related hospitalisation but there was no effect on all-cause hospitalisation or mortality. This review does not include more recent studies while others, have shown no benefit (Bucknall 2012, Bischoff 2012). One study found excess mortality in the self-management group (Fan 2012). The differences may be related to differences in the study populations, study context and extent of self-management support provided.In COPD, behavioural education alone is effective, although less effective than integrated pulmo­nary rehabilitation programs that include an exercise com­ponent (Ries 1995). An additional systematic review evaluated a suite of complex interventions including self-management and their effect on reduction of urgent health care utilisation.  Complex interventions were associated with a 32% reduction in urgent health care utilisation (OR 0.68, 95%CI 0.57-0.87).  However in a meta regression the authors could not identify the components that contributed to the additional effect (Dickens 2014) [evidence level I]. Another systematic review and meta–analysis by Cannon et al (Cannon 2016) aimed to evaluate the impact of COPD self management on health related quality of life, exercise capacity, anxiety and depression, self efficacy and hospitalisations. Twenty five RCTs involving 4,083 participants were included.  The results of this review were both concordant and discordant with previous ones.  Self management programs lead to statistically significant improvements in health status measured by the SGRQ (pooled MD -3.32 (95% CI-4.60 to -2.04; p=0.0001), however unlike the Zwerink Cochrane Review (Zwerink 2014) this did not meet the MCID of 4 units.  Exercise capacity measured by the 6MWD also improved (pooled 30.50m (95% CI: 3.32 to 57.68; p=0.028), as did the negative effect, physical exertion and behavioral risk factor domains of the COPD self efficacy scale.  There were no significant differences in anxiety, depression or hospital admissions (pooled MD 0.62, 95% CI: 0.35 to 1.11, p=0.106).

Similarly, a systematic review evaluated the effect of COPD self management following admission to hospital as a distinct intervention and failed to demonstrate any positive effect on all cause mortality or health care utilisation (hospitalisation) (Majothi 2015) [evidence level I]. Another systematic review that included single and multi–component interventions, reported that there was no impact on hospital admissions, but lead to improved health related quality of life (SGRQ [MD 4.87, 95% CI 3.96-5.79]).  The authors were not able to describe the package that lead to the most significant improvements due to the degree of heterogeneity within the interventions and study designs (Jolly 2016). These systematic reviews should be interpreted with caution due to the methodological weaknesses of the studies and heterogeneity of the interventions and outcome measures.

Jonkman et al (Jonkman 2016b) performed an individual patient meta-analysis of 3,282 subjects from 14 RCTs of self-management in COPD patients, with subgroup analyses to appraise if particular subjects were most likely to benefit. While several health service and patient centred benefits were demonstrated in this study, including 20% in all-cause hospitalisations, there was no consistent pattern of benefits across the health service and patient centred outcomes in any particular subgroup. Jonkman et al (Jonkman 2016a) also used this meta-analysis to evaluate whether certain self-management program characteristics were more likely to be associated with better outcomes. This evaluation demonstrated that duration of the intervention program, whatever it comprised, was most associated with reduction in all cause hospitalisations in COPD patients, but that other program characteristics were not consistently associated with positive effects across outcomes measured.  There is no particular type of patient who should be omitted from these initiatives and the greatest benefits were from enduring interventions.

The concept of written action plans for patients with COPD is derived from their success in asthma management indicating doses and medications to take for maintenance therapy and for exacerbations. Instructions for crises are often also included. A systematic review by Walters et al (Walters 2010) found that the use of action plans results in an increased ability to recognise and react appropriately to an exacerbation by individuals. However this review found that there was no reduction in healthcare resources utilisation or improved health-related quality of life. A 2011 randomised controlled trial showed that an individualised action plan, including ongoing support by a case manager, decreased the impact of exacerbations on health status. Action plans can be considered a key component of self-management programs in patients with COPD (Trappenburg 2011) [evidence level II]. However, there is no evidence these behavioural changes alter health-care utilisation.

A Dutch randomised control trial in 142 COPD patients with frequent exacerbations and no other significant co-morbidities showed that action plans reduced exacerbation duration and severity and lead to a reduction in ED and specialist visits but not GP visits (Zwerink 2016) [evidence level II]. The trial also reported on a significant reduction in overall health costs. This trial suggests that action plans can be useful in particular sub-groups of COPD patients.