Self-management exacerbation action plans in patients with COPD and common comorbidities: the COPE-III study

Chronic Obstructive Pulmonary Disease (COPD) is a chronic progressive lung disease with distressing exacerbations - acute deteriorations in respiratory health - that contribute to impaired quality of life and increased hospitalisations, mortality and healthcare costs. Frequently existing comorbid conditions in COPD, such as cardiovascular diseases, mental health issues, and diabetes, have an important impact on disease severity, hospital admission rate, and survival. These comorbidities share common risk factors with COPD and have overlap in symptoms. In COPD patients with the added complexity of comorbidities a “one size fits all” approach that focuses solely on COPD symptoms may be inadequate and could lead to the initiation of incorrect or delayed treatment.

Twenty-two studies were evaluated in a Cochrane review comparing the effectiveness of COPD self-management interventions including an action plan for acute exacerbations of COPD with usual care. We observed that self-management interventions including a COPD exacerbation action plan are associated with improvements in health-related quality of life and a lower probability of respiratory-related hospital admissions, without excess all-cause mortality.

We report the design of the COPE-III self-management intervention, that combines self-initiated patient-tailored action plans for COPD and comorbidities (chronic heart failure, ischemic heart disease, anxiety, depression, diabetes mellitus) with ongoing case-manager support. We demonstrate that our international multicenter randomised controlled trial is the first to test and confirm that patients with COPD and important comorbidities have better outcomes if they receive a self-management intervention that addresses their multiple conditions compared to usual care. Furthermore, we found two subscales for the Dutch Partners in Health (PIH) scale: 1) knowledge and coping; 2) recognition and management of symptoms, adherence to treatment. We recommend using these two subscale scores when assessing self-management in Dutch COPD patients.

In summary, our implications for future research and clinical practice are:
•consider the self-treatment of comorbidities in patient-tailored exacerbation action plans together with associated self-management training for patients with COPD and comorbidities;
•cautiously only using action plans together with self-management interventions;
•provide more detailed information regarding the delivered self-management intervention;
•identify patient characteristics that predict successful COPD self-management; and
•reach consensus on a final version of the Partners in Health scale.