D3. Self-management

Patients may benefit from self-management support [evidence level I, strong recommendation]

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).

A number of systematic reviews have been undertaken to evaluate the effect of self-management in COPD (See Figure 5 for abbreviated table and Appendix 6 for full table).  Whilst these have consistently reported 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 found self-management interventions were associated with reduced probability of respiratory-related but not all-cause hospitalisation, all-cause mortality, dyspnoea or exacerbation rate (Lenferink 2017). However, exploratory analysis showed a small but significantly increased respiratory-related mortality. The differences may be related to differences in the study populations, study context and extent of self-management support provided. Earlier reviews have found reductions in both respiratory-related, ED and all-cause hospitalisations (Jonkman 2016b) as well as improved dyspnoea (Zwerink 2014), a reduction in urgent health care utilisation and improved exercise capacity measured by the 6-minute walk distance (6MWD) (Cannon 2016). However, reviews have also reported no differences in 6MWD, anxiety and depression, hospital admissions and mortality (Majothi 2015, Zwerink 2014, Cannon 2016, Jolly 2016, Jonkman 2016b). These systematic reviews should be interpreted with caution due to the methodological weaknesses of the studies and heterogeneity of the interventions and outcome measures.

In 2019, Aboumatar et al reported an RCT that recruited patients admitted to hospital with a COPD exacerbation, or patients who had a previous diagnosis of COPD who were hospitalised and were receiving treatment for an increase in COPD symptoms (Aboumatar 2019). Patients (n=240) were randomised to a three-month intervention that involved: 1. A transition support aimed at preparing patients and caregivers for discharge and ensuring they understood the post discharge plan of care, 2. Individualised COPD self-management support to help patients take medications correctly, recognise exacerbation signs and follow action plans, practice breathing exercises and energy conservation techniques, maintain an active lifestyle, seek help as needed, and stop smoking, and 3. Facilitated access to community programs and treatment services. The intervention was delivered by COPD nurses. Usual care involved a general transition coach to follow the patient for 30 days after discharge, with a focus on adherence to the discharge plan, and connecting to outpatient care. The intervention resulted in an increased number of COPD-related acute events per participant at 6 months compared to usual care (difference 0.68 (95% CI 0.22 to 1.15); p=0.004). There were no differences observed in health status measured by the SGRQ at 6 months (difference 5.18 (95% CI 2.15 to 12.51); p=0.11).

Earlier reviews have found reductions in both respiratory-related, ED and all-cause hospitalisations (Jonkman 2016b) as well as improved dyspnoea (Zwerink 2014), a reduction in urgent health care utilisation and improved exercise capacity measured by the 6-minute walk distance (6MWD) (Cannon 2016). However, reviews have also reported no differences in 6MWD, anxiety and depression, hospital admissions and mortality (Majothi 2015, Zwerink 2014, Cannon 2016, Jolly 2016, Jonkman 2016b).  These systematic reviews should be interpreted with caution due to the methodological weaknesses of the studies and heterogeneity of the interventions and outcome measures.

The high degree of heterogeneity within interventions and study designs limits the ability to analyse which characteristics of self-management programs are associated with the most significant improvements.  However, a meta regression review of complex interventions identified that general education, exercise and relaxation therapy components contributed to reduced use of urgent healthcare (Dickens 2014) [evidence level I]. Additionally, Jonkman et al (Jonkman 2016a) demonstrated that intervention duration, regardless of composition, displayed the strongest associated with reduction in all cause hospitalisations in COPD patients.  Newham et al. identified that interventions targeting mental health were the most effective in improving Health-related Quality of Life (HRQoL) and reducing ED visits (Newham 2017).

Health coaching, when using motivational interviewing methods, and including components of goal setting and education, when delivered in person, has been demonstrated in a meta-analysis of 10 RCTs, to lead to significant improvements in quality of life, as well as COPD–related hospital admissions (54% reduction [OR 0.46 95% CI 0.31 to 0.69]).  However, the benefit appears not to be sustained beyond 12 months post-intervention (Long 2019).

COPD self-management programs overwhelmingly lead to improved health-related quality of life, with reduced exacerbations being a positive outcome of many studies. However, due to the heterogeneity of the study designs, setting and outcomes, we are unable to make recommendations regarding the essential elements of a COPD self-management program.

Overall COPD self-management programs appear to improve HRQoL. The effect of these interventions on exacerbations remains unclear. Studies have reported positive outcomes, whilst others have reported increased rates of exacerbations associated with self management interventions (Aboumatar 2019). Due to the heterogeneity of the study designs, setting and outcomes, and conflicting results, we are unable to make recommendations regarding the essential elements of a COPD self-management program.

Written Action Plans

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. Lung Foundation Australia has developed a COPD Action Plan which can be downloaded from https://lungfoundation.com.au/resources/?user_category=32&search=copd%20action%20plan. The Action Plan should be completed by the clinician and patient together and guides the patient in recognising when their symptoms change and what action they should take.

A systematic review by Howcroft et al. reported that supported use of COPD exacerbation action plans with a single short educational component reduced ED visits and hospital admissions (Howcroft 2016). The number needed to treat to reduce one hospital admission was 19. Studies that included an exercise program and longer education sessions were not included in this review. A subsequent RCT not included in this review confirmed a reduction in ED visits in patients who utilised an action plan  (Zwerink 2016).

A multicentre RCT (Lenferink 2019) (n=201) evaluated the effect of patient-tailored symptom-based written action plans embedded within a multi-disease self management intervention on COPD exacerbation days compared to usual care in patients with COPD and one or more comorbidity. Patients were given written action plans to prompt management of both COPD exacerbations and comorbidities (congestive heart failure (CHF), ischaemic heart disease (IHD), anxiety, depression and diabetes), together with a self management education program. No difference in the primary outcome of COPD exacerbation days/patient/year was observed (intervention median 9.6 (interquartile range (IQR) 0.7 to 31.1) versus usual care 15.6 days (3.0 to 40.3); (Incidence Rate Ratio (IRR) 0.87, 95% CI 0.54 to 1.30 (p=0.546)). There were however observed differences in the secondary outcome of duration of COPD exacerbations, in favour of the intervention (8.1, IQR 4.8 to 10.1 versus 9.5, IQR 7.0 to 15.1 days; p=0.021). There was no difference in overall HRQoL between groups, and the intervention group reported poorer emotional function on the CRQ compared to usual care.